3.1 Written Records (Including Retention)

1.1

Social Care Records

1.2

Scope of the Document

This Guidance relates to all information recorded in relation to service users, whether children or adults, or carers, regardless of the context in which it is written. It applies to records entered on computer, as well as any written on paper. All teams and units in children's Social Care are covered by this Guidance.

1.3

Purpose of Written Records

The purpose of recording is to:

• Comply with legislative requirements;
• Demonstrate that statutory and policy requirements have been met;
• Use recording as dynamic tool to provide evidence of work that has been undertaken;
• Demonstrate accountability in decision making;
• Give an account for service users of their history, significant issues or events and their involvement with Children's Social Care;
• Help workers to analyse and make decisions in assessment, care planning, reviewing and evaluation;
• Allow monitoring of change;
• Enable workers to measure whether or not goals or aims are achieved;
• Provide a reference and reminder for the case worker or key worker;
• Communicate information about a case to other workers;
• Show how decisions have been reached and in what order;
• Enable Managers to monitor quality of service;
• Provide information for responding to complaints and representations;
• Provide material for the quality assurance audit programme.

2.1

Content of Records

Whilst containing all essential information, case notes should be as concise as possible and avoid duplication. They should contain only sufficient information to enable the reader to understand the significant points of the case. They should clearly distinguish between different types of information and indicate their source:

• What has been observed by the worker;
• What has been said by the service user or others;
• Information from our sources, e.g. documents, letters, records of other agencies, telephone conversations;
• The worker's opinion, judgement or analysis;
• The worker's recommendation or plan;
• Description of action taken.

2.1.1

Timely

Case notes must be recorded on Framework file within 7 working days of contact, communication or event. If harm or injury has occurred, or potential harm or risk is identified, recording must be completed by the following working day.

2.1.2

Accurate

If significant information is not known, this must be indicated and the missing information completed as soon as possible. Estimated dates, ages or times should be indicated.

Names and addresses must be spelt correctly. The word order of names, the name the service user prefers and any other names they have been known by must be checked. The full names of family members must be asked for, not inferred from other names in the family. People referred to must be clearly identified. If a name other than the name on the person's birth or marriage certificate is used, then this must be explained so that the reader can understand who is being referred to.

When the line manager has read and agreed a record, he/she must enter on the file that they have done this.

All sources of information and messages must be clearly recorded with dates and times of receipt.

2.1.3

Full

Dates and times of events must be recorded. The record of each contact must indicate, as relevant:

• The type of contact;
• The purpose of the contact;
• Who was present and who was seen;
• Who was expected to be present but was not;
• The significant points of what was said and by whom;
• The author's observations of significant actions, behaviour or interaction between people present;
• The outcome;
• Any actions (including plans or decisions) which were required as a result of the contact.

In relation to children/young people, the case note for every visit/contact, should include a separate section considering the views, wishes and feelings of the child/young person in relation to the purpose of the visit/contact, and the issue(s) discussed with them.

The case note should also include any observations of the behaviour of the child/young person, the interaction of the parents or carers with the child/young person and any relevant observations regarding the child/young persons welfare (e.g. conditions of the home, appropriateness of clothing, food provided). This is particularly important where the child/young person is unable to communicate their views, wishes and feelings because of age or disability.

Case notes must include:

• Details of the information obtained, its sources and the process by which it was obtained;
• Analysis or assessment of the information, including consideration of the needs of the people involved, any risk factors and the range of options available, and the reasons which lead to the conclusions drawn or decisions reached;
• An account of the decisions taken and the person(s) responsible.

2.1.4

Concise and Relevant

The information recorded must relate directly to the tasks being undertaken. It must also relate to the purpose of recording. Information should only be recorded if it is significant for:

• The current or future needs of the service user; or
• The needs of those whose lives affect them; or
• The provision of evidence of involvement (e.g. for legal claims); or
• Management of the work undertaken with or for the service user.

2.1.5

Clearly Understandable

All records must be written as if they will be read by the service user, regardless of whether or not the service user wishes to do so. Language used should be clear and understandable, without jargon or technical terms. If these are essential, they should be explained. Abbreviations or sets of initials should be avoided, or if they are used, they must be explained in full the first time they are used.

2.2

Presentations and Layout

The process of decision making must be clear, and plans and recommendations presented separately from descriptive detail.

It should be easy to see the order of events and who is responsible for compiling the record of each event.

• A summary of the case must be completed every three months, or sooner as required, as a separate case note, under the heading 'Case Summary' and states the dates the summary covers;
• Each record where decisions are made or action planned must include a brief summary of action or recommendations;
• Closure summaries and/or transfer summaries should be included where appropriate, using the appropriate Mosaic episode;
• All relevant and appropriate Framework episodes and processes must be completed;
• Records cannot be corrected after they are written, or gaps left. If it is necessary to amend records, or insert information:
  1. The original recording must still be in the file;
  2. The reasons for the amendment should be made clear;
  3. The amendment must be dated and recorded by the author and their line manager.

2.3

Style

Many different styles of writing are permissible, and there is no one "correct" style. It is important that records communicate clearly what the author intended. It is also important to write so that the service user will understand what is written.

It is not necessary to write in essay form - as long as the meaning is clear, note form or bullet points are acceptable, but should be sufficiently detailed to ensure the meaning is clear. Recording should be in a reasonably formal style and casual or colloquial expressions should be avoided. A more formal style will be necessary in some circumstances, e.g. court reports or case conference minutes.

Records should therefore:

• Be written in plain and straightforward language;
• Contain explanations of any technical terms or abbreviations;
• Refer to the service user and others in a way that is acceptable to them (e.g. only using first names if this has been agreed with the person) and appropriate to the context (e.g. using formal titles for case conference minutes)'
• Avoid unnecessary detail;
• Highlight significant points.
  
  

2.4

Information from Other Sources

2.4.1

Conversation or Discussion in Person or by Telephone

The person providing the information must be named and identified. The date and time when the information was provided must be recorded. The reasons for seeking or providing the information should be recorded.

2.4.2

Correspondence by Letter, Fax, Email

Paper communications should be scanned into the file in the appropriate place and referred to in the case notes with the date of receipt. Likewise, faxes should be scanned into the file.

When sharing concerns about a child's safety with another agency or referring to another Local Authority, we need to ensure it has been received, confirmation of receipt should then be recorded in our electronic case file system as a case note.

2.4.3

Supervision Discussions

Case discussions in supervision should be entered on the file under case management notes. The case note entry should state the names of the supervisor, supervisee and any other person present during the supervision (i.e. co-worker/student etc).

Advice given by the line manager outside formal supervision should be recorded in the case notes and confirmed by the line manager as soon as possible.

2.5

Referrals

Information gathered during the first contact with the service user or their representative when assistance from Social Care Services is requested or the need for action identified, should be recorded on Framework. It is important that the information is as accurate as possible at this stage, so that it can be entered on Framework promptly and monitoring of the management of the case can be as precise as possible. The purpose of gathering information will vary - for instance there are particular requirements for referrals for adopters. In general casework situations, workers must gain sufficient information to assist with decisions about whether or not the person is eligible for assessment and the priority of the referral.

• Full details of the referrer - so that information can be checked or clarified if necessary;
• Full details of the service user, including aliases, previous names, preferred names;
• Contact details of the referrer - to allow for follow up if further information or discussion is required;
• Details of significant health professionals and involvement;
• Information about other people - carers and professionals - including next of kin, people living with the service user, people who assist or support the service user - full names and an indication of who the person is or their relationship with the service user;
• Referral information - problems identified, service or assistance requested;
• Information about the service user's gender, ethnic origin, religion.
  
  

2.6

Assessments

Assessments should be recorded in the appropriate episode according to the level, type and complexity of need. All assessments must be recorded, including those which do not result in provision of Departmental services. The approach required and information needed will vary depending on the purpose of the assessment. The relevant policy guidance must be followed for each type of situation.

The process of decision making and the analysis of information gathered must be clearly defined and evidenced in the assessment documentation, so that the logic of the outcome is transparent.

Service user involvement in the assessment must be clearly recorded, including their views and preferences. Evidence of choices offered to service users must be recorded. Service users should be given copies of the assessment documentation wherever possible. A written summary of the outcome of the assessment or a service plan should be given to the service user where required by policy.

2.7

Case Notes

Case notes should contain information about on-going work. They should not be used to record assessments or parts of assessments where there are episodes on Framework for this purpose. If significant changes in the service user's needs or situation have occurred, a new assessment episode should be completed.

2.8

Plans

A plan is the outcome of the assessment, and records the action which has been identified to meet the person's needs. Workers in assessment teams, or residential, day care or other provider teams and units can complete plans. A plan links the needs identified in the assessment with the detailed action which will be carried out, and provides a structure for translating the goals into action. It also gives the basis for review of the degree to which the person's needs are being met and for evaluating change.

The content of plans will vary according to the circumstances. There will be particular requirements for format in certain situations. Guidance on completion of plans for specific areas of work must be followed. Plans should follow on from the assessment and should not duplicate information contained in the assessment documentation.

Plans should specify aims and goals and indicate how they have been identified and how the service user and carers have been involved in the process. Plans should be dated and timescales for review and on-going evaluation should be included.

For long term work, whether by provider services or fieldwork, the plan should form the basis for all subsequent work. It is therefore a vital and powerful tool for working with the service user. It should always be shared with the service user and, with the service user's consent, significant carers.

2.9

Summaries

Summaries must be included in on-going case notes at least every three months, and more frequently if required. They should be as concise as possible.

2.10

Reviews

Reviews should be carried out by fieldwork and provider staff in accordance with policy guidance, and recorded using the appropriate episode. Review documentation should include:

• Records of who was involved in the review;
• An update of changes to factual/biographical information;
• A review of the needs identified in the most recent assessment;
• A review of the objectives, aims and goals identified on the plan;
• A review of the actions and tasks identified on the plan;
• Records of progress in relation to the plan;
• Records of changes required to the plan;
• Summaries of discussions and how decisions were reached;
• The views of the service user, carers and other significant persons, including provider and assessment staff;
• Indications for re-assessment.

2.11

Reports

The content and structure of reports will vary according to the situation. Guidance must be sought on compiling reports for each particular circumstance, for instance, court reports. When writing a report the author should consider:

• The reader(s) - this will normally include the service user or carers/family, and the style of the report should be easily understandable by them, and respectful of them;
• The purpose - what do the readers need to know, and what does the author need them to know and understand;
• The aims of writing the report.
  
  

2.12

Minute Taking and Distribution of Minutes

Minutes of case reviews and other service user focused meetings should be sufficiently detailed to ensure that:

• A true record of the meeting is formed for future reference;
• Plans and decisions are recorded with timescales and outcomes expected;
• The information supplied and how decisions were reached is recorded;
• There is a record of who took part and how they contributed.

Minutes should accurately reflect the significant content of the meeting. The chair of the meeting will be responsible for ensuring the accuracy of the minutes.

The language used should be plain, clear and concise and indicate who said what. Inappropriate or offensive language or unclear words should be recorded in quotation marks.

Minutes of meetings should distributed in a timely way, with the recommendations of child protection meetings being available within 24 hours of the conference and the minutes being sent out within 10 working days.

With regards to looked after reviews, the Independent Reviewing Officers handbook states the: The IRO should produce a written record of the decisions and recommendations made within 5 working days of the completion of the review and a full record of the review within 15 working days of the completion of the review.

The full written record of the review including the decisions should be distributed within 20 working days of the completion of the review.

2.13

Complaints

The purpose of recording complaints is to provide accurate information about a service user's (or their representative's) dissatisfaction in order to resolve the complaint as quickly and effectively as possible, and to provide a record of action taken for reference in later stages. It is therefore important to record:

• Accurate details about the complainant;
• Exact information about the complaint, using the complainant's own words if possible;
• Clarification of what the complainant expects from the complaint;
• Dates and times of contacts;
• Details of action taken, with dates, times and details of people involved;
• Details of the complainant's response;
• Date when the complaint was resolved.

3.1

Legislative Background

3.1.1

General

Social Care Services must keep records about individuals receiving services as part of its function.

3.1.2

Access to Files

See the Access to Records/Subject Access Request Procedure which can also be called Access to Records Requests. A Subject Access Request (SAR) is simply a written request made by, or on behalf of, an individual for the personal information which the Council holds about them. A request is made under the Data Protection Act 2018 (DPA).

Sharing information as it is gathered and recorded reduces the need for formal requests for access to records.

It is important to note that there are particular requirements for access in some service areas, in particular, adoption records.

3.1.3

Data Protection

The General Data Protection Regulations (GDPR) and the Data Protection Act 2018 supersede the Data Protection Act 1998. Practitioners must have due regard to the relevant data protection principles which allow them to share personal information.

The GDPR and Data Protection Act 2018 place greater significance on the need for organisations to be transparent and accountable in relation to their use of data. All organisations handling personal data must ensure they have comprehensive and proportionate arrangements for collecting, storing, and sharing information in place. This also includes arrangements on informing service users about the information they will collect and how this may be shared.

The GDPR and Data Protection Act 2018 do not prevent, or limit, the sharing of information for the purposes of keeping children and young people safe.

To effectively share information:

• All practitioners should be confident of the processing conditions which allow them to store, and share, the information that they need to carry out their safeguarding role. Information which is relevant to safeguarding will often be data which is considered 'special category personal data' meaning it is sensitive and personal;
• Where practitioners need to share special category personal data, they should be aware that the Data Protection Act 2018 includes 'safeguarding of children and individuals at risk' as one of conditions that allows practitioners to share information with others without consent:
  • Information can be shared legally without consent, if a practitioner is unable to/cannot be reasonably expected to gain consent from the individual, or if to gain consent could place a child at risk; ◦ Relevant personal information can also be shared lawfully if it is to keep a child or individual at risk safe from neglect or physical, emotional or mental harm, or if it is protecting their physical, mental, or emotional well-being.

Practitioners looking to share information without consent should consider which processing condition in the Data Protection Act 2018 is most appropriate in the particular circumstances of the case. This may be the safeguarding processing condition or another relevant provision.

The GDPR and Data Protection Act 2018 covers all information relating to a living individual which is stored in manual files and/or computer records whenever this information was recorded. This includes information recorded in emails and covers facts and opinions as well as any indication of Social Care Services intentions and plans in respect of the individual.

Staff are required to conform to the principles of the GDPR and Data Protection Act 2018. Article 5 of the GDPR sets out seven key principles which lie at the heart of the general data protection regime.

Article 5(1) requires that personal data shall be:

1. “Processed lawfully, fairly and in a transparent manner in relation to individuals (‘lawfulness, fairness and transparency’);
2. Collected for specified, explicit and legitimate purposes and not further processed in a manner that is incompatible with those purposes; further processing for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes shall not be considered to be incompatible with the initial purposes (‘purpose limitation’);
3. Adequate, relevant and limited to what is necessary in relation to the purposes for which they are processed (‘data minimisation’);
4. Accurate and, where necessary, kept up to date; every reasonable step must be taken to ensure that personal data that are inaccurate, having regard to the purposes for which they are processed, are erased or rectified without delay (‘accuracy’);
5. Kept in a form which permits identification of data subjects for no longer than is necessary for the purposes for which the personal data are processed; personal data may be stored for longer periods insofar as the personal data will be processed solely for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes subject to implementation of the appropriate technical and organisational measures required by the GDPR in order to safeguard the rights and freedoms of individuals (‘storage limitation’);
6. Processed in a manner that ensures appropriate security of the personal data, including protection against unauthorised or unlawful processing and against accidental loss, destruction or damage, using appropriate technical or organisational measures (‘integrity and confidentiality’).”

Article 5(2) adds that:
“The controller shall be responsible for, and be able to demonstrate compliance with, paragraph 1 (‘accountability’).”

Therefore staff must:

• Always comply with the above;
• Never attempt to access personal data unless you are authorised;
• Never use or disclose any personal information acquired through your work to anyone outside of the work setting.
  
  

3.1.4

Human Rights

The Human Rights Act 1998 has put into law the Articles of the European Convention of Human Rights. There is a need to be aware of the implications of these when recording personal information.

In particular Article 8 gives everyone the right to respect for his/her private and family life. It is important that recording reflects proper reasoning of any practice issue, i.e. taking into account and balancing all the factors, options leading to a decision on course of action and how this might affect an individual's rights. If someone's right, for example, to a family life is likely to be infringed, the justification for infringement must be reasoned and recorded. A relevant situation may be the removal of a child from his/her parents on child protection grounds; the parents right to family life is clearly infringed by this action. However, the rights of the child to be protected from abuse supersede the rights of the parents, but this needs to be justified and recorded.

It is also important to record consideration of who will be affected by the provision, or non provision of services, not just the primary recipient, the child, and the Human Rights implications for them. An example of this will be the parents/carers of a disabled child and how their rights to a family life may be affected by decisions to promote or not promote certain services.

3.2

Accountability and Liability

3.3

Service User and Carer Involvement

Written records should show the involvement of service users and carers in their assessments and services and in the process of arranging them. Service users' views must be recorded and any disagreement with the outcome or worker's judgements. Records should be written taking into account the assumption that service users may read them. Service users should feel that their situation has been understood and represented fairly and accurately, even where they disagree with workers' conclusions.

Service users must be informed that records will be written about them and the reasons why they are kept.

It is good practice to share written records with the service user routinely and at the time of writing. This may include copies of running records, reports and correspondence. Where there are particular difficulties in sharing records, for instance if service users are not able to read or understand them in the usual format, other means of providing information should be considered. This is a possibility where service users have a learning disability or are young children. In these circumstances it will be necessary to tailor the method of sharing records to meet the needs of the individual. A separate service user held file containing relevant key information may be useful.

3.4

Equal Opportunities

Recording should reflect good practice in relation to equal opportunities. Records should take into account the individual needs of the service user and should be sensitive and respectful.

The format and content of records should, as much as possible, be accessible to the service user. Written English must be easily understandable and legible. Alternative languages or formats such as large print, Braille or tape recorded transcriptions should be made available where required.

3.5

Confidentiality

All personal information must be treated as confidential. This means that information supplied by service users about themselves will not normally be shared with any other individual without the service user's consent unless that person has a need to know because of professional involvement with the Department or with the service user. Information should only be shared where it is in the interests of the service user and necessary to enable workers to act on their behalf.

There are some circumstances in which there is a legal obligation to override confidentiality, e.g. in the interests of public health, to prevent/detect a serious criminal offence, or as a result of a direction of the Court.

Consent should, if possible, be gained from the service user to share information with others, including carers or parents. (For specific guidance on sharing of information about children with their parents see Pathway to Provision - Multi-Agency Thresholds Guidance and NSCP Child Protection Procedure). If this is not possible because of a person's ability to understand or give informed consent, workers must show that they have considered the service user's best interests. In some circumstances sharing information is mandatory, for instance in child protection work. Wherever possible, the service user should be informed of who will be party to information recorded about them. Confidentiality and disclosure of information can generate conflicts of interest between individuals and information relevant to them.

Records held by Social Care Services are the "property" of the Department which carries responsibility as the Data Owner, and therefore information is available to workers and managers within the Department without the need for the service user's permission. It is however always desirable to tell the service user about the people to whom the information will be given. Service users should be told about the purpose of records and the need to record information about them supplied by themselves and by others. They should be assured that all workers within the Department are required to respect confidentiality.

Service users should also be advised that all information necessary to enable work to be undertaken will be recorded, even if given "in confidence."

In some service areas there are particular requirements for confidentiality, for example adoption records. Policy and Procedure for these areas must be followed, and specialist advice sought.

3.6

Sharing of Information Between Agencies

Communication and information sharing between agencies is essential to assessment and case management. Its absence can put service users at risk or cause unnecessary delays.

Service users' consent should be gained where appropriate. Where agreements exist about automatic sharing of information (such as child protection work), consent will not always be required, and copies of key documents such as assessment forms or plans should be given to other professionals involved in the case. (See Pathway to Provision - Multi-Agency Thresholds Guidance and NSCP Child Protection Procedures)

In multidisciplinary teams, all workers may complete Social Care Services documentation. These records are Social Services records and covered by the Open Access Policy even if they are completed by professionals who are not Social Care Services employees.

Social Care records should be fully accessible to members of a multidisciplinary team. Access to files held by other agencies or by non-Social Care employees is subject to agreements with those agencies.

Information held on a Social Care file supplied by another agency is not available to the service user without the permission of the author or agency. If possible, workers should seek consent at the time the information is given.

Unborn babies recording on Mosaic

• There is no minimum gestational age at which a referral is accepted, but there is an expectation that the pregnancy will have been confirmed and deemed viable by a medical practitioner;
• The Mosaic case record needs to be created as soon as possible, once the pregnancy is confirmed. The only relationships that should be added at this point is Unborn: Mother and father’s details;
• The social worker must complete all details and update case records as they become clear (for example, gender of the baby);
• Under “Date of Birth” the social worker should enter the expected due date once this is established. The social worker is responsible for updating the ‘date of birth’ once the baby is born;
• Once the baby is born the social worker should change the name from ‘unborn’ to the given name and add any relationship links;
• Should the pregnancy not continue to term, the social worker should close the record and end any workflow in progress. The social worker should enter a case note onto the file, to confirm the end of the pregnancy and indicate the cause of the pregnancy not continuing to full term;
• If the pregnancy ends due to miscarriage or a termination then the Due Date should remain and the date of death is completed. For a still born child the due date should be changed to the actual date and the date of death added;
• If the mother subsequently becomes pregnant again, under no circumstances should the social worker ‘resurrect’ the record of the previous ‘unborn’ child. Every child, whether unborn or born, must have a unique case record;
• If a record is accidentally added for a non viable unborn child then e mail framework development-team to arrange for the record to be deleted.

3.7

Sharing of Information Between Teams and Units

All Social Care employees are bound by the principles of confidentiality, but only the minimum information required for the stated purpose should be shared. The manager of the team or unit holding the information will be responsible for deciding what will be shared or restricted, and should seek advice if necessary.

Information should be shared between workers involved in a case according to their need to know, either by supplying copies of significant documents or, if necessary, by giving access to case files. It is good practice to advise service users of this wherever possible.

3.8

Recording of Risk

When risk of harm is identified as significant, it is important to record accurately.

• The nature of the risk identified;
• The information on which the identification of risk is based;
• The degree and level of risk;
• The likelihood of harm occurring;
• Evaluation of priority of risk and the implications of courses of action;
• Plans or action recommended or implemented;
• Reasons for decisions about intervention or non-intervention;
• Service user's or carers' disagreement with the evaluation of level of risk, action or outcome.

3.9

Management of Records

Each individual service user should have a file in his or her own name, and Information which is common should be duplicated on all files of individuals within the family, but the issues for each child should be clearly identified.

3.10

Storage and Security of Records

Hardcopy files and electronic records must be kept secure so that confidentiality is assured and they are easily accessible in the caseworker or key worker's absence.

Hardcopy files must not be removed from their official location unless there are exceptional circumstances. Permission from a Team/Unit Manager or another representative of the Locality Management Team must be gained to do so. For workers not located in Locality, advice should be sought from the line manager.

The person working on a file at the time is responsible for its security. This includes ensuring that hardcopies of files/records are locked in secure places especially outside normal office hours, or when it is necessary to remove files from the office.

3.11

Retention

The case record must be kept until the 75th anniversary of the child's date of birth, or 15 years from the date of death in the case of a child who dies before reaching the age of 18.

See Important Note.

Click here to see the Children's Services - Retention of Records Table.