Understanding digital records systems: What the CQC expects from home care agencies moving forward.
The CQC recently released a statement of guidance (28th September 2020) that outlines how home care agencies should be using digital records - and critically, what this means for inspections.
The CQC guide “is intended to show CQC inspectors what they should look for when assessing how well these systems support high-quality care”. By taking a look now, and getting yourself familiar with what the CQC expects from digital records systems and how you can meet them with Birdie, you’ll be ready to take on your next inspection, and improve your rating.
What is a digital records system?
A digital records system is a way to keep track of your care records, care logs, care plans, MAR charts and assessments - digitally. Birdie is a digital records system, with features that allow you to record and track, in real-time, every area mentioned above (and in the CQC guidance).
Why does the CQC want home care providers to use digital records systems?
The CQC has already outlined their transitional regulatory approach - which means more time on virtual activity and less time on physical site visits.
Their new approach means that they will request more information from providers in a digital format. Crucially, this includes inspectors asking for access to digital care records when not on site.
“Where the inspector can access the digital records they need, they will not ask for paper copies. Inspectors will only ask for specific formats where it is necessary for regulatory decision making or enforcement action. They will give a clear explanation for this request.” (CQC statement).
What is the CQC looking for?
We’ve summarised the key guidance and how Birdie can help you meet it below, but you can read the CQC guidance in full here.
According to the CQC, the benefits of digital records systems are as follows:
Provide ‘real-time’ information recording about the care, and support people need and receive
Birdie features: Birdie’s Agency Hub allows you to record assessments, build care plans and build needs and goals that align with your clients' needs. When your care staff visit clients and record notes, medications and observations, you’ll be updated in real-time, and if there’s a concern, receive an immediate alert.
Help providers and carers to be more aware when people’s needs change, and respond to them more quickly
Birdie features: As care plans are no longer locked away in the office in paper files, care staff can have instant access to people’s needs, and raise concerns and alerts that help you to make more responsive decisions. With faster access to the information of the people they care for, care staff can be the eyes and ears on the ground, and be more proactive in flagging deterioration. When this happens, making changes to reflect the real-time situation of your clients can be done instantly.
Intelligent Monitoring and hardware like door sensors that allow you to get visibility over your clients’ habits also mean that concerning behaviour can be spotted earlier - even from the office.
Offer the ability to use and compare data to improve people’s care
Birdie features: The Birdie system is backed by data - and when you partner with us, we keep you on track with a weekly Q Score (Quality Score) report. It allows you to spot trends in your care delivery (like late visits or notes recorded) so you can improve your care delivery from the inside.
Intelligent Monitoring systems can also help provide the missing links, which lead to improved outcomes for your clients. One of our partners, Medacs Healthcare, explains:
“The Intelligent Monitoring solution provides our care coordinators with much better insight into the behaviour and wellness of our clients. Before having the sensors installed in selected users' homes, we could only observe our clients behaviour during a visit. Now the Intelligent Monitoring alerts warn us of any unusual behavioural patterns throughout the day, prompting us to review the wellness and care needs of our clients. The system and alerts have helped us to identify behavioural changes and prompted us to intervene, to the benefit of our clients.” Medacs Healthcare
Help information to be shared quickly, accurately and safely to support the provision of health and care services
Birdie features: When you store everything digitally, sharing information becomes more accessible. Whether you need to align with GPs, other care providers (like family members) or ensure a smooth transition for a hospital discharge, the information is there at your fingertips.
Plus, Birdie supports third-party access whilst remaining fully GDPR compliant. So if you need to share information quickly (even in an emergency), you can.
Help to minimise risks such as medication errors, dehydration or missed visits
Birdie features: Birdie was built to reduce risks. Our best in class eMAR that gives you an instant visual overview of medication administration. It’s been designed thoughtfully, alongside care managers to reinvent the standard spreadsheet MAR charts, so it’s effortless to use for both a carer and office staff.
Plus, with secure check-in and out, logs for fluid and food intake and instant alerts to keep you informed, your risks are instantly reduced, and you have a clear, concise audit trail for every aspect of your care.
“We have been using Birdie for nearly four months and have been blown away by the ease to use, reassurance it gives us being able to monitor each visit in real-time and also handling any issues quickly and effectively. Our staff love it, even the ones who claim to be technophobic!” Clover Health and Homecare
Help to support other important health and care functions, such as service management, planning and research
Birdie features: The Birdie platform has been built to support service management with a whole host of features to help you plan and manage your care delivery consistently and reliably:
- You’re able to see at any point where your care staff are, and what they've completed at any one time, which keeps things running smoothly.
- RAG ratings help you to plan for contingencies and keep you one step ahead in case of something unexpected.
- Third-Party Access is available securely, so if you need to share care notes, and keep a log of everyone that has accessed them.
Make it easier for people who use services to access their own records
Birdie features: The Birdie system allows recipients of care to access their care notes at any time online, using a specific Birdie portal on their computer. They can review reports, personal information and care visit logs whenever they need to, giving them more say in the development of their care.
Help to manage and support staff to do their job effectively and efficiently
Birdie features: We’re all about making our partners lives more straightforward. By making your business more efficient, we can help you to focus on what matters, just like Anita, the Care Manager at Enthuse Care. With less time wasted on laborious paperwork, she’s free to improve her business.
“We used to spend hours and hours checking everything. We audit now on a day-to-day basis. So basically, I can see straight away what has happened today, what has happened yesterday. That saves a huge, huge amount of time. Enthuse Care
Be easier to store, requiring less physical space
Birdie features: All you need is a computer (with internet access)! Your carers will need their own phones too, but that’s it. You can say goodbye to filing cabinets and bulky files in your office, saving you money on storage, paper and shredding too. Easy.
Support better use of resources across the health and care system.
Birdie features: We envision a world where care is fully connected - across the entire pathway. Today, one of the most frustrating issues that wastes resources is the number of times a client has to tell their story - because services are simply not joined up effectively.
Birdie is taking steps to change this. In a broader sense, within the industry, we are working on new ways to share data and align with healthcare bodies. But we’re also working on features that have an immediate impact. Our new ‘About Me’ area within the Birdie App is a building block to alleviating those issues. It allows care professionals to get to the essence of who someone is, so that multidisciplinary teams can all take note and deliver care in a way that genuinely meets needs - rather than wasting timeasking the same questions.
What does a good digital records system look like?
The CQC states that a good digital records system:
- Delivers good outcomes from the point of view of people who use services.
- Has the same outcomes - whether the records are kept digitally or on paper, although what providers need to do to deliver them might vary.
To measure if your digital records system is good, you should be able to answer the following ‘I statements’ as provided by the CQC:
“I have records that:
- Are person-centred. They describe what is important to me, including my needs, preferences and choices
- Are accessible. I can see the information that is important to me, in a way that I choose, and I can understand
- Are legible. Information about me is recorded clearly and can be easily read by the people who support me
- Are accurate. Information about me is correct and does not contain errors
- Are complete. There is no relevant or essential information about me that is missing
- Are up to date. They contain the latest relevant and essential information about me
- Are always available to the people who need to see them when they need them
- Are secure. My privacy and confidentiality are protected. Only the people who should see my records can see them (records are kept in line with Data Protection legislation, including General Data Protection Regulation (GDPR) requirements)
- Help the service that supports me to have good quality assurance systems and processes. They help the provider to assess, monitor and minimise the risks to my health, safety and wellbeing. They help the service that supports me to keep improving.”
Person-centred care is at the core of the Birdie platform, and we’re confident that when used correctly, Birdie answers every ‘I” statement above, for all of the reasons we outlined earlier.
The CQC also states that digital records systems must be safe and comply with the following regulations:
- Regulation 17 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
- Data protection legislation (including GDPR) requirements
- Accessible Information Standard
- Data Security and Protection Toolkit (where providers have access to NHS patient data and systems).
Are there any risks associated with digital records systems?
When you switch from paper to digital record systems, you’ll be actively taking steps to make your care safer. For the reasons the CQC outlines, a digital records system helps you provide better, safer care - but they also recognise that:
“Implementation of new technology will have associated risks. The CQC is willing to accept that risk exists, so long as these are being managed, and safeguards and processes are in place to ensure people continue to receive safe, high-quality care.”
This means that you can be safe in the knowledge that going digital won’t lead to any penalisation if you’re managing your risks accordingly.
At Birdie, our 24/7 support team are dedicated to helping you mitigate any risks associated with going digital, and they’re on hand to support you every step of the way.
"The Birdie team have always been so lovely and clear in their explanations and always been in touch and positive. Birdie has always been there if I have any questions or need support, and extremely understanding - I'm very happy and can't wait to be on board!" Martlets Care
Ready to meet CQC requirements and improve your rating with Birdie?