Recording Policy and Guidelines

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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 working in looked after children’s services to those who use those services. 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'.

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

This policy applies to the work of all Children's Services and to all recording in relation to children, their families and friends, carers, prospective carers or any other person Children's Services has reason to hold a formal record about (e.g. an adult who poses a risk to children). Such records are held electronically.

RELEVANT CHAPTERS

Children's Social Care Service Practice Standards Procedure

Coloured Cards – How to Record Accurately

Management Information and Performance Management Handbook

Case Records and Retention Procedure

Access to Records / Subject Access Requests Procedure

Confidentiality Policy

Corporate ICT Acceptable Use Policy

AMENDMENT

This chapter was amended in October 2020. Section 2, Background and Overarching Principles and Section 3, The Purpose of Case Recording are new.

Records Must be Kept on all Children
Background and Overarching Principles
The Purpose of Case Recording
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 Kept up to Date
Records Must be Written Clearly using Plain Language and Avoid Prejudice
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
Project Accuracy

1. Records Must be Kept on all Children

The child's record is an important source of information for them as well as a tool for planning actions and interventions. It provides information about the sequence of events which brought about Children's Social Care's intervention into their life and provides an explanation for the reasons why important decisions were made in the child's and/or family's life. The case record can be key to helping a child understand themselves and their past – especially where the child was unable to live with their parent/other long term carer.

The child's case record will usually be developed from notes taken in the course of a visit or interview and these may be used directly, or as a result of such information being in a report or court statement. The Family Court, in the case of RE M and N (Children) (Local authority gathering, preserving and disclosing evidence) advised that social workers/practitioners must make contemporaneous notes which form a coherent, contemporaneous record. The notes should be legible, signed and dated and record persons present during the meeting/conversation in question. The notes should be detailed and accurately attribute descriptions, actions and views etc. In some instances, sketches/diagrams may be helpful in establishing the veracity of explanations given, e.g. with regard to how injuries were sustained, etc.

Note: These original notes might need to be disclosed in a court.

It is very important when recording on LCS that information is accurate as well as complying with Information Governance requirements and being recorded in a timely way. For more detail on when recording should be completed by please see the Childrens Social Care Practice document (see Children's Social Care Service Practice Standards Procedure). Accuracy is important for performance management and business intelligence reports; for further guidance see Section 17, Project Accuracy.

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

Where documents are in a paper format, these must be uploaded to the child's electronic file onto Documentum.

All records 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 13, Records Should be Kept Securely).

2. Background and Overarching Principles

Overarching principles:

Recording should be clear, accurate, concise and up to date;
Recording will include fact, third party information, assessment, analysis and professional judgment. The distinction between fact and professional judgment should be clear and the source of information recorded;
Recording should be in plain English;
Recording must evidence consideration of equal opportunities, diversity and social inclusion issues;
The security and confidentiality of information must be maintained at all times. All Children's Services (CS) staff should be aware that unauthorised access to records is a serious disciplinary offence (see Confidentiality Policy;
Recording is an integral part of a CS worker's core activity;
All case files remain the property of LCC;
It enables risk factors to children and/or staff to be identified.

3. The Purpose of Case Recording

Accurate recording:

Enables understanding of the child's needs and the service provided by LCC CS, by all CS staff including children, carers, or others to whom the recording relates;
Enables all CS staff to reflect on the service that has been provided and plan any future service;
Enables children and their representatives to challenge CS, or to make a complaint about service, or lack of service;
Enables continuity of service, regardless of individual staff availability;
Enables management oversight;
Provide evidence for example, in court, complaint investigations, for serious case reviews, inspections, auditing, management reviews;
Management information regarding whole service performance.

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. The design should be flexible and promote ready distinction between historical and current information and not rigidly seek to reflect a presumed social work 'workflow'.

A 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 should be told what types of information/data is contained in their case records.

In particular, they should be helped to understand what data is collected on them, how it is used, who it might be shared with and how long it will be kept for. The most common way to provide information to Data Subjects on what data is collected and how it is used is through a Privacy Notice. Privacy Notices must be easily accessible to children, young people and their families, and should be part of the induction pack given to any new staff members.

See Confidentiality Policy and Access to Records / 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.

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.

Other professionals and partner agencies providing information/reports should be made aware that information provided by them may well be included on the child's file and that this could be accessed by them.

6.1 The Basic Record

Names and details (including ethnicity, religion and gender) 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;
Information about the child and /or family's communication needs;
A record of managers' decisions and reasons for making them;
Details of arrangements for Family Time;
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 Personal Education Plan (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 and contacts by all practitioners as well as the allocated practitioner.

6.2 Recording Visits

Each visit should be recorded within five working days 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 this was alone (and if not why this was the case);
Information exchanged;
A succinct narrative of the nature of the discussion;
Any views the child expressed; noting for children who have communication difficulties, what support was available and/or how these views were gleaned (see also Guide to Communicating with Families - to follow);
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;
The quality of the relationship between the social worker and the child;
Make explicit reference to risk identified within the CP, CIN or Care Plan, and whether this risk remains relevant or has changed, reduced or increased;
A reason for this change and what actions are to be taken in response needs to be made explicit;
An analysis and evaluation of the outcome of the visit, commenting within the context of the Plan and the Review Recommendations;
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), case summary 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, decisions made by Agency Decision Makers/Panels, 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. (Note: care should be undertaken to ensure a breach of the Data Protection Act 2018 does not occur through the inclusion of information about others via reports and emails, etc.)

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 other children in the family is inevitable and desirable, but again, care should be taken in respect of such 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:

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;
The recording should seek a proportionate balance to reflect positive and negative aspects of a child or family's life;
The structure of the recording should readily distinguish between current and historical events.

6.5 Case Summaries

Every 3 months the case file recording should provide a succinct summary of the work undertaken, specifically linking progress to the Recommendation/Outcomes of the Plan. It therefore promotes accountability, an understanding of progress and continued planning.

It should also highlight fresh issues that have emerged, both strengths as well as concerns, and reflect how these have been dealt with as well as acknowledging the impact (or otherwise) of any new issues on the overall nature of the case.

The summary helps to bring together the outcomes of all the information and actions with the child/family and reflect/analyse/evaluate upon the progress of the intervention, including the child and family's levels of engagement with the intervention.

The summary, in 'putting the child at the centre' should reflect and have regard to 'what is life like for this child.'

It should also include outcomes of supervision on the case and consider appropriately the local authority's, and partner agencies, decision-making and the impact this may have had.

The Case Summary can reflect on Case Reviews and should comment on the focus of work for the forthcoming 3 months.

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.

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.

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

Information contained in the case record should usually be shared with the Data Subject 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, this information should be restricted and the reasons should be recorded after taking advice from a manager.

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 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 / Subject Access Requests Procedure.

10. Records Must be Kept up to Date

Records should be updated from detailed notes made contemporaneously following a visit or interview; as various information becomes available, or as decisions or actions are taken as soon as practicable or, at the latest, within 24 hours of the event. (See also: Section 1, Records Must be Kept on all Children).

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.

11. Records Must be Written Clearly using Plain Language and Avoid Prejudice

Records must be written clearly and concisely, using plain language, and in a way that recognises the right of the child or their parent/carer to 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. Records must 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 Access to Records / Subject Access Requests Procedure and Case Records and 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. If a child / young person feels that information in their record is not accurate, they have a right to request that it is rectified. Local authorities have 1 month to respond to any such requests and, if any such request is received, the authority should take reasonable steps to establish if the data is accurate and rectify the record if necessary.

Records must distinguish clearly between assessments, judgements and decisions. Records must also distinguish between first hand information and information obtained from third parties. Records must reflect the distinction between fact and opinion. Although it is admissible to record opinion, it must be recorded as such and not presented as factual.

It is very important when recording on LCS that information is accurate as well as complying with Information Governance requirements and being recorded in a timely way. For more detail on when recording should be completed by please see the CSC Practice Standards document (see Children's Social Care Service Practice Standards Procedure). Accuracy is important for performance management and business intelligence reports; for further guidance see Section 16, Project Accuracy.

Note: whilst 'cutting and pasting' techniques are generally not recommended, on those occasions where it is used, great care should be given to ensure that other parties' details are not included and that the context of the recording is appropriate and proportionate, (e.g. events that occurred some time ago do not reflect a current tense or disproportionate sense of relevance).

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.

Confidential paper documents should always be stored in a locked cabinet, or a similar manner, usually in an office which only staff have access to.

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 2018. 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

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

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 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 (2018). 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 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.

17. Project Accuracy

Through Project Accuracy, we are working to improve the quality of practice and recording of case work and have introduced new weekly reporting arrangements to reinforce monitoring of activity and compliance.

For further information, visit our Project Accuracy webpage (found on the local Intranet).

Also see the following guidance:

Please ensure you have completed the Information Governance eLearning (on the local Intranet), which must be refreshed annually.

LancashireChildren's Social Care Procedures Manual