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EalingChildren's Services Procedures Manual

Recording Policy and Guidelines

AMENDMENT

This chapter was amended in June 2019 to reflect HHJ Greensmith's comments regarding M and N (Children: Local authority gathering, preserving and disclosing evidence) [2018] EWFC 40 (1 June 2018).

Contents

  1. Records Must be Kept on all Children
  2. The Design of Records and Forms Must be Approved
  3. Children and their Families Must be Informed about their Records
  4. The Practitioner Primarily Involved Should Complete the Record
  5. All Relevant Information about Children and their Families Must be Recorded
  6. Children and their Families should be Involved in the Recording Process
  7. Information about Children/their Families should Normally be Shared with them
  8. Managers must Ensure that Confidential Information is Identified
  9. Records Must be Kept up to Date (Timescales)
  10. Records Must be Written Clearly using Plain Language and Avoid Prejudice
  11. Records Must be Accurate and Adequate
  12. Managers Must Oversee, Monitor and Review Records
  13. Records Should be Kept Securely
  14. Removal of Records must be an Exceptional Occurrence
  15. Records Moved to a New Location must be Monitored
  16. Records must Usually be Retained After Closure
  17. Protecting Other People's Information

1. Records Must be Kept on all Children

The child's case record will usually be developed from notes taken in the course of a visit or interview and these may be used directly, or as a result of such information being in a report or court statement. The Family Court, in the case of RE M and N (Children) (Local authority gathering, preserving and disclosing evidence) advised that social workers/practitioners must make contemporaneous notes which form a coherent, contemporaneous record. The notes should be legible, signed and dated and record persons present during the meeting/conversation in question. The notes should be detailed and accurately attribute descriptions, actions and views etc. In some instances, sketches/diagrams may be helpful in establishing the veracity of explanations given, e.g. with regard to how injuries were sustained, etc.

Note: These original notes might need to be disclosed in a court.

Each child must have their own electronic case record from the point of referral to case closure; audio, video and digital recordings may also be kept.

Where paper files are also kept, information held in electronic records must accurately reflect the corresponding information recorded within paper files.

Records held on paper 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.

For further information see Ealing Guidance on Electronic File Plan Structure.

2. The Design of Records and Forms Must be Approved

Records and forms must be designed to fit their purpose and used consistently across the organisation.

A manager must approve the design of all records and forms before coming into use.

3. Children and their Families Must be Informed about their Records

Children and their families should be told what types of information/data is contained in their case records.

In particular, they should be helped to understand what data is collected on them, how it is used, who it might be shared with and how long it will be kept for. The most common way to provide information to Data Subjects on what data is collected and how it is used is through a Privacy Notice. Privacy Notices must be easily accessible to children, young people and their families, and should be part of the induction pack given to any new staff members.

See Confidentiality Policy, Values and Principles.

Where children have been adopted, see also Access to Birth Records and Adoption Case Records Procedure.

Information must be provided in a form that children and their families will understand - in their preferred language or method of communication. An interpreter will be provided if needed.

4. The Practitioner Primarily Involved Should Complete the Record

The practitioner primarily involved, that is the person who directly observes or witnesses the event that is being recorded or who has participated in the meeting/conversation, must complete records.

Where this is not possible and records are completed or updated by other people, it must be clear from the record which person provided the information being recorded. Preferably the originator should read the record to ensure its accuracy.

Records of decisions must show who made any decision as well as the basis on which it was made.

5. All Relevant Information about Children and their Families must be Recorded

Every child's case record must hold details of the child's full name, date of birth and any identification number.

It must also include a risk assessment, transfer/closing summary (where appropriate) and a properly maintained chronology.

All other relevant contacts with children, their families, colleagues, professionals or other significant people must be recorded in the same way, i.e. who was present or seen, the relevant discussions, actions or decisions taken and by whom, and the reasons for decisions. Full names and professional relationships should be recorded.

6. Children and their Families should be Involved in the Recording Process

Children and their families must be routinely involved in the process of gathering and recording information about them. They should feel they are part of the recording process.

They should be asked to provide information, express their own views and wishes, and contribute to assessments, reports and to the formulation of plans.

Generally, they must be asked to give their agreement to the sharing of information about them with others - but there are exceptions.

7. Information about Children and their Families Should Normally be Shared with them

Information contained in the case record should usually be shared with the Data Subject unless:

  • Sharing the information would be likely to result in serious harm to the child or another person; or
  • The information was given in the expectation that it would not be disclosed; or
  • The information relates to a third party who expressly indicated the information should not be disclosed.

Where information is obtained and recorded which should not be shared with the child concerned for one of the above reasons, it should be placed in the 'Restricted from user' section of the child's record and the reasons should be recorded.

See also Access to Records / Subject Access Requests Procedure.

Where children have been adopted, see also Access to Birth Records and Adoption Case Records Procedure and Confidentiality Policy, Values and Principles.

8. Managers Must Ensure that Confidential Information is Identified

See Access to Records / Subject Access Requests Procedure.

9. Records Must be Kept up to Date (Timescales)

Records should be updated from detailed notes made contemporaneously following a visit or interview; as various information becomes available, or as decisions or actions are taken as soon as practicable or, at the latest, within 24 hours of the event (see also: Section 1, Records Must be Kept on all Children).

A table setting out all timescales is available here: Timescales and Standards Procedure.

10. Records Must be Written Clearly using Plain Language and Avoid Prejudice

Case files must record information, which can be used to monitor the development of policy and practice, which is responsive to cultural diversity and to promote the effective equalities and diversity practice. For example it is essential that records on service users contain accurate information on ethnicity, language and religion.

The case record must show how service users with language and communication needs were facilitated to ensure fair and equal access to their files and where necessary when specialist equipment was needed, were helped to use the equipment if they were unfamiliar with it.

Records must be written clearly and concisely, using plain language, and must not contain any expressions that might give offence to any individual or group of people on the basis of race, culture, religion, age, disability, or sexual orientation.

Use of technical or professional terms and abbreviations must be kept to a minimum; and if there is likely to be any doubt of their meaning, they must be defined or explained.

See also Ealing's Translation and Interpretation Policy and Ealing Equalities and Diversity Policies.

11. Records Must be Accurate and Adequate

Care must be taken to ensure that information contained in records is relevant and accurate and is sufficient to meet legislative responsibilities and the requirements of these procedures.

Every effort must be made to ensure records are factually correct. If a child / young person feels that information in their record is not accurate, they have a right to request that it is rectified. Local authorities have 1 month to respond to any such requests and, if any such request is received, the authority should take reasonable steps to establish if the data is accurate and rectify the record if necessary.

Records must distinguish clearly between assessments, judgments and decisions. Records must also distinguish between first hand information and information obtained from third parties. Records must reflect the distinction between fact and opinion. Although it is admissible to record opinion, it must be recorded as such and not presented as factual.

When recordings are made from information supplied by an interpreter or signer, this should be stated in the recording. Where translation services are used both the original document and the translated version should be kept on file.

See Confidentiality Policy, Values and Principles.

12. Managers Must Oversee, Monitor and Review all Records

The overall responsibility for ensuring all records are maintained appropriately rests with line managers, although the responsibility can be delegated to other staff as appropriate.

The line manager should routinely check samples of records to ensure they are up to date and maintained as required and, if not, that deficiencies are rectified as soon as practicable.

See also: Supervision Policy.

13. Records Should be Kept Securely

All records held on children must be kept securely.

Children's paper files should normally be stored in a locked cabinet, or a similar manner, usually in an office which only staff/carers have access to.

These records should not be left unattended when not in their normal location.

14. Removal of Records must be an Exceptional Occurrence

The records held in Ealing are primarily electronic and accessed via the client database MOSAIC. Where held on paper records should not normally be taken from the location where they are usually kept.

If it is necessary to remove a record from its normal location, a manager should approve this and should stipulate or agree how long it is necessary to remove the record. The manager must also be satisfied that adequate measures are in place to ensure the security of the record(s) whilst they are removed. For example, records must never be left in unattended vehicles.

The authorisation for a record to be removed must be recorded and those who may have need to see the records should be informed of their removal. The manager must then ensure the record is returned as required/agreed.

See also Ealing's Policies on Email, Home working and Data Protection Regarding the Secure Transfer of Information.

Click on the following inside Ealing links for further information:

15. Records Moved to a New Location must be Monitored

Where records are moved to a new location, the date of transfer should be clearly recorded.

The sender should check that the records have arrived at their intended destination.

See also Ealing's Access to Records Procedure.

For transfer of cases to other local authorities see Team and Transfer Protocols.

16. Records must Usually be Retained After Closure

Files should be retained for the period set out in the Retention and Destruction of Records Procedure.

The member of staff responsible for the case when the case is closed is responsible for ensuring that the file to be retained is in good order and that unnecessary items have been removed, for example, compliment slips, duplicate copies etc.

In case where children have been looked after significant personal correspondence, photos etc from birth parents to children needs to extracted from the child's file and returned at the point the case is closed.

17. Protecting Other People's Information

Be aware of your obligation to protect other people's information.

See Ealing Council Guidance and Policies.

Further Information

In you have any queries contact: dataprotection@ealing.gov.uk or telephone: 020 8825 5512/5124.