cqc inspection

Care recording in volume for a CQC Inspection audit; exception reporting for practical care intervention

This series of blogs focuses on the particular aspects of our care-Log+ care record management software that assist care providers to prove the care they have delivered in structured record sets. Above all we want to describe how the functionality of the software helps you deliver an auditable trail for inspection by any regulatory body.

In our previous blog (on recording for a CQC Inspection) we wrote about the detail and volume of information that it appears a care home may be audited on in a CQC Inspection. Nutrition and fluid records seem to be a particular focus as inspectors try to ascertain that the care home is providing correct input of both – and evidencing this by their records.

We remarked how users of our care-Log+ care record management system were able to satisfy the volume of their record keeping needs, whilst not losing focus on the fact that their care staff are employed to care rather than be administration clerks, in two ways: First, through the facilities care-Log+ offers to define the care records that the management team want the care staff to record. So fluid intake could be defined in terms of millilitre bandings (‘less than 20ml’, ’20ml – 40 ml’, ‘more than 40 ml’ for example) or by description such as in the example of an evening drink with ‘few sips’, ‘half taken’, ‘all taken’, ‘declined’. Secondly, the care staff can quickly record these notes not at a PC (although of course the option exists to do this) but on a wirelessly connected tablet PC that is either carried by the carer or wall-mounted in convenient locations around the home such as in the dining room or lounge.

However, by giving carers an easy and accessible method of recording their shift notes, haven’t we just created another mountain of records to look through only in electronic form rather than paper-based? Well yes we have but there is an extra aspect of the recording functionality (that works with the defining of the prompts and dropdown options that the carer sees on the tablet) that makes care-Log+ a very pro-active care management tool that allows a focus on the exceptions.

That additional facility is the option to mark specific responses, if selected by the carer, as flagging alerts. So in the examples given earlier, the selection of ‘less than 20ml’ for fluid intake could be designated as an alarm and thus alert the management team that the resident has consumed an insufficient volume. A warning is immediately placed on their desktop and will also appear in the Shift Handover report. The software presents the alert in an alarm list. Clicking on a line will then take the senior or matron reviewing the alert flags to the shift note record and present options to enter additional comments, review associated care plans and/or health and risk assessments, add a care task that notifies the care staff on the tablet PC to be aware of a particular care need (such as ‘prompt to drink’ in this case) over a period of time (for example every day for the next week) and, if relevant, access the resident’s body map image.

In this way care-Log+ provides an exception-based environment in which records are gathered very easily and in the volume required through use of the tablet PCs, and then automatically filtered by the software between the few that require immediate review and the majority which are held for reporting as and when required in the future.

If you would like to discuss any functionality or issues raised in this blog please call one of our team on 01892 834406 or e-mail us on info@easylog.co.uk

Posted by administrator in Care home management, CQC Inspections, Domiciliary care and supported living, Nursing home management, 0 comments

Care plans are not a standalone document

When a CQC Inspector is auditing your care records one of the main things they’ll be looking for is to see that the recordings made in one are reflected in any other related documentation. So, for example, notes made on a carer’s shift that record a resident has been not eating to their usual pattern over the last couple of days or so, should be matched by evidence of a recent review of the ‘Eating and Drinking’ care plan. In this way written observations are closely linked to a reassessment of the required care interventions to ensure that the desired care outcomes remain achievable.

This of course describes basic good care and nursing practice but with the volume of care recording undertaken can it be guaranteed that this systematic review happens on every occasion?

A care plan is the central document that defines a service user’s care. Its on-going relationship is therefore not only linked to shift notes but with health assessments, risk assessments but prior to that with pre-assessments and social care (or life story) background information.

It is therefore pleasing to hear from our care-Log customers how the definable flexibility in the software is being used to ensure that each home’s unique and diverse documentation sets are being updated and reviewed as a complete entity. As Lesley Plumb from The Chestnuts care home in Meopham near Gravesend, Kent says,  At a CQC inspection, we were able to demonstrate how all the care we provided was both personalised and “in the round” – in other words, any problems raised were answered and explanations given, leaving no loose ends in relation to a resident’s care.

And of course that’s a very reassuring position to be in before any CQC Inspection.

For more information about the functionality in care-Log and how it can be harnessed to benefit your care home or supported living care facility please contact us.

Posted by administrator in Care home management, Domiciliary care and supported living, Nursing home management, 0 comments