RELEVANT CHAPTERS

Data Protection

Supervision

1. Introduction

Keeping comprehensive, up to date and accurate records applies to all parts of the service as a business, not just in relation to an adult’s care and support records.

As more and more data is sent, received and available via the internet the service has a duty to consider the storage and retention of electronic data in line with data protection legislation (see Data Protection chapter), as well as paper based records. More information about electronic data is available in

2. Case Recording

2.1 Introduction

Case recording is an essential part of daily care and support practice. It involves:

  • recording the views of the adult and their carers;
  • writing down the work that has been undertaken;
  • life history, assessment and analysis;
  • documenting the progress adults make towards their desired outcomes.

It also provides an evidence trail of the work done with the adult and their carer and is a vital tool to enable staff to reflect on their ongoing work with adults / carers and plan future work. Records should be used as part of supervision, in conjunction with their supervisors / managers.

Staff should always remember that in the event of a safeguarding inquiry or other investigation, case records will be used and scrutinised. Staff will be held accountable for all entries they make and should be mindful of this when documenting their actions and judgements.

Staff should also remember that records may be shared with the adult, and this should be refllected in the language used and the manner in which judgements are recorded.

2.2 The purpose of case recording

Whilst some of the main reasons for case recording have been noted above, overall the purpose is to:

  • document the involvement of adult social care services with the adult / carer, including the provision of services;
  • inform assessment and care and support planning;
  • enable staff to review and reflect on their work;
  • assist staff in identifying any patterns in behaviour or risk;
  • ensure accountability for actions taken and not taken, with reasons – documents decision making and thinking;
  • meet statutory requirements;
  • provide evidence for legal proceedings;
  • assist with practice continuity, including when new staff begin working with the adult;
  • provide performance information;
  • provide evidence for inquiries, review or complaints;
  • assist partnership working between staff and adults / carers;
  • document risks and risk management / contingency plans (see Positive Risk Taking and Risk Assessments).

2.3 Principles of case recording

Case records should

  • be based on a general principle of openness and accuracy:
  • be drawn up in partnership with the adult and / or their family / representative;
  • record the views of the adult, in their own words where appropriate, including whether they have given permission to share information;
  • be an accurate and up to date record of work, which is regularly reviewed and summarised;
  • include a record of decisions taken and reasons for them;
  • include a chronology of significant events;
  • be evidence based and ethical;
  • separate fact from opinion;
  • incorporate assessment, including risk assessment where appropriate;
  • include an up to date care and support plan (see Care and Support Planning);
  • record issues of race / ethnicity, gender, religion, language, disability;
  • training, journals and articles should be used to keep up to date with research developments to inform recording;
  • be used by the supervisor / line manager as part of overall measurement of staff performance;
  • in the case of hard copy records – be legible, signed and dated;
  • include management sign off for major decisions and referral onto senior managers;
  • be kept securely and shared in accordance with data protection principles (see Data Protection chapter).

2.4 Common issues in case recording

In addition to ensuring the principles above underpin case recording, other areas to consider include:

  • the adult’s voice should not be ‘missing’ from the case record: whilst actions taken in relation to them are documented, their wishes, feelings, views and understanding of their situation should be clearly recorded. There may be a tendency to focus on the views of a carer who is able to be more vocal, rather than the adult who may have more difficulty in expressing themselves;
  • the size of the record may make it difficult to manage: records should be focused and important information highlighted and regular summaries / transfer summaries included to make it easier to find for others reading the record;
  • a completed assessment should be on file: information must be analysed and a plan created for the assessment to be complete. An assessment is not just about collating information;
  • the record must be written for sharing: making it easy for the adult to read and understand. Language should be plain, clear and respectful, keeping social work terms and abbreviations / acronyms to a minimum. Records should be shared regularly with the adult to encourage them to contribute to the record;
  • the record should be used as a tool for analysis: it should not simply record what is happening, but also to analyse and hypothesise why particular situations and events are occurring. The use of genograms, chronologies and assessment records can help organise and analyse information.

2.5 Practice guidance

A record must be kept for each adult who uses the service.

Records should be complete, clear, factual and accurate, fit for purpose, up to date, indelible, remain confidential and maintain the dignity and confidentiality of the adult.

They should include an accurate record of all decisions taken in relation to the adult’s care and support and make reference to discussions with people who use the service, their carers and those lawfully acting on their behalf.

As well as electronic and paper forms, plans and case files, information relating to an adult’s care and support records can also include:

  • photographs, slides, and other images;
  • audio and video tapes, cassettes, CD-ROM etc;
  • emails;
  • computerised records;
  • scanned records;
  • text messages (SMS) and social media (both outgoing and incoming from the adult / representative) such as Twitter and Skype;
  • websites and intranet sites that provide key information to patients and staff.

Records should include discussions and documentation related to consent, and any advance decisions to refuse treatment (see Consent and Making Advance Decisions). Consent records should include when consent changes, why the person changed consent and alternatives offered.

Records should be completed in relation to:

    • daily care the adult receives, including information about their psychological and mental wellbeing as well as the physical care they receive;
    • findings and recommendations from any assessments such as speech and language therapy (SALT);
    • any input or liaison with professionals from other agencies, such as GPs or district nurses, and any planned or proposed changes as a result;
    • care and support planning (see Care and Support Planning);

Records must be stored in a secure, accessible way that allows them to be located quickly.

Records must be complete and up to date with all relevant information including that relating to physical care needs, mental health needs and significant risks when people move into another setting or are admitted to hospital as these are times when the communication of information to new staff is crucial to ensure the safety of the person concerned.

Records must be accessible to authorised people as necessary in order to deliver people’s care and treatment in a way that meets their needs and keeps them safe. This applies both internally and externally to other organisations;

Records must be updated, verbal communications documented and information from different sources integrated into the adult’s file as soon as practicable.

They must be kept secure at all times and only accessed, amended, or securely destroyed by authorised people.

Both paper and electronic records must be held securely, meeting the requirements of data protection legislation (see Data Protection).

Decisions made on behalf of a person who lacks capacity must be recorded and provide evidence that these have been taken in line with legation (see Mental Capacity).

Any issues related to deprivation of liberty concerning the care of the adult should be recorded, including any discussions within the service, discussions with colleagues in other agencies and any application to the supervisory body and the outcomes of such.

3. Other Records

Some of the issues detailed above apply to other records that the service should keep, such as health and safety, management, board and business meetings, including meetings with the Care Quality Commission, commissioners and safeguarding partners.

These include:

  • enabling staff to review and reflect on their work;
  • assisting staff in identifying any patterns;
  • ensure accountability for actions taken and not taken, with reasons – documents decision making and thinking;
  • meet statutory requirements;
  • provide evidence for legal proceedings;
  • provide performance information;
  • provide evidence for inquiries, review or complaints;
  • document risks and risk management / contingency plans;
  • document autonomy, responsibility and safeguarding concerns.

Some of the same principles also apply:

  • based on a general principle of openness and accuracy:
  • be an accurate and up to date record of work, which is regularly reviewed and summarised;
  • include a record of decisions taken and reasons for them;
  • include a chronology of significant events;
  • be evidence based and ethical;
  • separate fact from opinion;
  • demonstrate where risk assessments have been carried out and findings acted upon;
  • record issues of race / ethnicity, gender, religion, language, disability as appropriate;
  • training, journals and articles should be used to keep up to date with research developments to inform recording;
  • be used by the supervisor / line manager as part of overall measurement of staff performance;
  • in the case of hard copy records – be legible, signed and dated;
  • include management sign off for major decisions and referral onto senior managers;
  • be kept securely.

As with case records, other types of records that will need to be kept include:

  • photographs, slides, and other images;
  • audio and video tapes, cassettes, CD-ROM etc;
  • emails;
  • computerised records;
  • scanned records;
  • text messages (SMS) and social media (both outgoing and incoming from the adult / representative);
  • websites and intranet sites that provide key information to patients and staff.

4. Access to Records

Where a request for access to a record is made, all legislation and guidance in respect of Freedom of Information Act 2000 and data protection legislation must be followed by all staff. See also Access to Records and Information Sharing and Confidentiality.

5. Issues for Managers

Issues for managers include:

  • ensuring sufficient management action to support recording policies and procedures: audits of care and support recording should be regularly conducted to identify good practice as well as areas of concern, which should be discussed in staff supervision sessions (see also Quality Assurance);
  • policies and procedures should be sufficiently detailed to support staff: they should state what records need to be completed and when; they need to be relevant and staff adhere to them; care practice and recording should be integral and not seen as separate issues;
  • recording is not an integral part of performance monitoring: it should be referenced in job descriptions and on agenda items in staff induction, supervision and performance development reviews;
  • policies, procedures and practice tools should be developed and implemented with the involvement of practitioners: new developments should be informed by staff views of their expertise – staff involvement in developing policies, procedures and guidance is essential (see Staff Engagement);
  • systems should be developed or reviewed to ensure the same information is not requested multiple times. This saves the adult / carer from being repeatedly asked for the same information, as well as staff time and resources.
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