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'.
This chapter was amended in June 2020 to reflect a Blog written 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
The child's record is an important source of information for them as well as a tool for planning actions and interventions. It provides information about the sequence of events which brought about Children's Social Care's intervention into their life, and should explain the reasons for important decisions which were made in relation to the child and / or their 'family'. This record can be key to helping a child understand themselves and their past – especially in those cases where the child was unable to live with their parent/other long term carer.
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 their own electronic case record from the point of referral to case closure; audio, video and digital recordings may also be kept.
Where paper files are also kept, information held in electronic records must accurately reflect the corresponding information recorded within paper files.
Records held on paper may extend to more than one volume. Where more than one volume exists, the dates covered by each volume must be clearly recorded on the front cover.
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 Should 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 relevant Service Director or Assistant Service Director, must approve the design of all records and forms before coming into use. This authority can be delegated to relevant Head of Service where appropriate.
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.
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.
Click here to view the Council's Privacy Notices.
Where children have been adopted, see also Access to Information (Post-Commencement Adoption Orders) (Adoption East Midlands).
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
Every child's case record must hold details of the child's full name, date of birth, current location and any identification number.
Care should be undertaken to ensure the spelling of names is accurate, dates of birth are correctly recorded, and, where possible, evidenced e.g. birth certificate. In some instances, key information may change and it is important the record should reflect the current circumstance of the child / family.
Other professionals and partner agencies providing information/reports should be made aware that information provided by them may well be included on the child’s file and that this could be accessed by them.
5.1 The Basic Record
- Names and details of everyone who lives in the family home with the child, identifying the person who has Parental Responsibility;
- Where the child does not live at their home, the details of the Placement / arrangements and the legal status of the child;
- Names and details of anyone particularly close to the child with whom they have a lot of contact;
- Information about the child and /or family’s communication needs;
- A record of managers' decisions and reasons for making them;
- Details of arrangements for contact;
- Details and, where appropriate, copies of any Orders made on the child;
- Copies of reports provided during court proceedings, including specialist assessments, the Children's Guardian, etc;
- Additional information about educational progress and where the child is Looked After, the Personal Education Plan (PEP);
- Where a child has Special Educational Needs or Learning Disability, copies of any relevant information, including the Education, Health and Care Plan;
- Appropriate information about the child's health, and where the child is Looked After, a copy of the Health Plan and Assessment;
- Details of any arrangements for the responsible authority's functions to be undertaken by a private provider, e.g. an independent fostering agency or provider of social work services;
- Copies of all documents used to seek information, provide information or record views given to the authority in the course of planning and reviewing the child's case and review reports; and
- Record of visits and contacts by all practitioners as well as the allocated practitioner.
5.2 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 in response to missed visits under the Children's Social Care Services procedure guidance.
5.3 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. The record should also explain 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.
5.4 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;
- Recording should be made of the Review meeting's recommendations / outcomes that are trying to be achieved with a child and their family, key tasks, by whom and timescales;
- The recording of interventions and actions should seek to identify which 'Recommendation' or Outcome they relate to;
- 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.
5.5 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.
Information can be shared with the consent of the child and family. Consent means offering individuals real choice and control. Information can be shared without consent where there is a legal obligation or where the Local Authority is performing a task carried out in the Public Interest. Information sharing decisions should be based on a consideration of the safety and well-being of the person and others who may be affected by the sharing.
Public authorities and employers will need to take extra care to show that consent is freely given, and should avoid over-reliance on consent as there may be another lawful basis to share this information.
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;
- 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 Information (Post-Commencement Adoption Orders) (Adoption East Midlands).
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 identify and monitor confidential information held where there is a restriction on sharing it with child or family, 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 from detailed notes made contemporaneously following a visit or interview; as various information becomes available, or as decisions or actions are taken as soon as practicable or, at the latest, within 24 hours of the event (see also Section 1, Records Must be Kept on all Children).
The electronic case management system (Mosaic) records the date and time of data entry, however reasons for late entry should be recorded.
10. Records Must be Written Clearly using Plain Language and Avoid Prejudice
Records must be written clearly and concisely, using plain language, and in a way that recognises that the child or their parent/carer have a right to access their record (either 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. In certain circumstances local authorities need extra time to consider your request and can take up to an extra 2 months. If it is going to do this, it should let you know within 1 month that it needs more time and why.
Records must distinguish clearly between assessments, judgements and decisions. 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.
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 Should 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 work 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. Information Security Incidents or Breaches of Confidentiality
If you discover an information security incident you should report it immediately to your line manager, or whoever is deputising on his or her behalf, and ensure it is recorded on the online Service Desk Security Incident Reporting system.
You or your line manager should then take all "appropriate steps" to mitigate the impact of the information security incident i.e. lock away the confidential document that has been left on a printer until someone collects it, arrange collection of a confidential document sent to wrong address or contact the police if a laptop has been stolen.
If you need advice on what are "appropriate steps" to mitigate a information security incident please contact the Children's Services Information Governance Team on 01629 532011 or e-mail: email@example.com.
Additionally your line manager should immediately inform the relevant Head of Service if any of the following applies:
- Inappropriate information has been disclosed to a external agency or member of the public;
- The information security breach could endanger an individual or individuals;
- The information security breach may require the suspension of a member(s) of staff pending an investigation; or
- If the security breach may cause significant harm to the reputation of the council.
The relevant Head of Service should liaise with the Children's Services Head of Information & IT and relevant Children's Services SMT member in these circumstances over the response.
The Head of Children's Services Information & ICT will also notify the relevant member of Children's Services SMT if there are a series of minor related security incidents (i.e. three or more similar incidents by same individual, team or location in three month period).
Details of the incident will be passed to the Head of Children's Services Information & ICT Service or delegate by the Corporate Security Team who will then:
- Create an electronic record in the Children's Services Data Security Incident Investigations folder using the allocated incident number e.g. CAPA 999
The investigation will then be assigned to an appropriate investigator on the following basis:
- Head of Children's Services Information & ICT Service or delegate will investigate any breaches that may:
- Endanger an individual or individuals;
- Require the suspension of a member(s) of staff pending an investigation;
- Cause significant harm to the reputation of the council.
- A member of the Children's Services Information Governance team will investigate any other breaches not covered by above criteria
The investigator will then:
- Obtain details of the incident, how it occurred, if any data was lost or disclosed inappropriately and what action has been taken to mitigate the impact of the breach issues;
- Establish what actions and/or procedures have been put in place to reduce risk of breach being repeated; and
- Make recommendations on further action.
(Please note the investigator's role is not to recommend what disciplinary action should be taken against individuals, it is to record the facts of the incident and lessons to be learned, the investigator may recommend however that an incident should be referred to CS HR)
Lessons Learned Process
A report on the investigation will be passed to Head of Children's Services Information & ICT Service or delegate who will:
- Agree to recommendation of No Further Action (if appropriate);
- Refer back to investigator for further investigation (if appropriate);
- Refer recommendations to appropriate services that require immediate action; and
- Include recommendations in quarterly report to CS SMT on lessons learned. The quarterly report will include an action plan with deadlines for CS SMT to authorise.
Recording and Closure
The Children's Services Information Governance team will ensure all investigations are recorded appropriately and indexed.
When satisfied that the incident has been investigated appropriately the Head of Children's Services Information & ICT Service or delegate will close the incident on the Council Security Incident Recording system.
15. Removal of Records
15.1 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. Under UK GDPR if a breach is likely to result in a high risk to the rights and freedoms of individuals, you must inform those concerned directly and without undue delay.
15.2 Records Moved to a New Location Must be Monitored
Where records are necessarily moved to a new location, the date of transfer should be clearly recorded.
The sender should check that the records have arrived at their intended destination.
If records are moving because of a case transfer an audit should be carried out by a manager prior to transfer to ensure all relevant information and documents are available on the child's record.
16. Use of Computers at Home
Should the situation ever occur where a Council laptop/tablet/mobile phone 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.