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2.1.1 Recording Values and Principles

RELATED CHAPTERS

Children’s Social Care Policies, Values and Principles

Confidentiality Policy (including Freedom of Information Act, 2000)

Children's Consultation and Participation

AMENDMENT

In May 2020, this chapter was updated 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?).


Contents

  1. Keeping Records on Children
  2. The Design of Records and Forms
  3. Informing Children and their Families about their Records
  4. Responsibilities of the Practitioner
  5. Relevant Information
  6. Involving Children and Families
  7. Sharing Recorded Information with Children and Families
  8. Responsibilities of Managers
  9. Keeping Records Up to Date
  10. Records must be written clearly using Plain Language and avoid Prejudice
  11. Accuracy and Adequacy of Records
  12. Storage of Records
  13. Removal of Records
  14. Transferring Records
  15. Retaining Records
  16. Use of Computers at Home


1. Keeping Records on Children

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.

Records must be kept on all children. 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.


2. The Design of Records and Forms

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’.

A manager must approve the design of all records and forms before coming into use.


3. Informing Children and their Families 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.

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 Confidentiality Policy (including Freedom of Information Act, 2000); and the Access to Personal Information (including Subject Access Request Guidance).

Where children have been adopted, see also Access to Birth Records and Adoption 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. Responsibilities of the Practitioner

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. Relevant Information

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 and any identification number.

It 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. 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.


6. Involving Children and Families

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.

Generally, they must be asked to give their agreement to the sharing of information about them with others - but there are exceptions.


7. Sharing Recorded Information with Children and Families

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 concerned for one of the above reasons, it should be placed in the 'Confidential' 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 Records Procedure.


8. Responsibilities of Managers

See also Information Sharing, Confidentiality and Security of Information Procedure.

Managers must monitor information held on the 'Confidential' 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.

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 Personal Information (including Subject Access Request Guidance).

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.


9. Keeping Records 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. (see also: Section 1, Records Must be Kept on all Children).

Where records are made or updated late or after the event, the fact must be stated as a late entry in the record, and the date and time of the entry should be included.


10. Records must be written clearly using Plain Language and avoid Prejudice

Records must be written clearly and concisely, using plain language and 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 and abbreviations must be kept to a minimum; and if there is likely to be any doubt of their meaning, they must be defined or explained.


11. Accuracy and Adequacy of Records

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 believes 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, judgments 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. Storage of Records

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.


13. Removal of Records

The 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.


14. Transferring Records

The movement of records 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.


15. Retaining Records

Records must usually be retained after closure. Files should be retained for the period set out in the Retention and Destruction of Case Records Procedure.

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, compliment slips, duplicate copies etc.


16. Use of Computers at Home

Staff using computers at home for work purposes must ensure that they are working within the rules of the ‘data protection principles’ in accordance with the Data Protection Act (2018). Staff are required to familiarise themselves with the local information security policy.

This applies to staff using laptop computers and mobile devices in the course of their duties.

End