How many times is too many times? Duplication in care home data documentation


Chloe Bennett, Research Assistant Ageing and Multi-morbidity Applied Research Collaboration (ARC), University of Hertfordshire


Care home staff time is precious, with staff facing competing priorities to ensure that residents receive the best care possible. A key responsibility of staff that can be overlooked when thinking about care homes is recording data about the residents and the home they live in. This data is used to monitor the health and wellbeing of residents and is crucial to ensuring their needs are met. It is not solely the care home itself that requires this data, bodies such as the NHS and local authorities require data about residents to make decisions about resident care, the CQC collects data to monitor quality in care homes and researchers access data to improve knowledge into care homes and their residents. At present, there is no standardised approach to documentation in care homes, with each home adopting their own method of record keeping.

Sometimes these methods can lead to staff recording the same data in multiple places, something that I found in recent conversations with care home staff for an interview study that I am undertaking. Discussing their experiences of using videoconferencing to communicate with health and social care staff, many people reported using both paper and electronic notes to record the same resident data. For example, in an appointment with a GP they would record notes from the appointment on paper and then transfer these to a computer for their own electronic records or to share with other professionals. It is likely the GP would also record their own notes from the appointment. In this example, the same resident data has been recorded three times, in three different locations and this is not unique to appointments with GP’s or caused by virtual methods of communication. The people I spoke to recalled that this practice is similar to how face to face appointments and those with other professionals are documented.

In some instances, care homes must also record the same data in multiple different formats depending on the external professional requiring the data. For example, a physiotherapist might use a different measure to a GP, therefore requiring staff in the care home to record the same data in different formats. In addition to this, researchers will record yet more data that is specific to their research project that the care home will likely already have stored elsewhere.

It is clear that multiple professionals utilise the same data for a multitude of reasons and each are obtaining and recording it in different ways. This represents a huge duplication of effort and loss of time for staff both within and outside of the care home. A standardised approach to documenting resident and care home data that can be accessed by key professionals would save the time of care homes, the NHS, reporting bodies, commissioners, and researchers, by reducing the need for the same information to be documented by multiple people. The minimum data set (MDS) prototype being developed in the DACHA study aims to deliver this standardised approach to collecting data in a care home that can be used across the UK, thus saving the time of staff in care homes, as well as their colleagues across a variety of external organisations.


Funding Acknowledgement and Disclaimer

This study/project is funded by the National Institute for Health Research (NIHR) Health Service Research and Delivery programme (HS&DR NIHR127234) and supported by the NIHR Applied Research Collaboration (ARC) East of England.

The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.