7.1.4 Record Keeping in Children's Centres

This is a new chapter for October 2009

Note: The term Centre is used throughout this chapter to mean Children's Centres

RELEVANT CHAPTERS

This chapter should be read in conjunction with Supporting Families and Record Keeping in Children's Centres - Guidelines

Chronology Record Keeping Form

1.	Background Information
2.	The Purpose of Written Documentation in Centres
3.	Key Principles from 'Recording Matters'
4.	Standards in 'Family (Case) File Recording'
5.	Family Support - Family File Management
6.	Family Files
7.	How To Complete Forms
	7.1	The Referral Form
	7.2	Chronology
	7.3	Non-Sessional Record
	7.4	Family Plan
	7.5	Evaluation Record
	7.6	Common Assessment Framework
	7.7	Summary Sheet
8.	General Guidance
9.	Quality Assurance
10.	Confidentiality and Exchange of Information
11.	Procedure
	11.1	Exchanging Information with Parents
	11.2	Summary of Record Keeping Forms

1. Background Information

'Recording skills are less about writing ability, and far more about being able to observe and listen, to take in information, process and interpret it, while still being clear about how much your own subjective perception and understanding may be influencing the way in which you then describe to others what you believe you have seen and heard. As a sociologist, I am all too aware of how each individual can assume that the sense they make of the world, the meaning they give to their experiences, is somehow an objective fact, and that people do not always sufficiently realise how that same world can be looked at in very different ways.'
Liz O'Rourke - For the Record 2002.

The development of the Centres 'record keeping process' has been informed by the Wakefield's 'Recording Matters' document (revised July 2007) and though this document is primarily directed at Social Services staff, much of the good practice guidance and principles are applicable to the record keeping that takes place in the Centres'.

A good standard of record keeping should be applied in every situation where records need to be kept, however not every intervention with families in the Centre will necessitate formal record keeping. The forms described in this guidance apply mainly to Family Files where individualised sessions with families take place over an agreed period of time.

However, the Chronology and Non-sessional recording forms can be used for recording in very short term or 'one off' intervention situations.

2. The Purpose of Written Documentation in Centres

To document:

Family views and what they hope to achieve from the Centre's intervention.
Professional views and what they hope to achieve in collaboration with the family.
How the family have benefited from the interventions
Assessments.
Nature of the work to be undertaken & record of planning.
Progress towards objectives / learning objectives
Critical incidents.
Child protection and other concerns.
Actions taken.
Contacts / visits made.
Information / data for improvement, evaluation and monitoring.
Health, safety and welfare information.
Information which reflect the principles of equality and equal access.
Accountability

3. Key Principles from 'Recording Matters'

Case recording should tell the story of the work with families and children and other agencies, so that it is clear to anyone reading the file what has happened, what actions have been taken and why.

There should be a separation of observed or verified fact from worker's opinion.

Family files should record professional assessment and judgement.

The views and feelings of families should be clearly recorded.

There should be evidence of family partnership and involvement in the assessment, planning and reviewing process.

All contacts with families, professionals and others must be recorded and written within a timescale which ensures accuracy and completed within 5 days. The author of every entry and the source of all information, including third party information, must be clearly stated.

Recording should be accurate and relevant - only information which can be explained should be recorded.

Files should be well ordered, using the agreed format, and legible to ensure ease of access.

There should be evidence of accountability and quality assurance from line managers. As a means of accountability, records must be inspected at intervals by the author's line manger who may advise on style or content. The manager must sign their name in full and date the signature when they have read the records.

4. Standards in 'Family (Case) File Recording'

Standards in recording should demonstrate a strong commitment to high standards in 'case recording'

Record keeping (apart from child protection exceptions) should always be considered to be part of a collaborative relationship between parents and staff and open access should apply.
The quality and content of case recording should reflect both good professional practice and social care guidance.
The Centres should have guidance on and systems for, sharing case record information.
Management arrangements should ensure that the practice of case recording meets policy and procedural requirements.

5. Family Support - Family File Management

A family file is not necessary where:

Parent/s attend a group only.
Where an individual seeks advice or information, in this case a 'Non-sessional record can be used or Chronology

Click here to view flowchart

6. Family Files

To open when a family has been referred for individual support and where a longer period of work has been agreed.

As a principle for case file management the most recent entry should be on top in each section of the file and documents should be filed in chronological order. The Referral form with basic information should always be on top after the laminated contents sheet, for ease of access to key information. A Chronology should follow on in sequence from the Referral form.

To promote quality and consistency in 'Family Files' the structure of each file should be as follows:

Note: When a case files is closed a Summary Sheet should be completed and kept in front of the file, with a copy placed in one 'Summary' file so that summaries can be accessed quickly in the event of an enquiry.

Alert Information
Key Contacts - external professional/agencies/individuals
Section 1	Referral Form (all basic family details and reasons for referral
Section 2	Chronology (Key facts)
Section 3	Non-sessional recording form
Section 4	Family Plan
Section 5	Common Assessment Framework (CAF)
Section 6	Session Evaluations
Section 7	Child Protection Reports
Section 8	Health and other reports
Section 9	Correspondence
Section 10	Children's Section (where family workers are seeing children separately)
On case closure, a case summary sheet should be attached to the front of the file.

The file structure enables:

Consistency in how records are managed maintained and retained.
Accessibility for family case holders, colleagues, managers and service users.
A clear framework in which the process and outcomes of the thinking, planning, assessment, rationale for actions and interventions and outcomes, is clearly set out and evidenced
Accountability in decision making and for monitoring of quality assurance by managers.

For each family case file there will be a current working file, and so when opening a further file for the same family it will mean bringing forward documentation and must contain up to date information. This will include:

Referral
Chronology
Current plan

The file content sheet states the range of documents which can be kept in the 10 main sections. There may be documents that are not listed and so an element of common sense will be required when placing a document on file. If in doubt the line manager should be consulted.

In managing a family file it is important that those involved ensure that there is a cross referencing between day to day recording and other documents on file. The day to day recording should have the complete picture in chronological order.

All entries should be initialled and dated.

NOTE: Staff safety considerations

The ALERT INFORMATION FORM must be attached to the front sheet or Referral Form about any issues which may affect the welfare of safety of staff and a record kept if lone visiting is inadvisable and why. The Line Manager or Head/Deputy Head of centre must be made aware of this immediately.

Parents/Carers must know that sessions will be recorded and why.

Parents must be given the opportunity to see the forms, know they will be kept safe and provided with copies.

Records must reflect good practice - you wouldn't record anything that you wouldn't want your client to see - unless it was an issue of child protection and even then, only if it would put the child at risk or compromise an investigation.

This then doesn't mean only positive things can be written, it means that practitioners need to develop ways of challenging which are supportive, timely, non-judgemental and specific to behaviours which are likely to impact on the children. A good way to do this is to encourage the parent / carer to reflect first on what their perception is of the parenting in question before you comment - more often than not the parent has a very good understanding of what needs to change and just need help with the 'How'.

All recording should reflect a fair and balanced view, with both strengths and weaknesses recorded.

When evaluating a session parent's should be asked how they feel the session has gone, did they learn anything; did it live up to their expectations / give them food for thought? Often parents need time to think about it and put things into practice before commenting, if so this should be brought to the next session and recorded retrospectively.

Using a session in this way promotes the principles of collaboration, always remembering that the whole process is about the family, the improvements they want to see and the impact on the children and not about bureaucracy for its own sake.

Concerns should never be saved up until a meeting is held; parents have the right to know if the worker has any ongoing concerns or worries about them, their children or aspects of their parenting. For example; how would you feel if your regular supervision sessions seemed to be going well, only to find out at an appraisal meeting that your line manager had been recording negative statements about you after every session? Your trust would diminish, you would probably be annoyed and also less likely to take any criticism on board-however true it was.

7. How to Complete Forms

7.1 The Referral Form

Click here to view Request for Family Support services Form

Contains: family details, names, contacts, D.O.B. ethnicity, reasons for referral, outline of parent's/children's needs. This must be completed with and signed by the family. Referrals should not be accepted if the family have not signed the Referral Form.

*The Centre Registration Form could be given to the family at the same time as the Referral form, although the family do not have to fill in the things that are already recorded on the Referral, however the Registration Forms include signatures for photograph permissions and to include this on the Referral form may not be appropriate at a time when the family may be vulnerable or under stress.

7.2 The Chronology

Click here to view Chronology Record Keeping Form

NOTE: Chronology or Non-sessional Record

These forms can be used to record 'one off' or short term contact with parent/carer and can also be used to record safeguarding concerns.

Chronologies should be in the front section of every family file after the basic information or referral.

A Chronology is a work in progress and should be added to when necessary.

Chronologies are not a substitute for detailed recording they are key documents to enable staff to:

Track events
Identify trends
Present key information at a glance
Identify where more comprehensive information is kept on file.

Chronologies record the following:

Key facts (NB record if there is disagreement)
Key events (start of family sessions /end of work)
Historical chronology of family history, births, deaths, relationship changes etc.
Changes of address
Changes of school
Key meetings - e.g. child protection, date of family plan / progress meeting (only major decisions should be recorded on chronology)
Incidents which give rise for concern
History of positive events and incidents
Key communications e.g. letters, phone calls

A chronology should not contain opinion or judgement; it is a factual record of events only and it should be succinct.

More detail can be provided on either the 'non-sessional recording form' or in session evaluation - there must be cross referencing to these other documents in the chronology.

7.3 The Non-sessional Record

Click here to view Record Keeping - Non Sessional Form

This to be used to record 'un-planned' contacts with families, that is, anything that takes place outside the planned sessions agreed at the 'family plan meeting'.

E.g Family are having weekly sessions on a Monday morning, the plan is recorded on the session evaluation sheet as is the outcome of the session. On Tuesday the family contact the family worker and say that there has been a crisis.

The Chronology would record the phone call and visit & the non- sessional record would record the detail e.g ......

Chronology

9.1.07 Joan Smith telephoned in a distressed state. Patrick had left the household following an incident. See NS! 9/1/07, Eval. Record 15/1/07

NSR

9/1/07 Joan rang, she said Patrick had threatened her and 'trashed the house' .He had also taken all her money & the children were very upset. Joan was in a very distressed state, crying and saying that she didn't know what to do. She asked if she could bring the children to the Centre and talk to someone. I arranged to see her at 12pm and also arranged day care for the duration of our visit.

At the Evaluation session there will probably be some further discussion about the events, this can either be recorded on the NS1 or in the evaluation record, either way there should be reference to it on the Chronology as above.

7.4 The Family Plan

Click here to view The Family Support Plan Form

This represents the main document on file, it is a collaborative record between the parents/carers and Centre staff and other external professionals who may be involved with the family, of the plan of work. The Plan contains the:

Agreement (who will do what and how and what the family want to achieve and work on, others views on what they feel the family should work on and practical arrangements)
Progress record ( what has been achieved, how has it impacted on the whole family and what the next steps should be, this could be closure or new / continuance of objectives)

Both the family and the professionals involved must sign the plan and the family provided with a copy. (The family may choose not to take their plan home, in which case the Centre could keep it on their behalf)

7.5 Evaluation Record Sheet

Click here to view Sessional Evaluation Sheet

This records the planning, methodology and outcomes of individual sessions. These are summarised collectively for the progress meeting. They are shared with the parents who are also provided with a copy. (On occasions parents may prefer not to keep a copy in their home and so the family worker may want to offer to keep their copy at the Centre if they wish)

Records are always shared unless to do so would not be in the best interests of a child.

7.6 Common Assessment Framework

The Common Assessment Framework is a suitable tool to use as a baseline assessment. Eliciting information for the CAF should however be more creative and user friendly than just questionnaires;there are methods available that aid communication and give families the opportunity to discuss their views in depth.

NOTE: Tracker

A file tracker must be inserted into the file sling and signed, if for any reason the file is moved from its destination. This ensures that files are always accounted for.

7.7 Summary Sheet

On completion of a 'family plan' and file closure, a Summary sheet must be completed, which outlines the work undertaken and the outcomes, this should then be attached to the Chronology, with a copy for a single file which contains all summaries and chronologies for ease of future reference.

8. General Guidance

Records should clearly state the names of people who were involved in any incidents, telephone calls or other forms of communication and always signed and dated by the person writing the record.

Where relevant, records must always state when a professional opinion or comment is being used. For example:

I am of the opinion that Mary was under the influence of alcohol as I could detect the smell of it on her breath and she was slurring her words. I have observed her in a similar state on two or three occasions previously.

The example above clearly notes an opinion but also demonstrates evidence to back it up, doesn't use any emotive language or unsubstantiated judgement

Alcohol is a problem for Mary she is always coming into the Centre drunk and incapable, I have heard other parents say that she spends most of her money on drink.

This example doesn't back up opinion, it contains unsubstantiated hearsay and uses emotive language, it also assumes a problem for Mary.

To ensure accuracy professional notes should be made either at the time of an event or immediately afterwards. Making notes too long after the event can result in inaccuracies and poorer recall of facts.

Good Practice summary

Be clear about the purpose of the record
Know where you are going to record it
Distinguish facts from opinion
1. verifiable factual information
2. direct observations
3. understandings
4. hearsay
5. opinions, judgements, assessments, evaluations and recommendations
Remember to be accurate, relevant and concise while still providing a complete record
Be clear what you are going to write about
Write legibly in ink or word process. Do not use correction fluid.
Use clear and unambiguous language
Use language that is respectful, avoids stereotypical descriptions and values differences.
Sign and date each piece of recorded information, including messages (see below).
Be aware of confidentiality
Indicate who or where the information has come from.
Check the accuracy of the record with the service user if appropriate.

Messages

Messages should be recorded on a common message system or via email (ensuring read receipt is activated) these messages should then be recorded onto file. Loose paper notes should not remain on files for longer than 2 days. Administrative staff and others taking messages must also ensure that messages are accurate, dealt with and that important information does not get overlooked.

During periods of absence from the Centre, staff should activate their email 'out of office' reply system and sign the Wakefield permissions form, giving their line manager access to their email address, to ensure that important messages are not overlooked.

9. Quality Assurance

All files should be seen by and signed off by a line manager, mainly through the supervision process, but random checks could also take place.

Family workers should present family files on a rotational basis at their supervision meetings, any decisions made during supervision about specific families should also be recorded on the NS1.

The Head of Centre should also carry out periodic checks on all filing systems and report back to staff.

10. Confidentiality and Exchange of Information

It is the right of each individual to be confident that personal information about them, and their children, will not be given, or accessible to people who have no right to it.

11. Procedure

All documents which relate to individual children and families must be kept in locked metal filing cabinets. Where information is kept on a database, it must be password protected.

Personal information must not be kept on a portable data stick or lap top computer. Where staff record on to a data stick or lap top, the information must be transferred as soon as practical on to a file, disc or hard drive and deleted from the data stick/lap top. Discs must be treated like files and kept in a locked filing cabinet, with the tracker sheet used to document removal.

Main computer back ups should take place at the end of each day and a copy kept safely off site or in a fire proof safe. .

Closed files should be kept in a locked room. Any obsolete family support case files will only contain information which is not duplicated by Social Care ; that is core group, child protection meeting minutes which are also kept with Social Care case files, so do not have to be kept at the Centre. However a record of which duplicated records were kept on file, what they contained and when they were destroyed should be made.

Students should not be given access to case files, unless they are Social Work students and are working with the family in question. (The family must be made aware of this)

Any requests for access to personal files must be referred to the ISC /Head of Centre. (N.B. families should already have had access to and copies of their own files during the period of support)

Any requests by professionals for information by telephone should not be given unless the caller is well known to the staff member dealing with the request, or verification has been made by returning the call.

Parents or other Centre users must not, under any circumstance be given access to another family's personal file.

Any information shared must be on a need to know basis.

Staff must never discuss children and families with other children and families.

Where offices are fitted with security key pad locks - they must be activated when offices are unoccupied.

Personal (client) information must not be left out on desktops or tables where the person responsible for its safety is out of the office. Desks must be cleared of client information at the end of the working day and it must be locked away in a filing cabinet.

Care must be taken about the people who may be in the vicinity when telephone calls are made, which involves confidential information about a child or family.

Personal telephone numbers and addresses should not be given out, unless the person involved has given permission.

People must never be promised total confidentiality, as there may be occasions when information must be shared with relevant agencies, due to child protection matters. However, promises can be made that only people, who need to know, will be told.

When taking messages all staff should ensure that the information they are taking is correct. Telephone numbers should be repeated for clarification and names phonetically spelled out where appropriate.

11.1 Exchanging Information with Parents

Naturally, the exchange of information is a daily occurrence Centres.

It is important that the principles that underpin these exchanges are founded in respect, sensitivity, honesty and clarity and that staff members observe all the principles set out in the Data protection act and Centre's own Confidentiality Procedure.

Key to good practice

Ensure that information about children/parents/carers/ is accurate and up to date.
Be aware of body language and choice of words when exchanging information about children to their parents. If a child has difficulties which are manifested in his/her behaviour, ensure that the sharing of information is objective, clear and balanced with positives, the overriding purpose of any exchange of information must be to work together to improve the situation for the child/family, not to vent staff members frustration about a child who is making their life difficult.
Remember to share successes and celebrations
Find out what the adult's/child's preferred name is that you should use.
Ensure that information is exchanged in an appropriate environment.
Make eye contact where culturally appropriate (e.g. It is considered disrespectful for children to make eye contact with adults and men to make eye contact with women, in the Muslim culture)
Speak clearly and if necessary repeat the information to ensure that the recipient has understood what you have told them.
Consider how to verbally exchange information with an adult who doesn't speak English, the Language Line may help.
Give people the time and opportunity to ask questions either then or later.
Be very clear about what you are communicating and ensure its accuracy, in some situations consider following the exchange up in writing.
If an information exchange has the potential to arouse an angry response, consider asking someone else to be in attendance or near by (it is good practice to formulate a staff safety policy)
If you leave a message, leave a contact telephone number

11.2 Summary of Record Keeping Forms

File Tracker	Completed when family file leaves filing cabinet
Alert Information	Kept on file to warn of any possible danger to workers.
Key Contacts	Kept at the front of the file to record all key contact people related to the particular family.
Referral Form	Details about the family and reasons why they require support from the Centre.
Chronology	Factual recording of key events
Non-sessional Recording	More detailed recording of events which occur outside the normal family session. Recording of 'one off' or short term advice/ information Recording of child protection information (where referral made to SCD also use SCD referral form)
Family Plan	Record of aims and objectives and progress and who will do what and when.
Common Assessment Form	Forms baseline information
Sessional Evaluation Form	Records aims, methodology and outcome of individual sessions
Closing Summary	On case closure records overall outcome of intervention by Centre

End