Domiciliary Care in Penrith
Reporting & Recording in Home Care Settings
This guide is designed to enhance the recording skills of home carers in our organisation. The primary focus is on improving how observations, actions, analyses, and plans are documented. The underlying principle is Partnership emphasising collaborative recording with the individuals receiving support. The guide outlines 11 key tips applicable to various recording scenarios, including daily case notes, formal reports, or assessments.
Recognising the Significance of Documentation
Documentation plays a crucial role in social care. It goes beyond being a mere administrative task to complete swiftly; instead, it stands at the core of providing effective, person-centred support.
Six reasons why effective recording is so important:
- Supporting Quality Care: It underpins the delivery of good care and support.
- Legal Obligation: It aligns with legal requirements and constitutes a part of professional duties for staff.
- Facilitating Communication: Recording helps to maintain continuity of care and foster communication with other agencies.
- Identifying Themes and Challenges: It serves as a tool to identify recurring themes and challenges in an individual's life.
- Ensuring Accountability: Documentation is key to accountability, extending to individuals using services, managers, inspections, and audits.
- Providing Evidence: It serves as evidence for various purposes, including legal proceedings, complaints, and investigations.
Essential Tips for Effective Social Care Recording
Accurate and meaningful social care recording is essential, even though the challenges of your role and time constraints can make it difficult to prioritise.
To assist you in this crucial task, here are 11 top tips for maintaining quality social care records:
A social care record serves various readers, including your manager, colleagues, and other healthcare professionals. However, the most crucial audience is the client using the services and their families. It's essential to recognise the significance of the record for the person you are supporting.
Record information in a person-centred approach, mirroring the ethos of your overall practice. While you may have documented countless records, each one represents a unique social care record for that individual. Despite time constraints, consider that this record holds the power to influence the services the person receives and, consequently, the quality of their life.
In your recordings, precision is crucial. Whether presenting facts or expressing opinions, strive for accuracy and clarity, avoiding vagueness. For instance, rather than stating 'the front room was in a terrible state,' provide specific details like 'the front room contained 14 bags of rubbish, and I observed 20 empty fast food packages. Additionally, I noticed what appeared to be mice droppings in one corner of the room.'
This level of accuracy avoids potential value judgments and proves more beneficial to colleagues who might visit. They can then note any improvements accurately. Importantly, this approach acknowledges and recognizes the individual's efforts to address the situation, preventing their progress from being overlooked.
Recording in social care presents challenges, particularly considering the diverse readership, including the individual in question. The risk of vague wording arises, especially when describing behaviors causing difficulties. For instance, the phrase 'inappropriate sexual behaviour' can encompass a broad spectrum of actions, ranging from serious assaults to ill-advised comments.
To strike a balance, avoid vague descriptions like 'she has issues with personal hygiene' or disrespectful ones like 'she smells revolting.' Instead, provide explicit details, such as '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.' This may require more time to record but ensures precision for honest discussions with the individual involved.
A well-rounded social care record encompasses person-centredness, accuracy, detail, reflection, and analysis. Achieving these elements is more attainable when records are made promptly, capturing the essence of events while they are fresh in memory. Although the pressures on social care staff may delay note-taking, doing so can hinder colleagues working with the same person and create issues for the individual involved. If recording is unavoidably delayed, it's good practice to acknowledge this fact transparently in the notes rather than attempting to disguise the delay. This ensures openness and maintains the integrity of the recording process.
No Jargon - Plain English
The sentence "Because my allocated case Kim, despite her ASD, is an activated client, I decided to take an asset-based approach to her affective disorders" is laden with jargon, as highlighted by the Think Local Act Personal Jargon Buster. This jargon, often prevalent in social work and care, can quickly render our written communication incomprehensible, not only to the person we are supporting (the most crucial audience) but also to our colleagues and managers. It's important to recognize that even fellow professionals may not be familiar with all the jargon. A clearer and more accessible way to convey the message could be: "I am working with Kim, who has autism and a strong sense of the support she needs. Together, we are identifying her strengths to help address some of her mental health challenges."
In social work care records, it's essential to substantiate every observation and ensure accuracy in stating facts. While opinions are acceptable, they must be grounded in professional judgment, supported by evidence such as professional experience, knowledge of individual circumstances, or research evidence. Clearly indicating when an expression is an opinion and not a fact is crucial, along with providing the basis for that opinion. For instance:
"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."
This case note not only acknowledges the professional's concerns but also recognises them as unproven opinions at this stage. It records the different perspective of the person who uses the service and sets out the reasons for the professional's thinking, allowing colleagues and others to consider their professional judgment. Differences of opinion are a natural part of ongoing relationships, and it's crucial to transparently present varying views in recordings, whether they involve the person being supported, carers, fellow professionals, or other stakeholders.
Reading the Previous Record
Understanding the contents of social care records is crucial when supporting individuals, despite challenges like time constraints and filing systems. Updated case summaries that compile key facts, events, and people in an easily accessible format play a significant role. While it's important not to be strictly bound by previous records, as they may contain inaccuracies and circumstances may have changed, reading them is essential. Neglecting to do so could lead to missing crucial information about a person's history and the most effective ways to support them.
Illustrative Case: A person with learning disabilities placed in a women's refuge faced exploitation by another tenant. Subsequently, it was discovered that there was a note on the exploitative woman's file, indicating she should never reside in that refuge again due to a history of exploiting other vulnerable women. Failure to read this note allowed a cycle of abuse to persist. While the local authority should have implemented a system to highlight vital information, the support worker holds a professional responsibility to thoroughly read and comprehend the file, preventing such incidents from occurring.
While our emphasis on detailed and accurate recording, backed by evidence, might seem to promote lengthier documentation, our intention is not to burden you with additional time-consuming tasks. Concentrating on crafting detailed, factual reports with clear expressions of opinions when necessary can be more efficient and quicker than vague, unclear text. The key is to avoid unnecessary repetition. A well-made point expressed once holds more impact than repetitive statements throughout a report or case record. Quality and clarity can streamline the recording process without necessarily extending the time it takes.
In the collaborative landscape of multi-disciplinary teams, social care staff often contribute to a broader spectrum of paperwork about an individual. To enhance efficiency and, more importantly, to provide a comprehensive, holistic view of a person, it's beneficial to strive for a unified record. This cohesive record aids professionals within the multi-disciplinary team in understanding each other's contributions, enabling coordinated planning. For instance, a social worker may need insights from an occupational therapist to effectively assist a person in developing independent living skills before pursuing a one-bedroom flat. Additionally, having a single, shared record is advantageous if the individual wishes to review their case file, promoting clarity and simplicity in information sharing.
The majority of social care recording occurs through IT systems. In some instances, the social care record may be generated for a particular objective, such as a court report, safeguarding investigation, or housing application, requiring adherence to a specific template. Although IT systems may not consistently exhibit user-friendly interfaces, the responsibility rests with you as the professional to maximize the use of the provided system. It is essential to ensure accurate and appropriate recording on behalf of the person under your care, regardless of the system's user-friendliness.
As a professional, your recording work should reflect a high standard of professionalism. This encompasses adhering to the top tips discussed earlier, such as timeliness, evidence-based content, and clarity. To enhance credibility, it's crucial to avoid casual recording styles, such as using colloquial terms.
Remember, your record is a significant document that represents not only you but also the organisation you work for, and most importantly, the individual you are assisting. Social care staff have a unique role in working alongside and collaboratively with individuals to help them achieve their goals. Emphasizing this PARTNERSHIP is key in record-keeping, ensuring that your written records are as person-centred as possible, aligning with the person-centred approach in all aspects of your work.
Read about the next topic, Communication