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It’s required by law to provide documentation for the care you provide in your care service or nursing home. To provide a clear audit trail and evidence. It serves a pivotal role in all of social care. A role that will always be important.
But what if you could use your documentation proactively? And not just to evidence care or support because of lawful requirements?
This article serves as an encouragement and inspiration to think of documentation differently. It can be more than a tedious time-consuming chore. It can serve as the backbone of improvement in your service. At the end of the guide, we’ll provide our suggestions for you to get started on improving your practice.
Time is a resource in short supply in every care home. Every minute is precious. So why are we spending hours documenting every action in the back office?
There’s so much potential in gathering evidence. This data that can be used to optimise operations and improve care for the residents. Yet, it’s no use to spend extra hours doing so, if that takes away time from making a difference. Something’s got to give.
In theory, it all makes sense. You gather data and documentation, based on which you make improvements. Straight-forward, right?
Nobody wants to make mistakes. We all aim to reduce incidents and accidents in social care to an absolute minimum. But no matter how careful, errors will occur. And they occur even if you have prepared for every scenario. By having detailed observation logs it’s then again possible to identify indicators and predictors. Observations that can be used as a preventative measure. The CQC will love that.
These types of observations are typically stored as tacit knowledge in the organisation. Something that’s been learned through years of experience within a service and with particular individuals. When John behaves a certain way, he’s more likely to lash out.
How are agency staff and new hires supposed to know this?
If you have rich observations and explanations your most senior members of staff can easily transfer their knowledge to others. For the benefit and well-being of everyone involved.
You might think it’s blind luck that some care and nursing homes have very few incidents. And a high rating. Nevertheless “Chance favours the prepared mind” as Louis Pasteur once said.
Documentation is the greatest ally when it comes to quality assurance and consistency of care. If the care is thoroughly described, staff can provide a uniform way of delivering this. Particularly important when dealing with residents suffering from dementia, autism or in general complex needs. You become more reliant on fixed routines, and having a good structure in place.
If you are using documentation as the foundation of care, it’s even more important to avoid documentation errors. Everyone doing it the same way.
The best way to make this happen is by fixing how and what to document. Not surprisingly we recommend doing this in a digital care management system. Here, you can highlight and collect information in pre-defined templates. Either using market standards like those from the PRSB or implementing your own well-tested documentation. In Sekoia, we have even gathered a multitude of best practice over the years, which is free for all to use.
You could still be doing this on paper, but without the ability to easily search for things, have backups in place and streamline how care is delivered and evidenced.
As we’ve touched upon in a previous article one of the most demotivating documentation facts is when all the paperwork is not being put to use. Staff feel like they are documenting to a faceless machine. It’s simply not meaningful. Conversely, meaningful documentation can be used between colleagues, sharing information in real-time and collectively working on improving outcomes.
If we can reach this point, documentation serves a higher purpose. Not just a cover-my-back procedure. No, then the purpose of documentation is the people we support. To provide better care for them.
And it pays off. Never more clear than when browsing CQC reports.
Another benefit of a strong organisational documentation practice is the ability to look at the past, present, and future. There is no “one-size-fits-all” approach to improve your documentation practice. Every service is different in terms of history and organisation, and it is important to have this in mind.
Documentation allows you to look at the trends, set the team, and continuously improve your service.
As you document more about the service users, you’ll naturally learn more about them. Up-to-date and rich care logs will help provide more personalised care.
It can lead to a shift from providing preventive care to predictive care operations. What does that mean? And how?
If we record person-led learning throughout days, months, or even years it’s possible to identify the moment someone starts to change their behaviour for the worse. And act on it proactively to avoid the downward spiral. Something that’s often handled in Risk Assessments. The problem with this approach is that it often relies on subjective notes from staff and for them to notice the small changes. Which might be missed when pressed for time.
It needs something extra. More cohesion. More power to fully flourish.
Enter structured data.
If all documentation is gathered in a structured way, you can gather comprehensive reports and analytics from it. It can be transformed into meaningful information that will inspire and encourage compliance and impact on outcomes.
Oh, and another benefit of collecting documentation in a structured and consistent format?
Imagine receiving notice that certain residents’ quality of life is in decline. Or various health conditions are deteriorating. All based on objective data. Simply there to complement the expertise of the care professionals.
Incorporating AI into the care sector is already well underway. Albeit as tests to find the most applicable scenarios.
We’ve written about our path towards predictive care planning alongside Birley House Nursing home here.
CQC inspection reports are easily found for all care homes in England. It’s transparent to the public. Reports that are created based on the information available to the inspectors at the time of inspection. And naturally, if you have an overview of all the activities you carry out in your service, you are more likely to get an inspection report that reflects your standards of care and support.
Documentation becomes multi-faceted. Not only serving as proof of care, but also painting a more nuanced picture of your home.
Is it possible to create more observations in less time? The answer is yes if you ask Quinton House Nursing home near Stratford-Upon-Avon. They used to print a staggering amount of paper every month.
30,000 sheets to be exact.
Like many other nursing homes, they did this to make sure everything was sufficiently documented. But it’s neither cost nor time-efficient. After digitalising, they now spend less time in the back office. Less time at handovers from shift to shift. And staff no longer spend time on documentation when their shift is over.
Documentation is more than evidence. It’s an opportunity to guide peers and improve as a service by learning from previous experiences.
Over-documenting end-of-shift happens because people are unsure of what needs to be done. Hence a lot of time is wasted filling out paperwork. The old nothing missed, nothing forgotten.
Having predefined templates for daily notes, progress notes, assessments and more combats this challenge. As well as it supports the differences people have with the written word where some write a lot, and some don’t. A lot might have English as a secondary language or for other reasons find prose documentation hard. All irrelevant when everyone uses the same pre-defined terminology.
By definition, individual’s needs are ever changing. This is why we suggest linking activities, notes and assessments to their respective care and support plans. Giving every member of staff a sense of direction in their everyday work. If you’re helping someone eat, it’s a part of this person’s nutrition care plan. And so on. Everything is building evidence on respective care plans. For reporting. And for learning. Proper cohesion between what was planned and what went on.
The focus is on outcomes. Building towards better and more person-centred care. Don’t underestimate how important it is to build cathedrals, and not just lay bricks.
If it isn’t already, then make it a priority to deliver care based on individual needs. Not documentation based on administrative purposes. Unreliable or incomplete documentation doesn’t have much value either. So, it is important to provide your team with everything from a well-thought-of framework to a simple input at the point-of-care. Then your documentation will be as outstanding as your care.
By creating a best practice, it becomes easier to structure and standardise your service. If you already have a good structure in place, reviews get easier and you’re going from best practice to next practice. We’re seeing how this way of working is gathering momentum. Especially with the workforce crisis in mind. Regarding your team’s input as valuable, you’re not only building a solid care planning practice, but gaining a sound culture for delivering and documenting your care.
When members of the team are helping flag care plans that need review or updates, they are contributing directly to a strong compliance and home management.
Documentation is an important part of the job in social care. Making it easy is still a challenge for a lot of services.
By having the right processes in place your organisation can achieve great outcomes. Making it purposeful is elevating it to a next level.
Documentation isn’t the primary focus of a care service. Rather we’d see it as the best side effect of good care planning and delivery. Efficiency improvements are about reducing costs but even more so about improving the conditions for staff to provide care for the residents. Or as one of our customers, Bill Mehta, Managing Director of Quinton House Nursing Home, puts it:
“It’s not all about the cost-saving. It’s about freeing up the staff, freeing up the nurses’ working day. Freeing up the carers to spend more time with the residents and their families.”