2.1 Recording Policy and Guidelines

AMENDMENT

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?).

Minor amendments were made throughout in line with local practice.

1. Records Must be Kept on all Children

Each child must have his or her 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.

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.

1.1 The Purpose of Social Care Records:

  • As an agreed record of the agency's involvement;
  • As a statement of the purpose of the work;
  • As a way of recording plans and monitoring progress;
  • To facilitate communication between agencies and the children and families they serve;
  • To promote continuity throughout a child or young person's life regardless of whether workers are changed;
  • To provide a documentary record of part of the child's history. This will help to place important events in the context of the child's life; their family and wider social networks;
  • To assist in the process of supervision by providing a monitoring tool for managers and to evidence the worker's practice;
  • To promote accountability between family members and the agency;
  • To enable the consistent collection of information which can be used to determine the quantity and type of resources needed to meet the organisation's aims. Collection of information is also crucial to deriving data about equality of access to services;
  • The recording should seek a proportionate balance to reflect positive and negative aspect of a child or family's life;
  • The structure of the recording should readily distinguish between current and historical events;
  • Recording any views expressed by the child in their own words, noting for children who have communication difficulties, what support was available and/or how these views were gleaned.

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 design of all records and forms must be approved before coming into 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.

See:

Where children have been adopted, see also Access to Birth Records and Adoption Case Records Procedure.

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.

See also: Section 10, Records Must be Written Clearly using Plain Language and Avoid Prejudice and Section 11, Records Must be Accurate and Adequate.

5. All Relevant Information about Children and their Families must be Recorded

Every child's case record must hold details of the child's legal name, date of birth and any identification number.

If the case progresses to assessment, it must include a Social Care Single Assessment, transfer/closing summary (where appropriate) and a properly maintained Chronology. Guidance on completing chronologies is contained on ICS.

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 and/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/or reports;
  • The options that have been considered and the child and family's preferred choices and 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.)

Other professionals and partner agencies providing information/reports should be made aware that information provided by them will be included on the child's file and that this could be accessed by them.

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. It is good practice to see their voice within recording, as documented in their own words.

Generally, they must 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.

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; 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 or carers concerned for one of the above reasons, the reasons for restricting access should be recorded on a case file record. (All children's case files are redacted following an access to record request prior to the person being given a copy of their records).

See also Access to Records / Subject Access Requests Procedure.

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 restricted information held on 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.

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 at the timeof the visit or interview, within 2 days of the event (see also: Section 1, Records Must be Kept on all Children).

Where records are made or updated, the date the information became known should be recorded in the record and the date and time of the entry is electronically captured.

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 the right of the child or their parent/carer to access the record (whilst the case is active or at some point in the future).

Email 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.

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 facts, opinions, assessments, judgements and decisions. 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. Records must also distinguish between first hand information and information obtained from third parties.

Note: whilst 'cutting and pasting' techniques should be avoided, on those occasions where it is justified, 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).

See Confidentiality Policy.

12. Managers Must Oversee, Monitor and Review all Records

The overall responsibility for ensuring all records are maintained appropriately rests with practitioners and line managers.

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/carers have access to.

These records should not be left unattended when not in their normal location.

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. Removal of Records Must be an 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.

15. Records Moved to a New Location Must be Monitored

Where records are 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.

16. Records Must Usually be Retained After Closure

The member of staff responsible for the case when the case is closed is responsible for ensuring that the file to be retained is in good order and that unnecessary items have been removed, for example, duplicate copies etc.

16.1 Practitioner Diaries

Practitioner diaries represent important documents that detail work carried out and help to ensure accountability. It is good practice to retain practitioner diaries for 3 years. Practitioners should be recording their appointments in electronic diaries.