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a) Case File Management

Every service user, including individual children, receiving a direct service, should have a separate and full case record.

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. (There are some very specific exceptions to this rule such as The Child Permanence record/Placement with Parents Report - see Appendix 1 - Storage of Key Documents Guidance for further details.) 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.

All files held elsewhere i.e. in a Family Centre, day care unit or residential unit should be cross-referenced, with labels on the file cover identifying the location of the main file. This information should also be recorded in the CareFirst record. When the case is closed all modules held elsewhere should be incorporated into the main file.

All files will maintain a common modular structure, which reflects a process of referral - assessment- case/care planning - and- review. (See file module index for file contents) This modular structure has been re-written so that only documents that need to be placed on paper files have appropriate sections to house them.

On this basis there should be only a relatively small amount of paper based recording that needs to be placed on the paper file record. Appendix 1 sets out those pieces of work that still require filing in this manner. The filing of these paper records and the maintenance of these paper files remains the responsibility of the key Social Worker and not the Team Administrator. Requests for assistance with this task by the Team Administrator should be made to the Office Manager via the appropriate Operational Line Manager.

All new cases requiring a paper file should have one made up that combines the previous Main file and the previous Looked After Child file. Given that the majority of the sections within these two files will now be empty it makes sense to combine the two files for all new cases. Existing cases will maintain separate files until they are closed or are deemed to be full and a new single file replacement can be opened.

Appendix 1 of this policy document sets out those documents that can only be stored at present on paper files together with the location of all other documents and whether they are stored either in CareFirst or within the Shared Drive (or a combination there of).

Loose papers or notes should not be left in or on the paper file.

All correspondence received should be date stamped and filed on the paper file in the module to which the content of the correspondence refers.

A separate legal file should be opened to run alongside the main case file at the point at which legal proceedings commence. (See the legal file section for further detail). This will remain confidential to the Children and Young Person's Trust.

A separate Adoption paper file should still be opened at the point where Adoption becomes the agreed Local Authority care plan for the child/young person in question. Given the confidential nature of much of this recording there is still a need to store hard copies of many of these Adoption records in hard copy format on the Adoption paper file alongside the Shared Drive- pending developments to make the Shared Drive a more reliable environment. The precise requirements here are set out within Appendix 1.

b) Recording:

Recording by all staff will need to comply with the standards as in this document.

All records produced by staff should be typed onto 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.

• Accurate: All names and dates of birth should be checked with the Service User. Always re-read your work to check on accuracy before completing the record yourself and/or sharing with your manager for their authorisation. Use the spell check functions on all CareFirst records and those placed within Word documents/templates that are then placed on the Shared Drive.
• Up to date: Recording contemporaneously is essential in all cases. A list of key documents used in Social Work practice is set out below. Each has a timescale attached to it which indicates the expected completion date of the accompanying recording- either before or after the event depending on the type of recording and task concerned.
• Case note recording - should be within 2 weeks of being fully up to date across an individual case.
• Care Plan - Child In Need, Child Protection or Looked After- within 2 weeks of the corresponding decision e.g. Child Protection Conference, child becomes Looked After or is deemed in need of a Child In Need Plan.
• Looked After Child Episodes: Update the legal status for a child/young person and their placement details within 24 hours of the change, taking place.
• Strategy Discussion Record: Within 2 working days of the Strategy Discussion or Meeting having taken place.
• Section 47 Outcome Record: Within 7 working days of the end of the Section 47 Investigation.
• Social Work Report for Child Protection Conference Report: A minimum of 5 working days ahead of the Conference- the report to be made available to the Independent Reviewing Officer.
• Social Work Report for Looked After Child Review: A minimum of 5 working days before the meeting- the report to be made available to the Independent Reviewing Officer.
• Looked After Child Review Chairs Report: Ready for distribution within 2 weeks of the meeting- Independent Reviewing Officer and Team Administrator.
• Child Protection Conference Chairs Report (Minutes Report): Ready for distribution within 2 weeks of the meeting- Independent Reviewing Officer and Team Administrator.
• Chronology: For all children who are in receipt of a service from the CYPT the chronology should be updated at a minimum frequency of once every 3 months. Good practice should dictate that this is done more frequently and will be dependant upon specific case situations and developments. Updated versions of the chronology should then be saved onto the Shared Drive facility and clearly labelled in terms of the dates covered by this section of the chronology and the specific purpose of that chronology e.g. 'Chronology for Court April 06 to May 08'.
• Sequential and continuous: Ensure dates correspond and follow in date order.
• Clearly distinguish between fact and hearsay: Be clear that your recording differentiates between observed and evidence based information from that which is reported by a third party or uncorroborated. Case Note recording should also differentiate between fact and hearsay as necessary. Such recordings may be requested by the Court as part of care proceedings and should therefore always include a clear reference as to whether any opinion is factually based or not. Service users may also request to see their records at any time and their records need to be as up to date and accurate as possible at all times.
• Record all decisions made: Formal supervision recordings should continue to be made by the line manager responsible for providing the supervision. The line manager should also take responsibility to enter a clear case note recording in the following circumstances:
• In cases where Child Protection concerns are escalating and these require an overview or discussion with more senior management- e.g.- managing risks on a case or explaining why a case has been referred to a senior manager or a Resource Panel for discussion/decision making.
  1. Where the decision has been made to seek the accommodation of a child or young person- setting out the reasons for this decision.
  2. Where a child or young person is moving back home to the care of their parents or extended family/friends network- setting out the reasons for this decision.
  3. Where a decision is taken to share information regarding a service user with a third party- see Section 'Sharing Information' below for further details.
  4. Where a decision is taken to seek confidential legal advice regarding a child and their welfare.
  5. To help explain changes to a Care Plan for a child or young person.
• The content of the case note recording must always include the following information:
  1. Who was seen (if the contact involved a face to face meeting or visit)
  2. The purpose of the contact
  3. Action taken
  4. How the action relates to the goals i.e. how the care plan is being achieved-or not.
  5. Any follow up action required
  6. If choice was offered
  7. Unmet need
• Use brevity and clarity: Do not give unnecessary detail. Within all case recording the staff member must seek to analyse the information gained and not simply use recording time to describe narrative detail. Good quality recording is always a combination of narrative recording together with analysis of how such an event has impacted on the service user and what impact it has on the levels of risk and need pertinent to that service user. All text boxes within CareFirst documents are limited to one side of A4 paper recording. The size should promote analytical recording rather than purely narrative based recording.

• Eligibility: Should be addressed and recorded.
• Risk assessment and analysis of risk is recorded. All relevant CareFirst documents such as Initial Assessments, Core Assessments and Social Work Reports for Child Protection Conferences and Looked After Child Reviews have specific sections where these vital issues are to be recorded. Within these sections it is vital that the staff member addresses the issues of change relevant to that particular service user. Such sections need to include summaries of what specific issues of risk relate to that service user and how those issues have and may continue to change over time.
• Care Plans: Very child/young person who is in receipt of a service from the CYPT should have an up to date Care Plan record. This will set out the needs currently set out for that Service User together with the Interventions in place to address them. This is the case for children/young people deemed 'In Need'; 'In Need of Protection' and those 'Looked After'.
• Confidential Information: Within all CareFirst Documents the capacity exists to 'hide' certain parts of the report. This should be used in circumstances such as Child Protection Conferences or Looked After Child Reports where sections of the report need to be withheld from certain individuals due to concerns about the welfare of a child or service user if that confidential information were to be shared across all parties. In both of these cases it is the Independent Reviewing Officer who highlights the areas of the reports that are to be removed in certain cases. Information outside of the CareFirst system deemed to be confidential should be placed within the confidential section of the paper file.
• All recording must reflect the Directorate's policy on equality: Ensure issues of ethnicity, culture, race, gender, age, religion, language, communication, disability or sensory impairment are recorded sensitively and accurately. Case records should always reflect anti-discriminatory practice with care not to make assumptions or use stereotypes. All CareFirst documents have questions that relate to these issues and workers should complete them in all cases.
• All service users must be informed that a record will be kept of our intervention and involvement.
  
  Give each user or family a copy of the Access to Records leaflet and explain the purpose and reason why information is sought and obtained.
• Service users should be encouraged to contribute to their case file and be given copies of key documents such as the completed assessment, care plans and review decisions. The views of users and carers should be recorded, including any dissent. These should be clearly distinguished and relate to the sequence of events and decisions taken. Many CareFirst documents such as Initial Assessments, Core Assessments, Care Plan Part 1 and Social Work Report for Child Protection Conference and Looked After Child Review have specific sections to complete that record the views of the service users, child/young person or parent. These should be completed at all times.

Core CareFirst documents and how they fit together on clients records

Certain CareFirst documents should be seen as key ones that are relevant to all case file recording. For all cases that progress beyond the stage of Initial Assessment they should be seen as essential components of any client's record.

Chronology

The CareFirst chronology (released on 31-03-08) allows users to update their case chronologies in a clear manner. The CareFirst chronology will, when generated, produce a chronology report consisting of the following items already entered into the CareFirst system:

• Completed Case Notes
• LAC Episodes-Legal Status changes
• Life Events
• Placement changes
• Assessments begun
• Meetings such as CP/LAC reviews.
• Classifications
• Activities

The chronology can then be edited as necessary using professional judgment depending upon the forum it is required for e.g. Court, Child Protection Conference, Looked After Child Review meeting.

The chronology should be used as an ongoing working document that places all key events in date order. It should be used primarily to record factual detail alongside relevant analysis. This is in line with practice within the Court requirements for chronologies. E.g.- the chronology contains factual details regarding the Trust's involvement in children and families lives. The corresponding Statement and other assessment documents such as the Core Assessment sets out the analysis to the chronology.-e.g.- what this information is telling us in terms of risk and need for this child.

Core Assessment

These are meant to prompt analysis, summary and conclusion around the needs of the child/young person and the subsequent actions required, if any, in the future. Core Assessments are key documents within the Social Work process and should be opened and completed as indicated below:

For all children/young people subject to care proceedings:  In line with the Public Law Outline requirements. Core Assessment required at beginning of all new proceedings. All sections to be completed.

For all children/young people subject to a Child Protection Plan: All to have a fully completed age banded Core Assessment by the time of the first review of the Child Protection Plan- within 3 months of the decision to set up a Child Protection Plan. Subsequent to this Independent Reviewing Officers will make Decisions within Child Protection Conferences that the Core Assessment needs to be updated ahead of the next Review. In such circumstances the Social Worker should open a new age- banded Core Assessment and complete it fully- rather than simply incorporating such information within their Social Work report for the next Child Protection Conference Review. The Core Assessment informs the Social Work Conference Report but it is a distinct and separate document in its own right.

For all Looked After Children as follows:

• When a child initially becomes Looked After if one has not already been completed recently as part of care proceedings or as part of a Child Protection Plan (e.g. for those children/young people becoming accommodated).  A discussion around the need to open and complete a Core Assessment at this stage should take place between the Key Social Worker, line manager and Independent Reviewing Officer.
• At the recommendation of the Independent Reviewing Officer in cases of unmet need, placement instability or increasing risk to that child/young person. In such cases a new age banded Core Assessment should be opened & completed rather than the worker simply reflecting additional information within their next Social Work Report for the next Looked After Child Review.

For all Children In Need:

• As appropriate/necessary as a result of discussions between the Key Social Worker and line manager regarding the level of need/risk identified in relation to a particular case. These decisions may well be made and recorded within formal supervision. They are particularly encouraged in cases of ongoing concerns for children/young people in terms of physical & emotional neglect where the potential for these cases to experience significant drift has previously been identified.

For all children subject to Section 47 Enquiries:

Operational Instructions are clear that all children or young people who are made subject to a S47 Investigation also need to have a Core Assessment opened and completed regarding their welfare and current situation. It is recognised that Managers may decide that full Core Assessments are not required in some of these cases -e.g.- in cases where the S47 Investigation is ended with No Further Action. .This decision should always be made at Service Manager level as it is the Service Manager who would have authorised the accompanying Section 47 Investigation.

Care Plans

Every child/young person who is in receipt of an ongoing service from the Children & Young Persons Trust should have a clear and up to date Care Plan on their CareFirst record.

Care Plans should be opened and completed for children/young people whether they are deemed to be 'In Need'; 'In Need of Protection' or 'Looked After'. These plans are separate to the Court Care plans completed separately as part of care proceedings cases.

Care plans are essential documents that hold a wealth of information about the needs of a child at any point in time and the services and tasks that have been put in place to address these needs. Care plans are therefore very important documents for quickly and easily understanding the issues, risks and needs facing a child or young person at any point in time.

Each child or young person should have their own individual Care Plan reflecting the need for all clients to have a full and distinct case record.

Statutory Visit Recording

Children or young people who are either Looked After and/or deemed 'In need of a Child Protection Plan' require regular statutory visits to monitor their welfare. The requirements around the frequency of such visits are set out within Operational Instructions.

Separate exemplars/documents exist within CareFirst for recording these visits. These have to be overseen and authorised by the Line Manager.

Case Notes

Case Notes are designed to be used to record general day to day recording on cases such as records of telephone discussions across professionals or with parents, carers or family members.

They are also to be used in the types of specific circumstances identified above.

Wherever possible staff are advised to be clear and concise with their recording here. Whilst on occasions staff will want to record verbatim notes about a particular conversation this is not always necessary. Use the guidance notes below to assist here:

• The content of the case note recording must always include the following information:
  • Who was seen (if the contact involved a face to face meeting or visit) or spoken to.
  • The purpose of the contact
  • action taken
  • How the action relates to the goals i.e. how the care plan is being achieved-or not.
  • any follow up action required
  • If choice was offered
  • Unmet need

Care should be taken when recording case notes so that they are written in a way that will be understood in the future and by appropriate individuals not necessarily well versed in the history of the case. Try to avoid the use of abbreviations/jargon where possible and explain who individuals are rather than assume a reader will implicitly know this themselves- e.g.- if referencing a Senior Managers name always follow this with their professional title. Readers of this note in the future will not know who the individual is without this title being added.

The use of e mails within case note recordings

E mail communication has become widespread within CYPT practice over the last 2-3 years and is mostly between professionals across different sections of the Trust. Please follow the following guidelines when deciding whether to include such recordings in the case file.

• e mails are often written in an informal style and are not therefore appropriate to be cut & pasted across onto a case note- at least not without a degree of editing later.
  
  You need to remember that such case notes will then appear in the chronology and that clients have the right to seek access to these records at any time.
• some e mails are written in a way that means they are not concise. It may well be better to simply summarise an e mail in a short and concise case note rather than cut & paste it straight across onto the case file.
• e mail communications from third parties- such as other professionals are often sent to key Social Workers without the intention that they be cut & pasted across to the case file. Do not do so unless you think the recording is appropriate and you have the consent to do so from the sender of the e mail.

Case Notes and Sibling Groups

It is not appropriate to have incomplete case recordings across sibling groups. If a case note is deemed via professional judgement by the staff member to be relevant to all 5 members of a sibling group then it should appear on the case note recording of all 5 siblings- not simply the oldest child for example- otherwise individual children have incomplete records and will be unable to see their complete records if they seek to view them.

Whilst acknowledging that this is a time consuming process at times, particularly with large sibling groups, this is necessary if complete records are to be in place for all children and young people. This task should become much less time consuming once we are able to use the case Note duplication function- planned to be in CareFirst by the end of 2009.

Core Group Recording

The recording for these important meetings should be within CareFirst. A separate exemplar/document exists within CareFirst for this purpose. These have a managerial oversight/authorisation feature within them.

End