In this blog, our Process and Improvement Lead Eliza Tyrrell shares emerging learning from our work on case recording and considers what it means for practice, improvement and change across social care in Wales.
Over the last six months we’ve been exploring case recording practice across social care in Wales.
At the start we thought we were investigating a familiar challenge. Practitioners told us about duplication, increasing recording requirements, difficulties finding information and the growing pressure that recording can place on day-to-day practice.
We initially assumed that electronic systems and technology were at the centre of the problem. As our discovery work progressed, however, we found that conversations moved beyond technology and towards practice, culture and the wider conditions in which recording takes place.
One workshop participant captured this perfectly:
“Systems aren't necessarily the problem, but the [electronic information] systems are seen as the solution.”
Certainly, systems present challenges. Many local authorities are currently updating them and there is good reason for that. But our discovery suggests that technology is only one part of a much wider picture.
So far, we're finding that case recording is affected by the conditions that help people do good work, including organisational culture, confidence in using professional judgement, and confidence in analysing and interpreting information.
What we did in discovery
Before we could discuss improving recording, we realised we first needed to understand what people meant when they talked about recording, where information was held and how it was being used.
One of the first activities we ran asked a simple question: “What is a case record?”
The answers varied considerably. Some people described case notes. Others talked about assessments, care and support plans, emails, supervision discussions and entire case files. We also asked who uses case notes and learned there can be multiple authors, reviewers and purposes for the same information.
An encouraging aspect of the discovery has been seeing similar themes emerge from different pieces of work. Alongside our own workshops and analysis with subject matter experts, we revisited earlier Social Care Wales work exploring meaningful recording, reviewed learning from confidence-building work in Pembrokeshire and analysed practitioner interviews gathered through separate internal improvement research earlier this year.
One of the strongest emerging themes is that practitioners seem more comfortable recording facts than explaining their interpretation of a situation. Participants described being cautious about including analysis, observations or professional reasoning in their records. This remains a hypothesis rather than a conclusion, but it is a theme we want to explore further.
When practitioners talked about what helped them record well, they rarely asked for more rules, more auditing or more guidance.
Instead, they spoke about supervision, mentoring, examples of good practice, opportunities to discuss complex situations and learning alongside experienced colleagues.
“A good assessor is key."
“Good practice often depends on the assessor's knowledge and experience.”
A good mentor can help someone build confidence in making sense of a situation, weighing information, deciding what matters and communicating that reasoning effectively in their recording.
Finding information when it matters
Another recurring theme was findability.
When information is spread across multiple forms, systems and locations, finding what's needed becomes much more difficult.
One participant working in mental health reflected that: “Most of these things in mental health will have a defined timescale attached to them.”
When decisions about detention, treatment and discharge operate within statutory timescales, practitioners can't afford to spend valuable time searching for critical information.
The difficulty isn't simply about timescales. Information may not be where someone expects it to be. It may be stored differently by different people. Sometimes it may not be there at all.
Workers often need to decide for themselves where information belongs.
“It depends on what you're working on, who's involved... everyone did this to what makes sense to them. So there wasn't one place to look for one document.”
This points towards a broader challenge. The issue isn’t only the act of recording itself but the ability to find, connect and reuse information later.
What matters and the wider record
The Social Services and Well-being (Wales) Act 2014 introduced an approach centred on personal outcomes, strengths and understanding what matters to people.
Social Care Wales describes a What Matters conversation as “not an assessment in itself: it's a way of carrying out the assessment”.
During our discovery, a number of questions emerged about how this approach is reflected in day-to-day recording practice.
How do practitioners capture the person’s voice, outcomes and strengths across assessments, reviews, support plans and ongoing case records? How do different parts of the record work together? When information is recorded across multiple documents and systems, how easy is it to maintain a clear thread of what matters to the person over time?
These aren't conclusions. They're questions that have emerged from the discovery and which we hope to explore further as the research develops.
Organisational challenges
We also heard about challenges that exist at an organisational level, particularly around consistency, information sharing and recording standards.
One person asked:
“Are those organisations getting the same advice and guidance and training on case note recording?”
How consistent is recording practice when multiple organisations, and multiple people within organisations, contribute information about the same person? We heard that variation can exist not only between organisations but also within them.
Just the facts?
We spoke to someone who had worked in policy within a local authority who reflected on the guidance often given to practitioners: recording as quickly as practical, staying factual and including people's exact words.
This highlights an interesting tension. On one hand, practitioners are encouraged to be objective and avoid opinion. On the other, people repeatedly tell us that records should help others understand meaning, context, voice and outcomes.
This leaves us with an important research question: how do practitioners balance professional analysis with factual recording?
Training
Training may help someone understand how to record. But training alone can't answer questions such as: Which information matters most? How much detail is enough? What will future readers need? How should professional judgement be evidenced? What is the balance between facts and analysis?
Those questions are often resolved through supervision, culture, discussion and organisational norms rather than training courses alone.
A more interesting explanation may be emerging from our discovery work: recording behaviour may be influenced less by what people are trained to do and more by the organisational conditions in which they're expected to do it.
If managers, auditors, systems and local expectations all pull in different directions, recording behaviour may be shaped more by those conditions than by the training somebody has received.
Conclusion
One potential misunderstanding from these findings would be to conclude that practitioners simply need more training. Learning and development clearly matter, but the themes emerging from our discovery suggest recording quality is influenced by a much broader set of factors.
Practitioners work within organisational cultures, supervisory relationships, accountability structures, information systems and professional expectations that all shape how and why they record.
Training may be part of the answer, but it's unlikely to be the whole answer.
We've begun to identify a narrative around confidence, culture and professional judgement. The next step is not to prove that narrative, but to keep asking: “What evidence would make us think differently?”
We’d love your help
Some of the most valuable insights in this discovery have come from practitioners sharing their experiences openly and honestly.
As we move into the next phase of research, we'd like to hear from people across social care in Wales.
Do these findings reflect your experience? Have we missed something important? What helps you feel confident in your recording and professional judgement, and what gets in the way?
Most importantly, we want to hear the real stories behind the records. Your experiences will help us test assumptions, challenge our thinking and ensure that any future support is grounded in the reality of practice.
Take part
If you're interested in taking part in our case recording research opportunity, please complete this form.
