Commissioning care homes: common safeguarding challenges
Underlying causes – Record-keeping
Poor record-keeping is essentially poor communication and can put both staff and residents at risk. Records include:
- pre-admission assessments
- care plans
- risk assessments
- safeguarding referrals and investigations
- medication records and administration sheets
- end of life care planning, including clear instructions on whether individuals wish to be resuscitated
- referrals to other organisations and professionals
- staff handover documents
- staff supervision and training records
- Resident's care plans are person-centred and accurate.
- Care plans include risk assessment and risk enablement.
- There is evidence that staff adhere to care plans and they are regularly updated.
- All records are recorded clearly in a manner that can be easily understood by others.
- The home manager regularly monitors the standard of record-keeping.
- All records are accessible to those that need them while appropriate levels of confidentiality are maintained.
- Where the home manages any aspect of a resident's finances, either through resident choice or lack of capacity, the records are subject to robust and regular checks.
- All record-keeping practice is regularly reviewed, with input from frontline staff, as fit for purpose.
- There is evidence that the home uses complaints to improve quality and practice.
- There are records of regular staff supervision and team meetings and evidence that actions are followed up.
- CQC Essential standards of quality and safety &ndash Outcome 21: Records (p170)
- Essence of Care 2010: Benchmarks for Record Keeping