A care note is the short written account a care worker leaves after each home care visit. NICE calls the collection of them a care diary or care record. Most agencies call them daily notes or visit notes. Whatever the name, they are the main evidence that the plan agreed with the person was carried out, and the first thing the next carer reads before walking in.
They are also where record keeping most often goes wrong. A note that says "all fine, meds given" tells the next carer nothing, protects nobody if something is later disputed, and gives an inspector nothing to look at. This guide covers what the rules ask for, and how to write a note that does its job in the few minutes a carer has at the end of a call.
What the rules say a care note must be
There is no regulation called "care notes". The duty comes from the general requirement to keep a proper record.
Regulation 17(2)(c) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 requires the registered person to maintain securely an accurate, complete and contemporaneous record for each person using the service, including the care and treatment provided and the decisions taken about it.
CQC's guidance on Regulation 17 says those records must be complete, legible, indelible, accurate and up to date, with no undue delays in adding information. They should refer to discussions with the person and the people acting for them, and include consent records, including when consent changes, why, and the alternatives offered. Decisions made for a person who lacks capacity must be recorded in a way that shows the Mental Capacity Act 2005 was followed.
NICE guideline NG21 on home care is more specific to visits in someone's own home. Recommendation 1.3.22 says a care diary should be kept in the person's home: a detailed day-to-day log of all the care and support provided, which also highlights the person's needs, preferences and experiences, and the person should be offered a copy. Recommendation 1.3.23 says home care workers should make sure the diary completed on each visit is detailed enough to keep people, their carers and practitioners fully informed about what has been provided, should record any incidents or changes, and should read new entries if they have not seen the person recently. Recommendation 1.3.24 says everyone involved in providing care should have access to the plan and the diary.
Skills for Care's Care Certificate Standard 14 workbook, on handling information, gives new carers the same message in plainer words: records must be kept up to date, complete, accurate and legible, written so they are clearly understood, avoiding jargon, and factual rather than based on opinion. It also reminds them that care records may become legal documents of evidence if there is ever a concern or an enquiry.
Put together, a care note has five jobs. It shows what was done against the plan. It shows what was not done and why. It describes the person as they were on that visit, in their own terms. It flags anything that has changed. And it says what was done about it, or who was told.
A simple structure for every note
Carers write better notes when they have the same few prompts each time. One structure that fits a home care visit:
- Arrival. How the person was when you arrived, in plain observation. Where they were, what they were doing, what they said.
- Care given. What you did, following the care plan. Name the tasks from the plan rather than writing "personal care done".
- Not done, and why. Anything in the plan that did not happen. A refusal, a task the person chose to do themselves, a task you ran out of time for.
- What the person said and wanted. Their choices on this visit, in their words where it helps.
- Changes and concerns. Anything different from usual: skin, mood, appetite, mobility, the home, a new mark, a fall, a worry they mentioned.
- Action taken. Who you told, what you were told to do, and anything the next carer needs to know.
Medicines are usually recorded separately, on a medication administration record (MAR) or eMAR. The note does not need to repeat every dose. It should mention a refusal, a problem or anything you escalated, and it should agree with the MAR. NICE's medicines guideline for social care in the community, NG67, sets out how medicines support should be recorded, and our NICE NG67 guide covers it in detail.
Worked examples
The examples below are made up to show the difference in practice. They are not taken from any real person's record.
A vague note.
08:15. All fine. Personal care done. Breakfast given. Meds given. Left happy.
Nothing here is wrong, and almost nothing here is useful. "All fine" is an opinion. "Personal care" could mean a full wash or a quick face wipe. "Left happy" describes the carer's impression, not the person.
A better note for the same visit.
08:15 to 08:45. Mrs A was sitting up in bed when I arrived and said she had slept well. Supported her to wash at the sink, as in her plan. She washed her face and arms herself and I helped with her back and legs. Applied cream to both heels as prescribed. Skin on heels intact, no redness. She chose porridge and tea, ate all of the porridge and half the tea. Morning medicines given and recorded on the MAR. She said her right knee was more painful than usual when walking to the bathroom and she used her frame throughout. Told the office at 08:50. Office will ask her daughter about a GP appointment. Next carer: please ask about the knee and note how she is walking.
It is longer, but it can be written in a few minutes, and every sentence answers a question someone will later ask. It names the plan. It records what the person did for herself, which matters for her independence and for reviewing the plan. It turns a vague worry into an observation with a time, an action and a handover.
Recording a refusal.
Mr B said he did not want a shower today because he felt cold. I offered a strip wash in the living room by the heater instead and he accepted. Hair not washed, his choice. Shower to be offered again at the next morning call.
A refusal is not a failure to record. It is a decision the person made, and CQC's guidance expects the record to show the choice and the alternative offered. If refusals of the same care keep happening, that is something for the manager and the care plan review, not just the diary.
Common mistakes
These are the problems worth looking for when you check a sample of notes.
- Opinion instead of observation. "Seemed confused" or "was difficult" tells the reader how the carer felt. "Asked me three times what day it was" or "pushed my hand away when I tried to help with her top" tells them what happened.
- Writing up later. A note written at the end of the shift, or the next morning, is reconstructed from memory. Regulation 17 asks for a contemporaneous record. If a carer genuinely could not write at the time, the late entry should say so and give the time it was written.
- Copying the last note. Identical notes visit after visit suggest the note is not being written about this visit at all. They also hide gradual change, such as a person eating a little less each week.
- Jargon and abbreviations. Abbreviations that make sense in one office will not make sense to a district nurse, a family member, or a carer from another branch. Write words in full.
- Judgemental language. Words like "refused to cooperate", "attention seeking" or "non-compliant" describe a person unfairly and can end up in front of a family, a court or an inspector. Describe what the person said and did, and what they wanted instead.
- Rubbing out or deleting. A note that has been overwritten, scribbled out or deleted is no longer indelible. Correct it in a way that leaves the original readable.
- Missing the follow-up. "Noticed a red mark on hip" is the start of a note, not the end. Say where, how big, whether the person said it hurt, and who you told.
Write it as if the person will read it
They may. NICE NG21 says the person should be offered a copy of the care diary. Under UK GDPR people have a right of access to personal information about them, which includes their care record. Family members may also read the folder in the house, or a family portal, where the person has agreed to that.
A useful test before saving a note: would you be comfortable reading it aloud to the person it is about? If not, rewrite it. That does not mean leaving out concerns. It means describing them respectfully and factually.
It also means keeping notes about the person, not about other people. Details about a family member, a neighbour or a colleague belong in the note only where they matter to the person's care.
Corrections, security and how long to keep notes
Corrections. On paper, draw a single line through the error so it can still be read, write the correction, and sign, date and time it. Do not use correction fluid. In software, a correction should keep the original wording and show who changed it, when, and why. Ask any supplier to show you a corrected note before you buy.
Security. CQC's guidance says records must be kept secure at all times and only accessed, amended or destroyed by authorised people. A paper diary in the person's home needs an agreed place to live. Notes on a phone need to stay inside the care app, not in a carer's photos or messaging apps.
Retention. The Records Management Code of Practice for Health and Social Care in England lists adult social care records, including care plans, with a retention period of 8 years and a disposal action of review and destroy if no longer required. That is a minimum. Your own policy, a commissioner's contract or a serious incident may need records kept longer.
How managers can check care notes
Notes only improve when someone reads them. CQC's Regulation 17 guidance expects providers to audit their service and act on what they find. A simple monthly check of a sample of notes per person can look for:
- Does each note match the tasks in the care plan for that visit?
- Are times recorded, and do they agree with the visit times?
- Are refusals, changes and concerns recorded, and is there a follow-up?
- Is the language factual, respectful and free of abbreviations?
- Do the notes agree with the MAR and with any incident reports?
- Are there signs of copying, late entries or gaps?
What you find should feed back into supervision, into training, and into the care plan itself. A pattern in the notes, such as a person regularly declining a task, is often the best evidence that the plan needs reviewing. Our guide to care planning software covers what Regulation 9 asks of the plan the notes are written against.
Where software helps, and where it does not
Software does not write a good note. A carer does. What software can do is make the good note easier and the bad habits harder.
The questions worth asking of any system:
- Is the note linked to the visit and to the care plan tasks, so the carer is prompted by the plan rather than a blank box?
- Can a carer write the note in a house with no signal, and does it reach the office in order when the signal returns?
- Can a note be deleted? It should not be.
- When a note is corrected, is the original wording kept, with who changed it, when and why?
- Can the office see notes as they are written, so a concern raised at 08:15 is read before lunch?
- Can the person or their family see notes where the person has agreed, and can you control what they see?
On HomecareOS, care notes are written on the carer app against the visit, and adding a care note is one of the actions that works with no signal and sends itself when a connection returns. A visit note cannot be deleted. A care note can only be corrected with a written reason, and the original wording, who changed it and when are kept in a history nobody can alter. That behaviour is described on our care records page. It is our product, not a regulatory minimum, and the questions above apply whichever system you choose. For the wider picture, see our guide to choosing a carer app for home care.
A checklist for carers
Before you leave the house, check that your note:
- has the time you arrived and left
- names the tasks from the plan you carried out
- says what was not done, and why
- describes how the person was, using what you saw and heard
- records the person's choices, including any refusal and the alternative offered
- flags anything different from usual
- says who you told and what happens next
- agrees with the MAR
- is something you would be happy for the person to read
If you would like to see how a note is written on a real visit, book a short demo or call Phil on 01905 674704.
Sources
- Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, for the duty to keep an accurate, complete and contemporaneous record.
- CQC guidance on Regulation 17, for what makes a record fit for purpose, including consent and capacity decisions, security and audit.
- NICE NG21: Home care, recommendations 1.3.22 to 1.3.24 on the care diary.
- NICE NG67: Managing medicines for adults receiving social care in the community, for recording medicines support.
- Care Certificate Standard 14: Handling information, Skills for Care, for writing records that are factual, legible and free of jargon.
- Right of access, Information Commissioner's Office.
- Records Management Code of Practice retention schedule for care records, NHS England, for the 8-year minimum for adult social care records.
- HomecareOS care records and carer app, for how corrections and offline notes work in our product. Those pages describe our product.