Registered managers of care homes, domiciliary care and supported living agencies will be well aware of the work involved in the preparation for a CQC inspection. Indeed, at Bettal Quality Consultancy, we have developed a pre-inspection tool that provides guidance to managers.
Central to the CQC inspection process is the examination of records retained by the service.
Records are the holy grail for inspectors. They tell the inspector so much about what is happening in the service.
CQC and the regulatory position on 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 to the employment of staff and the overall management of the regulated activity.
List of documents
The manager will maintain:
• Securely an accurate, complete and contemporaneous record in respect of each Service User, including a record of the care and treatment provided to the Service User and of decisions taken in relation to the care and treatment provided.
• A list of all those procedures in force at any time, and other documents that are integral to the Quality System. For example, all core training material is sent to the service, health and safety and personnel documentation.
• A list of any related external documents which form part of the Quality System, for example Department of Health Guidance Legislation and guidance from the Care Quality Commission.
The manager will keep a list of all publications produced by the service for Service Users and purchasers and record the date of issue and any re-issue date.
Service Users and Staff Records
The manager should ensure that all Service Users’ personalised records and medical records are kept, maintained, monitored, and reviewed.
All Service Users’ records relating to their treatment and support are updated as soon as practical.
Staff ensure that any verbal communications regarding care, treatment and support are recorded within the Service User’s records as soon as is practical.
Staff ensure that when they make recordings relating to the care, treatment and support of Service Users, they are clear, accurate, factual and sensitive to the dignity and confidentiality of the person.
Service Users records should be used to plan appropriate care, treatment and support to ensure their rights and best interests are protected and their needs are met. The manager should ensure that all records relating to people employed and the management of regulated activities must be created, amended, stored and destroyed in accordance with current legislation and guidance.
What is a social care record?
There is some confusion about what constitutes a social care record but the following
would be included:
• Relevant contact details.
• Means of identification, including a photograph.
• Dates of entry and departure, e.g. when transferring to a hospital, another care home or another domiciliary care service, or date and time of death with information about cause of death.
• Healthcare provision.
• Accident and incident records.
• Risk assessments.
• Records of any restraints and restrictions imposed on a person with or without his or her consent.
• Records of consent.
• Terms and conditions of residency.
• Assessment of needs.
• Service User Care Plans.
This is not an exhaustive list; the manager may wish to add to it.
Keeping records up to date
CQC inspectors as part of the inspection process are not only looking to see that the registered manager has all the required documentation in place but there is evidence confirming that they are being kept up to date.
Regular auditing of policies, procedures and records is key to ensuring that records are kept up to date. Planned audits will inform the manager on the status of records and address any issues.
Importance of records in keeping on the right side of the law
I am sure that registered managers do not need reminding of the importance of having good traceable records available for regulators to inspect, but also as a means of avoiding any litigation or responding to complaints that may be faced by a social care service.
Good quality up-to-date records are essential to the successful operation of care homes, domiciliary care and supported living agencies. Regular audits of services and records of actions taken to will ensure that all records are kept up to date.
Good record keeping is not just a matter of meeting the requirements of the CQC inspection, it is essential to the safe operation of a quality service.
Albert Cook BA, MA & Fellow Charted Quality Institute
Bettal Quality Consultancy