Case Recording and Policy Guidance

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.

All case 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;
• 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;
• Pan Berkshire Child Protection 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.

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.

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's Service social care records whether paper or electronic.

5. Policies and Procedures

This policy should be read in conjunction with the following Policies and Procedures:

• Access to Files;
• Case Transfer Policy;
• Supervision Policy;
• 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; See Section 17, Recording Timescales Table for further information in relation to this.
• 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 West Berkshire Council. 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 UK General Data Protection Regulation and the Data Protection Act 2018 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 Internet Policy;
• Any emails copied and pasted to 'Case Notes' on Raise 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 Care Director;
• 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 Programme. 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 Care Director. 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.

9. Risk Alerts

Working with service users may on occasion give rise to the need to record a 'risk alert' on Care Director. The purpose of a risk 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 risk alerts are on Care Director; examples of these 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 risk alert to be recorded. Risk alerts are recorded on Care Director on the front screen, 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 risk alert started or was first known about and to describe the risk alert further in the free text box. This should refer to a specific dated case record(s) or document(s) in Care Director that details the concern, describes the risk, and notes which Head of Service agreed the risk alert record which 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's Services 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 relevant Head of Service although in the CAAS Team this responsibility may be proactively delegated to the Duty Manager.

11. Case Record Integrity

When information has been entered onto Care Director 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.

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 Care Director 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 'roll backs' will be exceptional and must be agreed by the appropriate Team Manager (or agreed delegated cover), with the relevant Service Manager monitoring the frequency of such requests.

13. Case Audit Forms

Completed audit forms will be stored as an attachment on Care Director 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 case transfer audit should also be attached to Care Director to evidence that the case is ready for transfer to another team with a Case Note entered on the relevant date.

14. Security and Management of Information

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

West Berkshire has 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 UK General Data Protection Regulation and the Data Protection Act 2018 and may be referred to Legal Services for advice.

15. Implementation

This policy shall take effect immediately and supersedes any previous policies.

16. Monitoring and Review

The Children and Families Management Team (CFLT) will review this policy every six months unless changes in legislation determine otherwise.

17. Recording Timescales Table

Child Protection

Child in Care & Care Leavers

Other Case Recording

Appendix 1: Recording Successfully - Avoiding the Pitfalls

Appendix 2: Adoption Files

Adoption records refer to any records about a child. This is the point at which the care plan for adoption is agreed.

The policy states that an additional red paper file should be opened to record any information regarding the family finding and adoption process. These records are also placed on Care Director. The child's social worker will continue to record discussions (case notes and attachments (e.g. planning meeting minutes)) about the family finding process. The child's social worker will need to take care that they do not record any identifiable details about the prospective adopters being considered for a child until a match is agreed. This is very important as the identity of families needs to be protected should a match not be agreed.

If a match is agreed for a child, the records will need to be restricted from this point to prevent inappropriate links being made between the child's birth and prospective adoptive families. The social worker would also need to take care that the adopters Care Director records are restricted and do not reflect their whereabouts.

In such cases access will be restricted to Social Worker, the Team Manager and Assistant Team Managers, the Adoption Team Manager, Post Adoption Worker and the Independent Reviewing Officer (IRO). 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.

The restricted Care Director records should reflect the following (although not exhaustive):

• Case notes (up until the Adoption Order is granted);
• Supervision recordings;
• The Prospective Adopter/s Report;
• Matching documentation;
• Minutes of the Adoption Panel and subsequent ratifications;
• Introduction documentation;
• LAC reviews;
• Reports regarding any pre-order services required;
• Any subsequent court proceeding or parents attempts to prevent the adoption;
• Copy of the Later Life Book and Later Life Letter;
• Correspondence.

Following the adoption the Care Director record needs to be closed and will be deemed as the child's birth record. The Post Adoption Team will open a new restricted record for the adopted child and their adoptive family and offer support.

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.