Doing daily records differently

04 March 2015 | By Helen Sanderson

Daily records – can they be both compliant and useful?

Why do we record what we do?

I was exploring this with an organisation that provides support to older people and people living with dementia during the day, through a day centre. They explained how their colleagues had 30 minutes at the end of the day to do their version of ‘progress notes’. I asked why, and the answers were variations of:

‘Because CQC require them’

‘In case we have a complaint’

I asked how else they were used and who could see them, for example, were they available to the family?

The answer was no one could see them – they were filed away as a silent record of someone’s day just in case they were required to justify or check what happened.

Is there a way that what is recorded about someone’s life could be both useful for learning and development as well as the required record to demonstrate compliance?

In a few services, learning logs have been introduced for a fixed period of time, for example, when the person is trying something new to capture what we are learning both about the person and what is important to them, and also what we are learning about the best way to support them. This information is used to update the one-page profile.

This animate shows how this can work – http://bit.ly/1E8FVxe

I am working with several home care organisations supporting them to deliver a more person-centred approach through using person-centred practices. So far we have been looking at using learning logs for the first 6 – 10 visits.

This short film shows where learning logs fit into the process – http://bit.ly/1BPlnd6

My thinking about this was challenged last week with from a member of staff in another organisation who simply asked – can’t we do both? Can we adapt the learning log so we can both record what we are learning AND comply with the requirements for daily records? Inspectors should see regular use of learning logs as part of the evidence that an organisation is meeting two of CQC’s 5 Questions:

* Is it effective?

* Is the service responsive to people’s needs?

Can we achieve this?

So we looked at this and here is the end result – simple.

 

Capture

 

The key issue here is that this is not just new paperwork, these learning and communication logs have to be reviewed every 6-8 weeks to look at what we are learning and updating the persons one-page profile from them. If this is not happening- then they are no better than the existing daily records.It has times on because it is being used in home care, one for residential care would just have ‘at this time’. Now, just when we thought we had done something interesting and exciting, my colleague, CEO of an innovative learning disability service told me she had been doing this for years. That’s great – and why we need to do a better job of sharing learning across sectors!

The next challenge is how we can make them open and shared with the person and family? Anyone doing this already? Please let me know.

Thanks to Colin Angel, UKHCA, for his helpful comments on this blog.

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