1.2.5 Recording Guidance

Recording is an essential aspect of providing a social work service, a tool for:

• Gathering and organising key information to inform decision-making and planning
• Reflecting upon and analysing information in order to develop and adjust plans
• Demonstrating openness with service users
• Maintaining accountability within the organisation
• Transferring information to other agencies

All social workers are responsible for completing social work records in a way which is timely, comprehensive and of good quality and are must therefore follow the policy and guidance set out in this procedure.

Managers are responsible for ensuring that their staff adhere to these standards.

Managers are responsible for arranging Framework training for all new staff within two weeks of employment. All staff are responsible for developing and maintaining competency in the use of Framework in order to manage their work generally as well as to complete recording.

The case record includes:

Structured Recording

• Child’s personal details, including all linked children and adults
• ICS documents – information gathering, assessment, planning and reviewing
• Other documents ‘embedded’ within Framework e.g. the record of statutory visit
• BAAF documents

Unstructured Recording

• Case notes
• Meeting minutes (when not attached to a Framework document)
• Emails
• Correspondence
• Management decisions (where not an outcome of a Framework episode)
• Legal Documentation
  
  All court related statements, care plans, reports, judgements and copies of orders
• Financial and Commissioning Data
  
  All information regarding requests for and agreements to finance or other resource provision
• Health and Safety Information
  
  Details necessary for the protection of social care staff and the public in general, including environmental hazards, risk of violence, transmissible disease etc
• Coded Data
  
  Data regarding the child and family; timelines; educational achievement etc. which are required to be reported as performance indicators and are drawn automatically from areas within documents.

Use of structured documents

All social work recording must be undertaken directly within Framework and wherever possible a structured document should be used to do this. In particular all planned contacts with looked after children and children who are subject to a child protection plan should be within a structured document. These documents are formatted to ensure that the child’s needs are at the centre of the process and give access to ‘prompts’ and to research data.

Structured documents include both ICS documents e.g. Initial Assessment - see Appendix 1 - ICS Documents and internally developed documents e.g. Record of Statutory Visit

Issues in Recording

Social work recording is a skilled process which develops with practice and experience. These notes indicate some of the main issues that arise and which staff should be aware of:

Clarity and detail

It is important to be aware that records will be accessed by others who do not have the same detailed knowledge as the author of a record. It is important therefore to be clear as to the identity and relationships of those involved. Each person mentioned in a record should be introduced by their full name and relationship to or within the family in question.

In some circumstances e.g. assessing whether an injury may have occurred accidentally it is important to be very clear as to room layout, time of day, sequence of events and who was present in the home: time spent recording these details can save a lot of time later.

Where concerns or allegations are raised it is essential that the maximum amount of detail is sought, as this can indicate both the seriousness of concern and how credible they are: if parents are alleged to be ‘always shouting’ at a child the informant needs to be asked on what occasions this has occurred recently – dates and times; where they were; what was exactly shouted, whether there were other witnesses etc.

Information source and corroboration

We gather information from a number of sources: our own observation; reports, verbal or written from colleagues, other professionals or members of the public. This may relate to events they themselves have witnessed, to what they have heard from others or judgements they have made.

It is essential when recording to be clear as to the source of the information and whether it has been in any way corroborated or cross- checked with others. Where this is not possible it is advisable to qualify that information e.g.

Ms Smith informed me that her former partner was involved in drugs; however under the details supplied he does not appear to have a criminal record or to be known to the drugs agencies.

It is very common for there to be more than one version of events and essential for recording practice to be aware of this. When making judgements as to the validity of information from different sources factors such as whether the informant was personally involved, and if so whether there is a close emotional involvement e.g. a parent, or whether they are likely to be more neutral and objective; whether there is other data such as hospital records; the length of time since the events in question and the informant’s overall credibility.

Where informants provide information regarding their background, as in fostering and adoption assessments it is important to make it clear that this is their account and to note which areas may need to be considered with more circumspection.

Avoiding judgemental terminology

It is important to use recording terminology that will be acceptable in all circumstances in which the record may be disclosed, including complaints enquiries, court hearings and access to records requests. Neutral and professional terminology also helps us to distance our own emotional reaction. Therefore instead of:

‘The flat was absolutely filthy and Mrs Smith reeked of drink’.

‘I saw evidence of waste food and soiled nappies on the floor throughout the living area. When I spoke to Mrs Smith there was a noticeable smell of alcohol on her breath’

Using analysis

An essential aspect of recording is the evaluation of the different types of information provided to make a judgement as to the issues at hand and the future action which should be taken. This involves:

Assembling the information:

‘A referral from Sunnyside Nursery regarding the Smith children indicated that their attendance had become irregular over the past month (Objective data from Nursery Register)

On the occasions they have attended it was reported that they were hungry and had not been bathed recently (Credible account from qualified professionals).

When I visited I saw evidence of waste food and soiled nappies throughout the living area and a smell of alcohol on Mrs Smith’s breath (Worker’s first hand observations)

Mrs Smith explained to me that she hadn’t been able to keep up with the housework as she has been visiting her mother in Mayday Hospital and she had a GP appointment about her knee pain. When I asked her if she had been drinking she said she had had two or three glasses of wine with a friend the night before. (Implausible explanations)

Arriving at a conclusion and analysis

On the basis of the information received and my assessment visit I would conclude that there has been a significant deterioration in Mrs Smith’s parental capacity to meet her children’s basic needs and that this is likely to be due to alcohol abuse, which she is not currently acknowledging.

Due to the likelihood that this is a long-term situation likely to cause damage to the children due to neglect I recommend that an Initial Child Protection Conference be called to consider the need for a formal child protection plan

Recording with sibling groups

A principle underlying both the Data Protection Act and the Integrated Children’s System is that a separate case record is maintained for each service user. This has the advantages of maintaining a separation of individual data in the event of a request for access and of encouraging a focus on the child’s individual needs. However; a consequence of this is that there can be a need for duplication of recording when there are a number of children with closely related difficulties.

In order to manage this dilemma the following considerations apply:

An Initial Assessment should normally be undertaken of the needs of all children living in the household of a child who is referred for service if it can reasonably be supposed that the concerns expressed in the referral might apply to those children. This would include all referrals where there are concerns regarding the standard of parental care or other severe stress within the family; however, where there is a specific issue such as a disability applying to one child it may not be necessary to assess siblings where there are no evident problems or concerns.

Assessment should recommend, and a management decision confirm which of the children within a family are receiving or need to receive a service. Where children are looked after or require a protection plan this will be clear. It may not be necessary to maintain a case record on all children in the family where there is no need for a direct service – though the personal details of all children should be linked, and a further Initial Assessment undertaken if the need arises.

The dimension of the ICS Initial and Core Assessment relating to the child’s developmental needs must always be completed on an individual basis. It is permissible to copy the dimensions relating to parental capacity and family and environmental factors between siblings, though these should always be reviewed in the light of individual circumstances e.g. where there may be different fathers.

Meetings

Records of all meetings that take place regarding service users should be part of the case record. While recording takes time, unless there is a clear purpose and outcome to professional meetings differing interpretations can arise which give rise to confusion and misunderstanding.

• The Team Manager (or DTM) responsible for the child is also responsible for ensuring that a record is maintained of all meetings. As a minimum the record must include:
• The purpose of the meeting, date, time and venue
• Details of who was present and their roles
• The outcome or action arising from the meeting – or areas of disagreement as relevant
• Responsibilities for this action.

Correspondence

Correspondence, electronic or postal, both sent and received forms part of the case record and must be uploaded or scanned into the Framework record. It is important that letters are:

Correctly addressed – the full postcode must be used to reduce the chances of miss-delivery.

Courteous – Mr, Miss, Ms or Mrs plus initial and surname must be used for all correspondence to adults. When writing to professional agencies or other official bodies take the trouble to find the name of the addressee: avoid Dear Sir/Madam.

Appropriate – Letters are fine as confirmation of discussion or decisions, or to make appointments where it is not possible to make contact by other means. They should not be used to convey difficult matters that have not been discussed face-to-face or by telephone unless there is no alternative

Use of clear and correct English

All case records, whether part of a structured document or otherwise must be written in clear and correct English. This is important to ensure clear communication, but also demonstrates professionalism on the part of the worker and respect for the service user. It is particularly important in external communications, where incorrect usage and poor spelling and grammar can undermine the Service’s credibility.

Managers are responsible for quality assuring their staff members’ records and need to be mindful of the particular issues that arise in their teams. Guidance is available on the intranet London Borough of Lambeth | House style for written material

Use of Emails

While email is a convenient way to communicate it is not always the most appropriate way to record views or to seek or convey decisions:

• It can avoid the use of the appropriate Framework work flow
• Strings of emails can be difficult to follow and may not be fully uploaded to the case record.
• There is a danger that confidential material is held less securely than if it were within Framework; and there is a greater risk of it being forwarded to or accessed by people who have no need of the data, in contravention of the Data Protection Act

Where emails are used in respect of a service user they must always be uploaded to the case record.

Emails should not be used where it would be possible to use an episode or message within Framework and in particular should not be used to seek management decisions.

Use of contemporaneous notes

Notes taken at or immediately following a meeting or visit, whether in manuscript or with a voice recorder etc are aids to memory; and are not in themselves parts of the case record. These notes should inform the completion of the substantive case record, which should be completed within the working week in which the note was taken.

Notebooks and diaries must be retained during your period of employment with Lambeth.

Legal Advice

All legal advice is professionally privileged and should not be disclosed outside of the Children and Young People’s Service. It is exempt from disclosure under the Data Protection Act.

Requests for anonymity

Where referrers and other informants request that their identity is not disclosed this must be respected. A clear instruction to this effect must be placed on the case record and this information must be made clear to all concerned with the case particularly where there is a transfer of responsibility of worker or of service unit.

Hard copy records can be maintained where it is necessary to have certain key documents in a portable and easily referenced form e.g. court hearings.

However, this must be a copy of the Framework record and not separate or different.

Hard copies can be maintained separately only:

• Where it is necessary to preserve an original document, such a birth certificate or photograph
• Where a third party document is awaiting scanning
• Where there is legal advice that it is not permissible to enter the document on to Framework
• Where a document is a working tool in the process of completion e.g. an Assessment and Progress Record where the use of a hard copy facilitates the young person’s involvement.

Principles

All staff are responsible for maintaining the security and confidentiality of the case records they are responsible for. This includes:

• Ensuring that hard copies of records of records are kept securely, particularly when taken out of the office. Records must not be left in unattended vehicles.
• Not disclosing your network or Framework password or allowing others to access the system using your password

Data Protection Act 1998 and access to personal records requests

All Children’s Social Care Records are subject to the above legislation. Most problems can be avoided through openness with service users – inviting contributions to draft assessments and plans, and provision of copies of key documents. Please refer to full guidance on the following link London Borough of Lambeth Intranet| London Borough of Lambeth Data Protection Policy. Detailed advice can be obtained from the Council’s Data Protection Advisor.

A key principle of the Data Protection Act is that data can only be used for the purpose for which it has been gathered i.e. the care and protection of children. It may not be used for any other purpose: a member of staff who accessed data on a case record concerning anyone with whom they had a personal or business relationship would be in breach of the act and liable to criminal proceedings and disciplinary action.

Responsibilities

Electronic Security

Staff who have been issued with a laptop PC and who wish to use it when it is not possible to connect to the Lambeth network e.g. while on a train journey may record onto the PC’s hard disk – C: drive providing:

• The document itself is password protected
• The document is re-saved onto the shared drive and deleted from the C: drive at the earliest opportunity.

The reason for this is to reduce the chances of confidential information being accessed if the laptop is lost or stolen.

Case recording is part of the service provided to users and carers

This means that we must use an open and collaborative approach in which users:

• Each have their individual case record
• Understand why a case record is maintained;
• Are aware of their right to have access to this and to be provided with copies of assessments and plans and to be given timely information regarding decisions that concern them;
• Are encouraged to contribute towards these and are able to correct inaccuracies and to add their own views.
• Are supported in accessing and in understanding their records

The quality and content of case records reflects good professional practice and internal guidance

Records must:

• Outline all significant aspects of the work undertaken; using the relevant ICS, BAAF or other embedded documents as appropriate
• Include decisions taken, reasons for these decisions and name and designation of the officer responsible for them
• Contain all contributions to assessment and planning, including differing points of view where appropriate.
• Be completed at a level of detail which is commensurate with the nature and complexity of the issue e.g. a Core Assessment should always be carried out where there is any likelihood of a need to accommodate a child.
• Reflect a competent level of professional practice and linked to recorded assessment and planning.

Principles and Purposes of Case Recording

Purposes, principles and legal requirements are clearly set out.

• Principles and requirements are clearly set out in the attached policy on case records, which includes clear expectations as to standards and responsibilities.
• These are supported by the Departmental Document Management Policy, corporate IT strategy and Data Protection Act policy.
• Clear information and guidance is available for the public via leaflets and the Intranet.

Contributions to case records and sharing information: the service has guidance on and systems for receiving contributions to case records from external sources and for the appropriate sharing of information from them.

• All work done directly or in connection with a service user is recorded
• Lambeth recording procedures provide for contributions both from service users and their family and social network; and from other agencies and professionals connected with the child or family.
• All information received is evaluated and its relevance assessed, where possible in agreement with the person supplying the information.
• Relevant aspects of case records are shared with other agencies on a ‘need to know’ basis and service users are informed when this takes place.

Equalities in recording practices: the service requires that service and corporate equalities policies are reflected in the case record.

• Recording guidance reflects good practice in equalities, including anti-discriminatory practice and sensitivity to the needs of all service users.
• Case recording identifies needs arising from ethnicity, culture, gender, age, religion, language, communication, sensory impairment, disability and sexual orientation.
• Arrangements are made for service users who have language or other communication needs to have access to records.
• Information from case records is routinely gathered for monitoring and planning purposes.

Management Arrangements: management arrangements ensure the practice of case recording meets accepted professional standards and the service’s policy and procedural requirements.

• Responsibility for ensuring the quality of case recording is clearly located with front-line managers.
• All managers are aware of and have access to guidance on recording and to appropriate training and development opportunities in this area.
• Managers ensure secure and confidential storage, access and transport arrangements for records.
• Data derived from case records is systematically monitored in order to plan and improve services to users.

Should be updated as necessary following each conference.

Runs alongside Care Plan for all children where adoption is being considered.

Replaces Part 1 of the Child’s Care Plan where adoption is the firm plan.