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2.1 Recording Policy and Guidelines

SCOPE OF THIS CHAPTER

Good case recording is important to demonstrate the accountability of staff…it helps to focus the work of staff and supports effective partnerships with service users and carers. It ensures there is a documented account of the responsible authority’s involvement with individual service users, families and carers and assists with continuity when workers are unavailable or change’.

(DfE, The Children Act 1989 Guidance and Regulations - Volume 2: Care Planning, Placement and Case Review (2015))

RELEVANT CHAPTERS

Case Retention Procedure

Subject Access Requests Procedure

Confidentiality Policy

AMENDMENT

In August 2016, this chapter was substantially updated and should be read in its entirety.


Contents

  1. Records Must be Kept on all Children 
  2. The Design of Records and Forms Must be Approved
  3. Children and their Families Must be Informed about their Records
  4. The Practitioner Primarily Involved Should Complete the Record
  5. All Relevant Information about Children and their Families Must be Recorded
  6. Children and their Families should be Involved in the Recording Process
  7. Information about Children/their Families should Normally be Shared with them
  8. Managers must Ensure that Confidential Information is Identified
  9. Records Must be Legible, Signed and Dated
  10. Records Must be Kept up to Date
  11. Records Must be Written in Plain English and Prejudice Must be Avoided
  12. Records Must be Accurate and Adequate
  13. Managers Must Oversee, Monitor and Review Records
  14. Records Should be Kept Securely
  15. Removal of Records
  16. Use of Computers at Home


1. Records Must be Kept on all Children

The child’s record is an important source of information for them. It provides information about the sequence of events which brought about Children’s Social Care’s intervention into their life and (in many instances) the reasons why important decisions were made in the child’s and/or family’ life. This can be a key feature for a child in understanding themselves and their past – especially where the child was unable to live with their parent/other long term carer.

Each child must have his or her own electronic case record from the point of referral to case closure; audio, video and digital recordings may also be kept.

Where paper files are also kept, information held in electronic records must accurately reflect the corresponding information recorded within paper files.

Records held on paper may extend to more than one volume. Where more than one volume exists, the dates covered by each volume must be clearly recorded on the front cover.

All records, irrespective of whether they are physical or electronic, should be securely kept and electronic messaging (e.g. e-mails) should also be sent in a secure and safe way so as to preserve their confidential and professional nature, (see Section 14, Records Should be Kept Securely).


2. The Design of Records and Forms Must be Approved

Records and forms must be designed to fit their purpose and used consistently across the organisation.

A manager must approve the design of all records and forms before coming into use.


3. Children and their Families Must be Informed about their Records

Children and their families have a right to:

  • Be informed about the records kept on them and the reasons why;
  • Their rights to confidentiality; and
  • To have access to their records.

See: Confidentiality Policy and Subject Access Requests Procedure.

Where children have been adopted, see also Access to Birth Records and Adoption Case Records Procedure.

Information must be provided in a form that children and their families will understand - in their preferred language or method of communication. An interpreter will be provided if needed.


4. The Practitioner Primarily Involved Should Complete the Record

The practitioner primarily involved, that is the person who directly observes or witnesses the event that is being recorded or who has participated in the meeting/conversation, must complete records. Where this is not possible and records are completed or updated by other people, it must be clear from the record which person provided the information being recorded. Preferably the originator should read and sign/finalise/endorse the record. All significant events must be brought to the attention of the line manager, for example the worker should notify their manager via a significant event case note. For children looked after statutory visits, the allocated workers should notify their manager when the statutory visit is completed via an ICS case note alert notification. The Team Manager should authorise/finalise that record.

Records of decisions must show who has made the decision and the basis on which it has been made.

See also: Section 11, Records Must be Written in Plain English and Prejudice Must be Avoided and Section 12, Records Must be Accurate and Adequate.


5. All Relevant Information about Children and their Families must be Recorded

Every child's case record must hold details of the child's full name, date of birth and any identification number.

Care should be undertaken to ensure the spelling of names is accurate and where possible, evidenced e.g. birth certificate. In some instances, key information may change and it is important the record should identify the current circumstance of the child / family.

5.1 The Basic Record

  • Names and details of everyone who lives in the family home with the child, identifying the person who has Parental Responsibility;
  • Where the child does not live at their home, the details of the Placement / arrangements and the legal status of the child;
  • Names and details of anyone particularly close to the child with whom they have a lot of contact;
  • A record of managers’ decisions and reasons for making them;
  • Details of arrangements for contact;
  • Details and, where appropriate, copies of any Orders made on the child;
  • Copies of reports provided during court proceedings, including specialist assessments, the Children’s Guardian, etc;
  • Additional information about educational progress and where the child is Looked After, the PEP;
  • Where a child has Special Educational Needs or Learning Disability, copies of any relevant information, including the Education, Health and Care Plan;
  • Appropriate information about the child’s health, and where the child is Looked After, a copy of the Health Plan and Assessment;
  • Details of any arrangements for the responsible authority’s functions to be undertaken by a private provider, e.g. an independent fostering agency or provider of social work services;
  • Copies of all documents used to seek information, provide information or record views given to the authority in the course of planning and reviewing the child’s case and review reports;
  • Record of visits by the allocated practitioner.  

5.2 Recording Visits

Each visit should be recorded to include:

  • The venue of the visit;
  • Who was present;
  • The purpose of the visit;
  • Identify whether an interpreter was used;
  • Whether the child was seen (and if not why this was the case);
  • Information exchanged;
  • A succinct narrative of the nature of the discussion;
  • Any views the child expressed;
  • Any views of the Parent/Carer expressed;
  • Identify whether there has been any significant change of circumstances for the child/or family, particularly membership of the household;
  • An analysis and evaluation of the outcome of the visit, commenting within the context of the Plan and the Review Recommendations;
  • Any follow up actions required, by whom and timescales for completion;
  • Failed appointments and visits where there was no response should also be included, together with any actions required under the Children’s Social Care Services procedure guidance.

5.3 Other Key Records

It is the workers responsibility to make sure that all relevant documents relating to the child are included within the child’s file. The record must also include a risk assessment, transfer/closing summary (where appropriate) and a properly maintained Chronology.

All other relevant contacts with children, their families, colleagues, professionals or other significant people must be recorded in the same way, i.e. who was present or seen, the relevant discussions, actions or decisions taken and by whom, and the reasons for decisions. This includes conversations, phone calls, visits, letters, emails, assessments and reports. The options that have been considered and the child and the family’s preferred choices and the reasons why an option has been chosen if agreement could not be reached.

The child’s record should also include relevant and appropriate copies of material from other, separate records/files that are kept, whilst ensuring that such records remain separate and that neither confidentiality nor the Data Protection Act are breached. It is recognised that a certain amount of cross-referencing with siblings is inevitable and desirable, but again, care should be taken in respect of sibling information that becomes available on the record.

5.4 Important Characteristics of the Record

The record should be structured and maintained in a way that:

  • The decision-making process is clear;
  • That the views of the child, carers and/or those with Parental Responsibility can be found and related to the decision-making that has been made together with the responsible authority’s actions;
  • That any material temporarily placed in the record that belongs to the child should be noted as such so that it can be returned to the child when required / appropriate;
  • Recording should be made of the Review meeting’s recommendations / outcomes that are trying to be achieved with a child and their family, key tasks, by whom and timescales; 
  • The recording of interventions and actions should seek to identify which ‘Recommendation’ or Outcome they relate to.

5.5 Case Summaries

All case files should include a case summary. Within ICS this is created/updated and viewed from the Case Notes tab of the child’s file.

What should a Case Summary consist of?

The case summary should provide the reader with an outline of the history of involvement with Children’s Social Care, the reasons why Social Care are currently involved and the purpose of that involvement. It should also include any crucial information and/or key safety features to be noted by the reader - examples of these might include people within the friends/family network who should not be having any contact with the child due to the risks they pose, or specific reference to the young person’s CSE safety plan (and where this document can be located) or issues with regard to payments from Children’s Services etc.

Case summaries must be updated as a minimum every three months.

Additionally, the case summary should be updated upon transfer to another Social Worker or Team. The updated case summary should not just be the adding of an extra paragraph, as, over a period of time, this would obviously make the case summary too lengthy and cumbersome. Instead, it should be an updated version of the child’s circumstances. However, some content would obviously need to be remain in every case summary, such as the reasons why the child became Looked After, when and why the child became subject to a Child Protection Plan.

Please note that each time a Case Summary is updated in ICS the system will automatically create a case note of that summary. This means that the reader will always be able to see the changes in the Case Summary over time by viewing the individual case notes or from a case note report and selecting the type ‘Case Note Summary’.

The summary can help to ensure continuity and is an important source of information for colleagues and supervisors in the absence of the case holder.

The case summary should be directly related to the aims and objectives set out in the child’s plan and can be a useful tool in setting out the tasks necessary to achieve the objectives. Completing or sharing a case summary with a family offers an opportunity to reflect on progress over the period covered by the summary and discuss both achievements and difficulties. It should also assist the practitioner with an opportunity to reflect on the effectiveness of interventions and review progress towards agreed goals.

The case summary should include:

  • A brief history of the child or young person;
  • Current circumstances and identified risks including risk of CSE;
  • Current placement for child or accommodation for young person;
  • Significant health issues;
  • Education/employment details;
  • Other agencies involved;
  • Financial information for care leavers;
  • Brief details of current plan/Pathway Plan;
  • Contact arrangements;
  • Date of last review;
  • Date of next review;
  • Contingency plan.


6. Children and their Families should be Involved in the Recording Process

Children and their families must be routinely involved in the process of gathering and recording information about them. They should feel they are part of the recording process.

They should be asked to provide information, express their own views and wishes, and contribute to assessments, reports and to the formulation of plans. The child should have the opportunity to have support to be able to do this if needed, through an Advocate and /or through specialist help, e.g. a signer.

It is recommended that any contribution the child may wish to make, any written material, certificates etc should be included on the record as copies, so that the child retains the original items so that they have their own record of their wishes, progress etc.

Children and their parents must be asked to give their agreement to the sharing of information about them with others. Information should be shared with the consent of the child and family if appropriate and where possible the wishes of those who do not wish confidential information to be shared should be respected. Information can still be shared without consent if it is in the public interest to do so. Information sharing decisions should be based on consideration or the safety and well-being of the person and others who may be affected by the sharing.

In such circumstances ensure that the information shared is necessary for the purpose for which it is being shared and shared only with those who need to have it. 

See DfE, Information sharing advice for safeguarding practitioners (2015)


7. Information about Children and their Families Should Normally be Shared with them

Information obtained about children and their families should be shared with them unless:

  • Sharing the information would be likely to result in serious harm to the child or another person; or
  • The information was given in the expectation that it would not be disclosed; or
  • The information relates to a third party who expressly indicated the information should not be disclosed.

See also: Subject Access Requests Procedure

Where children have been adopted, see also Access to Birth Records and Adoption Case Records Procedure.

When sharing a record it is important to record who it was shared with and when. The sharing of all decision-making documents such as assessments, care plans, reviews, reports and agreements make it easier for everyone to know what is expected and to work together better.


8. Managers Must Ensure that Confidential Information is Identified

Managers must ensure that confidential information is identified and must take all reasonable steps to consult the originator and take account of their views and wishes. See also Subject Access Requests Procedure.


9. Records Must be Legible, Signed and Dated

Those completing electronic records must show their name and the date when the recording was completed.

If possible, paper records should be typed or handwritten in black ink and all such records must be signed and dated and the pages numbered to assist in a reader being able to follow ‘the child’s story’. 

Any handwritten records must be produced so that readers not familiar with the handwriting of the writer can read the records quickly and easily. It must be possible to distinguish the name and post title or status of the person completing the record. If there is any doubt of the identity of the writer from a signature, the name should be printed.


10. Records Must be Kept up to Date

Records should be updated as information becomes available or as decisions or actions are taken as soon as practicable or, at the latest, within 24 hours for significant events and all other events within 5 working days.


11. Records Must be Written in Plain English and Prejudice Must be Avoided

Records must be written concisely, in plain English, and must always be written in a way that recognises the child or their parent/carer will access the record (whether whilst the case is active or at some point in the future).

E-mail communication to colleagues and other professionals (that will be included in the record) should always be completed with the same care and attention. The recording should certainly not contain any expressions that might give offence to any individual or group of people on the basis of race, culture, religion, age, disability, or sexual orientation.

Use of technical or professional terms, acronyms and abbreviations must be kept to a minimum; and explained.

See Subject Access Requests Procedure and Case Retention Procedure.


12. Records Must be Accurate and Adequate

Care must be taken to ensure that information contained in records is relevant and accurate and is sufficient to meet legislative responsibilities and the requirements of these procedures.

Every effort must be made to ensure records are factually correct.

Records must distinguish clearly between facts, opinions, assessments, judgements and decisions. Records must also distinguish between first hand information and information obtained from third parties.

See Confidentiality Policy.


13. Managers Must Oversee, Monitor and Review all Records

The overall responsibility for ensuring all records are maintained appropriately rests with line managers, although the responsibility can be delegated to other staff as appropriate.

The line manager should routinely check samples of records to ensure they are up to date and maintained as required and, if not, that deficiencies are rectified as soon as practicable.


14. Records Should be Kept Securely

All records held on children must be kept securely.

Children's paper files should normally be stored in a locked cabinet, or a similar manner, usually in an office which only staff have access to. The electronic ICS record (additional tab) should be updated with details of where the paper file can be located (ICS Guidance for the Management of Children’s Case Files).

Other day-to-day records, such as Contact or Daily Records, should also be kept securely in a manner authorised by the manager.

These records should not be left unattended when not in their normal location.

All electronic records must be kept securely and comply with the requirements of the Data Protection Act 1998. This will include arrangements such as:

  • Password protection;
  • Automatic log out of screens;
  • Logging off computers;
  • Changing passwords on a regular basis.

Where staff are working in an ‘agile’ / ‘mobile’ / ‘hot-desking’ context, care must be exercised to ensure that records or computers are not left on or overlooked by others.


15. Removal of Records

15.1 Exceptional Occurrence

Records should not normally be taken from the location where they are usually kept.

If it is necessary to remove a record from its normal location, Managers must ensure that effective systems are in place, for tracking the location of files, containing confidential information. The tracking system must record information about where, when, by whom and why a care record was moved from its permanent or temporary place of storage if it is not returned the same working day. Managers must also be satisfied that adequate measures are in place to ensure the security of the record(s) whilst they are removed. For example, records must never be left in unattended vehicles.

A clear record of the files which have been removed from the designated storage area, and by whom, should be maintained; (Tracking Service User Files Procedure) - to folllow.

  1. Files should be requested through business support and the borrower will be responsible for them whilst out of their designated storage;
  2. Business Support will complete the File Removal Spreadsheet, which is stored on the shared drive. They must fill out the following:
    1. Name and volume number of File Removed;
    2. Date File Removed;
    3. Name of person removing the file;
    4. Reason for and Place of removal;
    5. Date File to be returned.
  3. The minimum number of files required for the purpose should be removed. Paper files which are removed should also be recorded on the service user record on ICS;
  4. Files should be returned as soon as possible;
  5. It is the responsibility of those borrowing the files i.e. the requester of the file to ensure that they are returned promptly;
  6. Checks should be carried out by the relevant manager to ensure files are returned as required/agreed.
Should the situation ever occur where a file / documents are lost or mislaid, the local authority officer must report this immediately to their manager and every reasonable effort should be made to obtain their recovery. The service user should be advised of such an event.

15.2 Records Moved to a New Location Must be Monitored

Where records are necessarily moved to a new location, the date of transfer should be clearly recorded. Movement of a child’s paper should be recorded electronically on the ‘Additional’ tab of the child’s ICS record and in accordance with the current ‘ICS Guidance for the Management of Children’s Case Files’.

The sender should check that the records have arrived at their intended destination.

If records are moving because of a case transfer an audit should be carried out by a manager prior to transfer to ensure all relevant information and documents are available on the child’s record.


16. Use of Computers at Home

Staff have access to an encrypted laptop with access via a secure network if they are working from home.

Should the situation ever occur where a laptop is lost or mislaid, the local authority officer must report this immediately to their manager and ICT Services and every reasonable effort should be made to obtain their recovery.

Consideration should be given as to whether service users should be advised of such an event.

End