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5.1.15 Recording with Care Guidance

SCOPE OF THIS CHAPTER

This guidance applies to all employees working in Children’s Services and to partner agency employees handling information on behalf of the Council. The document aims to provide a robust set of recording standards which enable employees to record personal information in a clear and consistent manner. The standards apply to existing and new records, whether stored in paper format or on electronic systems.

AMENDMENT

This chapter was amended in December 2015 to recognise the importance of a child’s record containing education assessments, health and Personal Education Plans. (See Section 5, Case File Presentation). Links have also been introduced to some key references, including Information sharing: advice for practitioners providing safeguarding services (2015) to enable accessibility.


Contents

  1. Introduction
  2. References
  3. Record Keeping in General
  4. General Principles
  5. Case File Presentation
  6. Recording Standards
  7. Supervision of Records
  8. Storage
  9. Security of Information
  10. Definitions


1. Introduction

This document sets out a framework for consistent recording methods, underpinned by a common set of values which are to be considered when recording information in any format. The guidance is intended to benefit children and their families/carers, as well as employees working in Children’s Services and its partner agencies. 

The guidance will assist employees to create and maintain clear historical records for reference by colleagues, partner agency employees, children and their families/carers. All records will be complete and easy for the service user to understand, providing transparency and accountability for decisions made and actions taken.


2. References

Children Act 2004
Data Protection Act 1998
Freedom of Information Act 2000
Caldicott Principles
Human Rights Act 2004
Mental Capacity Act 2005
Information Commissioner’s Good Practice Guidance
Information sharing: advice for practitioners providing safeguarding services (2015)
Records Management policy
Information Sharing Policy
Arrangements for Operational Management Supervision and Professional Support of Integrated Children's Teams Procedure


3. Recording Keeping in General

Record keeping is key to providing integrated services to children, and their families/carers. Consistent recording processes are essential for service planning, decision making and information sharing. Quality recording will assist employees in the following ways:

  • Providing documentary evidence of the authority’s involvement with individual service users;
  • Providing information to assist with analysis, service/care planning and reviews;
  • Documenting services provided to individual service users;
  • Documenting performance against expected standards and targets;
  • Allowing continuity when workers change or are absent;
  • Providing information when dealing with investigations or complaints;
  • Supporting supervision and employees development;
  • Providing service users with a complete record of their care.


4. General Principles

Appropriate records must be kept of all contact with children and their families/carers, and a clear case summary/Chronology should be maintained.

There must be a consistent approach to all recording, and records should be:

  • Accurate and concise;
  • Up to date;
  • Relevant;
  • Easy to read and in plain English, with any abbreviations explained;
  • Easily understood by the service user.

All recording must be included in the record within two working days of the event, unless a specific endorsed Children’s Service procedure includes a different timescale. In the event of it being a safeguarding issue it must be recorded and reported immediately. Wherever possible, children and their families/carers should be involved in writing their records, and their wishes and views (including issues around consent) are to be recorded.

Service users and carers are informed of all decisions and outcomes relating to requests for services, and should receive a written copy of each assessment.

Service users and carers are informed of their right of access to their records and the procedures for doing so. Services users are encouraged to access their personal records, and supported in understanding the content, correcting errors and omissions, and recording personal statements, including any dissent.

All practitioners are responsible for ensuring that appropriate information is recorded.

All recording should be evidence based with clear distinction between fact and opinion. Reasons should be given for decisions made and all reports must be signed and dated.

Original entries in records should not subsequently be removed or amended. Any additional comments from the service user or professionals can be added to the report. All additions must be signed and dated.

All services commissioned by Children’s Services should adhere to these recording principles.

All records must comply with current legislation and LCC policy (see references section).

Consideration must be given to race, culture, religion, age, disability, gender or sexual orientation. Case records should document any issues which arise.


5. Case File Presentation

The case file will contain all the information about a child who has been referred to Children’s Services. Information may be paper and/or electronic, and could include audio, video and digital recordings.

Within the case file, each individual case record will provide a written account of the work with the child, and will detail the following:

  • The child’s full name, date of birth, all personal core information and identification number;
  • Individual contacts with the child and family/carers;
  • The work to be undertaken and relevant objectives;
  • Analysis, decision making;
  • The procedure to be followed;
  • The assessment of need;
  • Any Education Assessments;
  • The child’s plan, including Placement, Health and Personal Education Plan;
  • The child’s plan;
  • Timing of events;
  • Process and outcomes of any review;
  • All relevant communications.

A child's paper file must include the following paperwork at the front of the file:

  • A basic information file front sheet;
  • Assessment, including risk assessment (where appropriate);
  • Child’s plan;
  • Review of the Child’s Plan;
  • Transfer/closing summary;
  • An up to date chronology should be placed in the inside cover of the folder (this is not required for those records which are being recorded on MOSAIC).

Recording methods and forms must be consistent across the Children’s Services. The design of all new recording forms must be approved using the design and endorsing process and stored in the Children’s Services Core Forms database on the intranet.

Paper case files 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.

Information held on electronic databases must accurately reflect the corresponding information recorded within paper files.


6. Recording Standards

Each service user will have a separate case file/record.

Basic personal information will be recorded following initial contact, and be reviewed and updated regularly.

Practitioners and managers have a responsibility to ensure:

  • All involvement or contact with children and their families/carers is documented. This includes detailing who was present, discussions which took place and action to be taken. Roles, responsibilities and timescales should be clear;
  • Case records contain evidence based explanations for all decisions made. All decisions must be recorded indicating who was involved, what information was considered and the reasons for the decision. Fact and opinion must be recorded;
  • The wishes, feelings and views of service users and their families/carers are sought and recorded under clear headings;
  • Each entry in the hard copy file is signed and dated by the employee member writing the record. The name and job title is be clearly identifiable;
  • Completed key documents are contained in the file; 
  • Records indicate appropriate authorisation from managers/supervisors.

Children and their families/carers must be informed of the records kept about them and their right to confidentiality and access to records. Further information is contained in the leaflet ‘What we do with your information’ which is available from the Council’s General Office.

Children and their families/carers must be routinely involved in the process of gathering and recording information about them, expressing their views and contributing to meetings, assessments, reports and plans.

Information must be provided in a format that children and their families will understand, and in their preferred language or method of communication. An interpreter will be provided as appropriate.

All service user information is confidential, but there may be circumstances where it is necessary to restrict access to specific information or reports which practitioners consider to be sensitive or harmful. This decision must be recorded in the file and the document(s) are to be clearly marked as restricted access. This information is to be accessed on a strict need to know basis, and where appropriate, managers may restrict employee access to whole files which contain large amounts of this type of information.

Service users must be asked to give their agreement to the sharing of information about them with others, but there are exceptions which are detailed in the Information Sharing Policy.    

The practitioner directly involved in an event which is being recorded must complete the record. Where this is not possible, and records are completed or updated by another employee member, it must be clear from the record who provided the information. The originator should read, sign and date the record.

Handwritten records must be legible and easily understood. Wherever possible, records should be typed. The name and job title of the writer must be clearly printed in the document.

Manual records must be typed or handwritten in black ink, signed, dated and the author’s name should be clear. Before saving, records should be spell-checked. All other records must be re-read and any mistakes corrected before authorisation. All alterations must be signed and dated, whether on paper or electronic recording systems.

Information is not to be removed from an authorised document, and any necessary amendments must be added separately and linked to the original entry. This applies to employees amending errors in records, and also to service users and their families/carers adding their comments to the document once they have received a copy. Each entry must be signed and dated.

Where records are made late or updated after the event, this should be clearly marked as a ‘late entry' in the record. Each entry must be signed and dated.

Records must be written concisely, in plain English, and must not contain any expressions which might offend any individual or group of people on the basis of race, culture, religion, age, disability, gender, or sexual orientation.

The use of technical or professional terms and abbreviations must be kept to a minimum; and their meanings must be explained.


7. Supervision of Records

Managers are responsible for ensuring there is regular supervision of case files and case records, offering guidance and training as appropriate.

The overall responsibility for ensuring all records are maintained appropriately rests with managers with day-to-day responsibility, delegated to other employees as appropriate. Please refer to the Arrangements for Operational Management Supervision and Professional Support of Integrated Children's Teams Procedure.

Managers should routinely check samples of records on a regular basis to ensure these are up to date and maintained to the required standard. Deficiencies are to be rectified as soon as practicable.

Managers must monitor ‘restricted access' information held on case files and electronic records, ensuring that the reason for it being restricted is valid. 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. For further information read the Information Sharing Policy.


8. Storage

All children’s files and records (open and closed) must be stored securely, in accordance with Records Management policies. For further information and guidance please refer to the Records Management homepage.

Where a file/record is temporarily removed from its usual location, the new location should be recorded on the relevant electronic system and/or paper file tracking card. Measures should be in place to ensure the record is returned within an agreed timescale

Where files/records are permanently moved to a new location, the reason and the date of transfer should be clearly recorded on the appropriate database/system.

After a Social Care paper case file has been closed for period of two months it must be transferred to off site storage, either in a Council basement or with the Council’s current remote service provider. All other Children's Services files are to be stored in line with current Records Management practice.

Employees must document the disposal of records in accordance with Records Management policies.


9. Security of Information

Employees should only access the records of service users which have been allocated to them.

Files/records must not be left unattended in a public place or in vehicles.

Electronic records must not be left unattended when displayed on ICT. Computers must be password protected and where possible, laptops are to be encrypted. Screens should be locked whenever unattended.

Employees using computers at home should only use encrypted laptops. Person identifiable material should not be held on the desktop of laptops, or on portable media such as memory sticks, CD etc.

Service user paper files must be locked away when not in use, preferably in a locked cabinet or drawer, in an office where only authorised employees have access.

When transporting files/records, regardless of the method of exchange (e.g. courier, recorded delivery, hand delivered), the sender should check that records have arrived at their intended destination. Adequate measures should be in place to ensure the security of the record whilst in transit and at the new location.


10. Definitions

Case file is a complete record of the child’s involvement with Children’s Services.

Case record is the individual report detailing a specific event or meeting.

End