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2.1 Recording Policy for Children’s Social Work

RELEVANT LOCAL GUIDANCE

HM Government, Information sharing – Advice for practitioners providing safeguarding services to children, young people, parents and carers (2015)

Records Management (Brighton and Hove City Council Corporate Intranet - The Wave)

Please see link to, One Story Recording.

This policy applies to Brighton and Hove City Council Children’s Social Work Teams.

There are currently three different locations for recording client information:

  • CareFirst: This is the database for children’s records;
  • Shared drive (CFS/Client Files): This is an additional system for saving word and other PC based documents that are not available on CareFirst;
  • IDOX: This contains scanned documents that cannot be saved on CareFirst.

Note: Any changes regarding these arrangements will be circulated as necessary pending the manual update.

RELATED CHAPTERS

Brighton and Hove Information Sharing Policy

Access to Records

Adoption Case Records

AMENDMENT

This chapter was significantly updated throughout in May 2017 to add links to Brighton’s Corporate Intranet including, ‘One Story Recording’ (see Relevant Local Guidance above) and to reflect local processes and procedures. A note was also added in respect of the Independent Inquiry into Child Sexual Abuse, which requires all institutions to retain their records relating to the care of children for the duration of the Inquiry, (see Section 1, Core Principles).


Contents

  1. Core Principles
  2. Delegated Responsibilities
  3. Quality of Recording
  4. Information Sharing
  5. Subject Access to Records (SAR)
  6. Data Security
  7. Management Decisions


1. Core Principles

Social work records should reflect the work undertaken with the child and their family. Social workers are the custodians of the child’s record and recording should reflect this. Staff should endeavour at all times to:

  • Use plain language, so any reader knows exactly what is meant;
  • Avoid the use of acronyms and jargon;
  • Be mindful that children and their families have a right to access their records in line with the Data Protection Act 1998.

Whenever a document is added to the child’s shared drive or IDOX it will be cross referenced within a case note.

The City Council is a public body accountable to its community and service users. The Council upholds that good case recording is a vital part of the accountability of staff working in the local authority to those who use the services; it helps focus the work of staff and supports effective partnerships.

Recording should be accurate in terms of service user’s dates of birth and names should be spelt correctly.

Recording should distinguish between fact and opinion.

Service users have a right to have any inaccuracies in their records corrected.

Records should be accurate and kept up to date.  

Recording clearly is a skill and requires judgement as to what is important to know and in what detail. Too much extraneous detail can make it more difficult to see what is most important.

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

Important Note: The Independent Inquiry into Child Sexual Abuse requires all institutions to retain their records relating to the care of children for the duration of the Inquiry under Section 21 of the Inquiries Act 2005. There is therefore an obligation to preserve records for the Inquiry for as long as is necessary. (See Letter to Chief Executives of Local Authorities.)


2. Delegated Responsibilities

2.1 Accountabilities

All staff are accountable for recording as follows:

  • Recording of all issues, actions, assessments, plans and reports relevant to a particular case - The allocated social worker holding the case or any member of staff carrying out any action on behalf of the allocated worker;
  • Recording of management decisions on a particular case - The manager making the decision;
  • Responsibility for ensuring data on service users is kept secure – All staff;
  • Responsibility for ensuring compliance with agreed protocols and recording standards – All Managers.

2.2 Authorisation

Please see, Wave, Toolbox for Social Workers, One story Management Oversight - what you need to know.


3. Quality of Recording

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.

The following are key guidance points to follow in achieving quality in case recording:

  • On an initial meeting with a family basic details should be checked e.g. full names, Dates of Birth, key dates and events. It is important that these checks are made to ensure that records are accurate;
  • Summarise where possible to ensure only pertinent information is succinctly recorded. Detailed conversations with service users or professionals are rarely necessary in case recording. The exceptions may be disclosures made by children and young people/Q&A interviews;
  • Conversations are best captured in terms of the following:
    • The purpose of the meeting or visit;
    • Who was present;
    • What issues were discussed;
    • Summary of how the parent and child responded on these issues;
    • Any agreements made/conclusions drawn;
    • Next actions and timescales.
  • Emails may be conversational and less formal in their language. Therefore it is not good practice to copy whole emails into Case Summary Records. The key sentences could be copied from emails or the contents summarised;
  • 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;
  • Avoid emotive or subjective language in describing what you see. This may give an impression of being judgemental or even biased – (for example, describing a room in a home as looking “disgusting” as opposed to saying that it was ‘in a very poor condition due to the hygiene levels of some of the surfaces and the clutter preventing children being easily able to play’). Often being more specific about what you see also helps avoid concerns about over-generalisation – e.g. is all of the house dirty?
  • Whose views are you reflecting? Recording, like assessments, should be considered in terms of its overall balance. Does the recording appear to reflect the views of one parent or family member more than others? This may be due to access being less to one parent who doesn’t live with the children or could even reflect some unconscious bias. A good case record will reflect the views of all key family members, whether they live in the home or not, on key matters of concern or dispute;
  • When recording a concern about a parent expressed by a third party which is historical in a review report, the information should be put next to that parent’s response to and their view about that concern in order to achieve a balanced account;
  • Choose language carefully when describing the matters of concern in a family. Parents who live separately may have very different recollections and perspectives of certain issues or incidents. Where these incidents are disputed it is important to reflect this and if one account over another is being favoured, objective evidence should be provided to support this;
  • Good recording of visits to families and assessments of them include the attempts that are made to speak and listen to the child/young person and to understand their world and their experience. Analysis can then be used to compare this experience to other children using experience and research;
  • Analysis should reflect all of the above principles. It should focus on the reasons for determining why one view of events is more likely to be correct than another and explain why. This should also always be viewed from the child or young person’s point of view;
  • Analysis in case records, including assessment and case supervision records should be drawing together what has been seen and learnt from visiting the family. It should also include professional updates and compare this with the outcomes that have been set as necessary for the child/ren in the case plan. This can be used to inform a judgement about whether what the work undertaken making the situation better for the child;
  • Identity is a key part of the assessment of the child/young person so should feature in the recording in order to reflect the child’s world within their family, their peer group/school and the wider community;
  • Recording should be sufficient to create a permanent record of the work completed with a family but needs to be succinct, focussed and purposeful.


4. Information Sharing

(See also Access to Records Procedure) and HM Government, Information sharing – Advice for practitioners providing safeguarding services to children, young people, parents and carers (2015).

4.1 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.

When children and families first receive a service, it is important to explain to them what and how information will, or could be shared and why, and seek their consent. Once their consent has been obtained this must be recorded on the assessment record.

In addition, children and families should be advised at the outset of the work, that if they have concerns about specific information being shared more widely, they should inform the social worker who will record this request on CareFirst.

Young people aged 16 or over can withhold consent in their own right regarding personal information. In such cases you must make a professional judgement on the facts of the individual case and any decision should be taken in accordance with the legal, ethical and professional obligations outlined in the Brighton and Hove Children’s Services: Code of Practice for Information Sharing.

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.

[1] NB: Whilst the Children and Young People’s Trust is no longer a term used to describe the partnership working between BHCC and the NHS, the code of practice is still valid.

4.2 Information Sharing Key Principles

In most cases decisions on information sharing will be straightforward. The following principles are the key ones to observe:

  • Explain to families at the outset, what and how information will be shared and why, and seek their agreement. The exception to this principle is where to do so would put the child or others at increased risk of Significant Harm, or if it would undermine the prevention or detection of a serious crime;  
  • Always consider the safety and welfare of a child or young person when making decisions on whether to share information about them. Where there is concern that the child may be suffering or is at risk of significant harm, the child’s interests must be the over-riding consideration;
  • Where young people or families do not consent to share confidential information, you must, where possible, respect their wishes. You may still disclose if in your judgment on the facts of the case the public interest is sufficiently strong to over-ride that lack of consent;
  • Seek advice where you are in doubt, especially where your doubt relates to a concern about possible serious harm to a child or significant harm to others;
  • Ensure that the information you share is accurate and up-to-date, necessary for the purpose for which you are sharing it, shared with those people who need to see it, and shared securely; and
  • Always record the reasons for your decision – whether it is to share information or not.

4.3 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. As in Section 5.2 above, if the information provided by the third party is related to a child protection concern, we will be required to share the information but in most cases we will try and protect the anonymity of the third party.

Please also see the Pan Sussex Child Protection and Safeguarding Procedures, Actions and Decisions of the Conference for information sharing in these circumstances.

The Brighton and Hove Children’s Services has a single protocol for information sharing in these circumstances.


5. Subject Access to Records (SAR)

Service users should be given information when they come into contact with Children’s Social Work and at regular points thereafter about their right to request access to the information held about them and how to go about doing so. Where a written request is made records must be made available to the service user no more than 40 days following this request.

The City Council position for this is fully covered in the Operational Instructions, see Access to Records.


6. Data Security

Please see the records management page on the Wave (Intranet Link).

6.1 Background

High profile losses of personal data at a national level has led the Information Commissioner’s Office (ICO) to fine public bodies for significant data breaches.

The general principle is that data should be handled in a way that you would hope to have your own data handled. The welfare of the service user and their trust of the Social Work service can be damaged if information about them is not taken care of.

6.2 Guidance

Emails: Please see council guidance

Sensitive information being sent outside the council must be sent to and from secure email addresses only (GCSx), or by encryption. Please see separate guidelines above regarding this.

NB: Please note that NHS.net email addresses have a number against them if there is more than one person on the national NHS network with this name. Staff must ensure they have the correct email address before sending sensitive information.

  • Posting personal data: The social work service is required to send out copies of all assessments and reports to families. It is essential that staff check that they have the correct address before sending any sensitive information by post. Therefore Social work staff must ensure that details are up to date on CareFirst. Particular care must be taken at the point of case transfer to ensure that all personal details including the correct address are recorded on CareFirst. Where an address does not provide a secure facility for post, any sensitive documents should be hand-delivered. If there is any doubt about the address, staff should not include any sensitive information and should ask the recipient to contact them for further details; 

    If materials (including personal data) are being sent by mail to other professionals then it is crucial to be certain of the address. Those attending meetings should be asked to confirm their email and/or postal addresses whilst attending for the purposes of sending out minutes. When packing large amounts of post these should be ‘second checked’ to ensure that the right contents are going to the right addressee in the right envelope;
  • Transporting case records: The majority of case recording is electronic. In the event that hard copy material (e.g. reports) has to be taken out of the office, staff must ensure that this can be done securely. Staff should consider whether there is an alternative to travelling with confidential information, e.g. printing information at the meeting venue;
  • If staff have no option but to take records on public transport, they must exercise vigilance and must keep the records securely in their bags throughout the journey  to prevent loss, theft or breaches of confidentiality;
  • Never take case records into shops, pubs or restaurants;
  • When driving never leave confidential papers in the main seating area of the car even for a short period of time;
  • Staff leaving their cars must always take their  bag and documents with them;
  • Staff should avoid taking documents relating to one service user into the home of another. If this is unavoidable, the records must be kept securely fastened in a bag throughout and must stay with the worker at all times;
  • If workers are delivering reports or assessments by hand to a family then they must re-check before handing over the envelope that the correct documents are contained in it.

Laptops

It is a requirement that:

  • Laptop users must sign an agreement for use which confirms that they are aware of the expectations for safe use as below;
  • Laptop users must not keep written copies of the log in details with the laptops in any circumstances;
  • Laptop users should not take laptops out with them to bars, restaurants or shops.  If travelling by public transport  keep the laptop in your sight at all times;
  • Laptop users should report  immediately any loss of a laptop to the ICT department in order that  its access can be disabled;

When working at home all the above rules apply. Staff should keep case papers as securely  as possible at home whilst not working on them. There are Council-wide IT rules about the security of data stored on devices other than Council PC’s. Documents containing personal client data should not be created or saved on home PC’s. Staff members must take steps to prevent others from viewing screens or accessing any confidential documents.

Confidentiality

  • Conversations: Conversations about service users either over the phone or face to face should not take place in public areas of buildings, on public transport or in the street in order to preserve confidentiality;
  • Storage of information at work: Paper records must be secured in locked cupboards/cabinets overnight;
  • Office moves: It is essential that all cabinets, drawers and cupboards are fully checked and cleared before an office move. This means the removal of all personal information and documents. The drawers/cabinets must be locked or sealed once confirmed as empty. Staff must not put items in these once they are marked as empty and sealed;
  • Children in care placement details: staff should ensure the section of the Combined Review (Looked After Review) and the Adoption Plan Review detailing who should be sent a copy is correctly completed to prevent unauthorised release of information relating to a child’s placement. h. Identifying details of adopters must not be placed on a child’s CareFirst record. First names only should be used and no addresses or location recorded;
  • Sibling records should only be duplicated if the information is relevant to the child concerned.

Enforcement

Failure to follow this guidance may be a disciplinary matter.


7. Management Decisions

Records of management decisions and the reasons for these form a crucial part of the narrative as to why particular interventions are decided upon at a given point. Without these there can sometimes appear changes of direction without explanation. Without these it is also not possible to evidence in audit or inspection that managers at the appropriate level are making decisions which are necessary.

The following management decisions outside of those confirmed in existing assessment documents are required to be placed on CareFirst records:

  1. Regulation 24  - emergency placement of child under S.20 or ICO with relatives: Must be entered by Head of Service as an ‘Activity’ on the CareFirst record of the carer concerned – not the child. Effective start date should be either the date child placed or the date the looked after status was confirmed if this comes after placement;
  2. Placement with Parents of a Child In Care under legal order – (ICO or full CO): Must be entered by Head of Service as a Management Decision on child’s CareFirst record;
  3. Admission of a child into care – emergency: The Head of Service should complete ‘Management Decision on the child’s CareFirst record. This should specify where relevant what type of placement is/isn’t agreed to and also how long the agreement is given for;
  4. Agreement to planned admission into care or agreement to Legal Planning Meeting:

    These decisions are made by the Care Planning Panel. Decisions of the Care Planning Panel should be entered by the responsible Manager;
  5. Change of CIN Plan: This can be added by the Pod Team Manager assuming that this decision doesn’t involve any of the above;
  6. Variation of the CIN visiting schedule: The CIN visiting frequency is deliberately set as flexible to meet changing needs and risks at a given point, (see CIN Policy & practice guidance). The visiting frequency must be set out in the CIN plan. If this is varied after discussion in supervision then this must be added to the case supervision record which is signed off by Pod Team Manager. Where this is varied in between supervision sessions in an emergency situation Practice Manager should add a ‘Management Decision’;
  7. Change of CP Plan: This can be added by the Pod Team Manager following discussion with the IRO;
  8. Missed CP visits: Single missed CP visits outside of the 10 working day timescale should be recorded in the Case Summary Record. In the case of repeated missed visits, the manager should enter a management decision outlining the course of action to be taken. Consideration should be given to referring the case to care planning panel;
  9. Looked after children: Admissions to care or discharges home under Placement with Parents Regs or to extended family under Regulation 24 (see Family and Friends (Connected Persons) Procedure) agreement are approved by Heads of Service and should be entered on the system by the Head of Service or a person authorised and delegated by them to do so. Changes of Care Plan should be discussed with IRO’s and then entered by manager of appropriate delegation;
  10. Other decisions - other occasional important decisions are made by Pod Team Managers - e.g. change of placement, use of resources etc. These should be entered at the delegated level by the manager as a Management Decision Case Note.

End