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Record Keeping within Care Homes

When an individual needs some extra help to continue living independently, and the family are not in a position to support them, residential care is often the best solution. They will be able to enjoy the company of other residents while benefiting from specialist, round-the-clock care and support.

From the day a new resident arrives at a care home, and throughout the entirety of their stay, a great deal of information needs to be held and recorded. Employees are responsible for updating the records and referring to existing records when they need to.

The importance of keeping up-to-date data was brought to light recently when a Care Quality Commission (CQC) report about a care home in East Grinstead revealed that residents? records were not accurate.

What Could Happen If Records Are Poorly Kept?

This report highlighted an incidence where a resident?s record showed a Do Not Attempt to Resuscitate form in her care plan. It was claimed that her husband had authorised this, however it was not made clear if he actually had power of attorney, according to a report in the East Grinstead Courier. Without power or attorney, he would not have the legal right to make that decision. If something had happened to the lady and the care home did not try to resuscitate her, this could have had alarming consequences.

This example highlights the importance of keeping and maintaining up to date records of all aspects of a patient?s care. This is particularly crucial for when employees change over at the end of a shift or for when staff come and go.

It is also important for employees to be aware of who has the power of attorney over residents with limited capacity, such as those with dementia.

Keeping Records Is an Important Part of the Job

Record keeping is important both for patients and care home employees. It is vital that staff are given training in record keeping and realise the importance of updating and referring to these files.

The Care Quality Commission has a particular regulation relating directly to keeping accurate care records. All in all, the CQC has 28 regulations, designed to encourage care homes to ensure high quality records are kept.

Families should also be able to check these records to make sure they are correct. The next of kin should be able to see these records, and any reputable care home should be only too willing to share these with family at any given moment. If in doubt of the records being held for your loved one, requesting a copy will help to alleviate any worries you may have.

Balcombe Care Homes believes record keeping is of paramount importance for resident and families as well as its employees. Keeping accurate, up-to-date and timely records about residents is a crucial part of our daily routine to make sure we continue to provide a high quality of life to each and every resident.

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