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2.1 Recording with Care - Recording Policy and Guidelines

SCOPE OF THIS CHAPTER

This chapter was added to the manual in September 2014. It reproduces information from leaflet D1 and outlines the principles behind good quality record keeping, and the standards required.

RELATED GUIDANCE

Recording Template

Recording MAPPA Information

Recording MARAC Information

Risk Assessment Plan (for children and young people who present a risk of harmful behaviour)

Manager’s Overview of Risk


Contents

  1. Introduction
  2. Recording Principles
  3. Recording Standards


1. Introduction

Good quality recording is an essential part of social work practice and is part of the service we provide to children, young people, their families and carers. It is the basis of good assessment, and is the tool for planning and monitoring work. It also shows how and why decisions were made and provides data for evaluation purposes. It is also a source of information to children and young people about their lives and experiences. Children, young people, their families and carers have a basic right to access their records and so we have a duty to record our work with them accurately and fairly.

It is the responsibility of all staff to ensure their records are maintained to a satisfactory standard. It is the responsibility of the Team/Unit Manager to ensure these standards are maintained. Senior Managers are responsible for the quality assurance of their service's work against these standards and for ensuing that any learning/required action is responded to.


2. Recording Principles

All case recording must be on Framework-i, the child’s electronic social care record. Case recording must not be stored elsewhere (such as in team U Drives).

The following principles underpin good social work recording:

  • Good case recording is central to good social care practice;
  • Case records must be based on good professional practice and conform to Children’s Case records contain detailed assessments and care plans at an appropriate level;
  • All contributions from children, young people, families, carers, other professional to assessments and care plans, are recorded appropriately. This must include recording disagreements and their possible resolution;
  • All management decisions are recorded, including who made these decisions, when and for what reasons;
  • Case recording must conform to Framework-i guidance;
  • Case recording must comply with the requirements of the Data Protection Act 1998;
  • Sharing of information with other public and independent agencies must conform to the relevant local Information Sharing protocols and national guidance;
  • Case recording must be accurate, justified, proportionate, fit for purpose and legible. Wherever possible jargon must be avoided and plain English used;
  • The content of case records must give a sufficient account of all significant work undertaken;
  • Service users have the right to request access to their social care records, though some exemptions may apply;
  • Case recording is only retained for as long as necessary and is subject to the County Council Retention of Records guidance.


3. Recording Standards

The Standards of Personal Professional Practice highlight the need for good quality recording:

  • Standard 1: I will understand and record the child's lived experience;
  • Standard 2: I will work within the statutory and local framework;
  • Standard 3: I will communicate effectively with children, young people, their families and partner agencies;
  • Standard 4: I will effectively engage with children, young people and their families;
  • Standard 5: I will ensure there is effective decision making and management oversight;

The following recording standards are based on these personal professional standards.

STANDARD 1 – MY CASE RECORDING WILL BE TIMELY, ACCURATE, FIT FOR PURPOSE, PROPORTIONATE AND FAIR

Case recording on Framework-i must:

  • Be of an acceptable professional standard;
  • Be contemporaneous (i.e. made at the time or as close to this as possible);
  • Timescales:
    • High risk events/information by the end of the same day;
    • S.47 investigation interviews/Strategy Discussion outcomes/significant events within 24 hours;
    • Statutory visits within 72 hours;
    • Other recording within 5 working days.
  • Accurately record what has happened impartially and in sufficient detail;
  • Properly reflect the work done;
  • Be relevant. Non-case related information must not be recorded on Framework-i;
  • Not just be a summary of facts, but also include the worker's assessment of need and risk and include professional opinion.

STANDARD 2 – MY CASE RECORDING IS A KEY PART OF THE WORK I DO WITH CHILDREN, YOUNG PEOPLE, FAMILIES AND CARERS

Every child, young person, family member and carer must:

  • Have a separate Framework-i record;
  • Be informed of Children’s Services policies on case recording;
  • Be helped to understand the purpose and content of their case records and invited to contribute to these;
  • Be informed of their right to access to their case records and how to do this;
  • Have their views taken into account and for these to be recorded clearly and accurately. This includes encouraging and supporting them to read their records, correct errors and omissions, recording any dissent and personal statements;
  • Be informed about decisions and outcomes of requests for service;
  • Receive written copies of their assessments and care plans, and be kept informed at all stages. There must be a Framework-i case note to record what documents have been given to whom and when.

STANDARD 3 – I WILL SHARE APPROPRIATE INFORMATION WITH OTHER PROFESSIONALS

  • There is evidence to show that information received is evaluated, and its relevance assessed, whenever possible in agreement with the person giving the information;
  • Written guidance states that case records show when information has been shared;
  • Service Users and their carers where appropriate, are always asked, and in specific circumstances told, when information about them is to be shared, and the reasons why;
  • Relevant information about Service Users is made available to providers prior to the delivery of service or support;
  • Relevant records are transferred to another area or local authority at appropriate times when a Service User or family moves.

STANDARD 4 – I MUST ENSURE THAT EQUALITY AND DIVERSITY IS FULLY REFLECTED IN MY RECORDING

  • Case recording identifies special needs arising from ethnicity, race, culture, gender, age, religion, language, communication, sensory impairment, disability and sexual orientation;
  • Case records reflect anti-discriminatory practice and demonstrate sensitivity to the needs of all people in the community;
  • The recording demonstrates that those with language and communication needs are assisted to have their say and access services they need;
  • Case records contain sufficient information for monitoring and planning purposes, and to promote good equal opportunities practice.

STANDARD 5 - THERE WILL BE EFFECTIVE MANAGEMENT OVERSIGHT OF MY WORK

Managers are responsible for ensuring that case recording is of a good professional standard, and meets policy and procedural requirements. Managers are:

  • Responsible for the quality of their workers' case recording;
  • Aware of all Children’s Services policies and guidance on case recording and that these are accessible to and used by all relevant staff;
  • Ensure all workers use case recording effectively as part of their assessments, to make good plans, to aid decision making and the monitoring of care plans;
  • Ensure that staff have appropriate development and training opportunities to learn about good professional recording standards, Children’s Services policies and guidance and how to put them into practice;
  • Routinely monitor the quality of case records and efficiency of case recording practice;
  • Ensure the secure storage of case records and other confidential information, and their destruction in accordance with guidance and legal requirements.

End