Case Study 1: Care Planning & Daily Record Alignment

Learn how Perform 2 Excel helps care providers bridge the gap between static care plans and daily practice. This case study explores our targeted auditing approach that ensures records are accurate, contemporaneous, and provide robust evidence for CQC inspections.

The Context: Beyond "Tick-Box" Documentation

Many care services struggle not because they lack care plans or risk assessments, but because those records do not consistently reflect the care actually delivered on the floor. Common challenges include:

• Care plans that are not updated when a resident’s needs change.

• Risk assessments that exist in a folder but are not reflected in daily notes.

• Daily records that lack reference to known risks or specific support strategies.

• Managers relying on audits that fail to test if different records actually align.

This disconnect creates real risks for residents and leaves services exposed during regulatory inspections

Our Focus: Creating "Live" Documentation

Rather than simply adding more paperwork, Perform 2 Excel focuses on strengthening the vital link between care planning, risk assessment, and daily records. Our goal is to ensure:

• Care plans remain "live," meaningful documents.

• Risk assessments actively inform day-to-day care.

• Daily records provide clear evidence that care plans are being followed.

The Perform 2 Excel Approach

We introduced a targeted auditing and oversight approach focused on continuity and follow-through.

1. Integrated Reviews: We review care plans and risk assessments together to ensure risks are clearly described, proportionate, and current.

2. Alignment Audits: We move beyond "tick-boxes" to check if daily records actually document changes in a resident’s presentation or the escalation of concerns.

3. Managerial Support: We help managers schedule manageable audits and use findings to trigger timely reviews and staff feedback.

Impact on Practice & Compliance

This approach transforms how a service views its documentation, moving from administrative burden to quality assurance. Key outcomes include:

• Improved Accuracy: Clearer links between assessment, planning, and delivery.

• Early Intervention: Better identification of changing risks and needs.

• Staff Confidence: Care teams report a better understanding of "why" recording matters, not just "how" to do it.

• Inspection Readiness: Increased confidence when discussing care planning and records with the CQC.

Evidence for CQC & Regulation 17

This work provides defensible evidence across the CQC Single Assessment Framework by demonstrating that documentation is a true reflection of the person-centred care being delivered:

• Safe: Proving risks are assessed, monitored, and responded to through contemporaneous records.

• Effective: Evidencing that care and support are based on up-to-date assessments and that staff have the correct information to achieve good outcomes for residents.

• Caring: Showing that staff truly know the people they support by recording meaningful, dignified, and person-centred interactions rather than generic "tick-box" phrases.

• Responsive: Evidencing that care is adapted in real-time as needs change, with clear links between identified needs and delivered support.

• Well-led: Demonstrating effective oversight, robust auditing, and a commitment to embedded improvement.

• Regulation 17: Meeting the legal requirement for maintaining accurate, complete, and contemporaneous records regarding every service user.

The Focus: Ensuring care plans remain "live" and daily records evidence how plans are followed.

The Impact: Improved accuracy, earlier identification of risk, and increased inspection confidence.