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))
This chapter was added to the manual in October 2017.
- Recording Values and Principles
- Records Must be Kept on All Children
- The Design of Records and Forms Must be Approved
- Children and their Families Must be Informed about their Records
- The Practitioner Primarily Involved Should Complete the Record
- All Relevant Information about Children and their Families Must be Recorded
- Children and their Families should be Involved in the Recording Process
- Information about Children/their Families should Normally be Shared with them
- Managers must Ensure that Confidential Information is Identified
- Records Must be Legible, Signed and Dated
- Records Must be Kept up to Date
- Records Must be Written in Plain English and Prejudice Must be Avoided
- Records Must be Accurate and Adequate
- Managers Must Oversee, Monitor and Review Records
- Records Should be Kept Securely
- Removal of Records
- Use of Computers at Home
1. Recording Values and Principles
- Electronic Social Care Record;
- Working Together 2015;
- Framework for Assessment for Children in need and their families;
- Recording with Care: SSI Inspection of case recording in social service departments (DoH 1999).
- Children Act 1989;
- Adoption and Children Act 1989;
- Children Act 2004.
Recording is a core skill. It is a dynamic, and is an essential and integral part of all service delivery. It is a means by which staff can be accountable for their actions on behalf of the Service, including professional, financial and legal decisions. High on Devon's agenda is to ensure that every child and young person is visited and asked about their views and experiences within their family – and that we'll listen so that sound decisions can be made. The child's voice will always be recorded (see Children's Consultation and Participation Procedure).
Good quality recording will reinforce good quality practice, promoting equal opportunity, diversity and social inclusion. Good quality recording allows Children's Services to be confident about their actions when held accountable to the child / young person, their family or carers, partnership agencies, auditors and inspectors.
Case recording is the written account of the social care service's work with or on behalf of a child / young person, their family or carers.
Recording includes descriptions, analysis and professional judgement. It is essential therefore that a distinction is made between fact and opinion and third part contribution.
The allocated social care worker has a professional responsibility to ensure that all information about a child / young person and their family is appropriately, accurately and timely recorded on the correct electronic or paper record. The social care worker also has the responsibility wherever it is appropriate, to share what they have recorded with the child / young person and their family or carers.
It provides a permanent record of all the information gathered, services delivered and the involvement of the child/ young person and their family/ carers.
There is an explicit expectation that accurate recording is a core function of social care work.
Recording is a tool to gather information for strategic planning and reporting to government.
Recording is undertaken by all practitioners and managers.
All records are the property of Devon County Council.
Security and Confidentiality
Article 8 of the Human Rights Act 1998 gives everyone the right to respect for their private life, their home and their correspondence. All public authorities must respect this in all their actions including when gathering and processing information relating to individuals. By ensuring proper procedures are put into place, Children and Young People's Service will be able to show that service users' right to privacy is being respected.
The Data Protection Act 1998 implements the European Directive on the protection of individuals with regard to the processing of personal data, and on the free movement of such data. It also gives effect to the judgement of the European Court of Human Rights concerning the right to access social work records.
The Data Protection Act 1998 enhances the rights of the data subjects in gaining access to information about themselves and as such Public Authorities who have well maintained records will find it easier to comply with the requirements of the Act.
General Principles of Recording
- Recording is a professional activity which is central to good social care practice;
- Service users should be made aware that records are maintained and are accessible to them. Where possible and practicable, service users should be given the opportunity of contributing to their own records;
- Records will be written in a respectful way which recognises that children, young people and family may access their records if they wish to;
- Records will hold information which is correct and up-to-date;
- Records will show what decisions have been made, by whom and on what basis;
- All recording will be brief, clear and concise using simple language which can be understood by children, young people and their families;
- Hand written records should be avoided. Any handwritten records will be legible and be easy to read;
- The electronic case record will ensure that the name and role of the person making the record is clear and accessible;
- All important decisions, including those taken in supervision and/or panels will be recorded on the electronic record showing who has taken the decisions, and making it possible to track the decision making process.
2. Records Must be Kept on All Children
The child's record is an important source of information for them, particularly if they wish to understand their journey when they reach adulthood. It provides information about the sequence of events which brought about Children's Social Care's intervention into their life and 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.
All records will be kept electronically, not on paper files. Any material that is printed will be disposed of in line with the confidentiality policy (i.e. by way of confidential shredding).
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 15, Records Should be Kept Securely).
3. 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 senior manager must approve the design of all records and forms before coming into use.
4. 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.
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.
5. 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/endorse the record.
Records of decisions must show who has made the decision and the basis on which it has been made.
6. 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.
6.1 The Basic Record
- Names and details of everyone who lives in the family home with the child, identifying 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;
- Minutes of meetings;
- Details of assessments and plans;
- Record of telephone calls, correspondence, visits or any other contact by the allocated practitioner or other social work professional.
6.2 Recording Visits
Each visit should be recorded to include:
- The venue of the visit;
- Who was present;
- The purpose of the Visit;
- Whether an interpreter was used;
- Whether the child was seen (and if not why this was the case);
- Whether the child was seen alone (or in the case of infants, seen awake);
- Information exchanged;
- A succinct narrative of the nature of the discussion;
- Any views the child expressed;
- Any views the Parent/Carer expressed;
- 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 visit, including the outcome and actions arising;
- 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.
6.3 Other Key Records
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.
6.4 Important Characteristics of the Record
The record should be structured and maintained in a way that ensures that:
- The decision-making process is clear;
- 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;
- Recording is 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 identifies which 'Recommendation' or Outcome they relate to.
7. 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.
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 considered necessary to safeguard a child or vulnerable adult. 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.
8. 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.
Where information is obtained and recorded which should not be shared with the child concerned for one of the above reasons, it should be placed in the 'Restricted from user' section of the child's record and the reasons should be recorded after taking advice from a manager.
See also Access to Records 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.
9. Managers Must Ensure that Confidential Information is Identified
Managers must monitor confidential information held on the 'Restricted from user' section of case records, ensuring that the reason for it being considered confidential is valid; if not, it should be available to be shared with the child.
However, before sharing any such information, the manager must take all reasonable steps to consult the originator and take account of their views and wishes. See also Access to Records Procedure.
10. 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 should be typed and placed on the electronic file.
11. 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 of the event.
Where records are made or updated late or after the event, the fact must be stated as a 'Late Entry' in the record, and the date and time of the entry should be included.
12. 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 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.
13. 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.
14. 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.
15. Records Should be Kept Securely
All records held on children must be kept securely.
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.
16. Removal of Records
16.1 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, a manager should approve this and should stipulate or agree how long it is necessary to remove the record. The manager 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.
The authorisation for a record to be removed must be recorded and those who may have need to see the records should be informed of their removal. The manager must then ensure the record is 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.
Information Governance must be informed of such an event.
16.2. 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.
Moving collections of paper records containing sensitive personal data should be subject to an information risk assessment carried out by the council's Information Governance team. This would be to ensure that any risks to the availability, confidentiality and integrity of the information are assessed and mitigations put in place where necessary. The transfer of collections of digital records, for example, for system testing or service outsourcing, should also be risk assessed, with recommendations made to ICT SCOMIS, who would then determine the most appropriate technical method of transmission, such as an encrypted hard drive.When individual case records on paper are moved or transferred, consideration should be given first to digital alternatives, then to existing guidelines about protecting paper files in transit supplied to council employees. Transmission of individual case files using digital means is already covered by substantial existing policy and guidance.
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.
17. Use of Computers at Home
Staff using computers at home for work purposes must ensure that they are working within the rules of the 'data protection principles' in accordance with the Data Protection Act (1998). Staff are required to familiarise themselves with the local information security policy.
This applies to staff using laptop computers and mobile devices in the course of their duties.
Should the situation ever occur where a laptop is lost or mislaid, the local authority officer must report this immediately to their manager and to Information Governance 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.