Nottingham City Safeguarding Children’s Board Procedures Manual
Nottingham City Safeguarding Children’s Board Procedures Manual Nottingham City Safeguarding Children’s Board Procedures Manual

2.1 Recording Policy

AMENDMENT

In May 201, this chapter was revised to reflect the change from Carefirst to Liquid Logic. Section 8, Retention and Disposal was also revised to reflect Nottingham City requirements.


Contents

  1. Introduction
  2. Definitions
  3. Case Recording Standards
  4. Police Information
  5. E-Mail
  6. Case File Standards
  7. Storage
  8. Retention and Disposal
  9. Manager’s Responsibilities
  10. Access to Records
  11. Confidentiality


1. Introduction

1.1 This Policy applies to all information and documentation held by Children & Families Services about service users within both paper and electronic case records. 
1.2

The purpose of the case record is to:

  • Provide a primary record of involvement with service users;

Practice Guidance

For children in care this record will be a significant source of information about their life history and its detail, and accuracy is therefore essential to their understanding of the reason why they are in care and of the decisions made in relation to their permanence/care planning.

 
  • Provide information about staff working practice;
  • Provide management information;
  • Be a source of evidence in inquiries and complaints.
1.3

The benefits of good case recording are that it:

  • Supports effective partnership working with parents/carers and multi agency working;
  • Evidences and supports the management of risk;
  • Makes staff accountable;
  • Focuses involvement;
  • Ensures continuity when workers change or are unavailable;
  • Assists management oversight.

Practice Guidance

Social Care practitioners will increasingly be using documents and files as part of the Integrated Children’s System and Electronic Social Care Record. If any written records are made, the same standards for these records should be applied as is applied to electronic recording.


1.4 Children/young people and their families have a right to be informed about the records kept on them. They should be informed about their rights to confidentiality and of access to their records at the start of the assessment process.


2. Definitions

2.1 Case file - manual file which contains information about the individual or family.
2.2 Electronic file - electronic file which contains information about the individual or family, this includes Liquid Logic and Castle.
2.3

Case/electronic records - (Observations on Liquid Logic) Account of work with an individual or family which details:

  • Individual contacts with the service user;
  • The work to be done and its objectives;
  • Procedures and processes followed;
  • The assessment of need;
  • The plan of intervention;
  • The timing, process and outcomes of reviews;
  • These may be encompassed within the Running Record/ Observation or in Care Asses/ Castle Documents.


3. Case Recording Standards

3.1 All case recording will be in plain language (avoiding professional or bureaucratic jargon) that is easily understood.
3.2 Arrangements will be made on an individual basis for case records to be available in an appropriate form for individual service users (e.g. other languages, tapes, large print).

Practice Guidance

Facilitation for communication might be needed for children with disabilities or for children where English is not their first language. Where the use of communication aids or an interpreter is dispensed with, the reasons for doing so must be recorded on the electronic file.


3.3 Case records should reflect our work with service users and their views should be incorporated in the record.
3.4 Case records are confidential documents. Service users consent to information sharing should be obtained before any information contained in the records is disclosed. The only exception to this is safeguarding enquiries when information may be shared without consent if the obtaining of consent is likely to endanger the child. Information can be shared without consent if necessary and should be done so in accordance with the law.
3.5 Records should be accurate, succinct and factually based.
3.6 All case recording will reflect Nottingham City Council’s commitment to anti oppressive practice.
3.7 Day to day records will be written up and placed in the file within 5 working days of the contact (except in the case of Child Protection where the recording should be entered within 2 working days).

Practice Guidance

  • All contacts must be recorded - even if no access to the individual is gained;
  • If a visit is made involving more than one professional whose actions are recorded in the same case file, it should be agreed prior to the visit who will be completing the record of the visit as the record of the visit should be a complete account of actions taken and the reasons for them. Essential information may be missed if records of the same visit are kept in different locations on the file. If the visit is in relation to statutory looked after children responsibilities or Section 47/safeguarding actions, it must be the responsible social worker who completes the record;
  • If a referral is made to another agency for additional services, the purpose of the referral must be recorded on the case record.

3.8 Case records should indicate the type of contact, some brief detail and refer to other documents for amplification. If a video record of an interview was made, its existence must be noted on the case record with details of its storage and access. In some circumstances (e.g. child protection enquiries) it will be necessary to keep more detailed case records.

Practice Guidance

Details of a contact recorded may include:

  • Who was present or seen (including whether the child was seen alone);
  • Facts observed;
  • Information obtained or provided;
  • Agreements reached with the child/young person and family;
  • Actions or decisions taken - by whom and why;
  • Any issues that were not agreed;
  • Any views expressed by those involved in the contact.

3.9 Any statutory visits to the child or young person should be recorded in the relevant section of Liquid Logic with an entry made in the case record to indicate a statutory visit has been made.
3.10 All types of contact should be recorded in the case record. This includes phone contact, home visits and messages, including text messages, relevant to the conduct of the case.
3.11 Any personal or unsubstantiated opinion or comment should not normally be included on the case record. If opinion or comment is necessary to clarify actions or plans it should be clearly indicated as such in the record.

Practice Guidance

Electronic case recording will automatically identify the author of the case records with electronic signature.


3.12 The status of individuals referred to by name in the case record should be made clear e.g. John Brown, Team Manager.
3.13 All dates will conform to the standard dd/mm/yy.
3.14

A case summary should be completed at the point of transfer to another worker or authority. The transfer summary should detail:

  • The reason for involvement;
  • The assessment, plan, actions undertaken.
The transfer of responsibility should be recorded on the case record.
3.15 At the point of transition from the Children & Families Services to Adult Services, the Children’s case file will be closed and a new Adult case file will be opened.
3.16

A summary should be completed when the case is closed. The closing summary should detail:

  • The reason for involvement in the case;
  • Actions undertaken and outcomes achieved;
  • Other professional’s involvement in the case and their views.
3.17 The ‘Observation’ should adhere to the Guidance set out above and is specifically for the purpose of recording information in relation to the case. It should not be used by NCC staff to criticise other workers or teams or any decision making processes. There are alternative processes for escalating these concerns.

Practice Guidance

  • Service users access to records should be promoted from the start of involvement;
  • Service users should contribute to assessments and plans and their views recorded;
  • There should be an indication in the case record of how assessments and plans were shared with the service user.


4. Police Information

4.1 Police information requests (CRIMS) including DV referrals should be stored in Castle in the appropriate section which will have restricted access.

Practice Guidance

All Police disclosures and information should be stored in Castle with a clear heading ‘Restricted Access Police Information’ (currently in process of developing a separate Restricted Access section in Castle).


5. E-Mail

5.1 Email is often used now where previously communications would have taken place using paper documentation. Emails may therefore document case decisions and business activities and in doing so become essential records of those transactions. Email records therefore need to be managed under the Service’s records management system like any other record.
5.2

Every member of staff is responsible for:

  • Creation of email records which are specific and relevant to their business purpose and which do not include personal comment or identifying details of children to whom the record will not apply;
  • Identifying emails and their attachments that are appropriate for retention as case records, because of their business function or content.
5.3 If an official action is taken related to an e-mail communication, and if the communication is needed for adequate and complete documentation of the action, the e-mail communication will be an official record for the individual undertaking the action, regardless of whether copies are retained elsewhere. If a communication is received for information only and no action is taken related to it, the communication would not be a record.
5.4 Emails which are a necessary part of case documentation should be copied onto Liquid Logic or Castle as appropriate. 

Practice Guidance

All legal papers and recording of any legal issue should be kept as a paper copy in a confidential legal folder (currently in the process of developing a separate restricted access section in Castle).


5.5 Only records pertinent to the individual child to whom the case file applies should be included.
5.6 There should not be reference to other children and there should not be reference to personal issues concerning the sender or recipient of the Email. This includes the use of emotions, for example, smiley faces and abbreviations.
5.7 The e-mail record must include the transmission data that identifies the sender and the recipient(s) and the date and time the message was sent and/or received.
5.8 If an E-mail communication contains attachments and it is determined that the communication is a part of the case documentation, the attachments must also be included in the case file as they are a related item that provides context for the message.
5.9 If an Email is sent back and forth and the most recent communication has the entire sequence of correspondence, it is only necessary to keep the final communication (including the previous communications and replies) as long as it also contains attachments and other data such as the sender, receiver, date, and time, that are necessary for a complete record.
5.10 Email that is not a case record may be deleted when it is no longer of use. If an E-mail is determined to be a case record and has been copied into Castle, the Email may then be deleted.


6. Case File Standards

6.1 Every child that is known to Children’s Social Care should have an individual I.D number and electronic case file/record. 

Practice Guidance

Children that were known to Social Care prior to the electronic system will have paper files. These may need to be recalled if appropriate.


6.2 An electronic case file will be created once a referral has been accepted and work has commenced with the service user.
6.3 The basic information must be fully completed and amended every time there is a change of detail.
6.4 The Case Chronology on Castle must be opened in Duty and must be updated every time there is a significant event in the child’s life following the guidance provided for completion of case chronologies.
6.5 The electronic records should contain a complete record of the current involvement.
6.6 The electronic records should contain a multi agency consent form signed by persons with parental responsibility agreeing to information sharing, and the assessment and plan on which current involvement is based.
6.7 Only one copy of a document should be on the system. If any alterations are made to the document, one copy of the newly amended document should be retained.
6.8 Documentation held on the records should relate only to the person who is the subject of the file.
6.9 Only Nottingham City Children and Families Services approved documentation should be used in undertaking duties on behalf of the Service. This approved documentation should be consistently used by all staff across the service.
6.10 Documents such as birth certificates or Court Orders should be retained in a plastic wallet in a Legal file, to prevent them from becoming defaced. Documents such as birth certificates of children who are Looked After should be returned to the young person once they reach adulthood or be given to the adopters once the adoption is completed.


7. Storage

7.1 If paper files are being used they should not be left unsecured on desks at times when the office is closed and should be stored away securely.
7.2

Removal of files from the office must be authorised by the worker’s line manager and a record maintained of:

  • The date of removal;
  • The location of the file and who has responsibility for it.
7.3 If a worker removes a file, they must ensure the safety and security of those files at all times.


8. Retention and Disposal

File Retention Period Disposal
Child in Care 75 years after DOB After 75 years unless known to Adult Services in which circumstance the file should be included with their main file
Child in Care Deceased before 18th birthday 15 years from Date of Death After 15 years
Privately Fostered Child 100 years from date of birth After 100 years unless known to Adult Services in which circumstance the file should be included with their main file
Adoption 100 years After 100 years
Adopted Child Deceased before 18th birthday 100 years After 100 years
Adopted Child Deceased after 18th birthday 15 years from date of death After 15 years
Adopters 25 years from date of closure After 25 years
Deceased adopters/withdrawn without child being placed 10 years After 10 years
Foster Carers 10 years after date fostering approval ends 10 years
Child Protection - all case files of children subject to s47 enquiries, whether or not they subsequently become subject of a child protection plan 25 years from DOB of child 25 years from DOB of child
Safeguarding Unit Review when the youngest child in the family reaches 18 years of age so file contains only relevant documentation. Retain for 35 years from closure 35 years
All other Children’s files, Child in Need 25 years from DOB of child 25 years from DOB of child
Adults who pose a risk to children Permanently Do not dispose
CPR Missing Persons Records 1 year from date of notification 1 year
Financial 6 years from the end of financial year 6 years


9. Manager’s Responsibilities

9.1 The worker’s line manager has overall responsibility for ensuring all records are maintained appropriately.
9.2 The manager must routinely check samples of records in accordance with the agreed audit programme to ensure they are up to date and maintained as required and, if not, that deficiencies are rectified as soon as practicable. The maximum interval of scrutiny of case files should be 6 months.
9.3 Managers should record any advice they give or decisions they make regarding a case by using the Case Discussion Record and Observations.
9.4 In addition line managers must authorise assessments, plans and reports by either Liquid Logic or countersignature. It is essential that management overview is evidenced on case files.
9.5 When a case is being transferred or closed, the Team Manager should check that all necessary actions on the case have been completed and that all necessary recording has been completed.
9.6 Managers must ensure that any ‘Third Party’ information that is being held on Liquid Logic or Castle is necessary and appropriate and ensure that the reason for holding it is valid. If the decision is made that there is no valid reason to separate out this information, it should be shared with the child/young person. 
9.7 If a complaint is received from another agency about the worker’s management of a case, the Team Manager will read and review the case records, should meet and speak with the complainant, and record the outcome of the discussion on Castle.


10. Access to Records

10.1 Any information that cannot be shared with the service user without obtaining prior consent should be clearly recorded as ‘Restricted Access’ to ensure readers are made aware. If appropriate, any restricted information may be kept in a separate file (see Access to Files protocol 2011).
10.2 All service users are entitled to access their records under the Data Protection Act using the Access to Files Policy and Procedure for Approved Organisations Procedure. Any third party information will be removed prior to the viewing of their records by service users.

Practice Guidance

If information is routinely shared with service users, access to files will be seen as a normal part of joint working.


10.3

Persons with a statutory right of access to the information contained in case files may be given access to individual case files e.g.:

  • Where the Court directs that records be produced or a Children’s Guardian is appointed;
  • Where information is requested by Ofsted.

The identity of the person requesting the information must be checked and confirmed in all circumstances and where there is any doubt the information may not be provided without the approval of a manager.

The person to whom the information relates should be informed that records have been requested, unless to do so would prejudice the purpose of the request. 

If the name of any person other than the subject of the enquiry is to be disclosed within the information provided, consultation must first take place with Legal Services. This applies whether a third party is a child or an adult.

10.4 A Guardian acting for a child in court proceedings may access the child’s record and make any copies required of documents contained within it by authority of the court (Section 42 of the Children Act 1989).


11. Confidentiality

Caldicott and Data Protection Principles

11.1 The handling of personal information is governed by the Data Protection Act 1998 and by Caldicott which both reinforce the importance of confidentiality. There are eight Data Protection and six Caldicott principles for handling personal information. 
11.2 Personal information held about children/young people and their families is subject to a legal duty of confidence and should not be disclosed without the consent of the subject except in exceptional circumstances such as the protection of the child, the investigation of criminal offences or the exercise of a statutory right of access. Those working with children/young people must make it clear that confidentiality may not be maintained if the disclosure of information is necessary in these circumstances. Even in these circumstances, disclosure should be appropriate for the purpose and only to the extent necessary to achieve that purpose. 
11.3 Consent to information sharing should be obtained as part of the assessment process in order to share information with colleagues, other professionals or agencies that may have a role to play in the delivery of services to the child or family.

End