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 (2015))
This guidance should be read in conjunction with Central Bedfordshire's Guidance on the use of Chronologies, see Practice Guidance on Social Work Chronologies.
This chapter was amended in March 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
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 provides and explanation for the reasons why important decisions were made in the child’s and/or family’s life. The case record can be key to helping a child understand their past – especially 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.
From April 2012 Central Bedfordshire Children's Social Care have used Mosaic as the children's database and recording system.
A paper file should be kept for documents such as birth certificates, passports etc.
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
All Records and forms including those in Mosaic 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 CCMS team will design all documents for Mosaic and these will be subject to approval by managers before implemented for 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.
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.
Where children have been adopted, see also Access to Birth Records and Adoption Case Records Procedure and follow the guidance on how to record in Mosaic.
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 allocated social worker is responsible for maintaining the child's record and ensuring it is accurate and up to date. All records must be updated in a timely manner. The allocated worker who directly observes or witnesses the event that is being recorded or who has participated in the meeting / conversation is responsible for completing the record.
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. The originator should read and sign / endorse the record on Mosaic ensure its accuracy.
Records of decisions must show who has made the decision and the basis on which it has been 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, address, date of birth, identification number, ethnicity, gender, first language religion and key contacts. Care should be undertaken to ensure the spelling of names are accurate and where possible, evidenced e.g. birth certificate. In some instances, key information may change and it is important the file record should identify the current circumstance of the child / family.
It must also include an up to date assessment and plan and where a case is transferring / closing a, completed transfer / closure episode. All cases must have a properly maintained Chronology (see Practice Guidance on Social Work Chronologies).
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.
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.They must also be asked to give their agreement to the sharing of information about them with others - but there are exceptions which are identified in the next section. See Consent to Share Information Form.
7. Information About Children and Their Families Should Normally be Shared With Them
Information contained in a 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.
Where children have been adopted, see also Access to Birth Records and Adoption Case Records Procedure.
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 and/or their parent / carer.
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 when there are concerns about a child's welfare and safety. (See also: Section 1, Records Must be Kept on all Children).
10. Records Must be Written Clearly using Plain Language and Avoid Prejudice
Records must be written clearly using plain language and written in a way that recognises, the right of the child or their parent / carer to access the record (whether whilst the case is active or at some point in the future). The record 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.
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.
Use of technical or professional terms and abbreviations must be kept to a minimum; and if any doubt about meaning is likely, they must be defined or 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 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.
The line manager should routinely check samples of records on Mosaic, in supervision, 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.
Where a paper file on a child is necessary it should be stored in a locked cabinet, or a similar manner, usually in an office which only staff / carers have access to.
All electronic records must be kept securely and this will include arrangements such as:
- Password protection;
- Automatic log out of screens;
- Logging off computers;
- Changing passwords on a regular basis.
14. Use of Computers at Home
Staff using computers at home for work purposes must do so by using a fob.
All staff should ensure that use of computers external to Central Bedfordshire office locations is compliant with the council's ICT policies.