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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