Social care recording

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

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.

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.