Record Keeping Examples
Here are some examples to help you make good records
Jenny doesn’t know what to do. Her husband Mike is criticising her constantly about what she does and says. He humiliates her, calls her names, won’t give her enough money to shop properly and is bullying and violent. She doesn’t want to be left on her own bringing up the children because she thinks she won’t cope. She’s wondering if she is at fault and whether she really is as stupid as Mike keeps telling her. She thinks Mike is stressed by her behaviour and if only she could be different things would be fine. She doesn’t want to separate from Mike but instead make things work and make him happy.
Mike makes a good living. He is an extrovert and has lots of friends. He is a successful businessman. He likes to be in charge at home and thinks he can say and do exactly what he wants. They have 3 children. Two boys Tom aged 15, James aged 10 and a daughter Amy aged 5.
Jenny is a stay at home mum and has concentrated on bringing up the children. Mike had told her she wouldn’t be able to get a job even if she wanted one. Jenny is a quiet nervous woman who doesn’t like confrontation.
The three children are very attached to their mum and the two boys know Mike bullies her. They are concerned their mum will get seriously hurt. Amy is starting to be watchful and nervous around her dad.
No one talks openly about what’s happening and how it’s affecting them.
Here is a sample of Jenny’s records.
Jane and Mary are sisters. Their father, Harry, lives in a care home nearby. Harry went to live there after their mother had died. Jane and Mary visit Harry daily, taking it in turns. Harry is a former army officer and a stickler for routines and jobs being done properly. He’s opinionated and doesn’t mind complaining and having confrontations. He’s mobile, healthy and still makes good judgements.
Recently Jane and Mary saw a decline in the care Harry was receiving and Harry confirmed things were deteriorating. He said the staff knew things weren’t good enough; there were too few of them and routines were slipping. Jane and Mary have decided that things have to improve if he is to stay there and they want to take action to try to address the situation. Harry agrees.
Jane and Mary understand that if they are going to complain they need to make some record of the things that are a problem. Other visitors to the home and other residents are also unhappy with the quality of care. Jane and Mary will see if the others are willing to band together to complain to the manager of the home and whether they are willing to contact the CQC to complete their feedback form.
Jackie is a divorced mum with a young daughter living in a rented house in a city centre. She’s lived there for 7 years. She’s a part time prison officer in a men’s prison so is not someone who is easily frightened. Her neighbours are all reasonable people and she knows most of them.
Jackie is very worried by the behaviour of a new family who have recently arrived in the street. The mother Sandra seems drunk a lot of the time. Her three troublesome sons are aged 16, 14 and 12. A man is around sometimes too. He seems to be drinking and using drugs. He arrives in a new BMW, is always wearing designer trainers and clothes and seems to have a lot of money. Jackie suspects he is a drug dealer.
Jackie knows through her job that if you want to get something done about a problem you need to get evidence of it, not just write an account but also be sure to keep photos, for example to record a car number plate, take videos of anti social behaviour, make audio recordings of incidents and record evidence of anything else to make sure you can show what’s happening. If neighbours band together to complain and everyone has some evidence it strengthens their individual cases and makes them more powerful as a group.
Jackie sets about enlisting the help of all her friends in the street so that they complain. She is prepared to co-ordinate their efforts to make all the complaints as strong and as powerful as they can be. She knows that once they have some evidence they can report the problems to the council and to Sandra’s landlord. If there are criminal offences being committed they can go to the police. If the Council’s response to complaints is unsatisfactory there is also the possibility of getting it looked at again by means of a ‘community trigger’.
Here is a sample of Jackie’s records
John is a 50 year old father of 3. He has two adult sons by his first wife. He has a good relationship with them and he had never been criticised as being a bad father to them. Sophie is his 8 year old daughter by his second wife Alice who is 31 years old. John thinks he’s the victim of parental alienation as Alice has been making it very difficult for John to see Sophie. Alice is now saying Sophie doesn’t want to see him and is very resistant to any form of contact. Sophie has been seen by the CAFCASS officer who is saying Sophie is very clear about being frightened of him and has said that’s because of “what he’s done to mum”. John has no idea what she means and says he’s never been abusive or violent. Before their separation John and Sophie had a very good relationship and there had been no problems.
John thinks that Alice has been telling lies about Sophie’s availability for visits and he can’t trust what she says. He’s convinced Alice is influencing Sophie by making false allegations about him.
John believes Alice is motivated by money. When they were married Alice didn’t work and was inclined to over spend. This was the cause of arguments leading to their separation. The arguments got heated but never resulted in violence. They have been unable to agree a financial settlement. John believes this is the cause of the problems over Sophie and that it is Alice’s way of trying to get him to agree what she wants in the financial arrangements.
John’s parents are saying the situation will improve if he just lets things pass and he waits but he is afraid that he will lose contact with Sophie permanently and that he will lose everything; his daughter, a huge portion of his income and savings as well as the house. He doesn’t trust the system to deal with him fairly and thinks the CAFCASS officer is taking his wife’s side, believing her complaints.
Here is a sample of John’s records.
A few months ago things came to a head and Katy asked her husband Ben to leave home. He’d eventually agreed to leave and had promised to go to Alcoholics Anonymous. Katy had said that he could return home once he had stopped drinking.
Ben had started to drink heavily about 3 years ago. He was not violent but was bullying, rude and unkind to Katy and their two daughters Emma and Clare, when he had been drinking. He had been having problems at work with a manager who was “on my back”. He worked as a salesman in a builder’s merchants and there were targets he found difficult to achieve. If he had a bad month he was always worried about being singled out as a failure and being sacked, at which times he drank even more heavily.
Katy had become anxious that Social Services would get involved with their two daughters because of concerns about them being harmed. She worried that the school might alert them to a problem with the girls.Their teachers were asking the girls if there was something wrong at home and a friend of Katy’s had told her Emma was talking about her dad being “scary”. She didn’t want to be seen as not protecting her children from harm.
They had set up a contact plan and Ben promised to keep to it and not let the girls down. Once he had left home, their performance at school improved and they were less anxious and stressed. Both girls were keen that their dad stop drinking and come home.
Here is a sample of Katy’s records.
Richard is a bereaved father. His two children, a girl and a boy, live with him in the family home. Their mum died a couple of years ago. The children have found it really hard to adapt without their mum.
The eldest, Shaun is the most upset and he’s become anxious and withdrawn. Richard has discovered he’s being bullied at school. This includes physical attacks, threats and theft of his lunch money. Shaun is frightened and is missing days of school because of it. He’s lying to Richard to try to cover it up. He won’t say who’s involved other than that the ringleader’s father has a fish and chip shop. Other children are also being bullied but the school doesn’t appear to be doing anything about it.
Richard is worried. He’s concerned the physical attacks might get worse. He doesn’t trust the school to deal with things properly. He’s been talking to other parents trying to find out more and sets about compiling a record of the things that have happened to Shaun, how Shaun has reacted and what he’s said. He needs to recall things that have happened before he started making records and luckily he’s kept some written notes. He’s asking other parents to do the same to make it easier for them all to complain together and be more likely to get an effective response.
Here’s a sample of Richard’s records.
Emily is 17 years old. Her work is in an accountants office as a receptionist. She’s worked there for about 3 months. Having got to know the other members of staff it’s clear the boss has tried it on with several female members of staff and also clients. No one in the workplace wants to complain about it. They think they won’t be believed.
Emily’s boss makes sexual comments to her too and sometimes touches her inappropriately. She is dreading being on her own with him and fearful of being sexually assaulted. She’s unsure what to do. She feels she wouldn’t get anywhere if she complains on her own.
Emily is hoping that if she and others in the staff team work together and keep records of what’s happening to them they could make a case which will be believed.
Here is a sample of Emily’s records.
Bev has been going out with Neil for about a year and it was fine for a while. He was fun and charming. As the weeks have passed, though, Bev is starting to question whether Neil is reliable and honest. There have been examples of things happening which just don’t seem right. Bev is wondering – Is he lying to me? She wonders why he keeps getting moody now. She doesn’t know why she often, according to him, gets things wrong about what he’s said, which is making her question my sanity. She doesn’t understand why she gets stonewalled when she questions something and wants an answer.
Recently she has been told that Neil had gone out with someone known to a colleague of hers a few years back. It had apparently been fine to start with but then he’d got “really abusive” and the girl been off work for weeks and on anti depressants. What she heard made Bev anxious and she set out to test her suspicions by keeping records and seeing what else she could find out.
Because Neil is saying she’s getting things wrong Bev has decided to write important things down so she’s not questioning her memory. She thinks about the kind of things he questions and makes records of what they agreed. Otherwise she’ll think she’s losing her mind. He’s even saying she should go to the doctor to get ‘tested out’.
Here’s a sample of Bev’s records. You’ll see what she found out and what she did.
Sally is a single 33 year old supervisor of a sales team in a stationery company. She’s worked there since leaving school, gradually working her way up the ladder. She enjoys her work, is conscientious and puts in the hours. Her team like and respect her and they consistently hit their targets. She had been happy in her position till Nick Brown came to work for the company a year or so ago.
Nick is supervisor of the second sales team. Sally has learned that Nick has a higher salary, better holiday allowances and other entitlements she does not share. She thinks he’s better treated because he’s a man and that the directors think that, because she’s female, they can get away with paying her less.
This has made Sally investigate more. She’s discovering that her team regularly has better sales figures than Nick’s. Nick works fewer hours, arriving after her in the mornings and leaving before her in the evenings. He’s off sick more too. The directors don’t seem to have noticed.
Sally is furious that her attempts to get an increase in salary have been unsuccessful. She’s been offered more holiday entitlement but thinks it’s insufficient. She believes she’s being paid less not only because of her sex but because she’s agreeable, doesn’t like confrontation and the directors do not think she will resign.
Here is a sample of Sally’s records.
Greg, one of the Directors of GT Ltd. thinks he should sack Barry Smith, a member of his delivery team, because of his recent conduct but wants to be sure they have reasonable grounds before doing so. He doesn’t want to find the company is exposed to a claim for unfair dismissal. He’s also worried because until recently Barry has been a reasonably good member of staff, not the best but certainly the same as about half the other delivery team workers.
GT Ltd. is a family business with workers who all know one another. It’s a tightly knit community and Greg is worried about not being seen as fair but also wants to show other members of staff, who themselves are angry and fed up with Barry, that they shouldn’t have to put up with all the problems he is causing. Other workers have had to cover his rounds when he’s not come to work and has failed to give notice of his not coming in. One popular member of staff has been assaulted by Barry for challenging his work and attitude.
Greg is also worried that Barry’s problems are due to his situation at home, causing him to be unpredictable and aggressive and that maybe he should be showing some understanding and patience. What other options might there be to dismissal but which would ensure Barry knows he’s on thin ice and must behave appropriately? Greg wants to find out all the options before starting to take action.
Here is a sample of Greg’s records.
Julia is single, in her early thirties and is being stalked by Dave Arnold. She works in the accounts department of a large electrical company and has done so for 5 years. One of the company’s customers is a business owned by Dave Arnold.
Julia is frightened by Dave’s behaviour. There have been too many strange incidents for them to be chance meetings. She has told her dad who is very worried about her. He’s telling her to be careful and never to go out alone especially at night. She has a constant sense of being watched as he’s been following her and knows where she lives.
Julia’s friends and some of her colleagues are supporting her. Another member of staff, Marie the receptionist, had been questioned by Dave Arnold who had been asking her lots of personal questions about her, such as whether she lived alone. He was very pushy and had scared her.
Julia is worried that her boss won’t be happy if she complains about Dave Arnold because he is a good customer. She thinks she might get into trouble at work especially because Dave Arnold is now turning the tables on her by complaining about her behaviour. She’s feeling really threatened. Not only is she being stalked but the stalker is getting the upper hand.
Julia has heard that the police are sometimes unhelpful so she’s thinking there’s no point in reporting the stalking even though it’s a frightening situation. She wants to be able to prove she’s got a genuine problem and she’s not being paranoid.
Here is a sample of Julia’s records.
Susan is a daughter of Bill and Pam. On Boxing Day, Bill fell over in the garden and couldn’t get up. The family called an ambulance. He was taken to hospital and admitted as they found he had broken his hip. He’s now been on the ward for a while recovering from the operation. Susan, her brother and sister have all been visiting. Pam stays on the ward all the time she’s allowed and has seen some concerning incidents. The ward does not seem clean. On one occasion another patient had been calling for a bedpan. It took at least 10 minutes for anyone to attend to the patient and it had been distressing to watch. Another patient who clearly couldn’t feed herself had been given a plate of food and been left with it. Half an hour later the full plate was collected. Bill was worried about being on the ward and the quality of care.
The family are concerned about the care Bill is getting. It makes them worry about whether the operation will be done properly. Doctors are on the ward and yet they don’t seem to notice the poor cleanliness and lack of hygiene. Susan has been speaking to other visitors on the ward and there’s a general sense of unease about what they’re witnessing.
One person she’s spoken to says she’s seen some bad things happen and has been making notes of them. Susan has arranged to meet her to discuss it away from the hospital because staff seem to listen to conversations and might be alerted to a potential complaint. This person had been to see a solicitor who had said if several people complained it was more powerful and more likely to be dealt with. Individual complaints which are not coordinated appear to be easily fobbed off. It was important that the actual patients were the ones who complained so they need to have consented to their relatives gathering evidence of poor care.
See an example of the records below.
Ann is divorced, lives alone and works in retail. Her mother is 84. She had been living nearby, independently and had been fit and healthy until she fell and broke her hip. She was admitted to hospital and had a hip replacement but then developed a chest infection while still in hospital. She was stuck in hospital for a month, slowly recovering but unable to be discharged home.
Her mother was able to spend much of the day out of bed but still hadn’t recovered enough to go home so eventually, under pressure from the hospital, Ann agreed to take her mother in to help her recover further. Her manager agreed that Ann could go part time for 3 months while she looked after her mother but with the expectation she went back to full time after that. Ann’s GP, Dr A, would be providing medical care and the district nurse would visit.
Unfortunately, a few days after her mother had left hospital, she started being incontinent of urine. Ann could see that her mother’s health was deteriorating as she seemed less alert and more sleepy. She started spending more time in bed and it was difficult to get her up and to the toilet.
Ann was on her own trying to cope but found that her mother needed more attention than she could give while working part time. She heard about NHS funding for continuing healthcare, which would pay for more social and nursing care, and decided to apply.
These are the steps she took:
- She spoke to her GP, Dr A, who agreed to apply.
- Having got the address from the GP, she also wrote to her local Clinical Commissioning Group to say why she thought her mother should be given NHS continuing healthcare.
- Realising she needed to build her case for funding, she downloaded ONRECORD as the best way to record her mother’s problems day by day as evidence of her mother’s needs.
- She set up her ONRECORD account with 12 labels/headings so as to be able to make records in each of the 12 care domains of the Continuing Healthcare Assessment Checklist.
She was sent a date for the assessment and had just over a fortnight to put together a record of her mother’s health problems.
John and Jane are foster carers. They have a keyworker called Andy. He called to see Jane to tell her that there had been a Court hearing about Peter and Jake, their foster children who are subject to interim care orders. The Judge had said there should be a short assessment of the contact between the boys and their mother Alice because she is making an application to increase her contact from twice a week for 2 hours on each occasion to four times a week for 2 hours each time as part of her wish to get the children returned to her.
The contacts will be assessed at the family centre and observed by the supervisors who will report on it. Social services have prepared a schedule of the assessment and Jane has been given a form with a lot of questions which have to be completed after each contact.
Jane and John are being asked to comment on both of the boys’ behaviour and their reaction after each contact. They will be visited by the children’s guardian and solicitor during the assessment to ask factual questions about the children and get their views.
Andy asked about the children and Jane said they’d had a very settled time over the Christmas holiday and it had been much calmer and relaxed than the earlier weeks. Contact makes the children more difficult to look after because their behaviour deteriorates afterwards. She is wondering how disruptive the doubling of contact is likely to be for the boys.
To find out what happened next and how Jane made notes see the case summary.
Neighbour Disputes
Jackie is a divorced mum with a young daughter living in a rented house in a city centre. She’s lived there for 7 years. She’s a part time prison officer in a men’s prison so is not someone who is easily frightened. Her neighbours are all reasonable people and she knows most of them.
Jackie is very worried by the behaviour of a new family who have recently arrived in the street. The mother Sandra seems drunk a lot of the time. Her three troublesome sons are aged 16, 14 and 12. A man is around sometimes too. He seems to be drinking and using drugs. He arrives in a new BMW, is always wearing designer trainers and clothes and seems to have a lot of money. Jackie suspects he is a drug dealer.
Jackie knows through her job that if you want to get something done about a problem you need to get evidence of it, not just write an account but also be sure to keep photos, for example to record a car number plate, take videos of anti social behaviour, make audio recordings of incidents and record evidence of anything else to make sure you can show what’s happening. If neighbours band together to complain and everyone has some evidence it strengthens their individual cases and makes them more powerful as a group.
Jackie sets about enlisting the help of all her friends in the street so that they complain. She is prepared to co-ordinate their efforts to make all the complaints as strong and as powerful as they can be. She knows that once they have some evidence they can report the problems to the council and to Sandra’s landlord. If there are criminal offences being committed they can go to the police. If the Council’s response to complaints is unsatisfactory there is also the possibility of getting it looked at again by means of a ‘community trigger’.
Here is a sample of Jackie’s records.
Dominic is a musician and the youngest child of Mary. His older brother Tom is the attorney for Mary who signed the power of attorney about two years ago when their father died. He’s an accountant and lives with his wife Sian and their two children who are being privately educated. Tom earns a good living. They have a younger sister, Clare. Both Dominic and Clare had thought it was a sensible decision to choose Tom because he is an accountant, was organised and lived only 10 miles away from their mother.
Mary was always clear that if possible she wanted to stay in the family home and not be moved into a care home. Consequently it was decided that for as long as possible Mary would stay put and Tom would arrange a live in carer. The family would also support their mother as necessary. It was agreed that money would be spent on concerts and other trips to make Mary’s life as full and interesting as possible. As far as Dominic and Clare were aware their father had left sufficient funds after his death for this plan to be possible for at least 4 years.
The plan for Mary was going fine to start with but then things started to go wrong. Dominic and Clare became suspicious about how Tom was acting and what he was doing because he seemed evasive. Was he performing his duties of attorney honestly and as agreed or was he taking advantage of his position as attorney? Were the bills being paid and money being spent on their mother as decided? Or was something fishy going on? Did they need to act? Tom started to keep records of what was happening in case they needed evidence.
Here is a sample of Tom’s records.
Melanie and her husband adopted Tom when he was 5 years old. He is now 11. They also have a son James and a daughter Joanne who are both older. Tom’s background was of neglect and emotional abuse. His mum had drink and drug problems and had been very young when she had Tom. He’d been taken into care as a baby. There was no information about who his father was.
The family had received adoption support and were aware Tom might develop problems. He’d been seen by a child psychiatrist some time ago but now his behaviour was deteriorating again.
Melanie rang Dr Smith at CAMHS to talk to her about Tom. She gave an account of the deterioration in his behaviour and its impact on them as a family. He’d been fine for
a long time when he was first placed with them and after his adoption but things were bad about a year ago and now it’s got worse again since starting senior school in September. This also followed Melanie showing him some of the cards and letters saved from his mum as part of his life story work. James seems to be coping better than Joanne who is frightened of Tom. Tom is a big, tall boy who seems to enjoy seeing them scared. Dr Smith said it was important to keep a record of what’s happening and it’s impact on them all. She would arrange to meet them soon.
Here are some of the notes Melanie made.
Trevor Yoxall, an engineer and senior manager at AB Ltd, is married and has two children. He has worked at AB Ltd for nearly 25 years. He received a letter yesterday, from the management, to tell him about a complaint. The complaint is about some things he was overheard to say by a female colleague. He is being accused of making racist comments but with little detail given.
