Here at Bettal Quality Consultancy we have always recognised the importance of records to our Cared4 Quality Management System. In the development of our system, we have included over 180 forms that enable providers to keep quality service user and staff records. A form is a document, that becomes a record is filled out.
Records are how providers demonstrate to the CQC that the service they are providing complies with regulations and CQC Standards. It is therefore essential that management and staff have a clear understanding of what a record is and its importance to a social care service.
What are the characteristics of a record?
To help with our understanding of what a record is the International Standard Organization (ISO) records management defines the characteristics of a record as follows:
A record should demonstrate accountability.
A record should support the needs of a service.
Records should have:
Content: It should reflect what was communicated or decided or what action was taken and should provide enough information so that it is understood.
Context: It should reflect how it was used or why it was created (purpose), the date, the time, and the participants.
Meaning: It should be linked to other documents or information to which it relates. Authenticity: A record is one that can be proven:
• To be what it purports to be. • To have been created or sent by the person purported to have created or sent it; and • To have been created or sent at the time purported.
Reliability: Records must be trusted to be a full and accurate representation of the transactions, activities, or facts and can be relied upon in subsequent activities.
To ensure reliability, records should be created at the time of the transaction or incident or soon afterwards and by individuals with direct knowledge of the facts.
Integrity: A record must be complete and unaltered and must be protected from unauthorised changes, and verifiable unaltered.
Usability: To be useable, records must be retrievable, presented, and interpreted. The links between other records should be maintained.
What the regulations and the CQC say about records
The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 17 states providers must securely maintain accurate, complete and detailed records in respect of each person using the service and records relating the employment of staff and the overall management of the regulated activity.
CQC inspection and records
As a principal inspector of adult social care services in Cumbria the 3 key skills used by my inspection team were:
1. Observation of what was happening in the service 2. Talking to staff and services to establish level of satisfaction with the service and any concerns 3 Examination of records to ensure that they were completed properly and up to date.
Essentially, these 3 skills are the tools used by CQC inspectors to evaluate the performance of a social care service. You will note that the first 2 skills will give an inspector a picture on what is happening on the day or what they have been told. It is through examination of records that the inspector will establish if the service is complying with regulations and CQC Standards. Inspectors then are always looking for evidence that demonstrates the service is complying to standards.
Records however, are becoming more important to the CQC. Going forward it is more than likely that less time will be spent on a social care site visit and more emphasis placed upon a service sending digital records to the CQC for checking.
Summary
The management of records is a key issue for managers of social care services. It is a requirement of regulations and CQC Standards. More training should be provided for managers and staff on understanding the importance and characteristics of good records.
Given the emphasis the CQC places on digital records to establish compliance to standards now and in the future managers will need to ensure that their service records follow the characteristics
of good records and see they are kept up to date.
The Bettal Cared4 Quality Management System has all the forms, policies and procedures to enable managers to comply with the requirements of CQC.
Albert Cook BA, MA & Fellow Charted Quality Institute Managing Director Bettal Quality Consultancy