Case Recording Practitioner Guidance
SCOPE OF THIS CHAPTER
Responsibility for the professional regulation of social workers lies with the Health and Care Professions Council (HCPC). The HCPC has Standards of Proficiency.
- As a social care employer, there must be written policies and procedures in place to enable social care workers to meet the HCPC Standards of Proficiency for Social Care Workers. (Please see note above);
- Social care workers must be accountable for the quality of their work and take responsibility for maintaining and improving their knowledge and skills.
The information that Merton Council hold is essential to the delivery of high quality evidence based service on a day-to-day basis. An effective record management system ensures that such information is properly managed and is available.
The Children's Social Care and Youth Inclusion Division are committed to providing high quality services to its service users. In delivering quality services, we have a statutory and professional responsibility to ensure that information recording is effectively integrated into working practice and that sufficient emphasis is placed on the quality of the information we hold, including access, storage, retrieval, sharing and destruction.
As far as possible, we will ensure that through recording such information, we will seek to identify events or activities which could threaten the well being of service users, carers and staff and in doing so, assess risk accordingly.
Every staff member, including non social care staff, have a responsibility for records management and for maintaining confidentiality at all times with the data that they have access to.
This chapter was reviewed and updated in January 2019 following the introduction of the General Data Protection Regulations (GDPR) and Data Protection Act 2018 (see Section 10, Guidance on the Documents that should be Shared with Children and their Families
This policy is to enable staff to keep good quality records. The Framework is provided by:
In addition, there are a number of developments, which require an increasing awareness of the need for high quality records which includes:
- Delivered service is more client centred;
- Inter-Agency working is paramount (especially with the introduction of the Common and Single Assessment Framework and multi-agency information sharing protocols);
- The need for consistency and accuracy in case recording across partner organisations;
- The right of service users to access their records;
- Initiatives such as Caldicott and monthly case file audits within Children's Social Care and Youth Inclusion;
- Increased client awareness in respect of their personal information being held and possibly shared.
This Case recording policy is a reference tool for teams' practitioners/managers to assist with maintenance of good record keeping both on paper (case files / papers) and electronically on the social care information system and CareWorks.
Aside from the statutory requirements for keeping records, records should offer a complete account of work (which is concise and to the point) with users, including both positive and creative work that is carried out to achieve outcomes.
The Department recognises the need for professionals to continually develop their skills in record keeping. All professionals will be expected with their line manger to identify when and what training in record keeping they require.
It is the responsibility of each practitioner to request training through their supervising line manager within the supervision forum and if an urgent learning need arises then they should be initiating a discussion at their earliest opportunity. This enables reflective practice on the record keeping process and provides the opportunity to consider good record keeping practices, which contributes to improvement in the standards of care. The Department will offer training in recording as necessary.
The Health and Care Profession Council (HCPC) clearly outlines the requirements of standards and continuing professional training which practitioners have to adhere to maintain their annual registration:
The Health and Care Profession Council (HCPC) website.
Merton Children's Workforce Training is offered to all staff to access courses that will enable and empower them to carry out their duties and accessible on the Council's Learning and Development
internal webpages. Courses can be booked in prior consultation with your supervisory manager and all staff are encouraged to identity individual training needs.
There is a clear difference between case files and case records:
3.1 A Case Record
A record is anything which contains information in any medium e.g. paper, letters, visual records, microfilm, records of conversations on audio tape, videotapes, digital and multi media records, computer databases, notes, emails and faxes which has been generated as a result of the department activity by employees, including interim contractors, interim consultants and agency members staff.
A case record is a written account of the involvement of Children's Social Care and Youth Inclusion, with either an individual or their family, which details individual contacts with the service user, the work to be done and its objectives, including the assessment of need, the care plan, the timing, process and outcomes of reviews. Case records are increasingly being stored electronically.
3.2 A Case File
A case file is a folder electronic and/or hard copy which contains all the information about an individual or a family that has been referred to Children's Social Care and Youth inclusion and accepted as a "case" for allocation and/or further action. Such information may be in the form of letters, reports or legal documents and is stored in chronological order.
4. Main Purpose of Keeping Records
Case recording is part of our service to users and carers and provides one of the cornerstones of our approach to partnership and good practice. Recording should be given equal priority to face-to-face work with service users and carers.
In addition, keeping records helps to:
- Form the basis for planning a service delivery and gaining feedback on progress;
- Assist with the continuity of care provided by staff and agencies involved in the delivery of care and to provide written evidence that a service has been delivered;
- Meet professional and statutory requirements;
- Provide information for information management, self evaluation, audits, quality assurance, research, reviews and evaluation.
5. Records Management
Good records management is an essential part of the information governance process within the department and in order to be effective it needs to be seen within the overall management arrangements of the department.
The management of records is integral to the roles and responsibilities of all staff. This policy has been developed to ensure that the division's management issues have been addressed. A proactive approach to records management will ensure that we have the appropriate procedural arrangements to manage all records effectively.
The records management arrangements shall ensure that:
- There are effective and efficient arrangements for the creation, maintenance, storage and disposal or records (paper, electronic and otherwise);
- Good communications exist to ensure that policies and procedures and effective practice are adopted across the organisation;
- Support is given to the "access to records" process.
6.1 All staff members, including managers, permanent and agency staff
- All staff are responsible for the records they create;
- Staff will be personally responsible for complying with this policy and associated policies and procedures;
- Staff must familiarise themselves with all policies and procedures associated with this document (these include the Professional Capabilities Framework, Retention and Destruction of Records and Access to Records which can be found on the internal Intranet).
See also Access to Records Procedure
6.2 All Managers/Assistant Director, Children's Social Care and Youth Inclusion/Director of Children's Services
- All managers and Assistant Director of Children's Social Care and Youth Inclusion/Director of Children's Services are responsible for ensuring that this document is fully implemented and any arising problems are reported;
- All managers are responsible for taking actions to minimise any risk issues affecting their team;
- All Managers are responsible for contributing to the case record through recording of decisions and supervision discussions and ensuring effective management oversight;
- All managers are responsible for compliance with all policies and procedures associated with this document (these include Professional Capabilities Framework Retention and Destruction of Records and Access to Records which can be found on the intranet).
All staff and those carrying out the functions of the department have a duty of confidentiality to service users and a duty to support the professional ethical standards of confidentiality. The duty of confidence continues even after the case file is closed, in the event of the death of the service user or after an employee has left the organisation. Managers will ensure that arrangements are in place to ensure the security of these records at all times.
8. Case Recording including Looked After Children
Good quality case recording is an essential component of good social work practice; however, as it is not solely social work practitioners that access and input information on the social care information system and CareWorks. It is imperative that all staff maintain a duty of care with the data that they input, to minimise discrepancies and misinformation forming a part of a child's case records. Case recording in electronic files on the social care information system and CareWorks is an important part of the accountability of all staff working in Children's Social Care and Youth Inclusion.
The social care information system and CareWorks training and manuals are available to all staff and any training needs should be progressed as a matter of priority, so that staff are fully aware of any changes within responsibilities.
Good case recording and case file maintenance helps the focus of work undertaken:
- To give an account of all significant aspects of the work undertaken;
- To demonstrate interaction between social care practice and what is written down (evidenced based practice) including being a main source of evidence for investigations and enquiries and any legal proceedings that involve the local authority;
- To meet good professional practice and follow Children's Social Care and Youth Inclusion Policies and Procedures and take into account any legislative guidance from Central Government that informs practice;
- To allow decisions to be recorded, including those responsible for making decisions and the reasons behind the decisions;
- To assists with continuity when workers are unavailable or change and provides an essential tool for managers to monitor work and It supports effective partnerships with service users, families and carers;
- All Children Social Care and Youth Inclusion recording should be put on the social care information system or CareWorks database. The standards set out below are relevant to both electronic and written case records.
- Case recording should be clear, relevant, objective, up to date, comprehensive, analytical and succinct. Facts and opinion should be clearly differentiated (see case recording format below);
- Case recording should reflect anti discriminatory practice and take into account needs arising from ethnicity, race, culture, religion, disability, sensory impairment, gender, age, language, communication, health status and sexual orientation (including recording whether interpreters are used/not used and if so, the reasons for such a decision);
- Case recording should be kept in a consistent and uniform manner and in date order (most recent entry first - to the front of the file). Different categories of information should be kept separately so that they are accessible. (See case file format below);
- Case record/files should contain a front sheet as well as a three monthly, closure and transfer summaries;
- Case recording should include aims and objectives, and action taken should relate to this. Outcomes should be clearly identified;
- Case records must contain up-to-date information about information shared to other organisations. They must include up-to-date consent-to-share statements from service users as well as reasons why information has or has not been shared following a risk assessment;
- Case recording should give reasons for action and contain service users wishes and feelings and agreements (including recording views of children/young people and their parent/carer where a child is deemed "in need");
- Case records should confirm that relevant leaflets have been given to service users and their carers, i.e. Access to Records, complaints/commendations/ comments leaflets, and benefit advice;
- All records should be dated and signed;
- Records should be written in such a manner that any alterations or additions are dated, timed and signed, in such a way that the original entry can still be clearly accessed;
- Records should avoid abbreviations or jargon;
- All entries should be in a logical and systematic order with the most recent at the front of the file;
- Each separate sheet should be referenced;
- The supervisory manager will record, on file, the actions, decisions and discussions undertaken in supervision. All staff are expected to keep their own records from supervision as a way of reminder of shared discussion points and for cross referencing if need be;
- Professional judgement should be used to decide what is relevant and what should be recorded, with staff demonstrating that they have taken all reasonable steps to record information appropriately (including reasons for not taking/accessing legal advice/services);
- Supervisory Managers should read case files on a regular basis and endorse these records to indicate that this has been completed and the Team Manager is expected to have an overall perspective of the cases within the team;
- Social Workers and other front line practitioners working directly with Children and Families should tell them when information is to be transferred or exchanged between different parts of the service and provider agencies. Staff should secure any written agreement to this process and ensure that this is clearly recorded and a copy provided to the family for their reference. There will be occasions where information will need to be shared without their consent if there appears to be an issue of risk or the best interests of the child need to be promoted and they need to be made aware of this from the onset when the social work engagement starts. By fostering good practice when a new practitioners starts to work on a new case they should be pro active to ensure that they review the case file and any agreement's made, revising them, as need be if relevant in consultation with their supervisory line manager;
- Assessments should contain an analysis of the information gathered, the considerations made (and the weight given to them) and decisions about eligibility. Reasons for the conclusion reached should be clearly stated;
- Where an assessment leads to other commissioned internal or external services/interventions such as Community Based or Residential Parenting Assessment, Secure Placement (Welfare). These may form a part of a Children in Need Plan, Child Protection Plan, Care Plan within Care Proceedings or a Looked After Review. These should be completed with clear aims and objectives of any services/intervention planned explicitly outlying the projected costs and when this will be reviewed and the duration of the service being provided.
Looked After Children Case Recording
Looked After Children case recording must be established and maintained for each child on the social care information system or CareWorks, if they are part of a sibling group they must be linked together to ensure that their relationships are clear.
Theses records must include:
- The child's Care Plan, including any changes made to the Care Plan and any subsequent plans;
- Reports of any Medical Health Assessments;
- Any other document/s created or considered as part of any previous or on going external assessment of the child's needs, or of any review of his/her case should be uploaded to the social care information system or CareWorks;
- Any previous or current court order relating to the child;
- Details of any arrangements between Children's Social Care and Youth Inclusion to an independent fostering provider or other provider of social work services.
These should be regarded as the minimum requirements for the case record.
The Statutory Guidance recommends that records should also include:
- The frequency of contract arrangements for the Child and their family;
- Copies of all reports provided during court proceedings such as the guardian's reports and any other expert commissioned assessments;
- Additional information about the child's educational progress;
- Copies of all the 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;
- Records of all visits whether the child was seen or not;
- Any other correspondence which relates to the child and their family;
It is also recommended that any contribution that the child may wish to make, such as providing written material such as letters reflecting their thoughts, wishes and feelings, photographs, school certificates and other similar items, should be included in their file.
Care must be taken to ensure that the child retains either copies or originals of information which will form part of his/her own file to keep with him/her. Any papers temporarily placed in the record which are the property of the child should be clearly marked as such.
The social care information system and CareWorks records should be maintained in such a way that it is easy to trace the process of decision-making and in particular the views of the child and parents and explicitly outline observations, views and analysis.
The child's case records should be separate from other records, such as those relating to their foster carer or residential placement, which are not solely concerned with the individual child. Where some information on one of these other records is relevant to the child, a duplicate entry should appear in the child's social care information system or CareWorks case record.
Records should not be amalgamated even in the case of siblings, although a degree of cross-reference and duplicate entry will be necessary where there is clear linkage.
9. Timescales for Recording
The statutory guidance and timescales for recording may differ in each service area, such as Children's Social Care and Youth Inclusion. There is an expectation that all recordings, records of assessments and any other significant changing information, such as Looked After Child status are within the timescales set out as this can impact on other service areas that collate data and statistical information.
Any Safeguarding or Child Protection recording should be completed immediately and within the same working day.
taken on duty should be written up during the course of each referral and completed by the end of that working day
10. Guidance on the Documents that should be Shared with Children and their Families
Children and their families should be told what types of information/data is contained in their case records and this should be with the data subject as appropriate.
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.
These should be routinely shared with Children, if age appropriate, their family and their carers if placed outside of the family home.
Children In Need Plans/ Looked After Child Reviews/Care Plans/Service Plans/Child Protection Plans
These should be routinely shared with Children, if age appropriate, their family and their carers if placed outside of the family
Case Conference Reports
These should be routinely shared with Children, if age appropriate, their family and their carers if placed outside of the family
A record should be noted on the child's case files which type of leaflets have been given and if there was any feedback on them.
13. Guidance Case Files
Case Files are electronically created on the social care information system and CareWorks database, as paper case files are no longer kept within Merton Council except for Foster Carers within the Fostering Service.
Fostering best practice the File structure illustrated at Appendix 1 - Appendix 5 provide an outline of the documents that should form the basis of a case file for the relevant service areas.
- Key information should be readily identified and kept up to date;
- The case record should lead the reader through the contacts and any other key events, e.g. meetings, supervision, in chronological order. Where necessary it can be indicated that records are stored elsewhere;
- The file should provide not simply a record of work, but also the rationale for decisions and focused objectives for future work;
- A contact case record should be completed for all events, case discussion and decision making in supervision. All relevant contacts and actions/decisions should be recorded in the social care information system and CareWorks.
Chronologies should be continuously updated as the work progresses and reviewed not less than 3 monthly (see the Chronology Guidance). An up-to-date genogram should also be available.
14. Case and Transfer Summaries
Case Summaries local policy - to follow. Summaries should be used in case files to help with the following:
- An evaluation of previous objectives and whether these have been met;
- Analysis of work undertaken;
- Setting objectives for future work;
- Three month summaries should be completed in cases unless there is a recent assessment/report for review e.g. LAC Review to ensure there is a clear focus of work and it is maintained;
- Transfer Summaries should be used when cases are transferred from teams. Transfer summaries should also be used when transferring cases between the service areas so this can illustrate the journey that cases have had from the initial point of contact and interventions made. The transfer summary should contain information relating to the background of the case, work completed and work to be completed as well as an up-to-date chronology and genogram.
All significant events and change in information must be recorded on the social care information system and CareWorks other partnership agencies should be notified, if they do no have access to this information.
All staff should refer to the Case File Transfer Protocol
so they have a working understanding of how this is works across all of the service area.
15. Equal Opportunities in Recording Practice and Merton's Equal Opportunities Policy
All case records should reflect good practice in equality and diversity by:
- Adequately reflecting anti-discriminatory practice (ADP) and sensitivity to the needs of all people within the community, regardless of their race, culture or ethnicity;
- Identifying special needs arising from ethnicity, race, culture, gender, age, religion, language, communication, sensory impairment, disability and sexual orientation;
- Promoting access to records for people with language and communication needs;
- Containing information which is routinely gathered for monitoring and planning purposes to promote good equal opportunities practice.
Merton Council is committed to fostering service user participation and inclusion and their policies are reflective of this and practitioners can refer our equal opportunities policy on the following link: Merton Council Equal Opportunities.
Social Workers, Other Children Social Care staff and their Managers are expected to ensure that there is:
- Clear analysis in their case recordings including supervisory and management decision making with actions;
- The social care information system and CareWorks database are accurate and updated by the lead practitioner undertaking any work with the child, young person and their family;
- Evidence of a child or young person's journey documented and any direct work undertaken is shown;
- Evidence of a Case Audit by a Manager;
- An update of assessments completed and any financial packages of support (if approved) and these have been shared with the family and/or the carer and child, if age appropriate.
Appendix 1- 5 are a guidance for file content pages and embedded within our electronic records in the social care information system and CareWorks these illustrate the documents that capture and follow the child's journey.
Appendix 1: File Contents
- Personal Details including Date of Birth;
- Legal Status;
- Significant Events;
- Professional Contacts;
- Case Chronology;
- Current Child In Need Plan;
- Care Plan;
- Child Protection Plan;
- Referral forms including Merlins and EDT;
- Case Notes;
- Supervision Decisions;
- Change Reports;
- Transfer Summary;
- Three Monthly Summary;
- Annual Children In Need Review.
Assessments and Planning
- Common and Shared Assessment (CASA) and/or Previous Core Assessment/Initial Assessments;
- Written Working Agreements;
- Children in Need Plans.
Safeguarding and/or Child Protection Matters
- Section 47;
- Strategy Meeting Record;
- Child Protection Conference Record;
- Child Protection Plan Part 1;
- Social Worker Child Protection Report/Core Assessment;
- Core Group Records;
- Written Agreements.
Looked After Children /14+ Placements
- All LAC Plan;
- Permanency Planning;
- Looked After Children Care Plan;
- Review of Arrangements;
- Contact Agreement;
- Pathway Plan;
- Lodging Arrangements;
- Brightwell Reports;
- Consultation Papers;
- Child Performance Report;
- Maternity Report;
- Child Permanence Report;
- Foster carer reports.
- Initial Health Assessment;
- Review Health Assessment;
- Health Care Action Plan;
- Health Consents;
- CAMHS Reports;
- Antenatal Records/Parents' Medical History;
- Immunisation record;
- Medical reports from other professionals;
- Blue badges & travel permits.
- Personal education plans;
- Education, Health and Care Plan;
- Education reports;
- ETE Status;
- School reports/results.
- S17/S24 Petty cash vouchers;
- Sponsorship forms;
- RPF, WB Advice, Contact;
- Transport request forms;
- Financial Assessments;
- Home Allowance set up.
- All letters - not reports;
- Complaints and Compliments;
- E-mail correspondence.
- Court statements;
- Legal care plans;
- Record of Legal Planning Meeting;
- Written legal advice;
- Copies of orders;
- Correspondence with Legal Rep/Solicitor.
- Team Manager Case Audit Forms;
- Management action regarding staff (sealed envelope or electronically protected);
- Unsubstantiated allegations against carers (sealed envelope or electronically protected);
- Birth Certificate.
Appendix 2: Foster Carer File Structure
The foster carer file should be divided up into sections as follows: -
1. Foster Carer's Profile
- Updated annually at time of review.
2. Transfer and Closing Summaries
- Transfer Summaries;
- Closing Summaries;
- Annual Audit - Checklist for yearly audit.
3. Placement Section
- Placement sheet Placement Agreements Disruption Reports.
4. Officer's Reports Section
- All Supervising Social Worker's home visit reports and officers' reports. Supervision Decisions;
- Unannounced Visits.
- Full details of all complaints made together with correspondence and other documentation;
- Information which contains full details of all complaints made together with correspondence and other documentation;
- Incidents Reports.
- All letters and memos received (except references/complaints).
- Panel Resource and Service Package Agreement Forms, financial memos, requests for payments from carers etc.
- Foster Carer Training Profile;
- Details of courses attended and other relevant issues relating to training.
- All annual reviews of approval including any reviews taken to Panel.
NB: Minutes and documents must be filed under Panel Papers Section.
10. Panel Papers
- Application Form, Form F;
- Matching Reports;
- Panel Minutes and Decision, including those from reviews taken to Panel. Foster Carer Agreement;
- Letters of approval/variation/termination of approval.
11. Statutory Checks
- Social care information system Referral (Adult Enquiry Form) Medical(s) Adult 1;
- DBS (includes Police Check, Consultancy Index, Education and Skills, DHSC) Education;
- Consultant Community Paediatrician;
- Housing (if applicable) this includes Council or Private Landlord. NSPCC;
- Referees (3, two who are not relatives and one of whom should be a relative). Referee - Employer's reference (if applicant works with children);
- Armed Forces (if applicable);
- Other Local Authority (if applicable);
- Health and Safety Checks - should be completed twice yearly.
12. Information Not Cleared for Access
- Third party information (e.g. personal referees, Child Protection minutes and
Chronology of incidents relating to child in placement).
13. Annual Audit
- Completed checklist for yearly audit.
: An up-to date Foster Carer Profile, which includes details of all back-up carers should be kept at the front of the file. These should be updated yearly.
Appendix 3: Adoption File Contents Sheet
This appendix is currently under review - to follow.
The case file contents will be agreed with a Team Manager and/or a Head of Service.
Appendix 4: Inter-Country Adoption File Contents Sheet
||Dates of References* Managers file checklist
Record of Supervision/Decision Sheets
All correspondence (except references/complaints) Copy of e-mails
Application to adopt
Initial visit report
Consent to seek references/checks
CoramBAAF Form F Referees' letter
Health & Safety checklist
Letter of Approval & Panel Minutes
Record of training undertaken, evaluation & copy of certificates*
DBS (see section 12) NSPCC
Other Local Authority check
Medical Advisors letter to GP
Medical report on prospective adopter Consent to Medical Examination Guardian's declaration
Armed Forces (if applicable) Health visitor (if applicable)
||Placement Records/ Matching
Post adoption/contact form
IRF (96) Incident Report
Reports to Panel (allegations/complaints) Minutes from Panel
Agreement to Home Study Notification from court Copy of Adoption Order
Invoice & Receipt
Change of Details
Adoption support allowance assessment form
||Information not cleared for access/references
Original DBS check
Correspondence relating to references
NOTE: * indicates that the document must be copied and placed on any new case file.
Appendix 5: Youth Offending Service/ Youth Justice Service File Contents Sheet
- Sentence Notification (for all offences for which there are currently orders in place;
- Court Front Sheet; or Crown Court Notification;
- Statement of Understanding;
- Signed copy of induction sheet for all orders;
- Order/Licence and associated papers for current offences;
- Copy of Order/licence, signed;
- Copies of PSR Requests;
- Previous Convictions (most recent);
- CPS Papers for Current Orders (Not all of them, case summary would be best);
- 1 x copy of PSR for current offence(s);
- Subsequent PSR's or other reports prepared for court or psychiatric reports;
- Prison comments and custody paperwork;
- Assets for all current orders;
- Initial and Reviews including final - must be signed(Supervision Plans);
- Updates of contact from CareWorks in order;
- (Record of Contact);
- Reports/updates from any group work programme;
- Notes of inter-agency meetings;
- (Contact with Other Agencies e.g. Educational Welfare, Social Services);
- Progress Reports;
- Appointment Letters;
- Enquiring letters;
- Warning letters;
- Withdrawal of warning letters;
- Old Reports & Associated Material;
- CPCC Minutes;
- Confidential Third Party Information (not for disclosure);
- Victim Issues.
Appendix 6: Case Recording Format for Children and Family Files
Appendix 6: Case Recording Format for Children and Family Files - to follow
Appendix 7: Case File Contents Checklist for Practitioners
Appendix 7: Case File Contents Checklist for Practitioners - to follow
Appendix 8: Three Month Case Summary Sheet
Appendix 8: Three Month Case Summary Sheet - to follow