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2.1 Recording Policy and Guidelines

RELATED GUIDANCE

Independent Inquiry into Child Sexual Abuse - Notice of retention / non‐destruction of documents relating to the Independent Inquiry into Child Sexual Abuse. A request from the Independent Inquiry into Child Sexual Abuse to Local Authority’s to retain any records which may be potentially relevant to the Inquiry.

AMENDMENT

This chapter was amended in May 2019 to reflect HHJ Greensmith’s comments regarding M and N (Children: Local authority gathering, preserving and disclosing evidence) [2018] EWFC 40 (1 June 2018).


Contents

  1. Purpose of Case Recording
  2. Good Practice Principles
  3. Standards in Case Recording
  4. Records Must be Kept on all Children
  5. Use of Language & Recording Style
  6. Chronologies
  7. Recording Timescales Table


1. Purpose of Case Recording

Case records are primarily for the benefit of children and families that we work with and should be  accurate.

Effective case recording cannot be underestimated; it is a tool that facilitates good social work practice and also demonstrates the complexity and amount of work being undertaken. Best practice dictates that managers regularly use case recording to monitor and ensure that work is meeting requisite standards.

Effective case recording also fulfils a variety of other purposes to include:

  • Forming a biography, for example to show someone’s history;
  • Evidencing the views of children, families, carers and professionals and how this informs decision making;
  • Ensuring accountability and transparency in service provision;
  • Providing a documented account of involvement with children, families and carers;
  • Keeping the work of all practitioners focused and supporting effective partnership working with children, families and other professionals;
  • Enabling all staff to reflect upon the quality of the service provided and make plans regarding any future services required;
  • Ensuring that important information is not forgotten and providing an evidence base that explains the rationale behind past and proposed professional decisions, intervention, planning and review;
  • Providing evidence in response to complaints, investigations and other enquiries;
  • Allowing for continuity in service provision by supporting ‘seamless’ working when multiple personnel are involved with a child or family or when personnel change;
  • Evidencing that information sharing, for example, providing copies of assessments, plans and minutes of meetings, with children, families and professionals occurs as appropriate;
  • Ensuring consistency in the way information is collected to facilitate wider scrutiny and analysis of services, inform service priorities and provide information that allows the local authority to meet its reporting requirements for example, the Children in Needs Census and Children Looked after Returns.


2. Good Practice Principles

DO’s…

  • Be clear about why you are recording;
  • Record who you are, type your name, the date, time, place and people involved;
  • Be clear about fact, observation and professional opinion;
  • Be clear about what is third party information and any issues of confidentiality;
  • Record disagreements by service users, contentious issues and complaints;
  • Explain how decisions were made, who was involved and any other views;
  • Cross-reference (i.e. letters, emails, risk assessments, etc.);
  • Refer to people by their name and title initially;
  • Remember before you start writing that people have access to their records;
  • Complete recording as soon as possible and within the required timescales (see Section 6, Chronologies);
  • Completing regular summaries can be a good way of monitoring the person’s progress;
  • If there are safeguarding issues, remember to record the incident using the individual’s words to describe the incident;
  • Only record a person’s mood and behaviour if this is part of an agreed care plan / support plan or relevant to the situation.

DON’T…

  • Use jargon and unexplained abbreviations;
  • Use language that is discriminatory and judgemental;
  • Amend at a later date;
  • Make assumptions.


3. Standards in Case Recording

The following standards will apply in respect of all case recording:

  • Case record entries should be structured, using sub headings and paragraphs to assist with the clarity and understanding of what is being conveyed;
  • All significant contact with children, families, colleagues, professionals or any other relevant people must be recorded in the same way, that is, who was present or seen, the key points from the discussions had, actions taken or decisions made by whom and the reasons for the decisions;
  • Records should be secure and confidential, and should only be accessed by those who have professional interest or authorised to have access or those professionals external to the Local Authority who are authorised within a legal framework;
  • Recording must be accurate, appropriate, and timely, with all sources of information identified;
  • Case files must clearly identify who has Parental Responsibility for the child and where there are any interim arrangements for a child’s care, for example temporary placement with a relative or in foster care, these arrangements much also indicate who has decision making responsibility for the child, on what basis and for what duration;
  • Case records must evidence consideration of equal opportunities, diversity and social inclusion issues;
  • Purpose of visits to children and their families should be clear; the visits should succinctly record the main points and any actions for follow up. Records should confirm that the child has been seen and efforts made to communicate with child or observe (taking into account the needs of the child) must be stated. Case records should demonstrate how the child’s views were used to inform decision making;
  • All documents must have a title and appropriate classification before being uploaded on Mosaic to assist in later retrieval;
  • Inappropriate documents or conversations should not be stored or cut and pasted onto the child’s records. For example, emails that include personal conversations about holidays, social life or personal disagreements should not be stored on a child’s file;
  • Where cases are to be transferred to another worker a transfer summary must be completed providing overview of progress, plans and outcomes sought and for cases being closed, a closing summary must be completed giving clear reasons why a service, at a safeguarding level, is no longer required for the child or family;
  • Generally children and families must be asked to give their agreement (consent) to information being shared about them with others - but there are exceptions for example:
    1. Where sharing the information could likely result in serious harm to the child or another person;
    2. The information was given in the expectation it would not be disclosed;(for example information shared by police but which cannot be disclosed to children or families because of an on-going police investigation);
    3. The information relates to a third party who expressly indicated the information should not be disclosed.


4. Records Must be Kept on all Children

The child's record is an important source of information for them. It provides information about the sequence of events which brought about Children's Social Care's intervention into their life and (in many instances) provides an explanation for the reasons why important decisions were made in the child's and/or family' life. The case record can be key to helping a child understand 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 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.

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.


5. Use of Language & Recording Style

Plain English Principles should be observed consistently in case recording. Plain English is defined by the Plain English Society as “A message, written with the reader in mind and with the right tone of voice that is clear and concise.”

  • The use of language and tone should be appropriate and suitable for the child and family members to read and understand;
  • Recordings should be free from jargon, as stated above, and abbreviations should be explained when first used to ensure the reader can understand. Records should not include meaningless phrases, speculation, judgemental or offensive subjective statements;
  • Records 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 informal language is not acceptable. Spell check should be used for electronic recording;
  • Information is presented in a concise manner so that it can be easily read and understood;
  • Names and roles of professionals should be clear so that they are easily identified;
  • Family information may be duplicated so long as it is relevant for each child;
  • Chronologies must detail significant events in respect of child and history of involvement.


6. Chronologies

A chronology written for any purpose is a record of key events, in a sequential order. It is based on a study of recorded information, and in social work practice its overall purpose is to support the analysis of the history of a case with reference to the current state of work on the case.

There are different purposes for writing a chronology:

  • A chronology should frame your understanding of a service user and their family, and tell the story of their lives. In this respect, they complement a genogram and ecomap nicely - the chronology describes the past while the ecomap describes their present, and the genogram overlaps with both;
  • A chronology is a tool for a professional to use while working with a service user and professionals, and a tool for a service user to help understand their own life, and any relevant patterns - in other words, a wholly practice-based document;
  • It also has a key role in assessments, as a point of reference for the completed assessment as well as an analytical tool to help create the assessment in the first place.

Significant Events - helpful tips:

  • Focus on events and changes in circumstances that had a positive or negative impact on the child;
  • Start from the date of birth of the most significant person to the child’s story (this may be a grandmother or the parents);
  • Only include any type of visit if something significant happened;
  • Don’t clutter up the chronology by copying and pasting case notes or including lists of dates of visits;
  • Multiple significant events may be grouped together i.e.: Between April - June 2012 there were 23 incidents of absconding which increased in frequency and duration each week, rather than listing all 23 separate incidents;
  • If events are significant they require a response - a chronology of incidents with no details of what was done raises questions about the SW involvement;
  • If there was no action, explain why not;
  • Where relevant, bring together information from a variety of sources and always identify the source;
  • Always reference other documents clearly;
  • All open cases should have an up to date chronology and this should be a priority if one is missing or out of date.

What are significant events - this is not an exhaustive list:

  • Family history, births, marriages, new partner, separations, bereavements, changes in household composition, employment/unemployment & homelessness;
  • Referral history & outcomes;
  • Evidence of engagement or non-engagement with agencies;
  • Education, behaviour, exclusions, admissions, missed appointments;
  • Domestic abuse incidents;
  • Substance misuse issues;
  • Criminal Justice activity, parents, carer or YP;
  • Statutory meeting i.e. ICPC/RCPC & outcome;
  • Periods subject to LAC process;
  • Missing episodes of child or family member.
  • Concerns Re suspected specific issues CSE or Trafficking;
  • History relating to violence including convictions for such;
  • Any concerns Re Vulnerable Adults;
  • CP enquiries & outcomes;
  • Court appearances, hearing and orders;
  • Key management decisions and brief reasons;
  • Any other relevant concerns or positive improvements;
  • Sex Offender Registration - known to MAPPA or MARAC;
  • Disability, illness & mental health;
  • A&E attendance, hospital;
  • Relocations;
  • School changes;

Click here to view the Chronology template - Chronology template, WF and for court

Some additional tips when completing the chronology template

  • The template should be used as a standard chronology for all electronic case files;
  • The template also meets the requirements set out by the courts as part of care proceedings;
  • The source of the information need to be included, i.e.
    • Referral received from school;
    • MERLIN received from police;
    • During home visit by the Social Worker it was observed that…, etc.
  • The outcome/ decision taken needs to be clearly included, i.e.
    • Progressed to Child and Family Assessment;
    • Strategy meeting to be arranged;
    • Children made subject to a Child Protection Plan under the category of sexual abuse, etc.
  • An example of a complete entry on the chronology could be as following:

    16/09/2018: “Police Merlin received - regarding domestic abuse - 5th incident in 12 month period - alleged husband strangled wife and caused various bruises - wife taken to A&E  - Husband arrested, bail conditions  not to return home pending investigation - Maternal aunt supporting care of children - Outcome, progress to child and family assessment and strategy discussion”


7. Recording Timescales Table

Caption: recording timescales
   
Process/Event Framework Assessment/Observation/Activity Completion Date
REFERRAL & ASSESSMENT
Request for Support and Protection/significant contact Step: Request for Support and Protection/ significant contact Within 24 hours
Child & Family Assessment Child & Family Assessment Step Within 10 days of referral date
Within 45 days of referral date
CIN Meeting Child or Young Person’s Plan 5 days after the meeting
Chronology Chronology Step Updated at least 3 monthly
CHILD PROTECTION
Initial Strategy Discussion/Meeting Strategy Discussion/Meeting Within 24 hours of discussion/ meeting
Review Strategy Meeting Review Strategy Within 24 hours of meeting
CP Initial Conference Initial CP Conference Social Worker’s Report Within 1 working day before meeting to Chair and family
CPC Report - Decisions & Recommendations Within 24 hours of the meeting
CP Conference Record Within 15 working days of the meeting
Core Group Meeting Minutes Within 5 working days of the core group
CP Review Conference CP Review Social Worker’s Report 5 working days before meeting to Chair and family
Review CPC Report - Decisions & Recommendations Within 24 hours of meeting
CP Conference Record Within 15 workings of the meeting
CHILDREN IN CARE & CARE LEAVERS
CIC Care plan Child/Young Person’s Care Plan Within 10 working days of becoming looked after
Placement Planning Meeting Child/Young Person’s Placement Plan Within 5 days of the meeting
CIC Review Meeting Child/Young Person’s Care Plan Update 5 days
Social Workers Report for LAC Review Within 5 working days of the meeting
LAC Review Record of Meeting The decisions/ recommendations to be completed in 5 working days and for the full record of the meeting to be completed within 15 working days
LAC Review Chairs Monitoring Information Within 20 working days of the meeting
Pathway Plan WF My Pathway Plan 6 monthly review and report
OTHER CASE RECORDING
CIN/CIC/Care Leaver/CP visits Record of visits Within 5 working days of visit
Case notes- contacts/telephone calls Case notes - contacts Within 3 working days of contact
Significant events Record of significant event Within 24 hours
Supervision Case Notes - Record of Supervision Within 5 working days of supervision
Management decisions Case Note - Manager’s Decisions Within 24 hours of referral
Within 2 working days other case decisions being made
Meetings Record of meeting to include actions agreed Within three working days of meeting being convened (for example, legal planning meeting, NAEP meeting, CIN Meeting)
Pre-Proceedings Pre Proceedings Letter Copy of signed Pre Proceedings letter to be uploaded on file within 1 working day of the letter being sent to parents/carers
Pre Proceedings Meeting Within 3 working days of the Pre Proceedings meeting being held
Care Proceedings Letter of Intent to Issue Proceedings Signed letter of intent to issue to be uploaded on case file within 1 working day of the letter being sent out to parent/carers
Social Work Evidence - Statement & Care Plan Within 3 working days of the application being issued by Legal Services
Court Orders Within 2 working days of receipt
Expert Assessments Within 3 working days of receipt
Private Fostering Notification MASH record and referred to fostering assessment within 24 hours
Arrangement Start Assessment conclude within 42 days of notification
Visits First visit within 7 days and then record visit within 2 days
ADOPTION
Family Finding Referral to Adoption Team for Family Finding Next working day
Adoption Notification Meeting Within 2 days of the meeting taking place
Linking Report 10 days prior to meeting
Adoption Monitoring Form 20 working days prior to the adoption matching panel
Review Form 3 days prior to meeting
Adopters Assessments Adopters Initial enquiry forms Next working day
Date of registration of interest received Recorded within 5 working days
Date of checklist for adoption application By end of stage 1
End of Stage 1 summary Within 5 working days of stage 1 interview completed
Completion of Prospective Adopters Report 20 working days prior to adoption approval panel
Post Adoption Support Post Adoption Support Request Within 3 working days of request
Post Adoption Support Within 5 working days of post adoption assessment
Post Adoption Review Within 5 working days of the post adoption review being carried out

End