Electronic Care Recording – The New Standard in Monitoring Care?

Topics covered: care home inspection, care plans, CQC

In the last year Ridouts has seen many providers switch over from paper records to electronic care systems. It appears that across the sector there is a push to transition to paperless care recording. It has been said that this will allow providers to improve governance within their services, achieve better compliance with the regulations, and achieve better outcomes for service users.

Electronic care systems help to improve efficiency and completeness of care records. By having care records in one place, on one platform where all carers can access them, it should reduce the amount of time spent recording care and increase the time spent delivering care and having meaningful engagement with service users. However, at Ridouts we have also seen the CQC criticise service providers for using electronic care recording and monitoring systems on the basis that the records are not detailed enough to ensure that care is provided in a way that sufficiently meets service users’ needs and preferences. In particular, concerns have been raised by the CQC around the language used on such systems as not showing dignity or respect towards service users.

However, even the CQC appears to be changing its tune on electronic care recording. Recently the CQC were testing a new system to gauge service users’ satisfaction via icons. This system involved CQC inspectors to use “talking mats”, which is an interactive symbols tool it uses to help meet people’s communication needs.  Despite the CQC endorsing this approach to recording information on service user satisfaction, Ridouts has seen the CQC criticise a provider for using such icons to record the type of care received on the basis that it was not sufficiently detailed to show what care was delivered and that the stock phrases indicated a lack of dignified and respectful language which implied the care was inadequate.

Whilst this may not be true of the care that was actually delivered, it seems that providers will need to be wary of the content of entries in their electronic care systems when it comes to keeping a record of care. It is one thing to use simplified symbols to help people express themselves, but when using it as a record of care there needs to be more detail according to the CQC.

If providers choose to switch over from a paper to electronic care system they should be cautious and ensure that the system they use will continue to comply with the regulations in the same way that their paper system did. This will be especially prevalent when it comes to treating service users with dignity and respect, meeting service users’ preferences, and ensuring that person centred care is delivered.

The following would be good measures to have in place when switching to electronic care systems:

  • Set up a system for transitioning and tracking progress
  • Complete care plan audits as they are moved from paper to the digital system
  • Ensure oversight is in place for electronic care systems
  • Train all staff on the use of the new electronic care system
  • Ensure staff are aware of how to enter personalised notes on the care delivered to service users
  • Ensure care notes use dignified and respectful language
  • Ensure care notes are clear and up to date
  • Ensure care notes are personalised to the needs of each service user and not blanket instructions

Whilst there are benefits to using technology to increase the quality of care provided, providers will need to be wary of making the delivery of care a tick box exercise for record keeping purposes. The care notes still need to be personalised and reflective of dignified and respectful care in order to demonstrate that a provider is meeting its regulatory duties.

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