Ombudsman issues record keeping guide for care providers

The Local Government and Social Care Ombudsman has published a record keeping guide for care providers to aid them when dealing with complaints.

According to the Ombudsman, poor record keeping is commonly a factor when it comes complaints received from people receiving independently provided care.

The new guide focuses on a number of case studies highlighting various common issues relating to record keeping and includes good practice tips to help providers avoid such problems from occurring in their own settings.

Issues covered by the guide include customers being given wrong or no medication or food because records were not updated properly, delayed treatment for another customer because of inaccurate records, and the fabrication of records following serious incidents.

The guide sets out the Ombudsman’s approach to investigating complaints and references other regulatory bodies’ guides to meeting the requirements on record keeping. Good practice tips in the guide include ensuring all relevant staff are familiar with the recording system used, and maintain 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.

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.”

The new guide can be downloaded for free from the Ombudsman’s website at www.lgo.org.uk

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