February 8th 2023
The Local Government and Social Care Ombudsman has produced guidance in efforts to support providers with good record keeping after receiving complaints from people accessing care. The guidance demonstrates the nature of common complaints and explains what providers need to do to ensure good record keeping practices.
The guidance, published last week, provides a variety of examples of poor record keeping in the form of case studies. The Ombudsman advises that care providers ensure that
- All records are accurate, honest and comprehensive.
- All staff are familiar with the recording system used.
- Records are updated with new information in a timely way.
The guidance also explains that in any investigation, care records are one of the first things asked of a care provider when an investigation is called and that any gaps in records cast doubt on the integrity of the entire care provider record.
Speaking about the guidance, Adam Hunt, Digital Transformation Lead for the National Care Forum said:
“Quality care and support is reliant on accurate records, stored safely and shared appropriately. The new guidance is hugely important for learning lessons that highlight the importance of good record keeping practice. The free support and guidance on offer from Digital Social Care and Better Security, Better Care enables providers to turn these lessons learned into practical steps to ensure quality care records are embedded at all levels, regardless of whether they are paper or digital.”
The guidance encourages providers transitioning to digital records to seek support from the Digital Social Care website. Digital Social Care provides free resources and support for adult social care on technology and data protection issues. Record keeping is a part of this, and the website hosts a variety of resources that can support staff.
Registered managers of care services can access staff guidance on data quality and record keeping, and a template for a record keeping policy that can be downloaded and adapted for individual care services. If a provider needed extra support, the Digital Social Care helpline is available to help answer any questions, and the website hosts a library of additional template policies and resources that support good data and cyber security practices.
You can read the full report here.
Photo by Jan Antonin Kolar on Unsplash
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