1.5.1 Recording Policy

SCOPE OF THIS CHAPTER

This Chapter was issued in November 2009, it replaces all other Guidance on Recording e.g. dated 9/92 which should now be destroyed. It also supersedes the last Recording Policy update which was produced and dated March 2001.

1. Policy Overview

"The Children & Young Person's Trust recognises the importance of good quality recording to effective professional practice"

The following policy includes all the mediums currently used by Social Care staff within the Children & Young Person's Trust (CYPT)

The electronic records held within the Integrated Children's System (ICS) and CareFirst system records
The electronic records held within the CYPT 'Shared Drive' facility
The records held within paper file records

A Case Record will be kept on every service user, including individual children and carers, who are in receipt of a direct service from the social care element of the CYPT. Each child or young person should have their own individual record. This includes cases across sibling groups so that each child within a sibling group has their own full & distinct record rather than one shared across their siblings.

Case Records and files will be managed following the Information Sharing Code of Practice (To follow) and ordered in such a way as to ensure accountability for the services they provide. They will be kept securely and treated as confidential to the Trust except when the need to secure the safety of an individual requires information to be shared. In that event, this is done following the Information Sharing Code of Practice. This relates to both electronic and paper based records.

Case Records should be accurate and up to date. They will distinguish between evidence based and uncorroborated information. They will be signed and dated. In cases where the recording is electronically based the records will have an electronic 'completion' and 'authorisation' on them that acts as a signature by the appropriate worker and manager involved (e.g. - the workers 'completion' and the managers 'authorisation' on a Core Assessment Record on CareFirst).

Service users will be advised of the Trust's policy on Information Sharing and access to files, including access for those with sensory impairment, a language other than English or other communication needs. All assessment documents within the Integrated Children's System (ICS) include questions on these areas so that practitioners can record that these issues have been covered and appropriate action taken.

The consent of service users will be sought in all cases where it is necessary to disclose personal information to third parties. Consent will be sought but is not required where there is a need to safeguard or protect a child or vulnerable adult, unless by seeking that consent the child or adult is placed at further risk.

In the spirit of partnership, service users will be encouraged to contribute to their records and be given copies of their assessment and care plan. This will be in accordance with the Data Protection Act, and so long as it is in their best interest and does not breach the confidentiality of others or place a child or adult at risk of harm.

All recording will reflect equality of opportunity by taking into account ethnic and cultural diversity.

2. Legislative Framework

Human Rights Act 1998

Data Protection Act 1998

Children Act 1989

3. Definitions

Privileged information relates to any communication between solicitor and client i.e. Legal Services and Children & Young Persons Trust staff. This covers records of memos and letters, and minutes of legal planning meetings etc. These should not be made available to Children's Guardians.

Confidential information relates to all documents filed with the court. These are confidential to the parties to the proceedings. This confidentiality lasts indefinitely and does not end at the conclusion of the proceedings. Thus documents cannot be released to anyone outside the Children & Young Persons Trust e.g. other local authorities, Probation, other departments within Brighton and Hove, multi-agency teams (Clermont, Attachment Project, CAMHS, Permanence Panel) without the leave of the court. The views of other parties will be sought if an application for release of documents is made, but often the court will grant such leave even if other parties object. Leave of the court will be granted in writing, will look like a court order, and will be specific as to who the papers can be released to and for what purpose. The order granting such leave should be kept on file and social workers should be in possession of this before releasing documents to anyone outside the Children & Young Persons Trust.

Case Record: is the written account of the Children & Young Person's Trust (CYPT) intervention. It is contained on the Integrated Children's System (ICS) within CareFirst, the 'Shared Drive' facility and in paper files. It details contacts with the service user, their family and/or carers; work undertaken and to be completed; case objectives, procedures to be followed; the assessment; care plan; placements; movements and reviews.

For the purposes of this Policy document the title 'CareFirst' will be used for all references to electronic recording within the Integrated Children's System (ICS). 'CareFirst' will be used as a generic term to encompass ICS recording generally and 'Care Assess.'

The Shared Drive relates to the facility held by all CYPT teams to electronically store certain sections of recording not currently held within CareFirst. As the CareFirst system develops it is anticipated that the number of items held within the Shared Drive will continue to decrease.

Case File: is a folder which can be held on CareFirst, the CYPT Shared Drive facility and as a paper file, which contains information relating to work with an individual service user and contains Case Records; financial statements; legal documents; service agreements; correspondence and reports. As a main principle of this policy it is not a requirement to hold a hard paper copy of a particular document or piece of recording unless no alternative exists for storing that particular piece of recording. The vast majority of CYPT recording can now be stored electronically either on CareFirst or the Shared Drive and there is no need to print off these documents and additionally store them on a paper file. The exception to this principle is documents that are deemed too important or confidential to risk placing solely on the Share Drive. Documents such as Legal Planning Minutes, all Adoption Records (including JAS processes & Child Permanence Records) & Placement with Parents Reports should have both a hard copy & a copy on the Shared Drive. This duplication is a necessary safeguard until future developments take place with the Shared Drive to make it a more secure storage system. See for a full list of all documents Appendix 1: Guidance on the storage of key documents and their storage requirements.

As CareFirst continues to develop it is anticipated that the number of documents that have to be stored as hard paper copies will also continue to decrease and that ultimately such paper records may become unnecessary. Part of the overall Integrated Children's System Project Plan (To Follow) will be to explore placing as many documents as possible onto the CareFirst system-thus rationalising our recording systems.

At the moment we have three distinct recording mediums- CareFirst, the Shared Drive and paper files. One of the overriding aims of this Policy is to streamline this process as much as possible to prevent unnecessary duplication and repetition whilst maintaining complete and individualised records for all service users. This Policy identifies CareFirst as the primary and foremost recording medium for all recording and essentially the other two systems are only currently being used where CareFirst has yet to develop its own solution to producing and storing this particular piece of recording. Updates to this policy are anticipated as the scope of CareFirst increases and more of our recording requirements are met within this one system.

Appendix 1: Guidance on the storage of key documents attached to this policy contains a list of all items of recording currently used by CYPT Social Care staff. It sets out on which recording medium each item should be completed and stored on (CareFirst, Shared Drive or paper files). It is recommended that all practitioners familiarise themselves with this list so that they do not spend time duplicating recording unnecessarily and or placing it on the wrong recording medium.

Data: any set of information relating to an individual or individuals, which is being processed either electronically or manually with the intention that it is required for the purposes of recording, planning or auditing.

Service User: is an individual in receipt of a direct service from a social care team within the CYPT.

Carer: is a term given to a person assisting in the care or management of a disabled or elderly person or a child.

Stakeholders: the following will have an interest in recording or Case File management:

Service Users
Carers
Social Workers, Social Work Resource Officers, Practice Managers, Service Managers and Community Family Workers
Team Administrators and Office Managers
Foster Carers and Adopters
Middle Management
Senior Management
Health, Education, Police and other statutory agencies
Voluntary organisations and service providers with whom we are working in partnership
Legal Advisors and Children's Guardians
Elected Members
Local Authority Insurers

4. Delegation

Recording of all issues, actions, assessments, plans and reports relevant to a particular case:	Social worker holding the case or acting as duty Social Worker
Recording of all important decision making on a particular case in terms of formal supervision, risk management and individual issues of a complex nature:	First Line Manager supervising the case or acting in a duty manager capacity
Responsibility for ensuring Data on service users is kept secure:	Social worker
Responsibility for ensuring compliance with agreed protocols and recording standards:	Service Manager
Authority to vary these instructions in individual cases only:	Assistant Director

5. Statement of Purpose

CYPT is a public body accountable to its community and service users. The Trust upholds that good Case Recording is a vital part of the accountability of staff working in the Trust to those who use the services: it helps focus the work of staff and supports effective

Good recording demonstrates why interventions take place; the purpose of each step taken; the decisions made and the resulting action. Case Recording becomes the major source of evidence for investigations and enquiries.

Recording assists continuity when workers are unavailable or change and provide an essential tool for managers to monitor work and collate management information for planning purposes.

In supporting service users, particularly Looked After Children and those in need, recording becomes the historical and documented report of life events which significantly impact on their progress and development. It is essential such information is recorded purposefully, accurately and is retained for future reference should the child or adult wish to learn of their care history later in life. It is vital that these records are full and distinct so that each child or young person's record is able to illustrate the nature of professional involvement within it, the actions that were taken and the reasons behind such decisions being taken.

It is vital that all such records are detailed and fully accurate- especially given the level of sensitive and personal information that is often being recorded. It is also important however that the recording is not repetitive and that analysis is highly valued and prioritised alongside necessary narrative detail.

6. Effective Record Keeping

6.1 Case File Management

Every service user, including individual children, receiving a direct service or assessment, should have a separate and full Case Record.

Please see Appendix 3: Essential Record Keeping for full details on how the Case File management system is to be set up and maintained.

CareFirst takes primacy and all Data should initially be entered onto the CareFirst system. The paper case-file becomes more of a storage tool and will only hold documents within it that at present cannot be held within the CareFirst or Shared Drive electronic recording systems. It is absolutely not necessary to print off documents that are stored on either the CareFirst system or the Shared Drive and place a hard copy on the paper file. Paper copies of these documents can of course be printed off at any stage to give to service users or other appropriate professionals but they do not need to be stored on a separate paper file.

The paper case-file should be cross-referenced to CareFirst and the service user's personal identification number (PI) should be used to identify the file.

6.2 Recording practice

All records produced by staff should be typed and entered into the CareFirst or Shared Drive record. Any documents that cannot currently be stored on either of these mediums should still be typed but stored on the paper file. Un-typed documents from a third party will need to be stored on the paper file.

There is no current facility within the CYPT for an Electronic Document Storage System (EDS) although this issues needs to be addressed as an urgent issue in the near future.

Detailed guidance for all staff concerned with specific documents can be found within Appendix 3: Essential Record Keeping. Recording by all staff will comply with the standards set out in this document.

Specific guidance on how to complete documents on CareFirst related to both the Child Protection Conference process and the Looked After Review process are set out at Appendix 2 Careassess Report Processes.

7. The Role of the Team Administrator

In terms of this policy document the following section aims to set out the main roles of the Team Administrator in supporting the recording processes as undertaken by practitioners.

One of its main aims will be to achieve a degree of consistency across Social Care Teams within the Children & Young Persons Trust so that wherever possible processes and systems are common to all.

No Team Administrator has any responsibility for deciding or monitoring the content of recording material placed on any client's file- electronic or paper. Responsibility for the content of all recordings remains firmly with the practitioner.

The role of the Team Administrator is essentially a supportive one - taking on administrative tasks that support the recording undertaken by the practitioner. The following tasks are therefore deemed appropriate for Team Administrators to perform:

Cutting & pasting of case notes across sibling groups where the case note recording is deemed to be appropriately copied to other clients. It is for the practitioner involved to be clear with the Team Administrator which case note is to be copied and to which other clients. With the expected development of the case note duplication functionality within CareFirst expected in September 2009 this role of the administrative staff may be significantly lessened.
Assisting with the administrative process around the production and distribution of key documents such as Child Protection Conference minutes or Looked After Review Chairs Report. This process is a complex one for which a separate work flow process has been designed and is attached to this policy document as Appendix 2 Careassess Report Processes. Team Administrators are in no way expected to be involved in any decision making about removing sections of reports due to confidentiality issues. Such decisions will be taken by the professionals involved and not the Team Administrator. The function of the Team Administrator will be to carry out these agreed administrative tasks as set out by the relevant practitioner.

8. Sibling Group Recording

Throughout this policy document explicit reference has been given to the need to ensure all clients have their own distinct and complete records. For example each child within a sibling group of four should have their own Core Assessment on their record (if appropriate practice wise) and the Core Assessment should be individualised to their own individual issues, needs and situation.

Whilst it is entirely appropriate to use the Duplicate function where available within CareFirst to copy over records from one sibling to another it is imperative that users then individualise those duplicated records so that they are particular to that sibling and not merely a copy of the record of their sibling.

A separate guide to using the Duplicate function within CareFirst and the process involved is attached to this policy as Appendix 4: Sibling Group Recording.

Separate sections above refer to the need to ensure that case notes are copied over onto all sibling records where appropriate and the administrative support available to practitioners to ensure this task is completed.

9. Sharing Information:

Guidance on Sharing Information with Users and with Third Parties

Article 8 of the European Convention of Human Rights states that:

"Everyone has the right to respect for his private and family life, his home and his correspondence" therefore prima facie information about one person may not be disclosed to a third party without that person's permission.

All staff are subject to a common law duty of confidentiality. Unless there is a statutory requirement to use information that has been provided in confidence, it should only be used for the purposes that the subject has been informed about and consented to. It should only be given, with consent, on a need to know basis.

It is therefore essential that every service user or parent of a child receiving a service gives informed consent if information about them or their child is to be shared with a third party. This can be obtained at the point an assessment commences by obtaining their consent and recording this on the relevant CareFirst assessment document.

Most users understand the need for staff to share information in the interest of integrated services and will generally give their consent so long as they have confidence in the agencies providing the service.

Clearly there will be occasions when the duty to protect the public or an individual outweighs the responsibility to any one person. These occasions will be when there is an assessed risk of harm to a child or adult or when disclosure of information will identify an individual who supplied the information in confidence.

The Data Protection Act 1998 states that" disclosure without consent is only permitted for the prevention or detection of crime; the apprehension or prosecution of offenders; or where disclosure would prejudice the welfare of a child or adult and place them at some risk or harm".

In cases of child or adult protection it is therefore permissible to share relevant information with third parties in order to safeguard their welfare.

However, in cases where a child in need or other assessment is proposed and there are no concerns with regard to risk or child protection the assessment may not be able to proceed if the user (aged 16 or over) or parent ( with parental responsibility) of the child withholds consent to share information.

In all cases consideration must be paid to the Human Rights Act before a decision is made to disclose information to a third party. Your justification and decision must be recorded on file- the Line manager should use a Case Note entry to record this information- setting out what has been disclosed and the justification for doing so.

9.1 Sharing information from a Third Party

The same principles apply to information concerning the user, given by a third party, where consent from the informant is necessary if the information is to be shared. The Children & Young Persons Trust has a single protocol for information sharing in these circumstances.

More detailed guidance about all aspects of information sharing can be found in the Children & Young Person's Trust Information Sharing Code of Practice - to follow. There are also leaflets available to guide professional practice and information leaflets for service users.

10. Access to Files & Records:

Service User Access to their Files

This section gives general principles and guidance. The Access to records leaflet "Can I see my records?" and procedures are currently being updated.

The Data Protection Act 1998 require "Data controllers" such as the Children & Young Persons Trust to be open about how information is used and this extends to service user rights to see their records, comment on the content and record dissent.

(The Data Protection Act is concerned with personal Data. Depersonalised information; i.e. where individuals cannot be identified has no Data Protection implications).

Service users can request to see their files and this should be viewed in a positive light in the spirit of openness and transparency. Service users must be given copies of completed assessments and care plans and if we have been clear to users throughout our intervention then the opportunity to read their files should bring no surprises.

There are occasions however when users and parents of children receiving a service cannot see personal Data. These are stated above in "Sharing Information" and also where the disclosure of Data would reveal the identity of a relevant person who would be harmed as a result or where other enactments themselves prevent disclosure such as those covering adoption records, etc.

A separate guide to using CareFirst to record Adoptive placement is attached to this policy as Appendix 5: Guidance on Adoption Records.

Advice from the legal department notes a modification to the DPA relevant to social work practice. There are two specific instances where the Department may be exempt from providing personal Data to an individual on their request. The Data Protection (subject Access modification) (Social work) Order 2000 is summarised as follows: -

Data does not have to be provided to an individual in any case where provision of such Data is likely to prejudice the carrying out of social work by reason of the fact that serious harm to the physical or mental health or condition of the subject Data, or any other person, would be likely to be caused.
Data does not have to be provided to a person where the Data subject is a child and that person has parental responsibility for the Data subject in instances where that child has provided the Data in the expectation that it would not be disclosed to the person making the request, i.e. the Data was obtained as a result of any examination or investigation to which the child has consented in the expectation that the information would not be disclosed.

The same applies to a person who becomes incapable of managing their own affairs, where they had previously expressed the wish that they did not want personal information disclosed to the individual nominated to manage their affairs.

In all cases where an exemption or refusal to allow access is agreed, human rights legislation will require the key worker (Lead Social Worker) to give a clear and full account of how that decision was made and this must be recorded and retained on the file for future reference. A Case Note entry by the appropriate Service Manager is sufficient here. Written notification must also be sent to the user giving the reasons for such a decision.

An appeal process is available and will be addressed in the forthcoming instructions.

11. Permanency Foster Care and Prospective Adopters Access to Case Files and Confidentiality

Long term foster carers approved by Brighton and Hove Children & Young Persons Trust for permanency and prospective adopters are able to have access to the child's file to whom they are offering care (from 2nd October 2000) in order to have full information on the child for the future. Ensure the carers/adopters are appraised of the policy and that they have signed the following;

Commitment to observing confidentiality in connection with reading Case Files on children approved for adoption/permanence and
Confirmation that an approved prospective adopter/ long term foster carer has received Child Permanence Record and other relevant written information on children to be placed, has read the child/ren's Case File and understood the implications.

Supplies of these forms should be in each office.

12. Management and Supervisory Arrangements

Managers and supervisors should ensure that Case Recording and Case File management meets the Trusts standards and will be expected to audit practice on a regular basis. An audit form is available within CareFirst for Fieldwork services which provide a checklist of key standards. Managers and supervisors should undertake random audits as and when necessary, and routinely check every open Case File held by staff supervised or managed by them, at least once a year.

Any problems identified should be addressed in supervision and/or via personal development plans, training etc.

Managers and supervisors should countersign all key decisions.

As of 9 July 2009 a new Case Supervision document has been made available within CareFirst. These should be added by the Line Managers on each case where they have undertaken case supervision. Supervision issues relating to Human Resources issues should not be recorded on CareFirst. These should continue to be stored outside of CareFirst- on either a hard copy paper file or on the Shared Drive facility.

Managers should remember to make sure that the Start & End dates they allocate to the Supervision Record form on CareFirst MUST be the date that the supervision session/discussion took place- and not the date that they are writing up this supervision recording.

In this way the link that is retained between these forms and case notes/the chronology will work in the right way. A summary of the Supervision & the Agreed Future actions will be automatically created in a case note and that in turn will populate automatically into the case Chronology.

Separate guidance is available on this feature- both in the forms themselves and outside of CareFirst. See Appendix 6: Case Supervision Guidance for further guidance.

13. The Legal File

A separate paper legal file should be set up for all cases where legal proceedings are commenced. There should be one paper file containing all documents relating to a particular set of proceedings and not separate files for individual children.

The reasons for this are twofold:

In terms of file management this provides easy access to paperwork from a particular set of proceedings and ensures it is not spread over different files.
To ensure that confidential and privileged information is stored appropriately and access is restricted to those eligible to see the papers.

Legal files should contain all paperwork relating to a set of proceedings including correspondence and recording as well as statements, reports, application papers and orders. Modules should be set up to separate information. Legal Services will provide an index for all documents filed in the course of proceedings but cannot provide a copy of the complete bundle.

In situations where legal advice is sought but proceedings do not follow, the advice (memos, recordings, and minutes of meetings) should be kept on the legal module on the child's paper file. Documentation should be moved onto a separate legal file if proceedings commence at a later date.

Where Section 7 or 37 Reports are prepared, consideration should be given to whether a separate legal file is warranted, depending on the complexity of the proceedings.

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