3.4 Recording actions under adult safeguarding
A record of all actions and decisions must be made. Good record keeping is a vital component of professional practice. When abuse or neglect is raised managers need to look for past incidents, concerns, risks and patterns. We know that in many situations, abuse and neglect arise from a range of incidents over a period of time. In the case of providers registered with CQC, records of these should be available to service commissioners and the CQC so they can take the necessary action. At a minimum there should be an audit trail of:
- Date and circumstances of concerns and subsequent action;
- Decision making processes and rationales;
- Risk assessments and risk management plans;
- Consultations and correspondence with key people;
- Advocacy and support arrangements;
- Safeguarding plans;
- Feedback from the adult and their personal support network;
- Differences of professional opinion;
- Referrals to professional bodies.
Records may be disclosed in courts in criminal or civil actions.
All organisations should audit safeguarding concerns and outcomes as part of their quality assurance. Local Authority should use existing codes within the Safeguarding Adult Collections categories. Supervisors should ensure that recording is addressed in supervision and that staff are clear about their responsibilities. SABs should regularly review the quality of recording as part of its performance and quality data scrutiny.
Learning lessons from past mistakes and missed opportunities highlighted in Safeguarding Adult Reviews, Serious Case Reviews and other reports emphasise the need for quality recording especially when managing abuse, neglect and risk. This includes providing rationales for actions and decisions, whether or not they were taken, and if not the reasons for this.
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. For more information see the University of the West of England advice on the importance of keeping records.