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)
AMENDMENTThis chapter was amended in June 2020 to reflect the Ofsted Twitter Blog of 24/7/19 by Yvette Stanley, Ofsted's National Director for Social Care. The Blog highlights feedback from a number of inspections and explores what good recording should look like. (Ofsted: developments in children's social care – What makes an effective case record?).
1. Records Must be Kept on all Children
Children's case records are a valuable tool to demonstrate accountability for the quality of practice and decision making in Children's Services and the lasting impact it has on the lives of children, young people, and families in Wandsworth.
Child focused recording is a key practice standard in delivering outstanding practice
Children's records must capture a clear and comprehensive overview of critical moments for the child and family in a thoughtful and compassionate way. They must be accurate, respectfully written, well organised and contribute to delivering good outcomes.
Under the Data Protection Act 2018 and GDPR, it is the Right of individuals to Access their Personal Data; commonly known as making a Subject Access Requests (SAR) By working with families and sharing records as they are created we hope to minimise the need for parents to request access to their children's records but there will be times when they request formal access. Care experienced adults also request access later in life to make sense of what happened to them as a child. To this end children's case records must be maintained to the highest standard, accessible and helpful to people who experience practice.
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 13, Records Must 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. 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'.
The Mosaic Overview Group 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 should be told what types of information/data is contained in their case records. The Privacy Notice is in information packs and can also be accessed here.
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 the record to ensure its accuracy.Records of decisions must show who made any decision as well as the basis on which it was made.
5. All Relevant Information about Children and their Families must be Recorded
The Person Summary in the child's record which holds the child's personal details must be completed to a high standard and kept up to date. All other aspects of the child's record must be written and maintained with the child in mind. The link below will take you to the Mosaic User Guides that will assist
5.1 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, noting for children who have communication difficulties, what support was available and/or how these views were gleaned;
- 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;
- 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.
5.2 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, 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 siblings is inevitable and desirable, but again, care should be taken in respect of sibling information that becomes available on the record.
5.3 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;
- The Child's Plan must be Specific Measurable Agreed Realistic Timescales;
- 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.
5.4 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 level 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.
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.
7. 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, 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.
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 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 / Subject Access Requests Procedure.
9. 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.
10. Records Must be Written Clearly using Plain Language English 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 their record (both 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.
11. 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 facts, opinions, assessments, judgements and decisions. Records must also distinguish between first-hand information and information obtained from third parties.
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).
12. 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.
13. Records Must 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.
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.
14. Removal of Records
14.1 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.
14.2 Records Moved to a New Location Must be Monitored
Where paper records are necessarily moved to a new location, the date of transfer should be clearly recorded in the file location section on the child's personal details screen should be kept up to date with the movement of any related paper files.
The sender should check that the records have arrived at their intended destination.
15. 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.