South West Safeguarding and Child Protection Procedures
South West Safeguarding and Child Protection Procedures South West Safeguarding and Child Protection Procedures

2.1 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))

RELEVANT CHAPTERS

Case Records for Children Looked After Procedure

Access to Records Procedure

Confidentiality Policy

AMENDMENT

This chapter was reviewed and substantially updated in May 2016. It should be read in its entirety.


Contents

  1. There is a Separate Case Record for Each Service User
  2. The Content of the Case Record Reflects Professional Practice
  3. Records are Legible and Use Plain Language rather than Jargon 
  4. Recording is Child/Young Person Focused
  5. Records Clearly Identify the Outcomes or Results to be Achieved for the Child/Young Person
  6. Recording Distinguishes between Fact and Opinion
  7. There is Cross Referencing and Signposting to other Records on the Child/Young Person
  8. Case Records Show when Information has been Shared
  9. Records are up to Date within 3 Working Days of the Contact/Discussion/Meeting
  10. The Case Record includes an Updated Chronology and/or Summary
  11. Records include an Assessment of Risk
  12. Records Demonstrate Commitment to the Principle of Equality and Valuing Diversity
  13. Records Provide Details about the Achievement of Outcomes as Part of a Review of Progress and Before the Case is Closed
  14. Other Professionals and Practitioners Supporting the Child/Young Person and Family are Referred to in the Records by Name, Profession/Designation and Agency   
  15. Records are Respectful of Children, Young People and their Families
  16. There is a Record of Children's and Parents/Carers' Views                             
  17. The Case Record Identifies whether the Child/Young Person is Subject to a Child Protection Plan and/or is Looked After by the Local Authority
  18. It is Clear Whether the Case is Active or Closed
  19. There is One Record of any Multi Agency Meetings about a Child/Young Person or Family 
  20. Case Records Evidence Monitoring/Auditing by Managers
  21. Children and their Families Must be Informed about their Records 
  22. Removal of Records Must be an Exceptional Occurrence   
  23. Records Moved to a New Location Must be Monitored  
  24. Records Must Usually be Retained After Closure  
  25. Use of Computers at Home    


1. There is a Separate Case Record for Each Service User

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.


2. The Content of the Case Record Reflects Professional Practice

The content of case records should be sufficient to give an account of all significant aspects of work undertaken and why, regular review of progress of the work undertaken and what the outcomes or results are. In some agencies this will mean that a record is made of each contact with the child/young person and/or family, the purpose of each contact and any actions taken.


3. Records are Legible and Use Plain Language rather than Jargon 

To avoid misinterpretation by managers or others who access the case record, or the overlooking of important information, all case recording should be easily readable by being written clearly in black ink or recorded electronically. With some safeguarding provisions, service users have the right to see information recorded about them and so the use of professional jargon*, acronyms and uncommon abbreviations should be avoided to ensure records, and therefore the account of decisions made and actions taken, can be easily understood.

NB This does not include medical terminology although the use of unnecessary medical jargon will better ensure service users' understanding when accessing their own, or in some circumstances, their children's records.     


4. Recording is Child/Young Person Focused

Often practitioners are working with parents and carers who may be facing a wide variety of problems. In many cases the route to improving a child's outcomes is by supporting and helping the parents. However, it is important that practitioners maintain a child focus and give children a voice which should be clearly evidenced in the records. Parents/carers' needs should never dominate the child's record at the expense of the child.


5. Records Clearly Identify the Outcomes or Results to be Achieved for the Child/Young Person

Practitioners and professionals providing services to individual children or families need to start with the outcomes or results the intervention is aiming to achieve for that child and his/her family. This will be based on an assessment of need. Once the outcomes or results to be achieved have been agreed, a clear plan of action, with specified timescales, to ensure they are achieved will be developed in partnership with the child and family and may involve other services and agencies. Without a focus on results and outcomes, and a record of the actions identified to best achieve those results, practitioners' work with children and their families will be unfocused and reviewing progress will therefore be difficult.


6. Recording Distinguishes between Fact and Opinion

Practitioners may gather or receive information from a range of sources when providing a service to a child or young person and make observations themselves. Failing to differentiate between fact and opinion in recording can result in the significance of some information being overlooked, or opinions becoming accepted as ‘facts’,  thereby unduly influencing the management of the case. Records should contain both facts and opinions. However, opinions should be distinguished from facts and substantiated. The reasons for actions and decisions should be clearly recorded so that they are available to the service user and agency.


7. There is Cross Referencing and Signposting to other Records on the Child/Young Person

In some cases not all information about a child/young person can be kept on one file. In many cases this would render the file unmanageable in terms of the size of the record. For some agencies, a child's record might be a collection of a number of component files or records held in different parts of the agency. To ensure that important information is not overlooked, there should be a record of all the different components of the case file on the main record, and their location, to ensure that important parts of a child's records do not go missing and to effectively signpost anyone accessing the records.


8. Case Records Show when Information has been Shared

Inquiries and investigations repeatedly highlight the failure of agencies to effectively share information about children and young people. Conversely, sharing too much information is rarely raised as an issue in cases where services have failed to safeguard children. Practitioners should routinely record which information has been shared, with whom, when and how including with young people and their families.


9. Records are up to Date within 3 Working Days of the Contact/Discussion/Meeting 

Maintaining up to date records is part of the service provided to children and families and therefore an essential task for staff. Timely record keeping helps to ensure robust agency decision making, particularly in the absence of key practitioners and professionals, and the importance of keeping up-to-date records has been highlighted in the findings of many inspection and inquiry reports. Recording should not be allowed to accumulate and managers should ensure sufficient time is available to enable practitioners to complete recording in a planned way. Reliance on memory and failure to record within reasonable timescales may result in key information being forgotten and missed from the record. For some practitioners there will be a requirement to comply with shorter, agency specific recording timescales.


10. The Case Record includes an Updated Chronology and/or Summary

A Chronology lists in date order all the major changes and significant events in a child or young person's life and is a useful tool to gain an overview of events in respect of an individual child. The chronology should be a record of factual information and starting a chronology could involve the child and family and will provide an opportunity to check out the accuracy of information. A chronology draws on various sources of information such as previous agency records, information from other agencies and information from the child or young person and his or her family. The chronology should not replicate detailed case recording but is more a timeline of significant events and major changes. Maintaining a chronology in a child's records can support agency decision making by highlighting how particular events have impacted on a child or young person.

A case summary provides a summary of events, changes and work undertaken by key practitioners over a specified period of time. Completing or sharing a summary with a family offers an opportunity to reflect on progress over the period covered by the summary and to discuss achievements as well as any difficulties or challenges being experienced. Writing a case summary provides practitioners with an opportunity to reflect on the effectiveness of interventions and to review progress towards the planned results or outcomes. It is also useful when cases are transferred between practitioners. Completing regular case summaries can support staff supervision processes, include information from and the perspectives of other practitioner working with the child and family, help to ensure continuity when cases are transferred and are an important source of information for colleagues and supervisors in the absence of the case holder.


11. Records include an Assessment of Risk

There are a number of risks associated with all aspects of providing services to children and young people. All staff working with children, young people and families have a responsibility to take all reasonable measures to ensure that any Significant Harm to children's wellbeing is minimised. Practitioners are responsible for identifying risks to the children and young people they are working with, and any risks to themselves, and they should ensure that these are recorded with any decisions made about their management. Where there are concerns about significant harm to a child's wellbeing, a record should be made of those concerns and appropriate actions taken in line with local procedures and protocols.


12. Records Demonstrate Commitment to the Principle of Equality and Valuing Diversity

Delivering the appropriate services to support children, young people and their families to contribute to improving outcomes needs to be based on a commitment to equalities and valuing diversity. Records should include accurate information about:

  • Gender;
  • Nationality, race and culture;
  • Language(s) spoken in the home;
  • Religion and current practice;
  • Disability and/or health conditions.

Recording should evidence a commitment to anti discriminatory practice and demonstrate that practitioners are working with diversity sensitively and in a non judgemental way to identify the particular issues for children and young people. Case records should identify issues arising for ethnicity, race, culture, gender, age, religion, language, communication, sensory impairment disability, sexuality and how these have been taken into account.


13. Records Provide Details about the Achievement of Outcomes as Part of a Review of Progress and Before the Case is Closed

Every practitioner needs to focus on improving outcomes and making a difference to those children, young people and families who receive services and interventions. The process of evaluating the impact of services and interventions on outcomes needs to start when the planning of the service or intervention starts. Evaluation should be built around a well-informed needs assessment and a rationale for why particular actions will produce the sorts of changes that will meet those needs. It then needs to be supported by the collection of information to enable progress to be regularly monitored and the achievement of outcomes to be evidenced. Records should therefore provide evidence of evaluation of what has changed for a child/young person as a result of interventions and therefore evidence of the effectiveness of agency involvement. Case closure should only be approved by supervisors and managers if an evaluation of outcomes achieved has been undertaken and recorded.


14. Other Professionals and Practitioners Supporting the Child/Young Person and Family are Referred to in the Records by Name, Profession/Designation and Agency

For many children their needs cannot be met by one agency and this will be reflected in the range of services supporting them and their families. Where records refer to other professionals and practitioners involved with a child/young person, these should include name, profession or designation and agency with relevant contact details. This will provide a full picture of those supporting a child and enable easier and quicker contact.


15. Records are Respectful of Children, Young People and their Families

For the practitioner, the case record will be just one of a number of similar records they keep as part of their duties in the agency. For the service user it is their record. Although the practitioner makes the records, they are made about, for, and ideally with, the service user. The case record does not simply provide a documented account of the agency's involvement with an individual service user. For many young people, particularly, those looked after, the case record may be the main source of information about significant events, decisions and people in their lives. It is not simply what is recorded, but the way in which the record is maintained that provides a reflection of the agency and practitioner's attitude towards service users. Care should be taken to ensure that:

  • Names are spelled correctly and consistently throughout the record;
  • Dates of birth are recorded accurately;
  • Unsubstantiated opinions are avoided;
  • Oppressive and discriminatory statements are avoided;
  • The general presentation of the case file/record is of an acceptable standard.


16. There is a Record of Children's and Parents/Carers' Views

Children and their parents/carers have a right to participate in decisions which affect them, to have their views recorded and in their own words. Where different tools have been used to help children express their views, such as drawing or games, their use should be explained in the record. Letters and notes from children can form a legitimate part of the case record and can also be used to evidence progress towards, or achievement of, planned results and outcomes.


17. The Case Record Identifies whether the Child/Young Person is Subject to a Child Protection Plan and/or is Looked After by the Local Authority

Children who are subject to a Child Protection Plan and/or who are Looked After by the local authority are particularly vulnerable to poorer outcomes than other children. Where agencies are providing services as part of a multi agency plan for a child/young person subject to a child protection plan or a Child Looked After, the case record should clearly identify this to ensure appropriate responses and decision making in the absence of key staff.


18. It is Clear Whether the Case is Active or Closed

Delays in responding appropriately to children and young people can be avoided if records easily evidence whether the case is active, and therefore a child/young person is currently receiving a service or intervention from the agency, or closed and the intervention has ceased.


19. There is One Record of any Multi Agency Meetings about a Child/Young Person or Family

A key aim of Children Services is to ensure that agencies work collaboratively to more effectively meet children's needs and improve outcomes. Increasingly, decisions about individual children and young people are taking place in multi agency and multi disciplinary meetings or through multi agency discussions which include children and their parents/carers. One record of such a meeting/discussion should be produced which can then be copied to all attendees including the young person and family. In this way, there is a clear and consistent record of decisions made and actions agreed which can be included in each agency's records.


20. Case Records Evidence Monitoring/Auditing by Managers

Case records are the key source of evidence for the decisions made by both practitioners and agencies. As such they have become increasingly important measures of accountability and organisational and personal effectiveness. Managers should accord recording a high priority and undertake regular monitoring and auditing of case records to ensure practice is consistently of a sufficiently high standard across the agency or service. A record of such quality assurance activity should be maintained on the file. Managers also contribute to records through recording or approving decisions and recording supervision discussions.

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


21. Children and their Families Must be Informed about their Records

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.

See Confidentiality Policy.

See also Access to Records Procedure.

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.


22. 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. The manager in conjunction with Business Support, must then ensure the record is returned as required/agreed.


23. 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.


24. Records Must Usually be Retained After Closure

The member of staff responsible for the case when the case is closed must inform Business Support of this and ensure that paper files are passed to Business Support who will then ensure the files are securely archived for the correct retention period.

Paper files for Children in Need cases are retained for 2 years after the final contact with the Local Authority.

Paper files for children who have been subject to Section 47 Enquiries but not made Subject to a Child Protection Plan are retained for 5 years after the final contact with the Local Authority.

Paper files for children who have been made Subject to a Child Protection Plan are retained until the 75th anniversary of the child's date of birth.

Paper files for CLA children (including children who have been privately fostered) are retained until the 75th anniversary of the child’s date of birth.


25. Use of Computers at Home

Staff may use personal computers to access CITRIX from home. Reports and records may only be saved on council encrypted memory sticks. Laptops provided by the Local Authority may be used outside the working environment with the permission of a manager.

End