Social care recording
Published August 2021
This resource aims to support social care staff, including service managers, frontline care workers in care homes and home care, personal assistants, and other care providers, to improve recording skills – how you write down what you have seen and done, your analysis of that, and what you plan to do as a result.
It is based on the concept of PARTNERSHIP – that recording should be done, as much as possible, in conjunction with the person you are supporting.
The resource sets out 11 top tips to consider when recording, whether that be daily case notes, or more formal reports or assessments.
Are you a social worker? We have a separate guide about social work recording.
The importance of recording
Recording is an integral and important part of social care. It is not simply an administrative burden to go through as quickly as possible, but is central to good, person-centred support. Recording is vital:
- It supports good care and support
- It is a legal requirement and part of staff’s professional duty
- It promotes continuity of care and communication with other agencies
- It is a tool to help identify themes and challenges in a person’s life
- It is key to accountability – to people who use services, to managers, to inspections and audits
- It is evidence – for court, complaints and investigations
It will enhance your practice and the support you can offer people if you can make good recording a central part of your work.
Perspectives of the importance of social care recording
These three short films illustrate the actual harm that can occur if recording is done poorly. They show that recording is part of making sure people’s wellbeing is promoted, not just an add-on to your work.
The perspective of the person who uses services
Video transcript Open
You would think that as I have supported hundreds of individuals and their families through various health and social care assessments, as part of my work as an equalities consultant and advocate, that I wouldn't be troubled by my own review.
But just like many other disabled people, and people with long-term health conditions, the words assessment and review often fill me with dread and fear.
So, you can imagine, when my annual letter dropped through the post, telling me that my direct payments package was due for review, I had to take a little time to compose myself, before I was ready to deal with the situation.
After the initial panic, I began to follow the system that I have developed over the past 20 years to support people with very complex needs.
I knew that the key thing was to plan and prepare, as this allows individuals to identify what is important to them in their lives, and what support they need to achieve those aims and goals. It also provides valuable evidence that the assessor can take with them, to assist them with completion of the necessary paperwork.
So, my support staff and I set about gathering together the information we already had, and looking at what needed to be realtered, to reflect my circumstances at the time. We then drew up a full detailed care and support plan along with my family that included all aspects of wellbeing, and was based on not only issues of mobility, personal care and the daily impact of my many impairments, but also considered the importance of my relationships, my work, and even my love of floristry, cookery, music and my cat.
We then went on to prepare a breakdown of when support was provided by my husband as my carer and thus free of charge, by my access to work funds, as I work full time, and by my direct payment funding which had been set at 52 hours per week.
This gave us a detailed rota which highlighted who covered when as well as a breakdown of the various budget streams which were allocated to those times. We took time to review this information, and ensure that it was accurate and up to date.
So when the day came, armed with the paperwork, I felt confident that it would all work out. Especially as all my previous assessors had referred to my care and support plan which helped to smooth out the review process.
But the assessor reviewing my case on this particular circumstance, was not interested in any of my paperwork. She just seemed in a rush to get away. She definitely didn't want to take detailed notes and she was obviously really confused about how my support was divided between direct payment from my local authority and access to work. Indeed one of my support workers was so concerned that he asked her if she would like to take our notes, the support plan, and the rota, as she didn't appear to be really listening and was in such a rush to get out again, that she didn't even have a few minutes to wait for him to go upstairs to photocopy them. In fact, she thanked us for the offer, and said she had taken the information that she needed.
Anyway, a few weeks later came the decision letter. As the letter was being read out to me, my support worker and I were in disbelief. I had lost my entire package from direct payments.
So what could I do?
Well, I was left in the position that I had to have the 52 hours support, so I have to find a way of paying for it too. And this was an immediate priority. Especially as funds from direct payments would no longer be available to me, and wages were due in a week.
Fortunately I was able to negotiate a £5,000 overdraft with my bank until I could sort the mess out. But I was very concerned about the financial burden that was being placed on us all and just hoped that the case could be resolved within eight weeks as my overdraft would be exhausted by this time, paying two sets of wages.
I then started the laborious task of asking for a full review of my case. I insisted that someone else, apart from the previous assessor, looked at my case again. I also enclosed all evidence that the worker had not taken and a brief letter of explanation as to the reasons for my complaint.
Thankfully our hard work getting the information together paid off. Within 6 weeks they had reinstated my full package of 52 hours of direct payments based on the information the initial assessor would not take.
However, I had still been left for over six weeks with no funding for my support and although there was an apology for any inconvenience this had caused, back pay and fees were not included in the amount paid into my account.
Again I had to make another complaint and finally back pay was reimbursed.
But I never did receive the interest charge or the fee payable for the overdraft.
Although this was unfair and disappointing, this was actually not the main reason for my complaint.
The reality is that the way in which I have been dismissed left me feeling totally disempowered and in fact disregarded. You see, it had taken many days to organise and gather information that reflected my life and the very many difficulties I experience on a daily basis. I shared very personal information about every aspect of my life and how this was reflected in my support needs. Yet it feels like this particular social worker or assessor couldn't be bothered to get an accurate picture of my circumstances. Least of all to reflect those circumstances accurately in their notes.
This was not only very disrespectful to me and the value I place on being able to live independently, and contribute to society, but also entirely dismissed the detrimental impact that her lack of appropriate notes about my circumstances had upon me, my family and indeed my support staff.
I wonder if things would've been different if she had known this.
Key learning points
- Make use of the information people who use services and thier families provide for you
- Make sure you record things that really matter to people
- In a care plan, capture all the different strands of care and funding streams that people make use of, as per your duties under the Care Act
- Take the time to listen, and to take accurate notes
- Getting recording wrong can have a harmful impact on people
- It is disrespectful to dismiss what people tell you
The perspective of the carer
Video transcript Open
My name's Sandra, and I'm the carer for my mum, who has got bipolar and early onset Alzheimer's and lives in a care home. I care for my mum, and over the last few years the importance of recording has really been quite key.
I think there are three different levels to recording, at a very kind of low-level note taking approach, also an aspect that impacts in relation to safeguarding, and another level which is around kind of looking at a pattern, and looking at sort of changes in behaviour that you can actually record and understand why that's happening.
The first instance is around where - my mum was in need of some antibiotics, and it was on a Friday, they were trying to get them, they weren't able to get them till the Monday, and I went on the Monday, they still hadn't really managed to get them on the Tuesday I went in again and asked about this, and was told "Oh, we forgot". And that was a very simple and a very basic need that because it hasn't been recorded and other staff didn't know, it impacted on my mum quite considerably.
So there's those kind of things - at that very superficial level if you like, very basic level.
I think more importantly about recording, is where you make assumptions that what care homes are doing, what other professionals are doing, are recording and detailing things that are happening in the home.
And there's been an incident where my mum er - had had a man in a state of undress in her bedroom, there had been another incident where she'd had another gentlemen again in a state of undress in her room, and for me that was about the recording of - for that gentleman - what was happening with them, why was that happening, and their own kind of care, but also the impact on my mum.
And what I'd noticed was a change in her behaviour, and a change in her mood, a change in how she was presenting. And it was only through casual conversation that she told me that this had gone on. And when I checked with staff and asked - we looked back to see - there'd been no record of the incidences happening at all. Neither on my mum or on the gentleman's file.
And that was really important, for me, I had made some assumptions that this, these were the kind of things that would be recorded so they could understand maybe why my mum was feeling very low, feeling very depressed, and so it was a bit of an eye opener.
I think that other bit around the continuity of recording is key really, because you then get to see what's - what's the impact of things that have happened and the way in which staff are maybe treating her and there have been other incidences where she had concerns about and had commented on the way in which some of the members of staff had been treating her or spoken to her. And when again I queried those things, those hadn't been recorded.
So her views also actually hadn't been noted or any reference taken to that.
So I think it is really really important that both from the home's perspective the staff working within the home, carers and the resident's perspective, that if you don't record within a home incidences, that we make assumptions about that you do record, that then, how do you then start to track or understand the impact of that for the residents in the home.
Key learning points
Recording fulfils various functions:
- Recording significant events like safeguarding incidents
- Keeping track of key daily tasks such as ordering medication
- Monitoring patterns of behaviour over time
It is vital that each of these are carried out properly, for people to receive per-son-centred, good quality care, and for carers to have confidence in the sup-port being given to their loved ones.
The perspective of the professional
Video transcript Open
My name is Elaine Cass and I work for the Social Care Institute for Excellence. I worked as a social worker some years ago in London and in the learning disabilities team and I worked with a woman who had a very mild learning disability and a personality disorder.
She lived a very chaotic lifestyle and she often put herself in very high-risk situations. She was placed in a women's refuge for adults with learning disabilities and she was much more able than the other people who were in the refuge and she took advantage of that and she procured some of the more vulnerable women to have sex with men with whom she had links outside the organisation.
When we realised this was happening she was removed from the unit and she went to live elsewhere but I made it clear in her file that she should never again be placed with other vulnerable women because she presented such a high risk to those other people.
Hello my name is Hugh Constant and I, like Elaine, work at the Social Care Institute for Excellence. Elaine and I also worked together in the learning disability team in North London and so I was aware of the difficulties that she was having with the woman in the refuge you know procuring other women there for sex with men that she knew.
I subsequently went to work in a different learning disability team where one of the people I manage came to me one day to describe - to talk about a situation in which one of her clients had been procured for sexual abuse while staying in a women's refuge in East London.
She mentioned the name of one of the people in the refuge who had procured her client to go to these men for sex and I immediately recognised the name as the person that Elaine had been working with some years before.
I also knew full well that Elaine had very clearly recorded that this woman should never again be placed in that refuge or indeed anywhere where there were other vulnerable women and so I got on the phone to my previous employer the original local authority to say, to ask how come this person was back at the refuge when it was very clearly recorded on the file that that should never happen and the social worker who now had the case, who had taken over the case from Elaine acknowledged that, actually that - that had not - that she hadn't read that on the file and hadn't therefore been aware that she ought not to place the person back at the refuge.
And it just was a very clear illustration for me of the importance of reading the record because you know the failure to do so meant that you know, actual, you know, catastrophic harm was done to another vulnerable person because the record hadn't been read.
Key learning points
- It is vital to read a person’s file.
- It is therefore that organisations have systems in place to make the file easily accessible to future workers.
It is vital to get social care recording right. We usually know what to do but this is often difficult, given the many pressures on your time and other challenges of your job.
This resource shows 11 top tips for good social care recording and uses the acronym PARTNERSHIP as a checklist, and to emphasise that the record should be co-produced between you and the person to whom it relates.
Any social care record is written for multiple readers – your manager, your colleagues, other health and social care professionals – but the most important possible reader is the person who uses services themselves and their families, and you need to bear in mind the importance of the record for the person you are supporting.
Try to make your recording as person-centred as any other part of your practice. You may have recorded on hundreds of case files, and on every one, you will have been pushed for time. But each file is likely to be that person’s one and only social care record, and as such it has the potential to shape the services that person receives, and by extension the life they lead.
Alex asked if his home visits could be scheduled around his work, so that he didn’t need to take time off. This was recorded as ‘Alex needs structured home visits’, which was interpreted by a subsequent worker as ‘Alex needs structure’. Mention was then made of Alex’s need for structure and routine. Before long, someone’s request that a service be based around their work life was being recorded as an indication of possible autism.
It is helpful to take time to check the record you are creating with the person it is about. Sharing case records with a person can help correct misunderstandings and misrepresentations, but also helps focus professionals’ minds on recording respectfully and sensitively.
Whatever it is you are expressing – fact or opinion – state accurately what is happening, or what you believe, and avoid vagueness wherever you can. Saying ‘the front room was in a terrible state’ may be quicker than saying ‘the front room contained 14 bags of rubbish, and I saw 20 empty fast food packages. I also saw what looked like mice droppings in one corner of the room’. Recording in accurate terms like this avoids any possible value judgements and is more helpful to a colleague who might visit and see a room that is still in a ‘terrible state’, but where there are only six bags of rubbish and 10 takeaway packages, and who therefore can note a significant improvement. Importantly, this would help the person themselves, whose efforts to get on top of things would be recognised, rather than overlooked.
The fact that lots of people, including the person about whom the record is kept, may read a social care record, is one of the challenges of recording. This can lead to vague wording, particularly when aspects of a person’s behaviour may be causing them or other people difficulties. So phrases appear such as ‘inappropriate sexual behaviour’, which could cover a huge range of things from serious assaults to ill-advised comments. Such comments may still be distressing, but may prompt a different set of responses to criminal assaults.
There is a middle ground between the delicate but uninformative ‘she has issues with personal hygiene’ and the disrespectful ‘she smells revolting’. A more explicit record of ‘due to her advancing dementia, Roweena often forgets to have a bath, resulting in an increasingly unpleasant personal odour that I think is having a negative effect on her relationship with her neighbours’ may take longer to record, but identifies precisely what the issue is, enabling a more honest discussion with the person.
Clearly, everything that goes to make up a good social care record – person-centredness, accuracy, detail, reflection, and analysis – is easier to achieve if a record is made promptly, when things are fresh in the memory. And while leaving writing up your notes for another time is always tempting given the pressures on social care staff, leaving a record incomplete can hamper your colleagues if they are working with the same person, and can cause problems for the person themselves.
Sometimes it happens, of course – if so, it is good practice to note that the recording was not done at the time. Whatever the temptation to disguise late recording, it is more transparent to acknowledge when it has been necessary.
No jargon - plain EnglishOpen
‘Because my allocated case Kim, despite her ASD, is an activated client, I decided to take an asset-based approach to her affective disorders’ takes just a handful of the ‘A’s in the Think Local Act Personal Jargon Buster to illustrate quite how much jargon there is in social workcare, and how quickly it can make what we write incomprehensible. And it becomes incomprehensible not just to the person we are supporting (who is, after all, the most important audience) but also our colleagues and managers. There is so much jargon that not even fellow professionals will know all of it.
‘I am working with Kim, who has autism and a really good sense of what support she needs. So I am working with her to identify what her strengths are, as a way of helping her with some of her mental health problems’ would be a clearer way of making the point.
We are not suggesting here that every observation you make has to be backed up by an article in a peer-reviewed journal, but you must make sure that you can back up substantiate what you’re saying in a case record. So, if you are stating a fact, be sure that it’s an accurate one. If it is an opinion, make sure you can back it up with evidence from what you’ve seen or heard.
Opinions are OK in social work care records: you are, after all, employed to exercise your professional judgement sometimes. But that’s the key. It has to be a professional judgement, based on something – your professional experience of similar situations, your knowledge of the individual circumstances , some research evidence – and not just a hunch or an assumption. As well as clearly stating that your opinion is solely an opinion, and not a fact, you need to state what you are basing that opinion on. There should be a clear chain of reasoning from what you have observed, through the analysis of what you have observed, to the conclusion you have reached as a result. An example is here.
‘I believe that Sam is at risk from her relationship with the two men who come to visit her in the scheme. Sam has told me that she is happy to see them, but I have learnt from her that while a month ago she saw them once or twice a week, she is now seeing them daily, for hours at a time. I believe the risk comes from the effect this seems to be having on the rest of her life – I know she has missed college three times in the last week – and the behaviours of the men seem to fit into a pattern of grooming. I say this because they appear to be discouraging her other activities and contact with other people, and Sam has told me they have been buying her gifts, drinks and takeaways. I have therefore discussed a possible safeguarding referral with Sam, but she has not given consent. I am therefore holding off, but monitoring the situation.’
The case note acknowledges the professional’s concerns, but recognises that they are unproven opinion at this stage, and records the different perspective of the person who uses the service. The professional has set out their reasons for their thinking so that colleagues and others can take their professional judgement into account.
A note here about differences of opinion: as we see in the example, the professional and the person they are supporting have differing views about the situation. This will almost inevitably occur in any ongoing relationship between a social care organisation and its client. It need not be problematic in terms of recording – your responsibility is to set out your view clearly, and to do the same, explicitly and without bias, for the view of the person. Such differences may also occur of course between you and the carer, fellow professionals, or anyone involved in supporting a person.
Reading the previous record Open
It is vital that you know what is in the social care records of the person you are supporting. This can be difficult, because of time pressures and/or filing systems, but it is important to understand the histories, care plan, routines and issues of the people you work with. Updated case summaries, where key facts, events and people are collated in one place that is easily accessible can be really important.
However, it’s helpful not to be hidebound by what has been written before: it may contain inaccuracies; things may have changed; and you need to form your own judgements. But nonetheless you must read what is on the record. Not doing so may mean that you miss potentially crucial information, about a person’s history, and about how best to support them.
A person with learning disabilities was placed by social workers in a woman's refuge, where she was exploited by one of the other tenants. It was soon learnt that there was a note on the file of the exploitative woman that she should never again live in that refuge, because of a history of exploiting the other vulnerable women there. Because that note was not read, a pattern of abuse was allowed to continue. As an organisation, the local authority ought to have devised a system to flag up vital pieces of information, but the social worker has a professional responsibility to read the file properly.
Much of what we’re saying here focuses on the need to be detailed and accurate in your recording, and to back up what you’re writing with evidence. This might suggest that we are advocating ever-longer recording, when many of you will be struggling to make the time to record your work as it is.
But, if you concentrate on writing detailed, factual reports, with opinions being clearly expressed where appropriate, this need not take any longer, and in fact may be quicker and easier than vaguely-worded, unclear text. Make sure you avoid repeating yourself: a point made well once will have more impact than one that is repeated throughout a report or case record. Compare these two examples.
‘I visited Mrs Ali at 12:30pm today, and stayed for 20 minutes. She was a bit disorientated, and her personal appearance wasn’t good. She was sitting on her sofa. I massaged her legs and re-placed her protective socks. I heated up her lunch and asked about her mobility to ensure she was able to move around the house and use the bathroom. She said she was able to do this without too much effort although she said her back was still giving her some pain. I gave Mrs Ali her medication and checked she had enough meds to cover the next seven days. We talked about how her reablement was going and she mentioned that her daughter-in-law wanted her to go into a home. Her son did not want this and thought she could manage at home with care workers coming in regularly. I signed her care record and left to move on to the next person on my visiting list.’
‘I visited Mrs Ali at 12:30pm today. I massaged her legs and re-placed her protective socks. She said she was fairly mobile although she said her back was still giving her some pain. I gave Mrs Ali her medication and checked she had enough meds to cover the next seven days. Her family is discussing whether she should go into a home.’
Increasingly, social care staff are based in multi-disciplinary teams. Their record, therefore, will often be just one part of the paperwork that exists about a person. It is to everyone’s benefit – the professionals in multi-disciplinary teams, but more importantly the people they support – if it is possible to have one record that presents a coherent, holistic picture of an individual. So make sure information can be shared with colleagues where appropriate. Professionals need to know what their colleagues are doing with a person at any given time, so work can be planned in a way that makes sense – for example, a social worker may need to know where an occupational therapist has got to in helping a person develop their independent living skills before helping the person to apply for a one-bedroom flat. And should the person choose to see their case file, clearly it’s better to have just the one record to share with them.
IT compliant Open
Like it or not, most social care recording will be done recorded on IT systems. There will also be occasions when the social care record is produced for a specific purpose e.g. a court report, a safeguarding investigation, a housing application, and it may be necessary to complete a report using a template provided for the purpose.
While IT systems may not always be very user-friendly, the onus is on you as the professional to ensure that you do all you can to make use of whatever system is provided to record appropriately on behalf of the person you are working with.
You are a professional, and your recording work must reflect that.
Much of what that entails is covered in the top tips we’ve already looked at: timeliness, evidence, clarity and so forth. In order to enhance credibility, casual recording styles – for example using colloquial terms or ‘cutting and pasting’ from emails instead of tailoring the record for the specific purpose – should be avoided. Your record is an important document which represents you, the organisation you work for, and most importantly the person you are working with.
Social care staff are often distinct, though, in the way they can work alongside an individual, and work with them to help them achieve their goals. This PARTNERSHIP is key, in record-keeping as elsewhere, so make sure in your written records you are as person-centred as you can be, and as you strive to be in all of your work.
Keep up to date
We hope this resource has been helpful. Some aspects of recording are complex, and it is important that they are fully understood. SCIE offers bespoke training to make sure that you and your organisation are aware of good practice and legal duties in this area. If you would like to talk to our team about how we can help, please complete our enquiry form.