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Care home watchdog publishes guide to record-keeping

The Local Government and Social Care Ombudsman has issued a guide to help care homes learn from its complaints involving record keeping.

Poor record keeping is a common complaint from people receiving independently provided care. Among the case studies cited involving care homes is one where a care home had two versions of the care charts for a resident nearing the end of her life.  This led to a complaint by a family due to distress and lack of trust. In another complaint, a care home could provide no record of who attended a night-time call or the action they took.  As a result a serious injury did not receive attention it should have and the resident suffered for longer than necessary. The family was left with the distressing thought of their relative in significant pain because of the home’ failure to complete incident report records that led to late intervention.

The guide sets out the Ombudsman’s approach to investigating complaints on this matter, including information on electronic record keeping, and it references other regulatory bodies’ guides to meeting the requirements on record keeping.

Good practice tips in the guide include ensuring all relevant staff are familiar with the recording system used and maintaining accurate, honest and contemporary records.  Where the Ombudsman does find gaps in records, it may cast doubt on the integrity of the whole of the provider’s response.

The new free guide can be downloaded for free from the Local Government and Social Care Ombudsman

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