Problems with care home records? Mind your language…

Problems with care home records? Mind your language…

It is quite common for care home records to be in a jumbled and disorganised mess, containing incomplete and inaccurate information with lots of missing critical information. Good record keeping is essential for any resident in a care home or other care facility.

Logically, how can a care home responsibly care for its residents without an accurate description and record of each individual’s daily events and healthcare needs. What did they do in the day? Did they exhibit any challenging or inappropriate behaviours? What medication was administered, when and by whom? What did they eat and how much fluid intake did they have? Are they at risk of weight loss or malnutrition? Were they able to mobilise safely or need carers to assist with transfers? Did they fall? Were they left in bed or sitting too long, putting them at risk of skin damage and pressure sores? How was their continence and toileting managed etc? All these issues and more should form part of a resident’s daily care records.

You put your trust in the care home and believe that they will do their absolute best to look after your relative and keep them safe and well. But, how often are the records incomplete or inaccurate and simply not reflective of the resident’s actual care needs? So much so, that you may wonder if they’re actually talking about your own relative!

Good records are vital to supporting a successful application for CHC Funding.

All these daily records are, of course, not only vital for monitoring the individual’s well-being and for staff handover, but also form a very important part of the NHS Continuing Healthcare assessment process. The care home records should be considered and referred to by the appointed Clinical Commissioning Group’s assessors when conducting their assessment of the individual’s eligibility for NHS Continuing Healthcare Funding (CHC). The same records will also be an essential reference point at any subsequent appeal, whether conducted at a Local Resolution Meeting or by NHS England.

However, care home records will often be completed by staff with a poor grasp of the English language, which might account for some misdescription (or lack of description) of key events and errors in the notes.

Other difficulties arise due to a lack of training as to the quality and level of detail required for good note keeping.

Staff may become case-hardened and used to some challenging behaviours that become the ‘norm’ for that individual, and so may not necessarily think to record them in the care records.

Most commonly, however, the problem is caused by the sheer lack of time, with too few staff having to cope with too many residents.

If a contemporaneous note does get written up, it is quite likely to contain minimal content as staff have to keep moving and there will be other residents in need of their attention. Due to daily pressures of working, it is common for notes to be written up at the end of a shift when staff are tired and anxious to get home, or else by night staff.

Care home staff are there to provide care – they are not administrative record keepers. Missing entries recording key events and episodes are common. Some events might recur frequently during the day e.g. pad changes due to incontinence, but only get recorded as one single event to save time. Other entries can be so meaningless as to be worthless. For example, ‘Dorothy ate a cheese sandwich today’; or lots of repeated daily entries saying, ‘no daily change’. The latter sounds like a tick box exercise or a ‘cut and paste’ job. It is of absolutely no help to anyone and suggests that the author of the note just couldn’t be bothered to write what actually happened, or  thought this will suffice as they’re far too busy – without realising the wider implications.

You need to know far more detail, such as their actual Waterlow score, whether they were incontinent, and if so, how often? Were they resistive to care and product changes? What is their weight so you can monitor any fluctuations? Did they experience any breathing problems etc? Where is the Care Plan? Is it being adhered to? When was it last updated? Do the entries in the care records meet or contradict the Care Plan? Ask yourself, do the daily records reflect this sort of detail, and if not, why not?

We often see records that paint a rosy picture or ’blue sky’ the resident’s needs and write entries in nice ‘fluffy’ language, apparently, so as not to distress the family by describing the real state of their relative’s condition. However, beware! Playing down needs does not assist you and will undoubtedly count against the individual at any pending CHC assessment or appeal.

We hear from families who tell us that the records they have seen are totally inaccurate e.g. referring to their father having a healthy appetite and enjoying a roast pork lunch, when in fact they have lost several kilos and are at nutritional risk, and have such an acute intolerance and aversion to pork that they haven’t eaten it since childhood! It’s as if the records are fabricated, or else the author is thinking of an entirely different person! But, unless spotted and challenged, this type of erroneous entry will be a fixture in the records and could be referred to at a CHC assessment or appeal to your relative’s detriment.

Watch out for the language being used in the records as this can be misleading and distort the gravity of the individual’s health needs. Here are some real examples we’ve encountered:

“…pleasantly confused…” – this was used to describe someone with significant cognitive impairment on account of dementia.

“…eats well and finishes her meals…” – this elderly lady would eat just a few spoonfuls of food at mealtimes and was rapidly losing weight.

“…enjoys watching his favourite TV programmes…” – this gentleman could not engage in any way with people or with his environment; the TV was simply switched on and he was placed in front of it.

“…responds well to reassurance in due course…” – this lady had continual suicidal thoughts on account of her severe paralysis and she was deeply distressed by her situation.

“…speaks clearly and can communicate her needs…” – this person’s speech was impaired and further complicated by mental confusion; assessors attributed her ‘clear speech’ to the fact that her carers were used to her. This is in no way a valid argument in an assessment.

“…inconsistency in bowel action…” – this lady had serious problems on account of her double incontinence combined with other major health problems, which together were causing immense distress. The word ‘inconsistency’ here doesn’t come close to describing the real situation.

“…uses a wheelchair for distance…” – this lady was completely immobile and the only way she could be moved from one place to another was by someone pushing her in a wheelchair.

The cynic would say that it is not generally in a care home’s interest to keep good daily records because that could assist the resident achieve CHC Funding. It is better if needs are played down in an attempt (one would assume) to render the elderly person ineligible for CHC Funding. Otherwise, it can create a cash-flow problem for the care home and leave them substantially out of pocket. For example, let’s assume a care home usually charges £1,500 per week for a standard room, but the NHS agreed CHC bed rate with the care home is only £825 – that leaves a shortfall of £675 per week. Multiply that by 50 – 100 residents in a large care facility and they could be losing between £33,750 to £67,000 a week! That is a big loss to absorb when you have high standards, lots of staff, big overheads and manicured grounds to maintain. No wonder, few care homes are rushing to encourage residents to seek CHC Funding. This scenario was portrayed in the harrowing BBC drama, ‘Care’ featured in a previous blog. You can read more about it here: BBC Drama, “Care”, Shines A Spotlight On NHS Continuing Healthcare

Inadequate records can make the CCG’s task much easier to reject or withdraw existing CHC Funding at an MDT, especially if their assessors are dismissive of the family’s representations to fill in the missing gaps or correct information in the care records.

Also, don’t forget, that the appeal panels will not have seen the resident. All they have are the oral and written submissions presented to them. The CCG’s representatives will point to the lack of entries in the care records as justification for arguing reduced or low needs when opposing CHC Funding. Faced with poor records, the family will have a much tougher job persuading the CCG that their relative’s daily needs are complex, intense and unpredictable. That can be hugely frustrating, but unfortunately, quite common. Although family representatives can give evidence that those needs exist, without independent corroborative evidence in black and white print, it can make the adjudicators’ decision far easier to decline funding. Of course, when reaching an outcome as to eligibility for CHC Funding, there is an element of skill required to read between the lines and think about what level of care would have been required to meet the individual’s needs. But, the job is so much easier if the care records are up-to-date, complete and accurate. Otherwise, if it’s not there in print, then the MDT or appeal panel might conclude that if the care records are silent, it didn’t happen.

Read our blog: PART 3 – Looking At The Four Key Indicators: Completing the Jigsaw

So, be alert! Regularly check the minor detail in the care records carefully and look for any inconsistencies and contradictions. Do the contents accurately match your knowledge of your relative’s daily needs and how they are being cared for? Are they doing the things that the records portray? Be willing to challenge meaningless or inaccurate records, or records which are simply not true, or which seem designed to diminish or underplay their healthcare needs.

Beware of the care home’s reluctance or delay in sharing the records with you. They may have something to hide or reflect the home’s inefficiency in completing them on a daily basis. There may be huge gaps for their staff to complete.

Failure to address the records and keep on top of them could end up adversely affecting not only your relative’s well-being, but also their prospects of getting (or retaining) CHC Funding.

Keep a diary

When you or a family member are visiting a relative, it’s a good idea to keep your own diary or a daily log of events as a contemporaneous aide memoire and evidence of their daily needs, should it ever be required at an assessment or appeal.

Take an elderly and vulnerable resident with poor mobility who is at high risk of falling. Too many falls go unwitnessed and/or unreported, which can be indicative of an inadequate Falls Risk assessment and a general lack of care and supervision (ie neglect). However, it is vital that the care records record each and every falling incident or near miss, as it builds up a picture of need. If an individual has numerous falls within a short space of time, they shouldn’t be ‘swept under the carpet’ as ‘just one of those things’, because it happens frequently, or more worryingly, as a cover-up. You should be notified of each and every fall, and the care records should reflect the incident and not trivialise it. Keep your own records of any new fall, bruise or injury as this evidence may be vital (and be corroborated by records following hospital admission) even if the care home records don’t tell the whole story!

Encourage other family members to write in it if you’re not there. Include things like:

  • How your relative was – think of their pain, mobility (note any falls, new bruises), nutrition (weight loss or gain), cognition, behaviour, skin issues (new sores or patches developing) breathing, communication, medication, continence (accidents) etc.
  • Records dates and times of any relevant medical or healthcare appointments, eg physiotherapy, GP or Consultant visits, and other meetings to do with your relative’s health needs, declining health or general provision of care.
  • Any relevant conversations with staff and therapists (e.g. physiotherapy, occupational therapy, speech and language therapy, nutrition, etc) – and write down what was discussed.
  • Notes on anything that doesn’t seem right to you about the care being administered or errors in the notes and records.

From a family’s point of view this type of detailed information is required to build up a picture of their relative’s overall healthcare needs. Without it, they will face an uphill struggle to convince any Multi-Disciplinary Team or appeal panel to award CHC Funding.

For more reading around the subject, look at these blogs:

“So will you be self-funding?”

Ongoing conflicts of interest in NHS Continuing Healthcare

Why is it important to check your relative’s care home records?

Focus: Falling at the care home

If you have noticed bizarre, misleading or incorrect entries in your relative’s care home records, then let us know and provide details below (remember not to name the care home)…

4 Comments

  1. Tracy O'Neill 1 month ago

    Good article. My son has been turned down three times (all still at appeal) largely because care records are poor. At
    his previous carehome the hoe actually “lost” his care records (!!) when they were advised by the council that we had
    put in a major safeguarding complaint. We had seen the daily diary ion several occasions and it was shambolic, with
    notes in red by the manager saying she couldn’t read the entries and “gaps” which evidenced the missing support.
    The ICO were not very helpful, gave the home a ticking off, didn’t publish it or fine them. The council were unhelpful and
    covered up for the carehome. At his current placement the staff have admitted they don’t record his massive anxiety
    (part of his autism and the man reason for his care) because they know he’s anxious! There are “tick box” entries down via
    an app on their phones, often saying “was content” even though the entry states he was anxious… “ate a balanced meal”
    etc and God knows what was produced for the nurse assessor last year and thew year before, I never got to see the
    records. This time they wont be allowed to use them unless I see them and agree them first. The system is rigged so that
    there are many ways the CCG can turn someone down and this must be used very often. This time I will one taking along
    my notes (A4 diary logging every iPhone call, email, visit, etc etc) to show his needs. Be very careful if you think you can
    count on the carehome to produce reasonable records.

  2. Anne 1 month ago

    An excellent article – lack of detailed and inaccurate care home records combined with a lack of understanding of what information is required for a CHC assessment from care home staff, from management down, proved to be an initial stumbling block for us. If it wasn’t recorded it simply didn’t happen from CCG perspective, and add to that the assessors cherry picking of notes that did provide evidence of a PHN. I quickly realised the home weren’t going to help so I spent hours going through care notes myself, keeping detailed notes in a diary and making my own entries on the care home forms with my own observations. Mum was found eligible at her second DST/MDT assessment and the nurse assessor, acknowledging the dreadful record keeping, offered the home (part of a large corporate) training – they refused saying they didn’t need it! Mums first ineligible assessment was overturned at IRP who again accepted we had been hampered by lack of accurate records. The problem is the care staff are simply too busy to provide the detail required and in some cases do not have the written english skills required – despite being wonderful carers. You simply have to monitor the records yourself, extracting evidence as per the domains and key indicators. This was undoubtably the most stressful part of the entire process as it can lead to direct conflict with the staff who are caring for your relative unless very carefully managed. The current lockdown on homes also adds its own challenges to documenting evidence – I wonder if the CCG’s will take that into account!!

  3. Barbara Schaefer 1 month ago

    so necessary article! I wish I ‘d known this in detail when 11 years ago I was tasked with reviewing residents in a long-term mental health facility – as the only practitioner with a social model background. I just knew the records were often not truthful but I did not have the resources to dig deeper which may have helped with a Safeguarding Enquiry where I ended up making a public interest disclosure…

  4. Michelle Wetherall 1 month ago

    Thanks CTBD another informative article that highlights the huge problem of record keeping in care homes. The article mirrors everything that I encountered during the time my late father was in a nursing home. I kept a comprehensive diary for the duration of my fathers residency and it proved to be valuable evidence, when notes could not be found or indeed incidents that had happened were never recorded. So yes it’s the best piece of advice you can give.
    I vividly remember dad having numerous falls as he tried to mobilise and whilst those that resulted in injuries were recorded, those that didn’t were simply forgotten! It’s also true that carers have little understanding of the psychological and emotional distress caused through Dementia, disease and illness and failed consistently to record episodes of extreme distress and also apathy.
    Carers consistently failed to even recognise physical illness, so what hope is there when it comes to mental health?
    I could write a book about what I saw and learnt during the process of CHC.
    Care homes are filled with unqualified, under paid, under resourced (as we have all witnessed during the pandemic) and over worked staff. Twelve hour shifts working in an environment which can often be stressful, is it any wonder that care notes are not completed in a comprehensive way. It’s exhausting!
    Until Society decides it wants change to the Social/Care home sector and how it’s to be paid for, then sadly things won’t change.
    We need a radical re think of the profession. It needs to be equal to that of the nursing profession, with equal status and pay!

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