Recording Policy and Guidelines

• Names and details of everyone who lives in the family home with the child, identifying the person who has Parental Responsibility;
• Where the child does not live at their home, the details of the Placement/arrangements and the legal status of the child;
• Names and details of anyone particularly close to the child with whom they have a lot of contact;
• Information about the child and / or family’s communication needs;
• An up-to-date genogram;
• An up-to-date chronology;
• Where possible a photograph of the child/young person;
• A Children and Families Assessment completed within the preceding 6 months;
• An up-to-date plan reflecting the status of the child or young person;
• A record of managers’ decisions and reasons for making them;
• Details of arrangements for contact;
• Details and, where appropriate, copies of any Orders made on the child;
• Copies of reports provided during court proceedings, including specialist assessments, the Children’s Guardian, etc.
• Additional information about educational progress and where the child is in care, the PEP;
• Where a child has Special Educational Needs or Learning Disability, copies of any relevant information, including the Education, Health and Care Plan;
• Appropriate information about the child’s health, and where the child is in care, a copy of the Health Plan and Assessment;
• Details of any arrangements for the responsible authority’s functions to be undertaken by a private provider, e.g. an independent fostering agency or provider of social work services;
• Copies of all documents used to seek information, provide information or record views given to the authority in the course of planning and reviewing the child’s case and review reports;
• Record of visits and contacts by all practitioners, as well as the allocated practitioner.

All records should be:

1. Fit for purpose
   • Be compliant with legislative requirements;
   • Demonstrate that statutory and practice requirements have been met, provide evidence of the work that has been undertaken, give an account for service users of their history, record significant issues or events and their involvement with Doncaster Children’s Services and partner agencies;
   • Provide clear, accurate information and demonstrate accountability in decision making, including decisions/discussions made in formal and informal supervision;
   • Be complete and help workers to analyse decision making in child protection processes, assessments, care planning, reviewing etc;
   • Demonstrate how decisions have been made and in what order;
   • Provide evidence for inquiries or reviews;
   • Provide evidence for legal proceedings; and enabling continuity when a new worker takes over a case.
2. Quality Assured by managers
   • There should be regular monitoring of all case files and case recording by the responsible team manager in order to ensure accountability and to give feedback to practitioners, thereby aiding professional development. Feedback on the quality of case recording should be given during supervision and recorded on the supervision records.
3. Timely
   
   All records must be completed and placed on Mosaic on an on-going basis; key events such as section 47 enquiries, placement changes and critical visits should be recorded within 1 working day but as a maximum 5 working days for non-critical events. Any rough notes must be held securely until the file can be updated;
4. Non-discriminatory
   
   Case records must reflect anti-discriminatory practice and demonstrate sensitivity to the needs of all in the community. Case recording must identify special needs arising from ethnicity, race, culture, gender, age, religion, language, communication, sensory impairment, disability and sexual orientation;
5. Transparent
   
   The information in the case record is available to service users in accordance with the provisions of the UK General Data Protection Regulation (UK GDPR) and Data Protection Act 2018. It is good practice for the information contained in case records to be available to the subjects of those records, whenever it is safe to do so. The sharing of case records with service users is a key means of operating in a transparent way. Information should never be omitted from the case record, particularly reports, in order to make the report more suitable for sharing with child or adult service uses. The practitioner is responsible for exercising professional judgement in each case in order to determine the extent to which case information should be shared with the subjects of that information.

Case recording is a professional tool which evidences the contact and work undertaken with the service user, other colleagues and partner agencies. In addition, telephone calls, text messages, letters, e-mails, meetings and other events regarding the case should be recorded. It is expected that the majority of a child’s case file will be stored electronically but it is recognised that some original documents will need to be retained in a paper format. This policy applies to paper and electronic records. Practitioners are required to:

• Comply with Doncaster Children Services Case Recording Policy;
• Use plain English; be logical, succinct and to the point, avoiding jargon and explaining any abbreviations;
• State the purpose of the contact;
• Ensure that sources of information are clearly stated;
• Record direct observations;
• Provide evidence to show that information received has been evaluated, and its relevance assessed, whenever possible in agreement with the person giving the information;
• Ensure that when recording includes analysis, hypothesis or opinion (to assist in the assessment and decision-making processes), it is clear that this is what is being recorded. Furthermore, reasons for hypotheses and opinions must be stated;
• Ensure that all recording should act as a source of relevant information about a child's circumstances and how Children's Services has carried out its actions and duties in relation to a child and their family;
• State who the contact is with and always give the relationship of that person to the service user i.e. ‘Mary Smith, maternal aunt ….’ or ‘Sally Jones, mother …’ rather than only saying ‘aunt’ or ‘mum’;
• Provide the service user’s or professionals’ views;
• Ensure that the content of case records is proportionate and relevant;
• Ensure that case records are intelligible to others;
• Ensure that there are no unexplained significant gaps in case recording;
• Ensure that case recording is not used as a platform for airing professional differences of opinion;
• Complete case summaries every 3 months. The summary should provide a succinct summary of the work undertaken, specifically linking progress to the Recommendation/Outcomes of the Plan. It therefore promotes accountability, an understanding of progress and continued planning. The Summary, in ‘putting the child at the centre’ should reflect and have regard to ’what is life like for this child. ’It should also include outcomes of supervision on the case and consider appropriately the local authority’s, and partner agencies, decision-making and the impact this may have had.

1. Home and Office Visits
   
   Statutory visiting templates on Mosaic should be used to record statutory visits.
   
   Generally however records of visits should include:
   • The date, time, and place of visit;
   • Who was present during the visit;
   • Clear reasons for the purpose of the visit;
   • What information is to be gathered during the course of the visit;
   • Whether the child was seen (and if not why not) and whether seen alone or not;
   • Any views the child expressed, noting for children who have communication difficulties, what support was available and/or how these views were gleaned;
   • Observations of the child, non-verbal and verbal communication;
   • Any views of the parents/carers;
   • Observations of the home address/presentation etc.
   • Family interactions;
   • The quality of the relationship between the social worker and the child;
   • An analysis of progress risks or need with supporting evidence;
   • What actions are required, by whom, and by when;
   • That failed appointments and home visits (where no one was in) have taken place and any actions resulting from this;
   • The use of an interpretation service, or an agreed decision to dispense with these when English is not the service user's preferred language;
   • The recording should seek a proportionate balance to reflect the positive and negative aspects of a child or family’s life;
   • The structure of the recording should readily distinguish between current and historical events.
     
     They should also distinguish between fact and opinion in the recording and include relevant research in the analysis section.

2. 
   Supervised contact visits
   • When a supervised contact visit is undertaken a contact record template must be used and attached to the child’s record under documents;
   • When completing the 3 month summary case note the social worker must include any key points/issues from the contact recordings.
     
     
3. Meetings and recording of decisions (All meetings held about the child/family) 
   
   Mosaic meeting templates should be used where appropriate. Other meetings for example the Legal Gateway panel will also have specific templates to record decisions.
   
   In all other instances however records of meetings should include:
   • The date, place and time of meeting;
   • A list the people present and their designation, those who sent apologies or who were absent;
   • The purpose of the meeting;
   • A summary of discussion;
   • A rationale for decision/s;
   • Any dissent;
   • A list of action points;
   • An agreed timescale/ a specified framework for reviewing the agreed actions;
   • Who is responsible for carrying out the action?
   • Evidence that the action plan etc has been circulated to all those present or with responsibility for the action points;
   • Record of the date, time and place of next meeting.
     
     
4. Telephone/Text contacts with child/family/other professionals
   
   This should include:
   • The date and time of contact;
   • The name of individuals involved in the conversation (include professional job title)
   • The reasons for the telephone call (what information is to be gathered during the course of the telephone call?)
   • A summary of discussion (actions/decisions to be taken, by whom and by when)
   • Text messaging must be regarded as service user contact and recorded in case notes stating the content of the message.
     
     
5. Email, Faxes & letters
   
   This should include:
   • All e-mails should be entered onto Mosaic. The receipt and sending of an email should be recorded in the running reports (to include: date and name of person sending the e-mail). It is not appropriate to record issues in relation to staffing in any detail on Mosaic;
   • All e-mail content must be professional in nature, relate specifically to the child/young person or family and abbreviations for names should be used, e.g. John Smith becomes JS;
   • All faxes (other than those connected to a referral) should be attached to the child’s record under documents and cross referenced in a case note (to include:- date and name of person sending the fax)
   • All letters (excepting those from third parties, which contain confidential information) should be attached to the child’s record under documents and cross referenced in a case note (to include: date and name of person sending the letter).
     
     
6. Chronology
   
   Chronologies are essential in providing an overview of all important events/occurrences/interventions in the life of the service user. The Protocol on Judicial Case Management on Public Law: Children Act Cases requires that a chronology be submitted along with care papers.
   
   Individual events may appear to be insignificant 'one-offs'. They should, however, be recorded in the chronology as they may be part of a pattern, which would raise serious concern. Chronologies provide a sequential list of dates of significant events in a service user's life. They enable practitioners to gain a more accurate picture of the whole case and detail the history of a service user and their family. They highlight gaps and missing details that require further assessment and identification. Chronologies can also highlight risks, concerns, themes, strengths, resilience and weaknesses of a service user and their family. Current information can then be understood in the context of previous case history and inform professional assessment.
   
   If chronologies are to be of value they should be:
   • In ascending date order i.e. earliest date first;
   • Informing the decision-making process at any given point;
   • Owned by professionals and used as a tool in assessing progress and the level of concern;
   • Succinct recording of significant events including people involved and dates; and
   • Systematically and regularly shared with relevant professionals.
     
     
7. Chronology content
   
   Each child's and prospective adopter's/foster carer's file should contain a chronology. The chronology should:
   • Be located on Mosaic;
   • Be up to date;
   • Include the name and date of allocation to the social worker;
   • Include the referrals dates;
   • Include a brief reason for referral e.g. child protection enquiry, domestic violence etc;
   • Record all visits (including supervised contact)
   • Record the date of a strategy meeting;
   • Include evidence of user involvement, including distribution of assessments, core group, Care Plans etc. e.g., when was assessment signed and passed to parent/carer;
   • Record the date that the assessment commenced;
   • Record any court proceedings (including dates), court orders (including dates);
   • Record the dates of meetings (including child protection case conferences, core groups, strategy and professional, children in need, adoption, fostering, resource);
   • Record discussions with the team manager about a service user, whether within or outside of supervision, and any decisions made as a result of this conversation must be recorded;
   • Record significant events; i.e. birth of siblings, death of a close family member.
     
     
8. Care plans, child protection plans, child in need plans, action plans, support plans and similar plans
   
   Plans are outcome focussed, person-centred tools designed to ensure that the service user receives the support needed, in the way they need it and when they need it. Therefore, it is extremely important that the service user and their family, if appropriate, are actively involved in developing the plan. They should be present, if appropriate, at all meetings where their plan is being discussed. There must be proper channels through which they can complain if the action set out in the plan is not being implemented. Service users should be actively advised of the agency's complaints procedures.
   
   Plans need to be evidence based. Some plans are required by law and will be structured to meet statutory requirements. All plans are intended to provide a structure to enable people to meet the needs of a service user. Everyone, including the service user, must understand their individual role in achieving the desired outcomes. It is important that developing a plan is not seen as a paper exercise, but a dynamic and interactive process ensuring that a service user's needs are met. Key issues to be recorded include:
   • The names and designation of who is involved in delivering/monitoring the plan;
   • The wishes and views of the service user;
   • The immediate and longer-term plans for the service user;
   • Details of services to be provided to meet the service user's needs;
   • How these services are to be provided;
   • Who is responsible for delivering each of the services;
   • The time-scales for implementing the services;
   • The desired outcomes;
   • Alternative action should a service not be delivered; and
   • A date for reviewing the plan.

Remember, plans should adhere to the following principles: - Specific, Measurable, Achievable, Realistic and Time-bound (SMART) 

9. Supervision discussions
   
   High quality supervision is one of the most important drivers in ensuring positive outcomes for children/young people and their families. It also has a crucial role to play in the development, retention and motivation of the workforce. Effective supervision recording requires:
   • The case discussions with the manager are entered on the supervision form within Mosaic;
   • That when a decision is made in either formal or informal supervision, a record of that discussion must be recorded on Mosaic in case note (managerial oversight) or supervision record; and
   • That if the social worker and line manager are in disagreement regarding the plan for the child/young person, the social worker can request that the manager record the issues in the social worker supervision notes.
     
     
10. Quality Assurance (management overview) 
    
    The role of the social work manager is pivotal, requiring the manager to oversee performance and in so doing quality assure the work produced. The recording of quality assurance issues by a manager underpins practice and ensures that the service user remains at the forefront of the Children's Services focus. Specific areas include:
    • Regular monitoring of all case files and case recording by the responsible team manager in order to ensure accountability and to give feedback to practitioners, thereby aiding professional development;
    • That team managers examine case files on a regular basis via supervision;
    • Ensuring that feedback on the quality of case recording is given during supervision and recorded on the supervision records and on Mosaic if appropriate; and
    • That managers ensure that they show clear evidence that they have quality assured all relevant documentation i.e. quality assurance of assessments, reports etc.
      
      
11. Case transfer
    
    Prior to any internal case transfer taking place, the social work practitioner and their line manager must ensure that they have met the requirements as stipulated in Doncaster Children's Services Case Transfer Protocol. All files, when being transferred, must include a transfer summary. The content of the transfer summary must include; a complete and up-to-date chronology, up-to-date documentation, evidence that the child/family has received notification of the change in social worker, evidence that the key documentation has been, if appropriate, passed to the child/family/carer and that the case file prior to transfer has been approved and quality assured by the line manager.
    
    
12. Case closure
    
    A case reaches the point of closure when there is no further work to be done by Doncaster Children's Services. At the point where Children's Services work on a case is complete, the allocated social worker must complete a case closure record. The team manager must approve the decision to close the case and provide clear evidenced of approval on Liquid Logic. The responsible social worker and team manager must provide clear evidence that:
    • In cases involving a vulnerable child, the social worker has spoken with the child alone and recorded their views and wishes;
    • In cases involving a vulnerable child, the social worker has spoken with the carer and recorded their wishes and views;
    • In cases involving a vulnerable child the social worker has agreed a plan for the ongoing promotion and safeguarding of the child's welfare;
    • In cases involving allegations of deliberate harm to a child, the social worker has visited the accommodation in which the child is to live;
    • In cases involving allegations of deliberate harm to a child, the social worker has sought the views of all professionals involved;
    • In cases involving allegations of deliberate harm to a child, the social worker has agreed a plan for the promotion and safeguarding of the child's welfare; and
    • In cases involving allegations of deliberate harm to a child, the social worker has recorded formally all of the above.
    A clear closure summary will assist colleagues, if, in the future, further contact/referrals are made to Doncaster Children's Services. In addition, it may assist the child/young person at some point in the future, should they wish to access their records. Finally, it also helps capture statistical information which can be sued to track and evidence the outcomes of Children's Services work for children.

All personal information must be treated as confidential. This means that information supplied by service users about themselves will not normally be shared with others without the express permission of the service user. This is applicable to those children deemed to be a Child in Need (CIN) i.e. low level referrals. There are however, clear instances where the permission from the service user is not required. These circumstances include; child protection investigations and proceedings (including DSCP Serious Case Review / Child Safeguarding Practice Review), a regulatory inspection i.e. OFSTED, in the interests of public health, to prevent/detect a serious criminal offence, the result of a direction of the court (including a Child`s Guardian), and an officer investigating a complaint.

Solicitors acting for service user sometimes request access to a file for use in a criminal or civil proceedings. If such a request is received the matter should be passed immediately to the legal department for consideration.

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

Doncaster Children’s Services records should be fully accessible to members of a multi-disciplinary team. Information held on Children's Services case files supplied by another agency is not available to a service user without the permission of the author or agency.

Every member of staff has a responsibility under the Data Protection Act 2018 to ensure the appropriate disposal of their own confidential waste. If not shredded immediately, all papers relating to clients, service providers, financial transactions and other confidential or sensitive material must be held in a secured plastic bag, labelled as confidential and locked in a cupboard or other secure place. Confidential waste must be shredded at least once a week.

The Data protection Act 2018 contains 8 main principles which relate directly to case recording and information held in the case file. These can be summarised as follows:-

• Personal data shall be processed fairly and lawfully;
• Personal data shall be obtained only for one or more specified and lawful processes and shall not be processed in any manner incompatible with that purpose or purposes;
• Personal data shall be adequate, relevant and not excessive in relation to the purpose or purposes for which they are processed;
• Personal data shall be accurate and, where necessary kept up to date;
• Personal data shall not be kept for longer that is necessary for the purpose or purposes;
• Personal data shall be processed in accordance with the rights of data subjects under the act;
• Appropriate technical and organisational measures shall be taken against unauthorised or unlawful processing of data, accidental loss, damage or destruction to personal data; and
• That personal data shall not be transferred to a country outside the European Union unless that country has adequate protection for subjects of data.

Please refer to Doncaster Children’s Services Retention of Information policy for complete information.

See Children's Services - Retention of Records Table.