Case Recording Policy
SCOPE OF THIS CHAPTER
This chapter provides the context for all procedures.It contains the overall policy for the provision of services to children and families. It also sets out underlying values and principles for recording, confidentiality and consultation.
1. Recording Values and Principles
- Case records must be kept on all children
- Best Practice Guide to Recording
- Timescale Framework for Recording
- Children and their families must be informed about their records
- All relevant information about children and their families must be recorded on LiquidLogic
- Children and their families should be involved in the recording process
- Information about children and their families should normally be shared with them
- Managers must monitor information in the 'Restricted Access' section of the child's case record
- Records must be kept up to date
- Records must be written clearly using Plain Language and Avoid Prejudice
- Records must be accurate and adequate
- Records must be relevant and not excessive
- Managers must oversee, monitor and review records
- Records should be kept securely
- Removal of records must be an exceptional occurrence
- Records moved to a new location must be monitored
- Records must usually be retained after closure
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.
Each child must have his or her own individual case record from the point of referral: primary case records are held electronically on LiquidLogic but Adoption records may be in paper form.
The following is a best practice guide as to how to go about case recording:
What is the Purpose/Reason for Contact?
- What is the purpose of the case record? – Title the case record in accordance with the SERCO protocol for LL documents;
- If you are undertaking a home visit, state why?
- Ensure your case record is clear about what you have seen and heard and that the record reflects the purpose of your visit;
- Ensure your record contains details on seeing the child.
Open Recording and Reflective Practice with Families
- Where possible, record openly;
- Towards the end of your visit reflect with the child/family on what you have discussed and heard;
- Let the family know what you intend to write down;
- Let the parent/s, carer, child know what actions you are proposing;
- Ask for their view on what you intend to record is, whether they agree or do not agree and note their comments.
Content/Detail of Recording
- Who you have seen, children and adults, and whether you have seen the child/ren alone?
- What you saw, e.g. rooms, home conditions, observations of interactions between household members, visitors;
- What practice tools you used and how the family responded;
- What issues were discussed, advice given;
- The child's story as they have told it to you. This includes the child's views, wishes and feelings about what they would like to happen both now and in the future;
- What challenges were made to the family and how did they respond;
- Any safeguarding/risks or issues.
Style of Recording
- Be concise whilst documenting important detail;
- Use bullet points to list issues;
- Write in plain English, avoiding long and complicated sentences and words;
- If you need to use a specialist term, ensure that this is explained;
- Assume the reader does not understand local jargon and acronyms;
- Ensure that the record is based on evidence;
- Where professional judgement is being used to interpret a situation, state this and explain the rationale behind the professional judgement;
- Ensure that the child's voice is clearly recorded and provide the context within which this was obtained.
- Weigh up the issues, challenges and other information you have obtained against the purpose of your visit/contact;
- Consider the strengths of the situation set against any concerns or risks and what impact these issues will have on the family;
- How is the family progressing towards the plan and the outcomes we are trying to achieve.
- Using your analysis, determine what actions are needed next;
- Also consider any other actions to take forward;
- Consider how to fold these actions into the plan SMART-ly.
All Case Recording should be timely. Below is the framework for timeliness of recording. Compliance with this framework will ensure that all legislative and regulatory requirements are met and that services and actions are planned and monitored based upon accurate and timely data.
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.
Please see Information leaflet 'Access to Your Records'.
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.
For children, the Directorate's records are one of the most detailed accounts of large parts of their lives. It is important, therefore that this information is gathered and kept in such a way that they are able to gain the maximum understanding and benefit from it.
It is the responsibility of workers to ensure that children know about their lives and are given access to this information when they are sufficiently mature to cope with it.
Every child's record must include basic information, an assessment, analysis of any risks, a properly maintained Chronology and a transfer/closing summary (where appropriate).
All relevant contacts with children, their families, colleagues, professionals or other significant people must be recorded on LiquidLogic, i.e. who was present or seen, the relevant discussions, actions or decisions taken.
E-mails should be uploaded into the case notes section of LiquidLogic.
Records of decisions must show who has made the decision, the reasons why it has been made and the evidence upon which it is based.
Case summaries should be updated whenever there is a significant change in the plan or at no longer than two monthly intervals.
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.
Generally, they must be asked to give their agreement to the sharing of information about them with others - but there are exceptions.
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;
- The information is relevant to the prevention or detection of a crime and to release it would prejudice the investigation.
In relation to adoption, see Access to Birth Records and Adoption Case Records Procedure.
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 Access' section of the child's record and a note of the lodging of the document, together with reasons, should be recorded.
Managers must monitor information held in the 'Restricted Access' section of files, ensuring that the reason for holding it there is valid; if not, it should be shared with the child and/or moved to another section of the record.
Records should be kept up to date with any new information from detailed notes made contemporaneously following a visit or interview; as it becomes available, or as decisions or actions are taken. Any change of address, change of school, change of responsible social worker and/or the start/end of particular services should be updated on LiquidLogic as soon as practicable or, at the latest, within 24 hours (see also: Section 1, Case records must be kept on all children).
The sooner the record is updated, the more accurate it is and the better evidence it provides.
Records must be written clearly and concisely, using plain language, and 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 and abbreviations must be kept to a minimum; and if there is likely to be any doubt of their meaning, they must be defined or explained.
It should always be remembered that clients have a right of access to their records and records should be written with this in mind. It is anticipated that as much information as possible will be shared with clients as part of working with them.
Records must be accurate and distinguish clearly between facts, opinions, assessments and decisions.
Opinions should have a clear indication as to their foundation. 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 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.
Unsubstantiated comments have no place in records unless the source and truth of comment are also recorded as far as they can be determined.
If a member of staff receives information from an anonymous source, this fact must be recorded together with a record of the social worker's attempt to verify the information and the extent to which it was successful or unsuccessful.
Only the information needed to do the job should be collected - don't ask for things because you think it would be 'nice to know'.
The overall responsibility for ensuring all records are maintained appropriately rests with managers with day-to-day responsibility, delegated to other staff as appropriate.
Files must contain evidence of management oversight/endorsement of decisions, which should support work and ensure accountability. Decisions made in supervision should be clearly recorded and held on the child's record.
The 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.
All members of staff have a responsibility to ensure that the information contained in records is kept securely.
This involves preventing unauthorised access by keeping passwords secret and protecting electronic records from corruption caused by hardware faults or a virus.
Children's paper records should normally be stored in a locked cabinet, or a similar manner, usually in an office which only staff/carers have access to.
These records should not be left unattended when not in their normal location.
Paper records are only held on Adoption cases. These should not normally be taken from the location where they are normally 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.
Where records are moved to a new location, the date of transfer should be clearly recorded on LiquidLogic.
The sender should check that the records have arrived at their intended destination.
Files should be retained for the period set out in the Case Records and Retention Procedure.
The member of staff responsible for the case when the case is closed is responsible for ensuring that the record to be retained is in good order and that unnecessary items have been removed, for example, duplicate copies.
2. Confidentiality Values and Principles
- Personal Information is subject to a legal duty of confidence;
- Disclosure of confidential information is permitted in exceptional circumstances;
- Informing children about disclosure;
- Disclosures and sharing information with colleagues and agencies;
- Freedom of Information Act 2000.
Personal information held about children is subject to a legal duty of confidence and should not normally be disclosed without the consent of the subject.
The legal framework for confidentiality is contained in the common law duty of confidence, the Children Act 1989, the Human Rights Act 1998 and the Data Protection Act 1998.
The law requires that data must be:
- Fairly and lawfully processed
'Processing' includes obtaining, recording, changing, using and disposing. Personal data cannot be processed unless the conditions of the Data Protection Act 1998 are met, usually by obtaining the person's consent to the processing;
- Processed for limited purposes
We must be open about how information is to be used and not use it for any other purpose;
- Processed in line with the rights of the individual
We must inform them that processing is taking place, allow them to inspect any personal data we hold about them and correct or erase information that we are told is wrong.
Whilst the general principle is that information obtained about children must be shared with them and not with others, there are exceptions. The public interest in child protection overrides the public interest in maintaining confidentiality and the law permits the disclosure of confidential information necessary to safeguard a child or children.
Disclosure should be justifiable in each case, for example to provide information to professionals from other agencies working with the child, and where possible and appropriate, the agreement of the person concerned should be obtained.
Those working with children must make it clear that confidentiality may not be maintained if the disclosure of information is necessary in the interests of the child. Even in these circumstances, disclosure will be appropriate for the purpose and only to the extent necessary to achieve that purpose.
There may also be situations where third parties have a statutory right of access to the information or where a Court Order requires that access be given.
The circumstances in which information held in records on children and families can and should be disclosed and shared with others with or without consent are set out in the following sections.
In all other cases, where third parties such as advocates, solicitors or external researchers request access to information, this should only be given if written consent is given by the person concerned.
Children should be informed of the circumstances in which information about them will be shared with others. It should be made clear that in each case the information passed on will only be what is relevant and on a 'need to know' basis.
Sharing information promptly with others working with the same child, or who may need to know, is invariably the key to safeguarding the child's interests.
Therefore, relevant information about children must be shared with colleagues, other professionals or agencies that may have a role to play in their care.
However, the general principle is that information may only be shared on a 'need to know' basis.
- Where professionals are undertaking a Section 47 Enquiry in relation to a child;
- Where the Police are investigating a criminal offence or require information to help them find an absent, missing or absconded child;
- Where information is requested in the furtherance of an inquiry or tribunal, or for the purposes of a Serious Case Review.
In such circumstances the person to whom the information relates should be informed that records have been requested unless to do so would prejudice the purpose of the request.
Any objections they have should be considered before responding to the person making the request.
Where information or records are passed to others it should be noted and confirmed in writing.
Information may also be disclosed to persons who have a statutory right of access to the information, for example:
- Where the Court directs that records be produced or a Children's Guardian is appointed;
- Where information is requested by the Regulatory Body (who have specific statutory powers that permit access to records).
Where information is requested by telephone or electronically, great care must be taken to ensure that the recipient is entitled to receive the information requested. Where there is any doubt the information may not be provided without the approval of a manager. In any event, a member of staff must not hand over information to anyone unless satisfied that:
- The person/agency is entitled to that information;
- The identity of the person/agency can be established without any doubt;
- The person/agency will maintain an appropriate ethical approach to the confidentiality of the information provided.
The Freedom of Information Act 2000 came into force on 1 January 2005.
Under the Act anybody may request information from a public authority (which includes all local authorities). The Act confers two statutory rights on applicants:
- To be informed in writing whether or not the public authority holds the information requested; and if so;
- To have that information communicated to him/her.
The Act applies to all information whether recent or old.
The Act sets out 23 exemptions from rights of access to information. If the information is exempt, there is no right of access under the Act.
One exemption relates to personal information. This means that an application for personal information under the Act is exempt and will not therefore be dealt with under the Act. A person's right of access to such information must still be dealt with in accordance with the Data Protection Act 1998.
Another category relates to information provided in confidence where disclosure would involve an actionable breach of confidence. This would include information provided by a member of the public about a child protection issue where the provider has provided the information on the basis that anonymity will be maintained.
The Act therefore does not change the legal position into the principles of confidentiality set out in this section.