In recent Prevention of Future Deaths (“PFD”) Reports there is a recurring theme that care homes are failing to keep adequate records to safeguard their care users from harm.
In February 2021 a PFD Report reported that a service user living at Baedling Manor Care Home had an unwitnessed fall and subsequently passed away from the injuries she sustained. Of concern to the Coroner was the lack of reporting of both that incident, and a previous similar incident earlier in the year. The standard of record keeping was found to be “poor” with care plans not changed or updated and notes not presenting an accurate picture of the resident and their needs.
A year later, in February 2022 another PFD Report concerned a service user living at Tamworth Court Nursing Home who died following an unwitnessed fall in her bedroom in October 2021. Again, the Coroner reported that no record was made of the incident in the nursing records, no incident form was completed and no investigation of the accident or the circumstances giving rise to it was undertaken.
These are just two examples from 16 PFD Reports between January 2021 and July 2022 where the coroner cited poor record keeping as a cause for concern.
More seriously, in May 2022, Bupa Care Homes (CFHCare) Limited was ordered to pay £123,699.00 in fines and costs following two service users suffering preventable injuries attributed to poor document and record management at West Ridings Care Home, Wakefield. Both service users suffered falls and for service user Mrs Smith, although her falls were recorded, the service provider did not reassess her care planning or put action in place to reduce the possibility of recurrence. For service user Mrs McDonald, her family were not informed of her fall, an x-ray was not arranged and she was given pain relief medication to which she was allergic. In both cases, the Court found that failures in record keeping and proper care assessment combined with poor management led to avoidable harm.
For organisations, not only do they risk breaching health and safety law, but also their governance and record keeping duties under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Whilst these cases shine a light on the issue, the reality is that PFD Reports and prosecutions are likely to only represent the tip of the iceberg. In reality, poor practices are likely to be far more extensive and far-reaching due to substandard record keeping.
Besides the obvious risks of prosecution and reputational damage, good record keeping is essential for care providers to be able responsibly to care for their residents and to fulfil their legal duties to ensure the safety of service users. Individual care user records ultimately inform care plans, meaning incomplete and inaccurate records can severely impact an individual’s daily events and put them at risk of not having their healthcare needs met.
Care user records and care plans act as a form of communication between staff on how to care for an individual. Care plans and control measures are there to protect a service provider and failure to keep an accurate record of them significantly increases the risk that they will not be implemented in practice, putting care users at risk of injury.
Having a robust record keeping system, including allocated time for staff to update and review care plans, provides evidence of good leadership with a clear management commitment to controlling risks and creating a safe environment. In contrast, it is a simple step for Coroners and indeed regulators to interpret poor/incomplete record keeping as evidence that organisations are not fulfilling their legal obligations and that they lack the competence and resource to do so.
Recording incidents allows care providers to identify hazards and spot trends to prevent similar incidents happening again. In some cases, there is also a legal requirement to report them.
Care Quality Commission (Registration) Regulations 2009: Regulation 18 states that care providers must notify the CQC of all incidents that affect the health, safety and welfare of people who use services. Full details including the regulation can be found here.
Certain incidents are also required by law to be reported under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013 (RIDDOR) and due to the nature of care homes, the chances of a reportable incident happening is higher than in many workplaces. Please see the following HSE guidance for examples of reportable incidents. You must keep a record of any reportable incident for three years and this must include:
Incidents inform risk assessments as they identify hazards for which appropriate control measure can be introduced. Incidents not recorded may prevent incidents being investigated, patterns identified and lessons learnt to prevent a similar incident occurring again. In the event of an Inquest or prosecution, it also provides evidence of no commitment to learning from incidents with a view to safeguarding residents.
Care providers should ensure that they have good systems in place to regularly review and update records, including risk assessments. This includes allocating dedicated time for staff to update, read and digest records. To help implement appropriate systems, care providers are encouraged to review and follow HSE and CQC guidance on Health and Safety in care homes.
In May of this year the CQC provided a guide on ‘What good looks like for digital records in social care’, highlighting the benefits of moving to digital systems to create better integrated patient management and record keeping systems. Whilst not essential, digital systems can help information to be shared quickly, accurately and safely, minimising the risks of errors and helping to manage and support staff to do their job effectively and efficiently. The guide also clarifies what CQC inspectors should be looking for when assessing how well systems support high-quality care, making it a useful starting point for service providers to carry out internal assessments of their systems.
Death from an accident in a care home does not automatically indicate neglect and when robust record keeping and reporting systems are implemented, a care provider will be better able to protect themselves should they find themselves the subject of an inquest. More importantly, they will be more able to safeguard care users from an accident occurring.
If you would like advice on how to handle an inquest or around the legal requirements for keeping care user records and reporting incidents, including any concerns you have about GDPR, please contact our Business, Risk and Regulation team via Ian Manners.
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