10.2.3 Recording Matters

Policy Statement
Legal Requirements
Standards in Case File Recording
Principles of Good Practice
Specific Expectations of Safeguarding and Family Support Staff
Electronic Case File System
Case File Audit and Quality Assurance
Summary of Responsibilities
Data Protection, Confidentiality and Access to Files

Appendix 1 - National Standards and Criteria - to follow

Appendix 2 - Case File Audit Tool - to follow

1. Policy Statement

The work we undertake within Safeguarding & Family Support requires a high standard of case file recording in order to ensure a quality service is provided. Case file records are a key tool in developing assessments and plans. They also form a basis for information gathering to enable us to shape and develop the services we provide and can be used to inform life-story work with children.

'The case file is the single most important tool available to workers and their managers when making decisions as to how best to safeguard the welfare of children under their care.

Reference to the case file should be made at every stage of the case and before any significant decision is made'.

(Lord Laming - the Victoria Climbie Inquiry, January 2003).

'Good case recording is an important part of the accountability of staff working in social services to those who use the services. It helps to focus the work of staff and it supports effective partnerships with service users and carers. It ensures that there is a documented account of a service's involvement with individual service users, families and carers. It assists continuity when workers are unavailable or change and provides an essential tool for managers to monitor work'.

(''Recording with Care' - report of the inspection of case recording in Social Services, SSI 1999).

All records must comply with legislation. All records are the property of Wakefield MDC and must reflect corporate policies relating to Data Protection and Equal Opportunities statements.

Service users have rights of access to personal records and should be provided with information to that effect. Systems are in place to comply with that duty. In addition it is important to recognise the need to give service users every opportunity to contribute to their own records, capturing their views, wishes and feelings.

2. Legal Requirements

Case file records must comply with the following legislation and guidance:

LAC (87)10 - Data Protection (subject Access Modifications) (Social work Order 1987)
Data Protection Act 1998
LAC (88)17 - Personal Social Services Confidentiality of Personal Information
Local Authority Social services Designation of Functions Order 1989

3. Standards in Case File Recording

The Social Services Inspectorate report in 1999 set out 6 national standards in case recording that have been adopted by Safeguarding & Family Support and continue to have relevance for the work we do. A summary of the standards is as follows:

Standard 1	Case recording should be seen as being part of the overall service to users and carers, with the views of service users clearly recorded and with service users receiving copies of records such as assessments and care plans
Standard 2	The quality and content of case recording reflects good professional practice as well as social care policy and guidance
Standard 3	The purpose of case recording, together with underpinning principles and legal requirements, should be set out in the policies of the organisation
Standard 4	The agency should have guidance on, and systems for, receiving contributions to case records from external sources, and the appropriate sharing of such information received
Standard 5	Good practice in equal opportunities should be reflected in the case record
Standard 6	Management arrangements need to ensure that the practice of case recording meets accepted good professional standards as well as the policy and procedural requirements of the organisation

4. Principles of Good Practice

From the 6 standards, Safeguarding & Family Support have identified the following principles to apply in all case recording activity:

Case file recording should 'tell the story' of the work we do with our service users and partner agencies in a way that clearly describes what has happened, what actions we have taken and why.
There should be a separation between observed or verified fact and worker's opinion. Opinion is valid but reasons must be evidenced.
Case records should show professional assessment and judgement.
All contacts with service users, partner agencies and others must be recorded. Records should be written within a timescale that ensures accuracy and that can be defended in legal proceedings. For most services records should be made within 5 working days of an occurrence, but in some services such as Social Care Direct shorter timescales may be the expectation.
Recording must be relevant.
Views and wishes of service users must be made clear in recording.
Service user involvement in assessment, planning and review processes must be recorded.
Evidence of due consideration to diversity issues must be demonstrated within the case record
There should be evidence of accountability and quality assurance within the case record.
Records are securely and confidentially maintained through electronic systems and will only be accessible to those within Wakefield MDC who have a professional interest or those professionals external to the local authority who are authorised to have access within a legal framework (see section 9 below).

5. Specific Expectations of Safeguarding and Family Support Staff

When a case is allocated a manager should ensure that the allocated worker is clear about what has been allocated, what action is required and how work will be reviewed. This will continue through the process of assessment and case activity
When a referral is made to a partner agency this must be recorded, to include the purpose of the referral and that the referral is agreed by the manager
Records should contain all contacts, whether face-to-face, through telephone contact, by email, letter, fax, etc
Records must contain key decisions made and the reasons for those decisions
Decisions made in Supervision must be included in the record
All open case records should have summaries at a minimum of 3-monthly periods, highlighting progress, plans and desired outcomes
Purpose of visits should be made clear
Records of visits should detail clearly and succinctly the main points of the interview or other contact
Where opinion is being expressed, that should be made clear
The case record should leave the reader clear about planned next steps in the case
Records should demonstrate the process of decision through investigation, assessment, planning and review
When legal advice is obtained it must be recorded
Where a child is subject of a Child Protection Plan the team manager must record on a monthly basis to indicate that monitoring and case planning is in place
Recording of statutory visits to a Looked After Child must be clearly titled and contain the required information about Health, Welfare, Education, Contact with Natural Family and Placement circumstances. Comments by the child and their carer should be included. The record should confirm that the child has been seen and that the worker has been able to see the child alone. The record must demonstrate that sleeping arrangements have been checked to be satisfactory
Arrangements made to facilitate interview of a child and/or family where there are communication issues (language difficulties or learning disabilities) must be stated
Where a Section 47 Enquiry is conducted the fact that the child has been seen must be recorded
All meetings must be clearly recorded and referred to in case notes.
Received paper documents such as letters should be scanned into the electronic system
Personal documents for Looked After Children, such as copy of birth certificate and qualifications achieved, should be scanned into the electronic record in accordance with guidance and policy

6. Electronic Case File System

In Wakefield MDC Safeguarding & Family Support an electronic case management system is in place. The system offers case file security. It provides tools for case file management, with separate but linked sections covering child protection, child in need plans, LAC documentation etc. It includes templates, chronologies, work management tools and so on.

Workers must be clearly informed as part of their induction process about the potential consequences of accessing files inappropriately. They should be informed of the Wakefield MDC Information Security Policy.

7. Case File Audit and Quality Assurance

The Case File Audit Tool is to be used by line managers to ensure that case file recording is taking place and that records are being kept that meet the requirements of 'Recording Matters'.

The Case File Audit Tool is included as an Appendix to 'Recording Matters'.

8. Summary of Responsibilities

Front line staff are required to:

Familiarise themselves with 'Recording Matters' and periodically refresh
Maintain case records in accordance with 'Recording Matters'

Team Managers are required to:

Ensure their staff comply with required standards
Enter case records themselves in accordance with 'Recording Matters'
Ensure that records are 'signed off' when cases are closed or transferred
Bring to the attention of Service Managers any issues of practice requiring action

Service Managers are required to:

Conduct sample Case File Audits across their service areas every 3 months, using the agreed format
Ensure training is in place to support the effective use of 'Recording Matters'
Update 'Recording Matters' in light of legal, research and other developments

9. Data Protection, Confidentiality and Access to Files

The Data Protection Act (DPA) 1998 covers both paper-based and electronic records. It affects anyone who processes personal data and Wakefield MDC is under legal requirement to ensure that all staff comply with the legislation.

When dealing with personal data we are in a position of trust and can be held to account in law. We must only use personal data to enable us to fulfil our service tasks. We must never disclose such information to any third parties and must never use it for our own personal purposes.

The DPA sets out 8 principles relevant to 'Recording Matters' as follows:

All personal data must be:

Processed lawfully
Held and processed for only one or more specified and lawful purposes
Adequate, relevant and not excessive in relation to the purposes for which it is processed
Accurate and where necessary kept up to date
Kept for no longer than is necessary
Processed in accordance with the rights of data subjects under the Act
Protected by appropriate technical and organisational measures to prevent unauthorised or unlawful processing of data or loss of data through accident or damage
Not transferred to a country or territory outside the EU unless the receiving country ensures an adequate level of protection for personal data

In addition, 6 'Caldicott' confidentiality principles stem from case law, namely:

Justify the purpose of recording data
Do not use personal data unless it is absolutely necessary
Use the minimum necessary personal data
Access to personal data should be on a 'need to know' basis
Everyone with access to personal data should be aware of their responsibilities
Understand and comply with the law

The DPA also covers the issue of access to personal files. Safeguarding & Family Support welcome the idea of service users being able to access their files. Case file recording should therefore be made with that in mind. Limitations on service users' right of access to their personal data apply in relation to third party information.

Requests for access to a service user's file will not normally be given to anyone other than that service user. For children under the age of 10 years parents will normally be granted access unless there are clear reasons why that would not be in the best interests of the child.

For more information on Data Protection issues go to the Wakefield MDC Data Protection website.

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