UK | Ombudsman issues guide for care providers on good record keeping

Among the complaints the Ombudsman receives from people receiving independently provided care, poor record keeping is commonly a factor when things have gone wrong.

The Local Government and Social Care Ombudsman therefore issued a guide to help care providers learn from its complaints involving record keeping. The new guide focuses on a number of case studies highlighting the common issues the Ombudsman sees, and also includes good practice tips to help providers avoid the problems from occurring in their own settings.

Issues covered by the guide include providers fabricating records after a serious incident, customers being given wrong or no medication or food because records were not updated properly, and delayed treatment for another customer because of inaccurate records.

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.

Michael King, Local Government and Social Care Ombudsman, said: “Record keeping isn’t just an administrative task that can be completed as and when necessary – poor records can have serious consequences for the people care providers look after. Our new good practice guide shares the learning from the investigations we have carried out. By highlighting some errors in real scenarios, we want to stress to care providers that not only does maintaining accurate records ensure compliance with the regulations – more importantly, it also saves people from real distress.”

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.

Source: Office of the Local Government and Social Care Ombudsman, UK