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2.1 Record Keeping in Children's Specialist Services

Important Note: The Independent Inquiry into Child Sexual Abuse (see Wirral LSCB 'Child Sexual Exploitation Procedure') requires all institutions to retain their records relating to the care of children for the duration of the Inquiry under Section 21 of the Inquiries Act 2005. There is therefore an obligation to preserve records for the Inquiry for as long as is necessary.

RELEVANT CHAPTERS

Case Records for Looked After Children Procedure

Access to Records Procedure

Producing Chronologies and Recording Significant Events (with ICS Guidance)

Issuing of Privacy (Formally Fair Processing) Notices in Children’s Specialist Services Procedure

Corporate Records Management Policy

AMENDMENT

This chapter was updated in March 2016 to reflect relevant links for the ICS throughout the process. Note also the Independent Inquiry into Child Sexual Abuse requires all institutions to retain their records relating to the care of children for the duration of the Inquiry under Section 21 of the Inquiries Act 2005.


Contents

1. Introduction
2. Principles
3. Procedure
  3.1 Purpose of Recording
  3.2 Definition of Case Recording 
  3.3 Responsibilities in Recording
  3.4 Managing the Case File 
  3.5 Standards for all Records (Paper or Electronic)
  3.6 Fact, Hearsay, Opinion 
  3.7 Records Should be Kept Securely
  3.8 Storage of Documents on Computers
  3.9 Removal of Records must be an Exceptional Occurrence
  3.10 Retention of Records


1. Introduction

Recording information is an essential part of delivering a quality service to users and carers.

This procedure and guidance provides additional information to guide staff on how to record information.

This procedure and guidance must be read in conjunction with the following policies and procedures:

There is an emphasis in this procedure about case recording, however the principles apply equally to all recording.

Records covered by this procedure include:

  • Children’s Case files;
  • Foster Carers and potential Foster Carers case files;
  • Child’s Adoption case record;
  • Adopters and potential adopters case files;
  • Special Guardians and potential Special Guardians case files;
  • Post Adoption, post Special Guardian support case records;
  • The records apply to hard copy and electronic records (ICS and ESCR).


2. Principles

The Local Authority has a responsibility of ensuring that:

  • Each child receiving a service has a separate written care record;
  • Once a decision has been made to formally consider a child for Adoption, the Adoption pathway will be started on the ICS system. Additionally to this, a paper file will be need to be kept made up of any original documents and papers with birth parents signatures;
  • Separate case records are kept for individual carers being assessed by Children’s Specialist Services such as Foster Carers, Private Foster Carers, Special Guardians, carers with Child Arrangements Orders and adopters.

In addition the Local Authority has a responsibility for keeping registers of Foster Carers, children in the care of Foster Carers, and children in residential homes.

Children and their families have a right to be informed about the records kept on them, the reasons why and their rights to confidentiality and of access to their records.

Children and young people in Wirral have told us:

Please remember when case recording, that what you record may be the only memories we have. So remember:

  • That our views should be recorded;
  • That all factors about us are clear;
  • That you can tell from the file what sort of child or young person we are growing up to be;
  • That all my achievements big or small are recorded and kept, such as my school reports, certificates, things I made at school;
  • That the smallest detail on file can make the biggest difference to the quality of information for us.


3. Procedure

3.1 Purpose of Recording

The overall purpose of recording is to demonstrate and enable the work of the department in the assessment and provision of services, for monitoring and reviewing and also to show the needs of individuals who may require or who are receiving a service. Recording also documents the staff that provides the service in order for them to be accountable for their work.

Good quality recording as electronic data systems and paper files enables:

  • An accurate account of the work of the department with the individual, their family, carers, other relevant people and care providers to be maintained;
  • A story to be told about an individual's life that provides a balanced picture of particular events and includes both positive and negative incidents;
  • Allows an individual, particularly a child, to look back at their life and recall clearly or where they may not have known all the facts, about at that time and the reasons for certain decisions;
  • A record to be made of important things in a person's life that may be necessary to explain to him/her at a later date;
  • A record to be made of the views of individuals and their family members;
  • The department to account in terms of the work that has been undertaken;
  • Partner Agencies, where appropriate, to share accurate information;
  • Evidence to be available of compliance with relevant legislation and departmental policies and procedures;
  • Staff to be able to reflect back on work undertaken and plan any future intervention;
  • Continuity in service being provided when staff change;
  • Accurate information to be provided as evidence in Court and other interagency forums as the basis for inquiries, inspections, tracking and auditing;
  • The production of accurate business information for performance management and quality assurance purposes.

3.2 Definition of Case Recording 

Case recording is the written account of the department's work with and on behalf of an individual, their family or carers:

  • The case records are primarily for the benefit of the child, parent or carer and should be an accurate reflection of the individual person's life. It is a record between the individual and the department not an individual member of staff's record;
  • Recording details the individual worker's contact with the individual and others, the work to be done and its objectives, the procedures to be followed, the assessment of need, decisions about eligibility, the Care Plan, the provision of services, the timing, process and outcomes of monitoring and reviews;
  • Recording draws on information and knowledge from a wide range of sources, including partners and other agency policies;
  • Recording includes description, analysis and professional judgement. It is essential that a distinction is made between fact and opinion and where there is a third party contribution.

3.3 Responsibilities in Recording

The practitioner primarily involved, that is the person who directly observes or witnesses the event that is being recorded or who participates 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 and sign/endorse the record.

Records of decisions must show who has made the decisions and the basis on which it has been made.

Allocated Social Worker - has a professional responsibility to ensure all information about individuals is appropriate, accurate and timely recorded in the individual’s case file either electronically or in paper form as appropriate. The professional responsibility means that others undertaking particular aspects of recording (e.g. specialist assessments) or specific recording tasks (e.g. operational support) are doing so on behalf of the allocated Social Worker, who retains overall responsibility for compliance with this procedure.

The Social Worker has the responsibility, wherever possible and appropriate to share what they have recorded with the individual.

Operational Support Staff - are responsible for opening all new case files, new volumes of paper case files and filing all parts of the record in the case file. Operational staff can also undertake other recording tasks, but the responsibility remains with the allocated Social Worker or the manager.

Family Support, Residential and other similar staff have a professional responsibility to ensure that service-specific records are kept and to ensure that appropriate information is shared with the allocated Social Worker.

  • First Line Managers - have a responsibility for ensuring that the quality of recording meets the principles, standards and requirements as outlined in this procedure. This means reading, signing off, recording the Manager’s rationale and auditing case files on a regular basis. As a minimum the Team Manager has responsibility for approving all significant events. They should also sample cases every 4 weeks and record that they have reviewed the case notes, state their professional view on the status of the case and make a decision for future action.

Team Managers should routinely audit files at the following points - transfer between teams, transfer within a team and upon closure. This will ensure all the required information is on the file and is in the correct place.

The audit tools can be found on ICS.

Group Managers - have a responsibility to ensure the auditing is taking place, and carry out quality checks.

3.4 Managing the Case File

All individuals will have an electronic file on ICS.

There must be separate records for the child and carers. Therefore Viability Assessments, Fostering Assessments and Special Guardian Assessments must be held on a carer’s file not the child’s file. A separate case file must also be opened for an Adopted Child when a decision is made at a statutory review that the plan for the child is Adoption.

Care must be taken that duplicate electronic files are not set up by undertaking appropriate searches. Where duplicate files are found the information must be transferred to one record and the empty record deleted.

All case files must be kept up to date. Paper case files must be organised in date order according to the relevant case file index. Any information recorded after 1st July 2011 does not need to be printed off and placed on the paper file.

A chronology should be started at the point when Children’s Specialist Services first became involved with a child and family, and must cover all involvement, from the first point of contact, referral and assessment, taking account of the whole history including periods of case closure, new contacts and referrals etc. The case chronology will highlight all the significant events in the child’s life in date order, and indicates the professional decisions made regarding the outcomes for the child/children. Further details can be found in the Producing Chronologies and Recording Significant Events (with ICS Guidance).

Each looked after child’s case file must include a pen picture which gives vibrant impression of the child as a person. The pen picture should be developed as a Word document and stored on the documents section of ICS.

It should contain the following information:

  • A physical description of the child, including a photograph;
  • Information about their family i.e. siblings etc;
  • Information about their cultural heritage;
  • Information about their religion;
  • Who they live with and where;
  • Their developmental progress;
  • Hobbies and interests;
  • A clear indication of child’s feelings about current circumstances and their wishes for the future;
  • Comments from carers and family members;
  • Comments by the child.

Sibling records must be the individual record for that child and should not contain copied information from other siblings unless the information is relevant for that child.

3.5 Standards for all Records (Paper or Electronic)

  • Recording must be accurate, appropriate, timely, with all sources of information identified;
  • All records must be written in the context of the individual that the entry is about (or their legal representative/advocate), that they could see the entry at any time or the record could be used as evidence in Court;
  • All individual pieces of paper must be identified with the individual's name, and date of birth / and ICS number;
  • Case files for children must clearly identify who has Parental Responsibility for the child;
  • All records of events must be written at the time of or as soon as possible after the events to which they relate. Good practice is that this should be within 48 hours;
  • All records must contain the date and time that the entries were made and the narrative contain the date and time that any events occurred. On ICS the time of the event should be contained in the subject header;
  • All entries on paper records must be signed with the staff’s name printed underneath;
  • All entries must be written, wherever possible, in terms which the child or family members will be able to understand;
  • When it is a significant event the tickbox must be selected on the ICS casenote to allow this to be pulled through to the chronology;
  • All reports must contain the name of the person writing the report, their signature (paper records), their position and the date of the report;
  • All additional documents must be signed and dated;
  • All hand written records must be written legibly and indelibly in black ink;
  • Contemporaneous notes must be kept and scanned into ICS or kept in the Prior to the ESCR implementation;
  • Where hand written records / notes are typed into a report / minutes of a meeting or entered into database the date that the contemporaneous notes were taken must be used for the recording and a case note recorded that contemporaneous note exists;
  • Records must be clear and unambiguous;
  • Only factual inaccuracies must be amended on records. Any alterations to paper records must be made by scoring out with a single line followed by the date, time and signed correct entry. Alterations to electronic records must be recorded as amendments. (Note there is an audit trail of all alterations to electronic records.);
  • Records must be written concisely, in plan English, with correct spelling and grammar, and must not contain any expressions that might give offence to any individual or group;
  • Use of technical or professional terms and abbreviations must be kept to a minimum. If there is likely to be any doubt, they must be defined;
  • Do not name any third parties involved in a serious incident. Where necessary use initials only with the full name included on the separate incident form for cross-referencing;
  • Electronic communications i.e. emails between professionals relating to a person’s care must be included in the case records either documents section of ICS or copying to a case note;
  • Wherever possible and appropriate the content of records should be shared with the individual it is about;
  • If an individual disagrees with the record this must be recorded;
  • Where it is necessary to record opinion, make sure that this is within the limits of your expertise. Be clear about the factual basis for any opinion;
  • Distinguish between Fact, Hearsay, Opinion.

Standards for the paper case file:

  • All papers must be secured within a file and maintained in date order;
  • Unnecessary duplicate documents must be removed from case files;
  • Polypockets and staples must be avoided;
  • When the file becomes full, a new volume of the case file must be opened, with the essential information carried forward.

3.6 Fact, Hearsay, Opinion 

Fact - direct observations of events.

Opinion - interpretation of behaviour or events that have been observed.

Hearsay - information told to you by others, which are relevant to the case but which you cannot personally verify.

3.7 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.

Other day-to-day records, such as Contact or Daily Records, should also be kept securely in a manner authorised by the manager.

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.

3.8 Storage of Documents on Computers

Personal information relating to service users or staff must not be stored on a computer desk top, c: drive or in ‘my documents’. The network folders (i.e. team or personal folder) must be used temporarily until transfer to ICS. Note: laptops have been stolen and information is not secure even with a password.

When a case is transferred any documents sent to the receiving Social Worker electronically must be deleted from the sending Social Workers folders relating to that case and if the case has transferred outside the team folder.

Managers need to be aware of where staff store information and need to know the procedure for accessing that information via WITS in the event of that member of staff being absent from work.

3.9 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.

3.10 Retention of Records

Important Note: The Independent Inquiry into Child Sexual Abuse (see Wirral LSCB 'Child Sexual Exploitation Procedure') requires all institutions to retain their records relating to the care of children for the duration of the Inquiry under Section 21 of the Inquiries Act 2005. There is therefore an obligation to preserve records for the Inquiry for as long as is necessary.

No record should be deleted or destroyed without reference to the retention period for that record. See the Corporate Records Management Service for information on retention of records, transfer and archiving of records.

End