Case Recording

1. Background and Overarching Principles

Overarching principles:

• Recording should be clear, accurate, concise, up to date and filed;
• Recording will include fact, third party information, assessment, analysis and professional judgment. The distinction between fact and professional judgment should be clear and the source of information recorded;
• Recording should be in plain English;
• Recording must evidence consideration of equal opportunities, diversity and social inclusion issues;
• The security and confidentiality of information must be maintained at all times. All Children's Services (CS) staff should be aware that unauthorised access to records is a serious disciplinary offence;
• Recording is an integral part of a Children's Services worker's core activity;
• All case files remain the property of Hertfordshire County Council (HCC);
• It enables risk factors to children/young people and/or staff to be identified.

2. The Purpose of Case Recording

Accurate recording:

• Enables understanding of the child/young person's needs and the service provided by HCC Children's Services, by all Children's Services staff including children/young people, carers, or others to whom the recording relates;
• Enables all Children's Services staff to reflect on the service that has been provided and plan any future service;
• Enables children/young people and their representatives to challenge Children's Services, or to make a complaint about service, or lack of service;
• Enables continuity of service, regardless of individual staff availability;
• Enables management oversight;
• Provide evidence for example, in Court, complaint investigations, for serious case reviews, inspections, auditing, management reviews;
• Management information regarding whole service performance.

3. Case Files

Each child/young person open to Children's Services, will have their own individual case file. The main case file will be held by the social work team who hold case accountability. As part of Family Safeguarding, an electronic workbook (on LCS) will hold information on the child/young person and their siblings and other family members with whom Children's Services may be working. This also includes the case recordings of Adult Workers (e.g. Domestic Abuse Officers, Recovery Workers, Mental Health Practitioners, Psychologists, etc.).

Some children in need in Children's Services will have sub files. For instance a case record held by the Children's Home in which the child/young person lives or by a Specialist Children's Team who are providing a specific service to a child / young person.

Case recording on sub files is the responsibility of the case worker / key worker of the Children's Services provider service and should be monitored and quality assured by the worker's direct line manager. When the work with the child /young person has been completed the file should be linked with the main case file and archived.

Children's Services commission services for children in need and children/young people looked after from the private and voluntary sector. Many but not all the records created by these agencies will have been passed to CS during the period of the commissioned work. However these agencies are required to retain their full information about their service to a child/young person. The Strategic Commissioning Team will ensure that contracts are in place with such agencies, so that files are stored safely, for the required time, and information about accessing them is available to Hertfordshire County Council.

When adoption is identified as the plan for a child/young person (i.e. at the relevant Child/young person Looked After Review meeting) a separate adoption file will be started. The adoption file will hold the information as set down in the Hertfordshire Adoption Procedures (see Section 10 of the Social Work Procedures Manual - Adoption and Permanence).

Each (prospective) foster carer, (prospective) adopter, or (prospective) Independent Visitor will have their own individual case file from the time of application (a joint record with their partner if they are fostering or adopting as a couple).

The information required to be held on the electronic records of foster carers and adopters is set out in the Foster Care Case Recording Procedure and the Recording Procedures and Visiting Schedules Procedure as relevant.

Supervising Social Workers of carers should ensure that all child/young person based information is entered on the child/young person's file, and thus available to the child/young person's social worker.

Adults, who Children's Services (CS) consider may present a risk have their own LCS record. The member of staff who places this on LCS should inform that person in writing. The hazard warning should be reviewed at regular intervals.

An adult, who works in a paid or unpaid capacity with children/young people and has been subject of a formal discussion, usually as a Strategy discussion under Section 47 of the Children Act. Where the allegation is substantiated there will be an action from the Strategy Meeting for this information to be recorded on LCS within the Allegations Workspace by a member of the LADO team. The Local Authority Designated Officer (LADO) will have detailed information of the allegation and how it was followed up and resolved, that CS staff can request if appropriate. The LADO will inform the person that this record is held. The record will be held until the person concerned is deceased.

4. Who is Responsible for Recording

Electronic Recording must be written within a maximum of 10 working days, unless information should be recorded earlier e.g. the same day, to support safeguarding and provision of appropriate services to the child/young person. Where records are made or updated late or after the event, this fact must be clearly indicated in the record and the date and time of the entry should be noted.

Records that are written contemporaneously are those that have been written at the same time as an event or as a person is speaking. These are considered to be more accurate, evidentially, than records written, even a short while afterwards.

Records must be completed and finalised on LCS within the timescale. Retrospective changes to records after an electronic record has been finalised is not permitted, unless the criteria for amendment or removal has been met.

If a child, young person, parent or carer identifies that information within the records is inaccurate the original document may not be changed (as decision making is based on the information available at the time of recording), but a case note should be added to record their views. Practitioners should also consider whether any new or updated information provided by a child, young person, parent or carer needs to be considered in other arenas (i.e. future assessments, plans, CP conferences, review meetings, etc.).

It is the responsibility of the allocated social worker to ensure that all addresses recorded against a child/young person on LCS are up to date. Failure to keep information accurate and up to date is a breach of Data Protection rights and may result in a serious loss of confidentiality if information is sent to an out of date / incorrect address.

The allocated case worker in LCS and any named case worker in EHM, has overall responsibility for ensuring that electronic recording is accurate, fit for purpose, evidences the work and records the wishes, feelings and views of the child/young person. This includes decision making by panels and or senior managers.

Practitioners who are working with a child/young person and has access to LCS / EHM should record their activities with the child/young person and notify the allocated case worker when an electronic record is added. Everyone who accesses a case record, and has additional information to add (including that a management oversight has been undertaken) is responsible for recording their name, job title and the purpose of accessing the record.

Allocated Social Workers, Case Workers and Team Managers should ensure that case information is available during individual or group supervision sessions and ensure that they accurately reflect the work that has been undertaken.

Supervision: The CS Supervision Policy states that both formal and informal supervision should be recorded in a supervision case note on LCS. The supervisor should finalise the case note. See Professional Supervision Procedure. For group supervision within Family Safeguarding, records should be updated every month.

The line manager should routinely check samples of records to ensure they are up to date and maintained and, if not, that deficiencies are rectified as soon as practicable.

The Team Manager has to quality assure electronic recording, commenting on the quality of the casework and recording. The Team Manager should identify required action to address any shortcomings to the case worker in the Managers Decision note labelled "Management Oversight" or "Audit".

It is the responsibility of Children's Services to ensure that there are adequate resources to support effective recording. For example that there are a sufficient number of computer terminals available and the office environment is conducive to recording e.g. quiet enough to allow for reflection on the electronic record.

5. What Should be Recorded

Every child/young person's electronic record must hold details of the child/young person's full name, date of birth, ethnicity, religion, language, immigration status, nationality, gender/or identified gender, whether disabled, any identification number, who holds parental responsibility and who has a close relationship to them. In EHM, the school attended is an imperative piece of information that should be updated with on and off role data when changes happen.

Unborn Babies

• Ethnicity and Religion should not be recorded for an unborn child/young person. On LCS use the 'Information Not Yet Obtained' option;
• If Gender is not yet known before birth use the 'Information Not Yet Obtained' option.

Once a Baby is Born

• Ethnicity can be added once the child is born. It is not possible to be certain about ethnicity until the child is born. Ethnicity is very unlikely to change;
• Religion can be recorded once a child is born but when this is recorded should be considered depending on the circumstances for the child (e.g. recorded following a religious ceremony into their respective faith or when a child decides for themselves when they are older, etc.). If it is not suitable to record a child's religion following birth, record the Religion as 'Not Stated' and make a note in the assessment once a child is born as to the reasons why. A religion can be recorded subsequently e.g. following a religious ceremony or the child's choice of religion;
• If Gender was not known at birth, it should be added once the child is born.

Information contained in records must be relevant, accurate and sufficient to meet legislative responsibilities. The level of detail will be determined by direction given in supervision and will depend upon the reason for the involvement with CS. In essence, the greater the risk the higher the level of detail required.

Where personal information is shared within Children's Services or externally the Case worker or Line Manager should record accurately what has been shared, when and with whom, including the name, job title and contact details, and why the information was shared. (The LCS Case Notes section can be used for this purpose).

When sharing information with other professionals the details of what has been shared and with whom should be recorded in the Workbook Summary for Family Safeguarding, Significant events can be copied into case notes and the chronology from the Workbook.

Records must distinguish clearly between facts, opinions, assessments, judgements and decisions. Records must also distinguish between first hand information and information obtained from third parties; the source of any information must be recorded.

It must also include a risk assessment, transfer/closing summary (where appropriate) and a properly maintained Chronology of significant events (see Chronologies and Historical Information Procedure). In addition, all children/young people subject to a Child Protection should include an Ecomap of other individuals and services in place around the family and Genograms. They should be uploaded into 'Forms'.

All relevant contacts with children/young people, their families, colleagues, professionals or other significant people must be recorded i.e. who was present or seen, the relevant discussions, actions or decisions taken and by whom, and the reasons for decisions. The electronic record for each child/young person should include a separate case note of each significant event, activity or transaction which relates to that child/young person, which describes in appropriate detail what happened, was observed, and was discussed.

For unborn babies - Home Visits/Stat Visits

• For home visits to mother/stat visits to siblings, the tabs for 'Seen' or ' Seen Alone' should not be used about unborn baby;
• For these instances, case notes should record a visit and reflect how the pregnancy is progressing for the unborn baby;
• Once a baby is born, the 'Seen' or 'See Alone' tabs should be used.

6. Case Summaries

The purpose of the case summary is to provide an up to date synopsis of what is currently happening for the child/young person and their family in order to ensure that in the absence of the allocated worker, any duty or out of hours practitioners will be able to gain an understanding of the child/young person's journey and how to proceed should actions be required.

Case summaries should be created at the point of referral and should be updated every 4 weeks or more frequently should circumstances change.

For children/young people managed by the 0-25 Together Service, it has been agreed that certain children/young people are reviewed less frequently, in these circumstances the case summary should be updated after every review.

Please see PGN – case summaries for further information which includes a case summary template.

7. Involving Children/Young People and Families

Children/young people and their families must be routinely involved in the process of gathering and recording information about them. They should feel they are part of the recording process.

They should be asked to provide information, express their own views and wishes, and contribute to assessments, reports and to the formulation of plans.

See Children's Services "Understanding Assessments" leaflet.

8. Information about Child/Young People and their Families that Should be Kept Confidential

This is if:

• Sharing the information would be likely to result in serious harm to the child/young person or another person; or
• The information was given in the expectation that it would not be disclosed; or
• The information relates to a third party who expressly indicated the information should not be (e.g. address of victim of domestic abuse must not be shared with perpetrator).

Managers must monitor confidential information, ensuring that the reason for it being considered confidential is valid; if not, it should be available to be shared with the child/young person, and his parent/person holding parental responsibility.

However, before sharing any such information, the manager must take all reasonable steps to consult the originator and take account of their views and wishes.

Where information is obtained and recorded which should not be shared with the child/young person concerned for one of the above reasons, the reasons should be recorded.

9. Information for Child/Young People and those for Who a File Might be Kept

Children/young people, their families and any adult whom Children's Services hold a record about, have a right to be informed about the records kept on them, the reasons why and their rights to confidentiality and of access to their records. See Access to Records Procedure.

They should be provided with the leaflet "Your Access to your Records".

Information must be provided in a form that children/young people and their families will understand - in their preferred language or method of communication. A translator should be provided if needed.

10. Security of Records

A 'clear desk policy' i.e. no printed copies of information/documents in electronic case records to be left unattended must be in place and monitored by the team manager.

Electronic records, containing any personally identifying information, should be kept securely. No one should access an LCS or EHM record, other than with their own log in details and passwords, which must not be shared with other people. If a member of staff believes their log in and password is no longer secure they can either contact the ICT User Support help desk to change the details or they can change their password themselves by going into My Profile. Arrangements will include password protection, automatic log out of screens, logging off computers and changing passwords on a regular basis.

Children/Young People's paper files should normally be stored in a locked cabinet, or a similar manner, usually in an office which only staff/carers have access to. These records should not be left unattended when not in their normal location.

11. Removal of Records Must be an Exceptional Occurrence and Must be Monitored

Case records are currently stored in electronic records and access to records is through the secure ICT system. This section applies in instances where a hard copy of a record exists.

Records (e.g. archived paper files or hard copies of electronic files) should not normally be taken from the location where they are usually kept.

If it is necessary to remove a record from its normal location, a manager should approve this and should stipulate or agree how long it is necessary to remove the record. The manager must also be satisfied that adequate measures are in place to ensure the security of the record(s) whilst they are removed. For example, records (e.g. paper documents, laptops, etc.) must never be left in unattended vehicles. Any breaches of security must be reported by staff immediately to their line manager.

The authorisation for a record to be removed must be recorded and those who may have need to see the records should be informed of their removal. The manager must then ensure the record is returned as required/agreed.

Where records are moved to a new location, the date of transfer should be clearly recorded. The sender should check that the records have arrived at their intended destination.

12. Case Closures

1. Closing Summary to be completed on LCS. Please see LCS Case Recording Guidance for more information;
2. The chronology must be updated and include the decision to close the case. See Chronologies and Historical Information Procedure for detailed information on what to include in a chronology;
3. Management Oversight detailing the reasons No Further Action or case closure is appropriate must be documented on each child/ / young person's record. See also the Professional Supervision Procedure for more information on Recording Management Decisions;
4. Inform the child/young person, young person and/or their family in writing that the case is being closed. Include any details about any available ongoing support or community services, if required;
5. Inform other organisations that have a continuing involvement with the child/young person or family;
6. For any open case for a child/young person moving out of Hertfordshire, please also refer to the Hertfordshire Safeguarding Children Partnership Procedures, Children Moving Across Local Authority Boundaries Procedure;
7. In instances where the LCS Workbook requires closure (e.g. Family Safeguarding, CIN Cases), follow the Ending A Workbook Episode process within the LCS Guide – The Family Safeguarding Workbook;
8. Ensure involvement on LCS has ended.

Closing a Case Where a Referral was Made and the Outcome was No Further Action

• Where there is to be no further action, feedback should be provided to referrers about the decision and the reasons for making it;
• In the case of referrals from the public, feedback must be consistent with the rights to confidentiality of the child/young person and her/his family.

Closing a Case Where a Referral was Made and an Assessment was Partially or Fully Completed but No Plan was Put in Place

• Follow Steps 1-8 above.

Closing a Case Where a Child in Need Plan is in Place

• Follow steps 1-8 above.

Closing a Case Where a Supervision Order is in Place

• Once the Order has ended, follow step 1-8 above unless the case is to remain open as a child/young person in need plan case;
• Please also refer to the East of England Joint Protocol on Supervision Orders for more information.

Closing a Case Where a Special Guardianship Order is in Place

• Follow steps 1-8 as above unless the case is to remain open as a child in need plan case;
• The file must be closed and archived at the point where the SGO is made unless there is an agreement to provide ongoing support set out in the support plan. Please also see the Special Guardianship Orders Policy and Procedure.

Closing a Case Where a Child/Young Person Protection Plan is in Place

• A case cannot be closed while the child/young person is subject to a child protection plan;
• After the plan has been ended (normally by the decision of the chair of a child protection conference). Please also refer to Hertfordshire Safeguarding Children Partnership Procedures, Child Protection Conferences Procedure, Chairing of Conference whereby a child/young person's case should remain allocated as a 'child/young person in need' for a minimum of three months from the date of the child protection conference where the decision was made to cease the child protection plan.

Closing a Case Where a Child/Young Person is Looked After / Care Leaver

• The child/young person's case cannot be closed while the child/young person is looked after;
• Once the child/young person ceases to be looked after and is no longer entitled to any leaving care services, Follow steps 1- 8 above; and
• When a decision has been made to close a case, practitioners must complete the Regulation 39 checklist process;
• Please also refer to the Ceasing to Look After a Child/Young Person under Section 20 Procedure;
• Shortly before a care leaver reaches the age of 21, they should be asked about whether they require ongoing advice and support. If they do require ongoing advice and support, the case should remain open. If not, the case may be closed. After the case has been closed care leavers may return to Hertfordshire to request advice and support by contacting the Customer Services Centre if needed.

Recording Feedback from Children/Young People and Families After Case Closure

• Where a parent or a child/young person wishes to provide feedback, such as a compliment or other comments following case closure, please see Hertfordshire County Council, Complain, compliment or comment about our services.

13. Records must be Retained after Closure

The member of staff responsible for the case when the case is closed is responsible for ensuring that the file to be retained is in good order and that unnecessary items have been removed, for example, compliment slips, duplicate copies etc.

See Retention and Destruction of Records Procedure.

14. Use of Computers at Home

Under the Hertfordshire ICT Acceptable Use Policy, whilst undertaking the Council's business, staff may use their own computers at home only by the HCC ICT prescribed methods for SMART working.

15. Confidentiality Agreements for Members of Staff

The manager must ensure a new member of staff signs the Children's Services Case Management Systems Confidentiality Agreement (CSF0026F1) to say they will only access LCS for work purposes. They must send the original copy to the Herts. HR Transaction Team, County Hall. 4th Floor, and keep a copy in the staff supervision file.

If a member of staff refuses to sign the form, their line manager must immediately pass this on to the relevant Services Manager or Head of Service to deal with.

Unauthorised access to a case record (for example for personal use) will be considered a serious misuse of the system and may lead to disciplinary action.