The Care Quality Commission (CQC) has released new guidance on what ‘good’ looks like for digital care records. The guidance, released in September 2020, outlines the best practice characteristics of an electronic care record, as well as what care providers need to do to achieve this.
Alongside the announcement from the industry regulator that it intends to make greater use of digital information in its regulatory approach, this new guidance is an important facet of making digital records in care the norm. Here is a short overview of what the new guidance says.
What are the benefits of digital care records?
Digital transformation is not a new theme in the care sector. Records and processes have been steadily digitising, only accelerated by the events of 2020. When implemented correctly (as the CQC is keen to stress), digital care records can realise some of the following benefits for care providers:
- Real-time information about care delivery
- Greater awareness of when people’s needs change so that they can be responded to more quickly
- The ability to use data to improve people’s care
- Fast sharing of information to other health and care services
- Minimise risks such as medication errors, dehydration or missed visits
- Make it easier for people to access their own records
- Help to support staff to do their job effectively and efficiently
- Easier storage, requiring less physical space
- Support service management, planning and research
- Make better use of resources across the health and care system
What are the characteristics of good digital care records?
A good digital care records system has four key features, according to the CQC. It should:
- Focus on outcomes – for the people that are cared for, as well as in terms of meeting a care provider’s business objectives
- Involve the right people – staff and service users understand the system and how it is used, whilst software suppliers stay involved to make continuous improvements
- Be well managed – new systems are carefully planned, with clear processes for accessing, storing, sharing and backing-up information
- Meet relevant standards and regulations – the new digital care records must comply with data protection, data security, consent, privacy and equality legislation
Above all, for the benefit of someone receiving care, electronic care records should have the typical characteristics of a care record in general – that is person-centred, accessible, legible, accurate, complete, up-to-date, available and secure.
What happens during a CQC inspection?
CQC inspectors can ask to see digital care records in the same way that they would ask to see paper records. This will usually happen in one of two ways:
Guest log-in – CQC inspectors are granted temporary permission to log-in to a digital care records system, usually with restricted access (i.e. they can view, but not change or delete information)
Supervised access – a senior member of staff logs into the system, allowing the inspector to view the records they need whilst the staff member is present (this could be physically or virtually via a secure screenshare)
An inspector should never be able to use someone else’s log-in details unsupervised.
Making the most of digital care records
You can be assured that our care management software already meets the CQC’s new guidance on digital care records. From having contingency plans in place to meeting data security and data protection regulations, to continuously improving and updating our software in a way that focuses on outcomes both for the care you provide and for your business, we are a partner you can trust.
Want to know more about technology and the CQC? Read our guide here.