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
complaints.

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.