1.9.1 Recording Policy and Guidelines

RELEVANT GUIDANCE

AMENDMENT

This chapter was updated in February 2019 when the link to Information Sharing advice was updated and text amended to reflect HHJ Greensmith’s comments regarding M and N (Children: Local authority gathering, preserving and disclosing evidence) [2018] EWFC 40 (1 June 2018).

Introduction
References
Record Keeping Values
Scope
Policies and Procedures
Recording “The Munro Review of Child Protection”
Principles
Chronology
Hazards
Restricted Records
Case Record Integrity
Roll Backs
Case Audit Forms
Security and Management of Information
Implementation
Monitoring and Review

Appendix 1: Recording Successfully - Avoiding the Pitfalls

1. Introduction

Recording is an essential aspect of providing a social work service. It is a tool for:

Gathering, organising and analysing key information to inform decision making and planning;
Reflecting upon and analysing information in order to develop and adjust plans;
Demonstrating openness with service users and evidencing their views and involvement;
Maintaining accountability within the organisation;
Transferring information to other agencies.

This document aims to provide a robust set of recording standards which enable employees to record information in a clear and consistent manner. The standards apply to existing and new records, whether stored in paper format or on electronic systems.

This document sets out a framework for consistent recording methods, underpinned by a common set of values which are to be considered when recording information in any format. This guidance is intended to benefit children and their families, as well as employees working in children’s services and its partner agencies.

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.

All social workers are responsible for completing social work records in a way which is timely, comprehensive and of good quality and must therefore follow this policy. Managers are responsible for ensuring that their staff adhere to the policy.

2. References

Children Act 1989;
Children Act 2004;
Data Protection Act 2018;
Freedom of Information Act 2000;
Caldicott Principles;
Human Rights Act 2004;
Mental Capacity Act 2005;
Information Commissioners Good Practice Guidance;
Working Together to Safeguard Children;
London Safeguarding Children Procedures.

3. Record Keeping Values

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

Appropriate records must be kept of all contact with children and their families/carers and a clear case summary and chronology should be maintained (see One Minute Guide: Chronologies).

There must be a consistent approach to all recording and records should be:

Accurate and concise;
Up to date;
Relevant;
Easy to read and in plain English, with any abbreviations explained;
Easily understood by the service user (whether this be the parent, carer or child).

Record keeping is key to providing integrated services to children, and their families and carers. Consistent recording processes are essential for service planning, decision making and information sharing. Quality recording will assist employees in the following ways:

Providing documentary evidence of the authority’s involvement with individual service users;
Providing information to assist with analysis, service/care planning and reviews and evaluation;
Documenting services provided to individual service users;
Allowing continuity when workers change or are absent;
Providing information when dealing with investigations or complaints;
Supporting supervision with employees development;
Providing service users with a complete record of their care and in some circumstances, for Looked After Children, their whole childhood.

All recording must be finalised within three working days of the event, unless a specific endorsed procedure includes a different timescale. In the event of a safeguarding issue it must be recorded and reported immediately. Where possible, children and their families/carers wishes and views (including issues around consent) must be noted and it should be evident that they were actively engaged during the activity.

Service users and carers are to be informed of their right to access their records and the procedures for doing so. Service users are encouraged to access their personal records and are supported in understanding the content, correcting errors or omissions and recording of any disagreement.

All recording should be evidence based with clear distinction between fact and opinion. Although it is admissible to record opinion, it must be recorded as such and not presented as factual.

Consideration must be given when recording race, culture, age, disability, gender or sexual orientation and how the needs of individual children have been acknowledged and supported.

4. Scope

This policy applies to all Children and Families Service social care records whether paper or electronic.

The main case recording tool is ‘Protocol’, where all information and contacts about work with individual children, young people and their families and/or carers where the threshold has been met for social work intervention. Additional paper files must only contain documents that need to be preserved in their original form e.g. Birth Certificates and legal documents setting out orders, such as Placement Orders.

5. Policies and Procedures

This policy should be read in conjunction with the Children and Families Service Policies and Procedures, held on tri.x. They include the following Policies and Procedures:

Access to Files;
Case Transfer Policy;
Case File Audit Policy;
One-to-One and Supervision Policy;
Life Story Work Policy and Procedures;
Email and Internet Policy.

6. Recording “The Munro Review of Child Protection”

In the Munro Review of Child Protection [1], Recommendation 31 says that Ofsted’s “new inspection framework should examine the child’s journey from needing to receiving help, explore how the rights, wishes, feelings and experiences of children and young people inform and shape the provision of services, and look at the effectiveness of the help provided to children, young people and their families.” The current Ofsted ‘Framework for the inspection of local authority arrangements for the protection of children’ [2] states that the inspection will focus on the child’s journey through intensive and extensive case sampling and case tracking.

[1] The Munro Review of Child Protection: Final Report (2011)
[2] Framework for the inspection of local authority arrangements for the protection of children (April, 2012)

7. Principles

The key principles that underpin good record keeping are:

Accuracy. Entries must be accurate and must distinguish between facts, opinions, assessments, judgements and decisions. Records must distinguish between first-hand information and information obtained from third parties;
Clarity. Recording should be clear and chronological. The reader should not be left with an interpretation of a recording that differs from the author’s meaning;
Relevance. Service users’ records should not include unnecessary material, messages or notes. Duplicate information should be kept to a minimum;
Timeliness. Entries should be written within three working days of the events actually occurring. Entries will be recorded by the date of the event, not the date of writing up, where appropriate;
Legibility. All recording should be written concisely, in plain English and avoid the use of professional jargon;
Responsibility. The management of information about service users is the responsibility of all employees of the Children and Families Service. The practitioner primarily involved, which is the person who directly observes or witnesses the event that is being recorded and 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;
Services Users’ Involvement. Entries will reflect that the views of child(ren), young people and their families have been actively sought and fully recorded. Also that they contribute their comments where they agree and/or disagree with professional opinion and these are recorded also. The means by which this information is obtained should also be recorded e.g. direct work with a child through use of play materials. Recording should be undertaken with a clear view of the reader in mind i.e. the service user. Care should be taken with both the content and the language;
Care must be taken when recording to ensure that confidentiality and the principles within the Data Protection Act 1998 are taken into account. Service users must be confident that information held about them will only be disclosed to others with their consent or when there is a legal duty or power to do so. In practical terms this means that information will be shared with other professionals who are involved in considering and responding to the needs of the individual;
When emailing or faxing information about service users it is important that staff ensure that information is transmitted accurately and securely. It is important that staff read the Email and Intranet Policy;
Any emails uploaded to the ’Documents Tab’ on Protocol or copied and pasted to ‘Case Notes Tab’ do not contain information relating to any other service user or any irrelevant communication between the sender and the recipient, including any disagreements between them. Uploaded emails must not take the place of case notes;
Confidentiality. Information will only be kept confidential from a service user for specific reasons e.g.
- Where disclosure of the information is likely to result in serious harm to their physical or mental health or to that of another individual (including a member of staff);
- Where disclosure would identify a third party who has not consented to being identified (this does not apply to third parties who have provided information in a professional capacity);
- Where disclosure would be likely to prejudice the prevention or detection of crime.
Consent. Written consent should be gained from a service user before any personal information relating to them is sought from other sources. However, a service user’s consent to disclose their personal information or seek information from other agencies is not required in instances where the law or public interest overrides their right to confidentiality. These include:
- If there is a concern about an individual’s safety;
- Where the courts have made an order;
- To prevent, detect or prosecute a serious crime.
Sharing of information. In situations where a request is made to or by another organisation, to share information the decision to share or not to share regarding who made the decision and the reasoning behind this, should be recorded;
Staff should include their full name, designation (e.g. Manager, Social Worker, Senior Practitioner) and team on every document on Protocol;
Where an interpreter is used this should be recorded, giving their name and whether they were from a contracted service or a named staff member, family member and/or friend;
Management oversight must be evidenced. The line manager should routinely audit files in accordance with Case File Audit Policy. Relevant sections of the record must be endorsed, and issues of concern of actions identified during the course of the audit recorded on the appropriate record;
Recording of decision-making to highlight the reasons for the decision-making and the decisions made, including assessing risk and why other decisions were not made, should be clear. All of the people who take such decisions should be identified and where necessary a copy of the signed decision should be uploaded onto Protocol. Every decision arrived at between supervisor and worker, whether in a formal or informal supervision session, must be recorded in the service user’s case recording at the time of the decision being made. Managers must also use supervision to ensure that the case record is being maintained in a reasonable state;
Anti-discriminatory practice. All records must demonstrate an anti-discriminatory perspective and must not include any derogatory comments by the author on ethnicity, race, culture, gender, age, religion, language, communication, sensory impairment, disability, family make-up and sexual orientation;
Sharing of case records should be routinely undertaken with children; parents and/ or their carers.

8. Chronology

A chronology is a sequential list of events (including positive changes and achievements) with dates, recording all significant changes in a child or young person’s life. A chronology should cover events that will be of specific interest to a child or young person in later years. It is the responsibility of the child’s allocated social worker to write up and maintain the chronology.

Chronologies start from the child’s birth or before birth where there is a significant event such as the death of an older sibling before the child was born, or a pre-birth assessment.

The chronology is a useful way of gaining an overview. It should be used as an analytical tool to help understand the impact of events both immediate and cumulative of events and changes on the child or young person. It can help inform the assessment and decision making. A chronology should be updated regularly. Please note that chronologies prepared for court may be more extensive than and in a different format (e.g. Template) to the Protocol version.

9. Hazards

Working with service users may on occasion give rise to the need to record a ‘Hazard’ on Protocol. The purpose of a Hazard alert is to provide a warning, for example about the recorded characteristics, behaviour or circumstances of a child or adult where these might give rise to a risk of harm to our staff or others. The list of Hazards is on Protocol; examples of Hazards are ‘Dangerous Pet’, ‘Persons Known to be Violent’ and ‘Need to Protect Information’. To ensure consistency of decision-making only Heads of Service can make the decision for a Hazard to be recorded and then record it. Hazards are recorded within the Risks Tab on Protocol, where Allegations and Offences as well as Risks to Children and MAPPA (Multi-Agency Public Protection Arrangements) can also be recorded. It is mandatory to record the date the Hazard started or was first known about and to describe the Hazard further in the free text box. This should refer to a specific dated case record(s) or document(s) in Protocol that details the concern, describes the risk, and notes which Head of Service agreed the Hazard record. Hazards must be reviewed by a Head of Service within six months of being recorded and at least six monthly thereafter.

10. Restricted Records

Staff must only access service user records appropriate to their allocated caseload and/or work or management responsibilities. However, there are some situations in which access to particularly sensitive records must be restricted to proactively prevent them from being accessed inappropriately. Examples of such records are those that relate to employees of the Children and Families Service or children who have been or who are in the process of being adopted.

Adoption records will be restricted at the point when a child is matched with their prospective adopters to prevent inappropriate links being made between the child’s birth and adoptive families. In these cases access will be restricted to the case worker, their team manager and the team’s senior practitioners, the Adoption Team Manager and the Independent Reviewing Officer (IRO). In non-adoption cases case files will be restricted to the caseworker, their team manager and their senior practitioner (if the caseworker is supervised by the senior practitioner) and the IRO (if the child/young person is a looked after child). The decision to restrict a record will be made by the Head of Service although in the Child Protection and Assessment Team this responsibility may be proactively delegated to the Duty Manager.

If a member of staff attempts to access a restricted record inappropriately the ICS Helpdesk will contact the Head of Service for the area in which the record is based, who will ascertain if there has been an intention to breach confidentiality.

11. Case Record Integrity

When information has been entered onto Protocol it should not be deleted. This is because subsequent records will have been written based on, or in the light of, that information and to remove it could render subsequent records incomprehensible.

If information needs to be amended or corrected this must be done in a new Case Note and recorded by the Team Manager with the correct information and reason for case recording being amended.

12. Roll Backs

Where it is necessary to correct a process related matter, such as the date that an assessment was authorised or where a decision has been ‘clicked on’ inappropriately, the ICS helpdesk can “roll back” a record to a specific point in time to allow this to be done. Given that casework records cannot be removed (see Section 11, Case Recording Integrity above) ‘roll backs’ will be exceptional and must be agreed by the appropriate Team Manager (or agreed delegated cover), with the relevant Head of Service monitoring the frequency of such requests.

13. Case Audit Forms

Completed audit forms will not be stored on Protocol but a Case Note will be entered by the auditor to state that an audit has taken place, the type of audit, who undertook it and the date that it was undertaken. Any actions arising from the audit will also be noted. The exception to this is the case transfer audit which is uploaded to evidence that the case is ready for transfer to another team.

14. Security and Management of Information

All staff should ensure that they log out of Protocol when not actively inputting or away from their desks. Any paper-based information must not be left open or easily accessible at any time.

The Children and Families Service has adopted a policy on ‘Access to Files’ which explains in detail the actions to be taken when a member of the public requests access to case records or a paper file.

There will be occasions when information about service users is requested by other local authorities. Such requests must be decided in the light of the requirements set out in the Data Protection Act 1998 and may be referred to Legal Services for advice.

As part of the process of information management, Team Managers, Senior Management and the Quality Assurance Team conduct case file audits at regular intervals to monitor the effectiveness of case file recordings.

15. Implementation

This policy shall take effect immediately and supersedes the Social Care Recording Policy April 2012 (CT36).

All managers should ensure that staff are aware of this policy and its requirements. This should be undertaken as part of induction and supervision. If staff have any queries in relation to this policy they should discuss this with their line manager in the first instance.

16. Monitoring and Review

The Children and Families Service Management Team (CTMT) will review this policy every two years unless changes in legislation determine otherwise.

Appendix 1: Recording Successfully - Avoiding the Pitfalls

Pitfall	How to Avoid it
Case Notes are out of date	Recording is an important task, not just for the Children and Families Service but for the child and their family or carer, even when what you are writing does not directly involve them. It is better to record as you go along because keeping information in your head to be recorded later may result in crucial information being lost. Allocate time for recording to minimise interruptions, remembering that all recording should be completed within three working days.
The child is ‘missing’ from the records	The child is a person not an object of concern and it is crucial that their wishes and feelings, their views and understanding of their situation are recorded. If this does not happen it suggests that no work has been undertaken with the child or that the child has not been an active partner in any work. Ensure that you see the child alone and record what the child says in their own words. It is important to observe a child’s body language as children communicate through their actions as well as words. Explain any tools you use and drawings etc. can be uploaded onto the file.
You can’t tell the difference between fact and professional judgements	Records should contain both facts and professional judgements but they should be clearly separated and not mixed up throughout the case notes so that it is difficult to tell which is which. If professional judgements (or opinions) are accepted as facts then they can unduly influence the management of the case. Use the sections of the case notes to help you by recording the facts in the detailed notes section, put your professional judgements and analysis (see below) of the situation in the analysis section and then note any actions in the actions section.
The record is not used as a tool for analysis	Case recording is a valuable social work tool, not a casework diary. Do not record simply what has happened but use analysis to move beyond this to hypothesise and explain why particular situations and events are occurring. Using recording for analysis requires you to assess the weight of the information gathered and to do this you need to draw on your knowledge from research and practice together with an understanding of the child’s needs. Record this in the analysis section of the case notes.
There is too much to read	It is important to maintain a clear focus in your recording. Record significant information, using research and supervision to assist you in identifying what is and what isn’t significant. Consider using the structure of the plan for working with the child to structure your recording. Cross reference rather than duplicate. The larger the record the more difficult it is to locate key information and identify patterns within the child’s life.

End