Recording Policy and Guidelines

1. The Importance of Good Case Recording

Good case recording is important because case records are:

• The central record of information about the child: accurate and timely recording describes the child's needs and voice. This ensures that the child does not have to repeat their story repeatedly to different professionals, and that key professionals have the information they need to help them;
• The record of the child's experiences: sensitive and clear recording will help the child to understand what has happened to them and why. Children and young people should be encouraged to read their records, as part of direct work; life story work and transition to adulthood;
• The record of practice and a source of learning: detailed practice notes and analysis help managers, auditors and others to understand what practitioners have done and why. This supports good supervision, quality assurance and learning from case reviews;
• The source for performance data: ICS produces the data Slough Children First uses to get a strategic understanding of needs, services, timeliness and quality and is used by Ofsted and the Department for Education to hold us to account. Good case records ensure that the needs of individual children inform our strategic decisions.

Recording should communicate our values and vision. It should be clear from the case record how the child or young person is being supported to be safe, secure and successful. This includes:

• Safe: A robust assessment of risks to the child and any risk that the chid poses to others, the steps taken to keep the child and others safe and contingency plans if the risks increase;
• Secure: A genogram and eco map setting out the family and other relationships that provide the child with security; and a clear indication of the longer-term plan for stability and permanence;
• Successful: A plan to support the child to participate in education, promote their physical and mental health and make a successful transition to adulthood.

Excellent case records reflect our practice principles and values. They should record how we have acted:

• Professionally: by meeting the statutory requirements for the type of record, including the requirements of the court where applicable; and in accordance with relevant data protection and equalities legislation;
• Respectfully: by being accurate, fair and sensitive to the feelings of children and families and other professionals who might read the file; avoiding negative language and jargon;
• Resourcefully: by describing the strengths and social networks and other services that the family can draw on for support; and using creative methods to illuminate the child's voice within the record;
• Reflectively: by including analysis of the professional's view of the child, and any management oversight and supervision related to the case.

2. 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.

Case records should reflect children’s lives, achievements and the work that is carried out with them, and clearly relate to the plans for their futures. The style and clarity of records should be such as to increase the understanding that children have about their histories, background and experiences.

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.

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).

Please refer to Informance Governance pages on Slough Children First intranet for the most recent policy and guidance.

3. 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'.

• Any form changes should be approved by a manager and considered via the ICS Information Governance Group where it will be an on line form;
• Forms are used to aid decision-making at a range of panels. Completing the right form, and providing the right information helps the panel make better decisions and avoids delay.

4. 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.

Children looked after and care leavers must have a copy of their Care Plan or Pathway Plan and understand its content. This supports them making a meaningful contribution to their planning and review.

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 Confidentiality Policy and Access to Records / Subject Access Requests Procedure.

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

4.1 Quality Standards

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.

• An interpreter will be provided if needed. If documents or forms are translated, the signatory must sign the translated version. Both the English and translated versions must be uploaded to ICS.

Information about the family and their circumstances must be recorded sensitively and, as far as possible, avoiding jargon. The best case records are suitable for sharing unedited with children and families as part of relationship building and direct work.

Case files for individual children should be written so that they can be shared with limited redaction of the personal information of other family members, taking into account the need for evidence and analysis of the family situation. Maintaining case files for individual children supports professionals to think about the child's needs and the impact of decisions on them as individuals. This is important part of a child-centred approach.

At the same time, family context is important. 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. 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.

5. 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.

5.1 Roles and responsibilities

The child's social worker is responsible for:

• Recording the outcomes, actions and minutes of case conferences and planning meetings;
• Amending the child's plan as a result of IRO challenge or review;
• Ensuring that other professionals record their interactions with the child in time for any plan review meeting.

The Independent Reviewing Officer is responsible for recording the outcome of the CLA Review meeting.

Clinicians and the Virtual School record directly onto the child's file.

Managers are responsible for:

• Recording authorisation of decision making and oversight activity;
• Recording supervision;
• Recording the outcome of panels of which they are the chair.

5.2 Recording decisions

Records of decisions must show who has made the decision and the basis on which it has been made. Using the correct forms and case note headings supports this by highlighting the required information. This also supports auditing of decision-making.

Relevant case note headings must be used and ICS holds a drop down list of headings.

See also: Section 11, Records Must be Written Clearly using Plain Language and Avoid Prejudice and Section 12, Records Must be Accurate and Adequate.

6. 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 identification numbers (Trust ID, NHS number and Unique Pupil Number).

Care should be taken 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.

6.1 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 genogram and eco-map;
• 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 Personal Education Plan (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 by the allocated practitioner.

6.2 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.

For further guidance on social work visits, see Social Worker Visits to Looked After Children Procedure.

6.3 Other Key Records

The Record must also include the following:

A risk assessment: Description of risks to the child or young person, and any risks that they may pose to others; actions taken to reduce risks and contingency plans if those risks occur. This might include risks of child sexual exploitation, going missing, harmful violent or sexual behaviour or substance misuse.

• Transfer/closing summary (where appropriate): See the case transfer policy for a template for a case transfer summary;
• A properly maintained Chronology: Significant events in the child's life should be included, as well as key social work interventions;
• Genograms: Description of the child's family tree for at least three generations. This, along with the ecomap should be completed with the child and family at the earliest opportunity;
• All other relevant contacts with children, their families, colleagues, professionals or other significant people. This includes conversations, phone calls, visits, letters, e-mails, assessments and reports.

Records of contacts and activity should include:

• Who was present or seen;
• A record of relevant discussions;
• Actions or decisions taken and by whom, and the reasons for decisions;
• The options that have been considered;
• 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.).

6.4 Important Characteristics of the Record

The record should be structured and maintained in a way that ensures:

• The decision-making process is clear and management oversight is evident;
• 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.

6.5 Case Summaries

Every 3 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.

Case summaries must include:

1. Reason for referral, brief background / historical information;
2. What we are worried about, include brief danger statement;
3. Brief profile of the child/young person and their views regarding their plan;
4. Important relationships for the child – including family and professional contacts;
5. What is working well;
6. A brief description of the plan for the child, including contingency plans;
7. Frequency of Social Work visits / any key visits pending;
8. Key dates to include: next CP / CLA/ CiN Review, PEP, IHA or RHA, Court dates, PLO, TAF etc.
9. Any health and safety alerts – e.g. don't visit alone.

The Case Summary template is available in Slough Children First intranet.

7. 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.

7.1 Consent to share information

Children and their parents must be asked to give their agreement to the sharing of information about them with others.

Consent to information sharing and asserting rights to privacy are important steps to empowerment and transition to adulthood. Asking for children's consent teaches them that it is appropriate for them to assert boundaries, an important skill in adult life.

• The views of older children and young people on who knows what about them should be given significant weight;
• If a child does not want a professional or someone close to them to know information about them, the reasons why should be explored with the child, and if information must be shared, this should be explained to the child with reasons.

Proper recording of consent to share information is particularly important at the point when a child enters care. Parents and young people must be asked to consent to the sharing of medical and other personal information with carers at the earliest opportunity to prevent disruption to the child's care.

Where possible the wishes of those who do not wish confidential information to be shared should be respected. The refusal to share information must be clearly recorded on the case file.

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. Any decision to share information without consent should be clearly recorded with the rationale for sharing clearly identified.

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.

7.2 Recording information sharing

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.

See also: Slough Children First Information Governance policy on the Information Governance page of Slough Children First intranet.

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 / Subject Access Requests 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.

Paper and handwritten records are not acceptable. Paper copies of letters and other handwritten documents that form part of the child's record should be scanned onto ICS.

10. Records Must be Kept up to Date

Records should be updated as information becomes available or as decisions or actions are taken as soon as practicable or, at the latest, within 24 hours of the event.

Dates are generated on ICS automatically when a record is amended. 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 Clearly using Plain Language and Avoid Prejudice

Records must be written clearly and concisely, using plain language, and in a way that recognises the the right of the child or their parent/carer to 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. 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 technical or professional terms, acronyms and abbreviations must be kept to a minimum; and explained.

See Access to Records / Subject Access Requests Procedure and Case Records and Retention Procedure.

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. If a child / young person feels 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, 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).

See Confidentiality Policy.

13. Managers Must Oversee, Monitor and Review all 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 Consultant Social Work Manager (CSWM) 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.

Records will be routinely reviewed as part of the Quality Assurance Framework, using the Professional Standards Case File Audit tool. The standards required by the audit tool are based on statutory guidance, and wherever possible, are set out in the relevant policy in this handbook.

14. Records Should be Kept Securely

All records held on children must be kept securely.

Other day-to-day records, such as Contact or Daily Records, should also be kept securely in a manner authorised by the manager. These should be typed up and recorded on ICS within 24 hours and paper copies disposed of in accordance with Slough Children First's Information Governance policy.

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.

See also: Slough Children First Information Governance Policy on Slough Children First intranet Information Governance Page.

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, Slough Children First officer must report this immediately to their manager and every reasonable effort should be made to obtain their recovery.

Any loss of records or documentation relating to one or more identifiable children or families must be managed in line with Slough Children First's Information Governance policy.

• The child or family must be notified of the data breach and the potential impact;
• Slough Children First's Information Governance Officer must be notified, who will consider what other steps need to be taken.

See also: Slough Children First Information Governance Policy.

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/Slough Children First 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.