Record Keeping - Writing Defensible Daily Notes Evidencing for CQC

Record Keeping - Writing Defensible Daily Notes Evidencing for CQC - Safe Recording and Evidence

Presentation, Handouts x 2, End of Session Knowledge Check Questions x 3 (Care Staff, Seniors/Supervisors/Nurses), Trainer Aide Answer Key x 3 (Care Staff, Seniors/Supervisors/Nurses).

All files editable.

Overall Training Aim:

To ensure staff who record care are able to produce clear, accurate, objective and outcome-focused daily records that reflect the care provided, support continuity of care and stand up to scrutiny by regulators, managers and external bodies, including the Care Quality Commission (CQC)​

This training supports staff at all levels to produce defensible, outcome-focused daily records that evidence safe, effective and person-centred care in line with CQC expectations.

Learning Objectives: - All Staff Who Write Daily Notes​

Explain the purpose of daily records and how they support safe, person-centred care and regulatory compliance.​

Describe what makes a daily note defensible, including accuracy, objectivity,
clarity and relevance.​

Record care in an outcome-focused way, demonstrating what difference the
support made to the individual rather than listing tasks completed.​

Use appropriate professional language, avoiding vague, judgemental or subjective terminology that could create risk.​

Accurately document changes, concerns, refusals of care and actions taken,
including when and how issues were escalated.​

Identify common recording errors and explain why certain phrases or omissions may be unsafe or misleading.​

Who This Training Is For​

Core audience ​

Care Assistants / Support Workers, Senior Care Workers /
Team Leaders, Nurses (if applicable)​

👉 Anyone who writes daily records​

Secondary audience ​

Registered Managers, Deputy Managers​

Quality / Compliance Leads​

👉 For oversight, auditing and assurance​

​Presentation (64 Slides)

Overall Training Aim​
Learning Objectives
Who This Training Is For​
SECTION - Why This Matters – All Staff​
Why CQC Cares About Records​
How Poor Notes Create Risk​
“If It’s Not Written Down, It Didn’t Happen”​
What “Defensible” Means in Practice​
SECTION - What CQC Expects from Daily Notes
The Purpose of Daily Records​
Linking Notes to Care Plans & Risk Assessments​
Objective vs Subjective Recording​
Timeliness, Accuracy and Completeness​
Professional Tone and Accountability​
What CQC Flag Immediately​
SECTION - What to Write (Care Staff Core Skills)
Example: A Routine Day​
Example: A Distressed Individual​
Example: Daily Notes A Distressed Individual​ - Scenario
Why This Stands Up To CQC Scrutiny​
Example: Refusal of Care​
Example: Daily Notes Refusals of Care​ - Scenario
Why This Stands Up To CQC Scrutiny​
Example: Potential Complaint Risk​
Example: Daily Notes Potential Complaint Risk​​ - Scenario
Why This Stands Up to CQC Scrutiny​
Example: Safeguarding Threshold​
Example: Daily Notes Safeguarding Threshold​ - Scenario
Why This Stands Up To CQC Scrutiny​
Recording Outcomes, Not Tasks​
Red Flags That Must Be Escalated​
Summary - How CQC Reads Daily Notes​
SECTION - What NOT to Write (Care Staff Core Skills)
Why "Harmless" Phrases are Risky​
Vague Language​
Judgmental Language​
Blame Shifting​
Contradictions and Assumptions​
Abbreviations and Slang​
Real World Poor Examples – Rewritten Safely​
SECTION - Role Specific Responsibilities
Care Staff: Personal Accountability​
Care Staff: When To Escalate Concerns​
Senior Staff: Checking Quality Before Sign-Off​
Senior Staff: Supporting Staff Who Struggle With Writing​
Nurses: Clinical vs Social Care Recording​
SECTION - Summary and Key Messages
Purpose and Defensible Recording – Key Messages​
Outcome Focused Recording – Key Messages​
Professional Language and Risk Avoidance – Key Messages​
Changes, Concerns and Escalation – Key Messages​
Common Recording Errors – Key Messages​
Role Specific – Key Points​
Final Take Home Message​
References and Further Information​

Word Documents

CQC Safe Daily Notes Key Messages
Writing Defensible Daily Notes
End of Session Knowledge Check Care Staff
Trainer Aide Answer Key Care Staff
End of Session Knowledge Check Seniors Supervisors
Trainer Aide Answer Key Seniors Supervisors
End of Session Knowledge Check Nurses
Trainer Aide Answer Key Nurses

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