Case Recording

1. Introduction

Recording is an essential task of Social Care teams within the Local Authority. It is the means by which there can be:

• Analysis of information and defining the needs of the service user;
• Appropriate care planning and the provision of services;
• Justification, explanation and accountability for actions;
• A permanent record (retained within the required time scales) of the service provided by Social Care within the Local Authority to service users and the information gathered to justify this as well as a record of the involvement of service users in formulating the service they receive.

The Local Authority carries out a number of functions, defined by statute, from assessing care needs and providing directly or arranging to provide a range of services to those who meet the eligibility criteria. There is no obvious collective term for all the various recipients of the Local Authority's Social Care services so, for the sake of simplicity, the term 'service user' is used throughout this document unless a more specific term is required.

2. Policy and Principles

3.1 Policy

Record keeping is central to the processes of assessment, decision making, service planning and delivery and as such must be given a high priority by staff members when planning their work.

All records will be kept electronically on Mosaic. Original documents and reports must be stored in the document management system (SmartOpen). All original documents received by Children's Social Care will be destroyed after scanning unless they are required for court purposes.

The only paper files generated will be those needed for specific purposes such as court work and adoption. Records will clearly show the nature of the Local Authority's involvement with service users, what decisions have been taken, by whom and on what basis.

3.2 Principles

Case recording is an integral part of the service to service users (and where appropriate to their carers). Children's Social Care will ensure that the case records and information held on those who make contact and are referred, assessed and receive its services meet the following principles:

• Case recording practice will reflect and demonstrate the Department's commitment to working in full partnership with service users and carers. The views of children and their families will be actively sought and carefully recorded so they can be central to planning services to meet their needs;
• Service users are informed of Children's Social Care policies on case recording, of their right of access to their case record and the procedures for doing so, in accordance with the Data Protection Act 1998;
• Service users are informed about decisions and outcomes of requests for services and will receive written copies of their assessment, care plans and reviews, as well as being kept informed at all stages;
• The Local Authority has protocols covering the Access of Third Parties To Information it holds on service users;
• Bracknell Forest Council actively promotes good practice in fair access for all and will ensure that case records identify special needs arising from ethnicity, race, culture, gender, age, religion, language, communication, sensory impairment, disability and sexual orientation;
• Bracknell Forest Council ensures their staff has appropriate induction, development and training opportunities to learn about good professional recording standards, the policies and procedures and how to put them into practice;
• In making it clear to staff Bracknell Forest's expectations and requirements relating to case records, systems are in place to ensure that practitioners achieve good professional standards. Furthermore, managers must ensure the Local Authority's requirements are carried out by routinely monitoring the quality of case records and efficiency of case recording practice;
• Case records must be kept in accordance with legal requirements and governmental guidance specifically addressing requirements for the work undertaken by each service area.

3. Case Recording Process

Information about service users is kept electronically. All original documents are scanned and stored electronically. Unless there is a legal or statutory imperative to retain them, the original documents are then destroyed.

All contacts and referrals and all personal information such as changes of address, school, placement, residence must be entered onto the system in the appropriate manner without delay. They will be held for the duration of the contact and after closure stored for the appropriate length of time (see Bracknell Forest Council Information Asset Register and Records Retention Schedule).

Holding service user files electronically makes the keeping of paper files redundant except in exceptional circumstances. These are as follows:

• In adoption cases where it is imperative to retain original documents and hold a paper adoption file and for 100 years following an adoption order in accordance with the retention and destruction schedule;
• Legal and important documents pertaining to looked after children such as the original birth certificates, care orders and other personal documents;
• Complex cases where documents and recording need to be kept together for a specific purpose such as attending an adoption or foster panel, child protection case conference or tribunal under the Mental Health Act. These files can be destroyed as soon as the work is completed;
• Paper files may be necessary when a complaint moves from a stage 1 to stage 2 or 3 for the duration of the process.

The requirements of the General Data Protection Regulation (GDPR) covers both manual and computer held records and has a significant impact on issues such as access to records and sharing information and disclosure arrangements. Staff Guidance is available on the intranet.

Service users have access to personal information about themselves wherever it may be located. See Information and Forms for Service Users Wanting to Access Their Records. Staff Guidance about dealing with Access to Records Requests is also contained in this link.

4. Case Recording Standards

These standards for the compiling of records held on service users within Children's Social Care apply to all teams and service areas. Where there are particular additional requirements relating to any one service area, details are given about the services to which these requirements apply.

4.1 Record Management

Each child will have a separate electronic record and unique electronic reference number when referred to Children's Social Care.

All children within the family will have relevant information added to their record. For Child in Need and Child Protection cases, siblings will have group steps on their records. Where an entry refers to more than one child such as siblings with separate records, other families, the worker must ensure it is added to all relevant files or appropriately cross- referenced on the relevant children's electronic record. All Children Looked After will have individual records.

The case notes system will be used to record the content of a visit, telephone call or supervisory discussion as well as to record that a meeting or review has taken place, the sending of letters etc.

Where children's information is sent via email this must be transferred into their electronic record. Any reply must also be transferred into the child's electronic record. Where children's personal information is sent outside Bracknell Forest Borough Council's internal e-mail system, the secure e-mail system must be used.

4.2 Accuracy and Timeliness

It is essential that every recording is:

• Accurate, including the use of spelling and grammar checks, and in a concise manner;
• Within timescales appropriate to the work undertaken;
• Easy to read and written in plain English so that service users can clearly understand the content;
• Contacts or event information concerning services users is recorded and dated (showing day/month/year and including the time of the event);
• Any decisions taken are recorded and clearly identified e.g. by using an appropriate heading in the recording.

Events must be recorded within 48 hours unless circumstances dictate otherwise e.g. child protection, matters relating to antisocial behaviour and where issues of risk and safety are involved, where recording must take place at the time/on the same day. Child Protection visits should be recorded as soon as possible or in any case within 24 hours.

Clear evidence on the record must show when copies of key documents (e.g. assessments of need, care plans, reviews, personal education plans, minutes of meetings) are supplied to service users.

Staff members will amend inaccurate information contained in a record in accordance with the service user's wishes unless independent evidence exists which refutes the service user's point of view. Any amendments should be clearly identified and the staff member making them also identified to ensure the integrity of the record. The date and time of the amendment will be recorded automatically by the electronic case management system.

Where there are differing views, reasons for any disagreement must be recorded.

4.3 Facts and Opinions

The case records will ensure:

• That evidence on which decisions are based is clearly shown;
• That records clearly distinguish between facts, opinion and analysis;
• That in each case any non-factual information must be clearly identified and recorded in a separate sentence or paragraph to factual information (see paragraph below).

Unsubstantiated and non-attributable information will be recorded on the file only if it is judged to be of current or possible future significance. The standing of this information must be absolutely clear. Attempts should be made to check its veracity as quickly as possible and to record the results.

Where there is unresolved disagreement with a service user about recorded facts, note this and record the service user's point of view as well.

4.4 Fair Access

Case records should reflect fair access principles and demonstrate sensitivity to the needs of all people in the community.

Case recording should identify issues arising from ethnicity, race, culture, gender, age, religion, language, communication, sensory impairment, disability, mental incapacity, sexual orientation and how these have been taken into account in applying eligibility for service criteria and care planning.

4.5 Relevance

The amount of information collected and recorded must be the minimum necessary for the particular purpose, but be complete, i.e. all essential information appearing to be relevant relating to a particular decision or purpose must be recorded. There must always be good reason for recording and continuing to hold any information on service users and third parties.

All recording must be relevant to:

• The service user's request for a service;
• The reason for the referral;
• The worker's assessment;
• Any service provided.

Dealing with the needs of children will lead to unique situations requiring sensitivity in what is recorded and in what detail. Individual teams and service areas will develop their own requirements regarding what is or is relevant to record. Staff members in any doubt should discuss this with their line manager or team manager.

There will be occasions where 'detailed' recording will be required and is likely to be used to cover what might be seen as significant events i.e. involving risk and safety, e.g. in child protection, and matters relating to anti-social behaviour. It should be born in mind that even where a detailed recording is required, this should still be as concise as possible.

4.6 Case Recording during Supervision

Where a decision is made as a result of a supervisory discussion, details of the reasons for and the evidence on which the decision is made must also be recorded by the supervisor in supervision and recorded on the case notes.

Dip audits by the supervisor occur prior to each supervision with a focus on case recording.

4.7 Participation of Children and their Families

The records will show that parents and children:

• Have been consulted;
• Have their views recorded;
• Have been informed of decisions and plans including how and when.

The following records should be routinely copied to parents, carers and children and young people if of appropriate age and understanding:

• CLA documentation including personal education plans (PEP's) and health plans;
• Minutes of reviews if appropriate (exceptions will occur if the child is placed permanently and it is not in the child's best interests to copy the review in its entirety to the parent or carer or the child has been placed for adoption and will come under the adoption regulations) core groups and planning meetings;
• Minutes of child protection conferences (minutes to be made available to young people at the discretion of the Chair – Child Protection);
• Key documents such as conference minutes and child protection plans should be translated and made available in an alternative format or language if required.

4.8 Cases where there are, or have the potential to be, legal proceedings

In some cases there will be involvement in legal proceedings both civil and criminal. In these cases the records of the Local Authority come under scrutiny of the courts and nothing is beyond their remit in terms of disclosure. (N.B. Legal advice must be sought when disclosure is required). All records in these cases must be clear, appropriate, up to date and detailed.

The following issues must be addressed in all recording:

• All recording for cases in court proceedings must be completed as close to the event as possible and within 24 hours;
• All handwritten notes of interviews with children or parents in the early stages of an investigation and those taken in joint investigations with the police must be kept and for safety scanned in case the originals are mislaid. The police have specifically requested this is done as they may be required in criminal proceedings. However, they may be required to be produced in any part of care proceedings even if a criminal prosecution is not relevant or pursued;
• Electronic records are admissible in court and can be requested in care/criminal proceedings;
• All family time/ contacts between parents and children must be clearly and fully recorded. If these arrangements are contracted to outside or agency workers the worker should be fully briefed by the staff member with primary responsibility for the case as to the expectations regarding the records that must be kept and ensure that a full written record of the contact is obtained. Records of contact are normally required for care proceedings;
• Discussion of legal issues or advice should be recorded as Mosaic case note type 'Confidential legal advice to LA' and legal advice documents stored to the relevant confidential legal folder in the document Management System so that this information is restricted to the key workers involved with the service user and the managers of the service.

4.9 ICS and scanned documents

Smart Office is the current electronic system for storing documents, reports, letters and hand written notes when appropriate. All documents are scanned into the document management system and can be accessed through the SmartOpen icon on your desktop.

It is important to ensure all scanned documents are clearly legible when scanned and the date they were scanned clearly seen on the original document and its authenticity verified. This task will be carried out by the administrative support staff.

A case note cross reference to a document being stored should be made on the service users file.

6. Information Sharing

With joint working, the number of partnerships involving the Council has increased over recent years. An important element in managing information is to understand when information can be shared lawfully.

Consent from service users for information sharing/gathering should be sought and obtained in writing, preferably using the BFC template.

The Council is party to information sharing or exchange arrangements, also known as Information Sharing Protocols.

On the issue of access to personal records for research purposes staff should first consult the Research Governance Guidance on the Intranet.

7. Monitoring Compliance with Standards

7.1 General Approach

All staff members have a responsibility to ensure that records are kept to the required standards set by legislation, central government guidance for Local Authorities and to the policies and protocols of Bracknell Forest Council.

The service user's allocated social worker or family worker is responsible for ensuring the case record is kept to the required standard and complies with the policy and procedural guidance on case records. Supervisors are responsible for monitoring this work and ensuring it is of a satisfactory standard, by checking that supervisory notes are included and regular monitoring/audits are conducted. Senior Managers are responsible for supporting supervisors in this task and ensuring that it is carried out.

7.2 Specific Responsibilities

• Social Workers or Family Workers will record visits to children and families using the template for CP/CIN and CLA visits and upload onto Mosaic;
• Child Protection & Child Looked After visits should be recorded within 24 hours and CIN visits within 48 hours of the visit occurring. If there are safeguarding concerns this should be recorded immediately / same day;
• Team Managers/ supervisors will dip audit their supervisees' case records prior to supervision. Monthly live audits will monitor supervision, management oversight and decision making;
• Team Managers will use Team Meetings periodically for their team to address the quality of case recording and address any deficit in the IT skills of staff members;
• Heads of Service in Children's Social Care will contribute to the regular, monthly live case file audits which include quality of recording;
• When a case is closed, stepped down or transferred to another part of the service, the record should be in good order and in such a condition that the essential details of the involvement of Children's Social Care and Adult's Social Care staff members with the service user can be clearly and easily seen. The chronology of involvement, the decisions taken, who took them and on what basis, as well as action following from these should be apparent, culminating in a summary of the situation at the point of closure/transfer, with reasons for closure/transfer. Evidence of service user involvement in the decisions about services which affect them is important and should be clear;
• The closure/transfer should be authorised by the appropriate line manager. This authorisation will indicate that the manager is satisfied that the condition of the records meet Children's Social Care requirements for case recording;
• The decision to no longer provide a service, step down or close a case should be recorded and the appropriate member of staff (key worker) responsible for that service user must ensure that the record is in good order.