We often find that care home notes and records inadequately or insufficiently record daily entries in relation to an individual’s care needs.  This could be for a variety of reasons, including poor training, lack of time and resources, or simply too few carers or nurses looking after too many patients.

Deficiencies in the care records and poor record keeping can present a significant problem for families undergoing a Retrospective Review for NHS Continuing Healthcare Funding (CHC).

Family members are usually best placed to understand their relative’s daily healthcare needs and know the level of care required to look after them.  They will have a better idea of the nature, intensity, complexity and unpredictability of their relative’s particular needs – but sadly, too often those needs are not adequately reflected in the care records.

An instance arose recently when attending a Local Resolution Panel Meeting on behalf of a Claimant’s family seeking CHC. It was clear that the individual had suffered twenty falls within the space of one year, requiring a number of hospital admissions – an average of one fall every 2.5 weeks or so. Whilst thankfully, the individual was not seriously injured, the number of falls is clearly indicative of a high’ score under the ‘Mobility’ Care Domain. 

Any one of these numerous falls could have resulted in serious injury, and given the frequency of falling – the risk of falling was undoubtedly ‘high’.

The issue:
Although there were numerous entries in the care records as to the incidence of falling, the care home had not provided any ‘falls risk assessments’. 

The mere fact that the individual kept falling, should have alerted the care home to undertake a regular falls risk assessment, and had they done so, it would undoubtedly have improved the individual’s scoring in this particular Care Domain.

However, the descriptor for ‘high’ needs under the ‘Mobility’ Care Domain within the Decision Support Tool states that ‘high’ needs include:

Completely unable to weight bear and is unable to assist or co-operate with transfers and/or re-positioning. 
Due to physical harm or loss of muscle tone or pain on movement needs, careful positioning and is unable to co-operate.
At a high risk of falls (as evidenced in a falls history and risk assessment).
Involuntary spasms or contractions placing of an individual or others at risk”.

The CCG’s representative argued their ‘party line’ that – because there were no formal falls risk assessments documented on file (or equipment such as a falls sensor being used as evidence of risk of falling), then there was not sufficient evidence to meet the above criteria of a ‘high’ risk here.  Regrettably, the Local Resolution Panel Meeting adopted this approach, sticking to the ‘letter’ of the descriptor within the DST, and despite the significant number of falls, downgraded the score for this particular Domain.

Our view:
It should not be the individual’s fault if the care home failed in its duty to carry out any falls risk assessment. Neither should the lack of recorded risk assessments be held against the claimant, particularly when there is clearly a documented history of falls; nor would a falls sensor have stopped the individual from falling so often!

More critically, surely the evidence of repeated falls speaks for itself! Regardless of whether or not there was an actual falls risk assessment in the care records, you cannot simply just ignore the number and frequency of falls, the risk of falling, and potential risk of injury. Common sense should have indicated to the Local Resolution Panel members that a falls risk assessment, even if documented in the care records, would not have made any difference. The matter is being considered for appeal.

Poor record keeping and missing records, can be costly. We know from experience that care records are generally incomplete, have lots of missing entries or contain insufficient details, and can therefore often present a misleading or inaccurate picture of daily needs. Whilst the CCG and Local Resolution Panel could have adopted a more reasonable approach here – especially when faced with evidence of so many falls – it does highlight the acute need for families to go through and regularly review their relative’s care home records.

We recommend that you:

  • Check what is being recorded in your relative’s care records
  • Check whether the entries accurately reflect and describe your relative’s daily needs. Saying that “Joan had a good day today…” is meaningless!
  • Check all relevant risk assessments are on file and up to date (eg health needs assessment, Needs Assessment under the Care Act 2014), Nursing assessment, behavioural assessment, falls risk assessment, physiotherapy assessments, psychiatric assessments, specialist medical/nursing assessments, Waterlow scores, Speech and Language Therapy assessments (SALT).