Case note recording and general recording throughout residential child care is an area in which practitioners have found difficulty, ensuring recordings are professional enough on one hand and personable enough on the other. In the professionalisation throughout the years the child and the relationship has often been lost. Staff throughout the profession have struggled to recognise that case notes or any recordings or reports can be written in a child centered way while remaining fit for purpose.
Over the years the issue of recording has been tackled through individual and group training sessions, however systems have remained in place which do not support change, therefore the developments have not been embedded in practice.
We have recently become aware of further research which again identified the negative impact current recording processes can have when viewed by young people in later life. Young people who believed they had good relationships with the staff they worked with, after reading the case notes are left with the impression the relationship was not as they had thought. A high percentage of these young people then feel the need for counseling.
As part of the ongoing development process at Moore House Care & Education the concept of writing a letter to young people had been discussed through the new induction process and through the attachment, trauma and resilience input all staff have been involved in. From these discussions the possibility of writing case notes to the young person emerged and was considered to be a positive way forward. Work then began behind the scenes with Zachari Duncalf a researcher from CELCIS and Judy Furnivall a consultant from CELCIS, both highly experienced and respected in the Residential Child Care Field.
There is an accountability aspect to case notes therefore discussions were required with the regulatory bodies to ensure any new way of writing case notes would continue to meet regulatory requirements. All checks have been done and we are now clear to make changes.
The Aims of making the changes to the way Case Notes are recorded are-
Aims & Objectives
Develop a standard and expectation of writing style which maintains the child at the center of the process
Improve the daily experience for young people who are looked after at Moore House Care & Education
Heighten awareness in staff of the impact of their recording in both short and long term.
Give staff a reason to reflect on the individual as a whole while recording specific aspects of life.
Make individuals more responsible for their recording.
Provide learning opportunities for all staff in regards to the impact of written material on the individual.
Improve the recordings held at Moore House.
Contribute to the continual improvement in communication and relationships between staff and young people.
Contribute to the practitioner research required to improve services for young people across the sector.
Our work has been supported and aided by information from the Care Leavers Association (https://www.careleavers.com)
Training and Implementation – All clear to go 16th September 2013
As most people are probably aware the training has now been done by almost all Care Staff. Zachari who has led on the training has been very impressed by the work done by the staff groups and the willingness to change what we do. The process of change will be just that, a process, with lots of support available if needed. Some people may change the way they write dramatically for others it will be small changes a bit at a time. The important part is the change is happening. September 16th has been chosen as the date of the changeover and from this date the process of change will begin.
As Case Recording is an issue throughout the residential and Social Work Sector, there will be some research done to capture the impact of the changes we are making. The research will be conducted over a period of time and as results are available I will make sure they are shared.
This is an exciting time for us as we are the first in the sector to make a real effort to change this aspect and will hopefully lead the change throughout other services. Many other Services/Organisations are aware of and envious of the opportunity we have taken and are keen to see the results, believing our results will give them the evidence they require to make the change themselves.
The key to all change is to make sure everyone understands and agreed the need for change and then to support people to make that change. Hopefully through the training the first step has been covered and now we need to make sure the support is there to back it up. If there is anything anyone feels would be helpful in this change process please let me know and we will do all in our power to support where we can.