CQC evidence, and where it actually lives
What an inspector asks for, and which screen it comes off. Written by a registered manager who has sat on the other side of the table.
Software does not make a home compliant, and anyone who tells you otherwise is selling. Good care makes a home compliant. What software can do is make the evidence retrievable, so a good home is not marked down because the paperwork could not be found on the day.
What gets asked for, and where it is
| What an inspector asks for | Where it comes from |
|---|---|
| Medication administration records | The eMAR, per resident and per round, with who recorded each one. More on the eMAR |
| Evidence that missed doses were noticed | The alert log, showing what raised each alert and when, including the scheduled checks |
| Care plans and their reviews | Per resident, with the review dates and who signed them off |
| Incidents and accidents | The incident record, each one with its own reference, body map and follow up |
| Observations and escalation | Observations with the times taken, and the escalation window that applied |
| Residents’ money | An add only ledger. Entries can be written and read, and that is all |
| Staffing on a given date | The rota and the clock in record for that shift. More on the rota |
| Training and supervision records | Per staff member, with what is due and what has lapsed |
| Handover between shifts | Built from the shift that actually happened, with what is not yet recorded listed as outstanding |
The part most software gets wrong
An inspector is not only asking whether something was done. They are asking whether you would know if it had not been. A system that prints a green tick whether or not the check succeeded answers the first question and fails the second one.
- Nothing is reported as complete because a lookup failed. If a figure cannot be worked out, the screen says can’t check.
- Every record carries who wrote it and when, including the ones the system generated itself.
- Care history is hidden, never deleted, so a record that existed on the day still exists at inspection.
- A save the database refused is kept and raised, not dropped.