RECORD KEEPING AND REPORT WRITING

GERRY BROPHYTALKING LIFE

GROUND RULES

Confidentiality We have the right to make

mistakes and not know things

Take responsibility for your learning by asking questions and giving feedback

Allow others to have their say, challenge the views not the person

You can leave the room at any time, without explanation

OUTLINE OF THE DAY

Do we always fully understand the importance of recording?

Do we think enough about Why? and Who? Is the information accessible? Is the information complete and up to date? Do we distinguish facts and judgments? Have we provided assessment and analysis? Is our language inclusive? Are our managers fully engaged?

EXERCISE

In small groups attempt to identify some of the issues that impact on staff when report writing/recording information

DEFENSIBLE RECORDING

Staff should be made aware of the legal obligations they have to recording. Any documentation may be used in court, disciplinary or safeguarding processes and as such it is the staff and managers responsibility to ensure the records reflect the events as they happened.

Defensible decisions are those based on clear reasoning with due regard to appropriate legislation, policies and procedures.

They demonstrate clear and precise record keeping. In other words what was the decision and how was it reached? What information / evidence was the decision based on?

LEARNING FROM INQUIRIES

Some general messages: “The Social Services files examined did not reflect an

adequate record of the work that social workers were undertaking with service users and families”

SSI: Recording with Care

“Numerous inquiries in the past have called for higher standards of case recording and the more thorough maintenance of case files by professionals from all agencies involved in the welfare of children. In view of the regularity with which deficiencies in this regard have been identified, it is disappointing to find them repeated with such regularity throughout Victoria's case.”

Lord Laming: Victoria Climbié enquiry

IN RECORDING WITH CARE:

A Director says: My staff are good at what they do, not what they

write down' A Social Worker says: “I didn't become a social worker because I

wanted to be a typist or a computer programmer. I want to work with people, not waste my time in front of a machine”'

But on the other hand: A Team Manager says: “I couldn't believe the information wasn't there! I

kept thumbing through the file, trying to find it. I know we've talked about lots of other things in supervision. I just thought it was being written down - but I don't have time to check!'”

PRINCIPLES We need to record information for different reasons when

providing a service for individuals:- It is a legal requirement To ensure continuity of support / care To record the rational for decision making (defensible

recording) To protect the individual, staff and organisations To show transparency of the work undertaken To provide evidence for investigations

Whilst many different provider services use various forms, tools and systems for recording, the principles always remain the same.

STAKEHOLDERS:

Customers and/or carers Case accountable workers Line managers and colleagues The organisation e.g. complaints, disciplinary

procedures Service providers Internal and external auditors Regulators and inspectors e.g. Care Quality

Commission (CQC) External bodies e.g. Police, Crown Prosecution

Service (CPS), Coroner, Ombudsman

QUALITY AND STANDARDS Fair Access to Care Services, Valuing People and

the Mental Capacity Act variously require that we must be and demonstrate in our records that we are:

Person-centred Outcome-focused Open and clear Proportionate in our response Active in supporting people to exercise choice

and control Active in ensuring legal and civil rights Actively promoting independence Actively promoting inclusion Starting with an assumption of capacity unless

proven otherwise

WRITING REPORTS

It cannot be overstated that once something is written in a clients file it is likely to have a profound effect not only on his/her immediate life but also for many years to come.

DUTIES AND RESPONSIBILITIES

In order to fulfil its duties to support, safeguard and care for those most in need of health and adult social services, the local authority has a duty to keep records which are full, accurate, confidential and secure.

This becomes a duty delegated to employees on behalf of the authority. It governs the accountability, conduct and performance required of all workers in relation to the quality and standards of record keeping they are responsible for.

The quality of records should reflect the required standards for record keeping as well as the quality of work being carried out with customers and carers.

The evidence provided by case records not only demonstrates what is happening to an individual customer but how teams and the wider organisation carry out the management role and how staff perform against standards, targets, performance indicators and outcome measures.

STATEMENT

Effective and accurate record keeping, both electronic and manual, is essential to good social care practice and when we record our interactions with our customers, we must show that they are our main focus (being person-centred).

We must demonstrate (evidence) that we take account of and respond to what is important to them from their own perspective, the things they hope for (their personal desired outcomes) and provide them with supportive and positive action and choice to achieve those outcomes, enabling self-directed support.

N.B. A desired outcome is the personal benefit/difference that a customer would like a service or an intervention to make to their life.

GOOD RECORD KEEPING

“Good record keeping is essential for local authorities so that when they are challenged – as is increasingly likely – they are able to demonstrate that decisions were not taken unlawfully or with maladministration.

Defensive record keeping can easily be poor record keeping....... This renders decision making opaque and difficult to defend against challenge”

(From an A- Z of Community Care Law by Michael Mandelstam).

GOOD RECORD KEEPING

Good record keeping is an integral part of professional activity and is central to good care management, social work and social care practice.

It should assist the process, is not separate from it, nor is it a matter of choice.

It is as equally important as the face-to-face engagement with customers, carers and partners and should have the same level of professional accountability.

DEFINITIONS

RECORDS (GENERAL) Records are recorded information (irrespective

of medium or format) which are created, received or maintained by an organisation or individual in pursuance of its legal obligations or in the transaction of its business.

A record should be regarded as information in its final form, and not subject to alteration.

DOCUMENT A document is an object that may still be

subject to alteration by editing. A document may ultimately become a record.

CASE RECORD (SOCIAL CARE)

A case record: gives details and evidence of each and any

worker’s contact (of all types) with the person, reflecting the work undertaken.

gives details of the person’s own contribution (or an advocate’s on their behalf) to their record, their desired outcome and whether, in their opinion, this was achieved.

brings together information from a number of sources, including from other agencies.

CASE RECORD (SOCIAL CARE)

will be clear, accessible and comprehensive. will clearly demonstrate risk analysis,

professional judgement, decision-making, actions and interventions, agreements and

authorisations. will show that it has been audited by line

managers within regular supervision and according to the prevailing case audit programme.

FRAMING YOUR WRITING

You will want to consider the usual questions:

How, Who, What, When, Where and Why.

In the planning phase, start with •Why (are you writing this)? •Who (for whom is it intended)?

EXERCISE

Read the following pieces of case recording placed on the file of a local authority Social Services Department Family Support Team.

Critically appraise these. What do they tell you? Why and for whom were they written?

1997 CALDICOTT PRINCIPLES

Principle 1 – Justify the purpose(s) for using confidential information

Principle 2 – Only use it when absolutely necessary

Principle 3 – Use the minimum that is required

Principle 4 – Access should be on a strict need-to-know basis

Principle 5 – Everyone must understand his or her responsibilities

Principle 6 – Understand and comply with the law

DATA PROTECTION ACT 1998

1. Tell people what any information is needed for, and take care with sensitive information.

2. Ensure information is used and disclosed only for the purpose for which it was collected.

3. Only keep information that is relevant and adequate for the purpose for which it is held

4. Keep information accurate and up to date 5. Hold information for only as long as is necessary for the

purpose 6. Allow individuals access to information held on them and

amend it where it is not correct 7. Take appropriate security measures to prevent unauthorised

or unlawful processing, disclosure, destruction, loss or alteration of information. Get written confirmation of data protection compliance from organisations you are sharing information with

8. Transfer information only to countries with an adequate level of data protection law

THE DATA PROTECTION ACT 1998 GUIDANCE TO SOCIAL SERVICES STATES THAT:

“3.13 Social services managers need to demonstrate a commitment to case recording as an important part of the service to users and carers and to ensure that policy and procedures are established.

The commitment should be explicit and reflected in recruitment, induction, training, performance appraisal, auditing, monitoring and review. In departments where this happens, and particularly where random routine auditing of case records takes place, there is evidence that standards of case recording do improve.

3.14 Throughout the process of assessment and intervention and the writing of the record, management oversight should support work and ensure accountability.

Decisions made in supervision are a significant part of the record for service users and they should be clearly recorded and held on the main case file as an integral part of the record.”

PURPOSE OF RECORD KEEPING

To provide an accurate and timely record of social care involvement, thus reducing or eliminating any potential or actual risk to the customer.

To aid continuity when individual workers are unavailable or change.

To provide information and evidence to assist enquiries into complaints, appeals, investigations, audits and independent or serious case reviews.

To provide an essential tool for managers to monitor and evaluate performance and quality assurance.

To focus work and conduct effective work across agencies

To help workers in the processes of assessment, care planning, review or safeguarding investigation.

PURPOSE OF RECORD KEEPING

To provide customers and carers with a record of events in their life To show how customers and carers have been involved in their assessment,

support planning, review or safeguarding investigation. To demonstrate how the services they have received have contributed to the

actual achievement of desired customer/carer outcomes To contribute to the evidence of people‟s experience of using services and

that of their carers To provide a record of the services or interventions arranged and their take-

up. To show how decisions are made and who is involved in making them. To provide accurate management information in relation to Performance Indicators for the Council, the Service and the Team To evidence compliance with legislative, policy and guidance requirements. To provide information to assist strategic and corporate planning processes.

CASE AUDIT

ascertain the extent of compliance with policies, procedures, regulations and legislation

review and ensure cases are being managed and recorded effectively

facilitate good practice recommend improvements The case audit role is a shared responsibility between

day to day line managers and supervisors and the twice yearly formal audit function.

There should be an objective for staff relating to recording with care.

Required practice could be for 2-3 cases to be audited per monthly supervision for each case accountable worker.

FEATURES OF QUALITY RECORDING

use appropriate and respectful language use full names, titles, designations and relationships record the customer/carer’s name as they would prefer

to be known. not use abbreviations, acronyms or jargon not use „text‟ terms, slang, or indirect terms unless

these are recorded as direct quotes from the person whose record it is

be clear, concise and written in plain English. be correct for grammar and spelling be comprehensive and capable of being understood by

the customer or any unknown reader either now or in the future.

be accurate not only in fact but also in differentiating between opinion, judgment and hypothesis

FEATURES OF QUALITY RECORDING

demonstrate fairness in forming opinion and making decisions, underpinned by clear evidence.

show judgments made and actions and decisions taken are recorded carefully.

clearly show where decisions have been made jointly across agencies or endorsed by a manager.

clearly record in the Observations Screen the outline chronology of events, meetings (i.e. assessments and review/reassessments) and contacts (i.e. all incoming and outgoing telephone calls/letters and emails)

reference should also be made in Observations Screen to other related activities e.g. matters of financial concern or complaint/appeal pending (not necessarily with full details)

be recorded in chronological order of events and contacts and capable of being readily followed during audit.

be recorded by time (using 24hr clock) and date of events (not the write-up) as well as who was the originator of the information (source) and signed (responsible)

FEATURES OF QUALITY RECORDING

be „completed‟ on the day of entry and whenever the worker is away from the record for any significant length of time.

never be amended but „completed‟ and re-entered separately and referenced with any correction required and signed.

if a record keeping entry has to be interrupted and continued at another time or a second entry has to be made as a continuation entry due to lack of space, the next entry should be noted and dated as such.

ensure any safeguarding entry begins with the word „safeguarding‟ after the recorded time e.g. 13:00 Safeguarding Strategy Discussion. This is to enable a safeguarding event to be more readily identified as a key and separate event from routine work.

demonstrate the use of anti-discriminatory and anti-oppressive language and practice.

PRACTICE GUIDANCE

The on-going record This section is key to the whole record as it details the

chronological progress of the case. It will refer to other relevant documents and reports, but will not need to duplicate the content of these.

Some events will be recorded in full on the ongoing record, while other significant records (e.g. review, assessments, statutory visits, court judgments) will simply be referred to, and held elsewhere in the file.

Deciding what will be recorded in full on the ongoing record, and what will be recorded as a fuller report (but referred to in the ongoing record) will be a matter of balance and professional judgement between the worker and supervisor.

PRACTICE GUIDANCE

Records should distinguish clearly between verifiable facts and opinions, based on the following guidelines:

Facts can only be recorded as such if supported by evidence. It must be clear who has this evidence (i.e. the allocated worker

or others) Where there is disagreement about the facts, this should be

recorded, and differing views noted. Where opinions are recorded, it should be clear whose they are

(i.e. the allocated worker or others). Opinions should be based on objective professional assessments,

facts and evidence.

Case records should be updated in a timely manner, and no later than 3 days after the event

WHEN LOOKING AT AN ENTRY IN A PERSON’S FILE CAN YOU ANSWER THE FOLLOWING QUESTIONS?

1. What was the decision? 2. How was the decision reached? 3. What information was used to inform

the decision? 4. What other evidence was used to inform

the decision? 5. What was observed? 6. Who was consulted about this decision?

EXERCISE

I visited Mrs Riley today to assist with cooking her lunch. When I arrived she stated she did not want any lunch today as she was tired and not hungry. I asked her if she felt unwell, she said she was okay. In my opinion, she did not look any different or unwell. There are no known medical reasons for Mrs Riley having to eat (e.g. she is not diabetic).

I asked her what she would do later if she was hungry and she asked me to leave her a sandwich in the fridge. She also has some bananas and apples on the table. She was due a further domiciliary visit in 6 hours so she could access further food then if needed.

There was nothing to suggest that Mrs Riley did not have the capacity to make this decision as she was able to answer questions appropriately. I ensured she had a cup of tea, left her a bottle of water and packet of biscuits next to her armchair and told her to ring the office or her GP if she felt she needed to.

STORAGE OF RECORDS

All records should be stored as securely as possible in order to avoid potential problems such as misuse and loss. This applies equally to photographic or electronic records as well as manual ones.

Staff should never store confidential customer information on a memory-stick.

REVISIT

RECORDING GUIDELINES

1 Be clear about the purpose of the record 2 Know where you are going to record it. 3 Distinguish facts from opinion · verifiable factual information · direct observations · understandings · hearsay · opinions, judgments, assessments, evaluations and

recommendations 4 Remember to be accurate, relevant and

concise while still providing a complete record. 5 Be clear what you are going to write about.

RECORDING GUIDELINES

6 Write legibly in ink. Do not use Tippex (sorry, correction fluid).

7 Use clear and unambiguous language. 8 Use language that is respectful. 9 Sign and date each piece of recorded

information, including messages. 10 Be aware of confidentiality. 11 Indicate who or where the information has come

from. 12 Check the accuracy of the record with the

service user, if appropriate.

MANAGING THE TASK

· Recognise that recording is an important task, not just for the agency but for the service user or carer.

· See recording as an integral and important part of your practice.

· Plan your recording. Allocate time to record and minimise interruptions and diversions.

· Record information as you go along. Keeping information in your head to record at a later date may result in key information being forgotten.

· Allowing recording in complex cases to accumulate can result in you being confronted by a seemingly impossible amount of paper work.

HANDOUTS AND POWERPOINT 1. Visit the website: www.talkinglife.co.uk

2. Select TRAINING BUTTON

3. Select Client LOG-IN BUTTON on left hand side of this page

4. Select Isle of Wight LOG-in

5.Sign in as follows: username: HERT180314 password: DEM180314

6. Select option: View Professional Log in information

7. Select course and follow links to various handouts and presentations for Hertfordshire