Record Keeping

We know that in many situations, abuse and neglect arise from a range of incidents over a period of time, so good record-keeping is a vital component of safeguarding practice. When abuse or neglect is raised managers need to look at past incidents, concerns, risks and patterns. Very often chronologies are highly useful aides for deciding next steps in response to safeguarding concerns. Records may be requested as part of a safeguarding enquiry, or in relation to a regulated care or legal matter

Records should include:

• Date and circumstances of concerns and subsequent action and the lead professional;
• Decision making processes and rationales;
• Risk assessments and risk management plans;
• Consultations and correspondence with key people;
• Capacity considerations and documented assessments (and best interest decisions);
• Outcomes, and conclusions;
• Feedback from the adult and their personal support network;
• Differences of professional opinion;
• Referrals to professional bodies;
• Associations/individual relationships.

Learning lessons from past cases, and missed opportunities highlighted in Serious Case Management Reviews (and other mechanisms for review) emphasise the need for quality recording especially when managing abuse, neglect and risk. This includes providing a clear rationale for any actions, or taking no action, and all related decision making.

Quality recording of adult safeguarding not only safeguards adults, but also protects workers by evidencing decision making based on the information available at the time. Documentation in relation to Safeguarding Adults can be central in providing supporting evidence when making referrals to the Disclosure and Barring Service, criminal cases, the relevant courts, disciplinary hearings and complaints. Record keeping is an integral part of professional practice and should support decision making. Decisions and action taken should be supported by evidence and rationale so that intentions are clear. Records should be kept in line with Manx Care recording policy and with respect of safeguarding case notes completed within 24 hours.