Case Recording Practitioner Guidance
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'.
AMENDMENTThis chapter was amended in June 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 the reasons why important decisions were made in the child's and/or family's life. This can be a key feature for a child in understanding themselves and 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 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.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 14, Records Should be Kept Securely).
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’.
A manager must approve the design of all records and forms before coming into use.
3. 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 and the reasons why;
- Their rights to confidentiality; and
- To have access to their records.
Where children have been adopted, see also: Access to Birth Records and Adoption Case Records (One Adoption).
Information must be provided in a form that children and their families will understand - in their preferred language or method of communication. An interpreter should 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 and sign/endorse the record.
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, date of birth and any identification number. Care should be undertaken to ensure the spelling of names is accurate and where possible, evidenced e.g. birth certificate. In some instances, key information may change and it is important the record should identify the current circumstance of the child / family.
Other 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.
5.1 The Basic Record
- Names and details of everyone who lives in the family home with the child, identifying the person who has Parental Responsibility;
- Where the child does not live at their home, the details of the Placement / arrangements and the legal status of the child;
- Names and details of anyone particularly close to the child with whom they have a lot of contact;
- Information about the child and /or family’s communication needs;
- A record of managers' decisions and reasons for making them;
- Details of arrangements for contact;
- Details and, where appropriate, copies of any Orders made on the child;
- Copies of reports provided during court proceedings, including specialist assessments, the Children's Guardian, etc;
- Additional information about educational progress and where the child is Looked After, the PEP;
- Where a child has Special Educational Needs or Learning Disability, copies of any relevant information, including the Education, Health and Care Plan;
- Appropriate information about the child's health, and where the child is Looked After, a copy of the Health Plan and Assessment;
- Details of any arrangements for the responsible authority's functions to be undertaken by a private provider, e.g. an independent fostering agency or provider of social work services;
- Copies of all documents used to seek information, provide information or record views given to the authority in the course of planning and reviewing the child's case and review reports;
- Record of visits and contacts by all practitioners as well as the allocated practitioner.
5.2 Recording Visits
Each visit should be recorded to include:
- The venue of the visit;
- Who was present;
- The purpose of the visit;
- Identify whether an interpreter was used;
- Whether the child was seen (and if not why this was the case);
- Information exchanged;
- A succinct narrative of the nature of the discussion;
- Any views the child expressed, noting for children who have communication difficulties, what support was available and/or how these views were gleaned;
- Any views of the Parent/Carer expressed;
- Identify whether there has been any significant change of circumstances for the child/or family, particularly membership of the household;
- The quality of the relationship between the social worker and the child;
- An analysis and evaluation of the outcome of the visit, commenting within the context of the Plan and the Review Recommendations;
- Failed appointments and visits where there was no response should also be included, together with any actions required under the Children's Social Care Services procedure guidance.
5.3 Other Key Records
The Record 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. This includes conversations, phone calls, visits, letters, emails, decisions made by Agency Decision Makers/Panels, assessments and reports. The options that have been considered and the child and the 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.)
The child's record should also include relevant and appropriate copies of material from other, separate records/files that are kept, whilst ensuring that such records remain separate and that neither confidentiality nor the Data Protection Act are breached. It is recognised that a certain amount of cross-referencing with siblings is inevitable and desirable, but again, care should be taken in respect of sibling information that becomes available on the record.
5.4 Important Characteristics of the Record
The record should be structured and maintained in a way that:
- The decision-making process is clear;
- That the views of the child, carers and/or those with Parental Responsibility can be found and related to the decision-making that has been made together with the responsible authority's actions;
- That any material temporarily placed in the record that belongs to the child should be noted as such so that it can be returned to the child when required / appropriate;
- Recording should be made of the Review meeting's recommendations / outcomes that are trying to be achieved with a child and their family, key tasks, by whom and timescales;
- The recording of interventions and actions should seek to identify which 'Recommendation' or Outcome they relate to;
- The recording should seek a proportionate balance to reflect positive and negative aspects of a child or family’s life;
- The structure of the recording should readily distinguish between current and historical events.
5.5 Case Summaries
Every three months the case file recording should provide a succinct summary of the work undertaken, specifically linking progress to the Recommendation/Outcomes of the Plan. It therefore promotes accountability, an understanding of progress and continued planning.
It should also highlight fresh issues that have emerged, both strengths as well as concerns, and reflect how these have been dealt with as well as acknowledging the impact (or otherwise) of any new issues on the overall nature of the case.
The Summary helps to bring together the outcomes of all the information and actions with the child/family and reflect / analyse / evaluate upon the progress of then intervention, including the child and family's level of engagement with the intervention.
The Summary, in 'putting the child at the centre' should reflect and have regard to 'what is life like for this child.'
It should also include outcomes of supervision on the case and consider appropriately the local authority's, and partner agencies, decision-making and the impact this may have had.The Case Summary can reflect on Case Reviews and should comment on the focus of work for the forthcoming three months.
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. The child should have the opportunity to have support to be able to do this if needed, through an Advocate and /or through specialist help, e.g. a signer.
It is recommended that any contribution the child may wish to make, any written material, certificates etc. should be included on the record as copies, so that the child retains the original items so that they have their own record of their wishes, progress etc.
Children and their parents must be asked to give their agreement to the sharing of information about them with others Information should be shared with the consent of the child and family if appropriate and where possible the wishes of those who do not wish confidential information to be shared should be respected. Information can still be shared without consent if it is in the public interest to do so. Information sharing decisions should be based on consideration or the safety and well-being of the person and others who may be affected by the sharing.
In such circumstances ensure that the information shared is necessary for the purpose for which it is being shared and shared only with those who need to have it.
7. Information about Children/their Families should Normally be Shared with them
Information obtained about children and their families should be shared with them 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 after taking advice from a manager.
See also Access to Records Procedure.
Where children have been adopted, see also: Access to Birth Records and Adoption Case Records (One Adoption)
When sharing a record it is important to record who it was shared with and when. The sharing of all decision-making documents such as assessments, care plans, reviews, reports and agreements make it easier for everyone to know what is expected and to work together better.
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.
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 Procedure.
9. Records Must be Legible, Signed and Dated
Those completing electronic records must show their name and the date when the recording was completed.
If possible, paper records should be typed or handwritten in black ink and all such records must be signed and dated and the pages numbered to assist in a reader being able to follow 'the child's story'.
Any handwritten records must be produced so that readers not familiar with the handwriting of the writer can read the records quickly and easily. It must be possible to distinguish the name and post title or status of the person completing the record. If there is any doubt of the identity of the writer from a signature, the name should be printed.
10. 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 of the event. (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.
11. Records Must be Written in Plain English and Prejudice Must be Avoided
Records must be written concisely, in plain English, and must always be written in a way that recognises the child or their parent/carer will access the record (whether whilst the case is active or at some point in the future).
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. The recording should certainly 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, acronyms and abbreviations must be kept to a minimum; and explained.
12. 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.
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).
13. Managers Must Oversee, Monitor and Review Records
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.
14. 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 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 comply with the requirements of the Data Protection Act 2018. This will include arrangements such as:
- Password protection;
- Automatic log out of screens;
- Logging off computers;
- Changing passwords on a regular basis.
Where staff are working in an 'agile' / 'mobile' / 'hot-desking' context, care must be exercised to ensure that records or computers are not left on or overlooked by others.
15. Removal of Records
15.1 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.
Should the situation ever occur where a file / documents are lost or mislaid, the local authority officer must report this immediately to their manager and every reasonable effort should be made to obtain their recovery. The service user should be advised of such an event.
15.2 Records Moved to a New Location Must be Monitored
Where records are necessarily 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.If records are moving because of a case transfer an audit should be carried out by a manager prior to transfer to ensure all relevant information and documents are available on the child's record.
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.
Should the situation ever occur where a laptop is lost or mislaid, the local authority officer must report this immediately to their manager and every reasonable effort should be made to obtain their recovery.Consideration should be given as to whether service users should be advised of such an event.