It Ain’t Necessarily So – 16: Is it right to say that if it isn’t recorded, it isn’t done?
With JOHN BURTON
Caring Times, May 2014
In ordinary life most things get done without being recorded. Ordinary life is also lived in good care homes where only those things that really need to be recorded are recorded. The absence of a record no more proves something that should have been done has not been done than the existence of a record proves that it was done.
A few years ago I was reviewing the management and practice in a care home that had recently had a poor inspection report. At about 11am I went into a room where about a dozen residents were sitting. A CD of Churchill’s wartime speeches was blaring out. None of the residents appeared to be listening, nor were they talking to each other or actively communicating in any other way.
A youngish man on the staff was sitting some way away from the others with a pile of ring binders by his side. He was intent on writing in one. I asked him what he was doing: “I’m recording the activity.” These were the residents’ individual activity files. I was told they were required by inspectors who had complained that there was no evidence of “activities” in the home. In each file the care worker had written: “11 – 12 Reminiscence activity: Mr/Mrs/Ms X enjoyed listening to Winston Churchill CD.”
He explained to me that he and his colleagues now had to record all activities for the inspectors. Neither he, his colleagues nor even the manager could see the utter pointlessness of the “activity” or of complying with the requirement to record it. As in this instance, it’s frequently true to say that if it is recorded, it may well not have been done.
There are several things in the ordinary life of a care home that must be recorded and the test of whether to record or not is whether doing so supports good care – the health, wellbeing and safety – of residents. Medication must be recorded, but we should remember that, even in this case, the record does not prove the action.
A common misunderstanding with record keeping is that everyone needs the same records (for example in care plans and risk assessments) and that records, once started for a good reason, need to be continued after the treatment or condition has ended (for example nutrition, pressure areas, continence). When the decision is made to stop some preventive or rehabilitative treatment, the decision should be recorded and the record should be ended. In other words, sign it off.
The Joseph Rowntree Foundation report on paperwork in care homes (featured in April’s Caring Times) showed that much record keeping is driven by fear of the regulators. This is understandable if not professionally justifiable or rational. Good inspectors treat paper trails with scepticism; they gather their information and make their judgements from listening, observing and getting the “feel” of what’s going on in a care home. Good managers keep records that are required for the core task of care and don’t ask their staff to fill in forms solely for inspection purposes.
We found a different way: Caring Times readers tell their stories
Care home owner/manager, Midlands: No, it’s not right to say that. Care staff are employed to give care. We all know that people who go into care work don’t have a university degree, yet we expect them to spend half of the shift writing. What are they writing for? Care homes are for care, not sitting at a desk or computer. Anyway, hardly any of the care staff can type and it takes them half an hour to type a sentence.
There simply isn’t the time to waste it like that. It’s all because we’re scared of legislation and inspectors, and now the local authority commissioners send in their bureaucrats to comb through the paperwork. It’s ridiculous.
Manager, South East: I agree in some cases that if it’s not recorded, it’s not done. But some things don’t need to be recorded and we’re only doing it because we’re scared of losing our jobs and getting a bad inspection report which will affect our occupancy and revenue. We’re moving away from the importance of care – the essence of what we’re supposed to do. Why are we failing? You could walk into any care home and know whether it’s any good or not; you don’t have to examine written records to know.
Let’s think about our own lives. Do we have a care plan to complete before we go to bed? My job and my future depend on inspection reports. I have to have all the records complete whether they are true or not. Sometimes, you have to compromise. I don’t agree with it but it’s a fact of life.