Case Recording

A record should be created at the point when there is a request for service from Children's Services.

Across the Council it is possible that one person may have a number of different elements of a record stored at different locations. For the purpose of this procedure the person only has one 'record' and it includes all of these parts. Local protocols for merging files and storage remain in place.

Effective records management standards are essential if the Council is to meet its legislative responsibilities, for example, compliance with UK General Data Protection Regulations (UK GDPR) and the Data Protection Act 2018, Freedom of Information, Local Government Acts and other legislation within which the Council works.

To ensure legislative compliance:

• Records must be destroyed in accordance with the Council's standards; and
• Back-up copies stored on alternative media (server/microfilm/paper) should be destroyed.

The Council's Retention and Disposal Schedule defines the minimum and permanent record retention periods for all records and:

• Identifies records that are to be kept permanently as part of the local archives;
• Prevents the premature disposal of records that need to be retained for a specified period to satisfy legal, financial and other requirements of public administration;
• Provides consistency for disposing of records not required permanently;
• Provides consistent records management standards for the Council.

• Should be child centred and an open, transparent and true record;
• Use appropriate and respectful language inclusive of anti-discriminatory and anti-oppressive language;
• Be complete, accurate, and up-to-date for all mandatory e.g. ethnicity, personal details and basic factual information. This should be regularly reviewed and updated;
• Be completed as soon as possible after an event or observation within the stipulated timescales;
• Be in plain language without the use of acronyms;
• All records should be kept in date order. This is the date when the activity or event occurred, not when it was recorded. If systems are not yet updated to achieve this please make the date of activity clear in relevant headings. Each entry should end with your name, role and date, and signature if handwritten;
• Make sure that the child/young person's first/ last name and case record number are recorded at the top of every page of handwritten records as one of the two identifying references required;
• Decisions or directions given by managers are recorded;
• Recording is generally in the third person. It needs to be clear who has provided the information, opinion or judgement. Where outcomes are stated they should be recorded in the first person;
• Where paper records are used, make sure that the file structure is strictly followed;
• Where an electronic recording system, for example, Mosaic, documents received or containing signatures should be scanned into the system unless other protocols, say otherwise;
• Original records should not be altered or erased. If amendments or additions are needed these should leave the first version so that it can be read clearly, usually by crossing through with a single line. Tipp-ex should not be used and blank spaces should be crossed out. Amendments or additions should end with the name and role of the person who has made them and the date the amendment or addition was made (and signature when handwritten);
• Demonstrate that the case record has been audited for quality assurance by line Manager;
• Be accurate not only in fact but also in differentiating between opinion, judgment and hypothesis;
• Demonstrate fairness in forming opinion and making decisions, underpinned by clear evidence;
• Show judgments made and actions and decisions taken are recorded carefully;
• Clearly show where decisions have been made jointly across agencies or endorsed by a manager;
• The core requirements of a child's case record will include all referrals, assessments, plans, meetings, visits and contacts (i.e. telephone calls/letters and emails). An accurate and up to date chronology through which information can be systematically shared and collated to identify history of the family, inform assessments, reveal patterns and themes, risks, concerns, strengths and weaknesses and Identify the effectiveness of intervention and professional involvement overtime.

Ensure record security, incorporating computer screen security and the UK General Data Protection Regulations, UK GDPR, and the Data Protection Act 2018 are taken into account, including for third parties, whose information should be treated in the same way as service user information and who also have rights of access to any personal data held on them.

Children, young people, families and carers have a right to be aware of records and, where appropriate consent to the sharing of information. They have a right to be informed at the earliest opportunity that records will be created and kept about them, the reason for the records, how their information will be used and possibly shared.

Children, young people, families and carers should be given an opportunity to provide their informed, written consent and the implications if consent is withheld (for example, not being able to carry out a full assessment). Unless the conditions described in the confidentiality section of this document are met, people can restrict areas of information-sharing.

• Always record that people are aware when a record is being created and kept about them and the reasons why;
• Always record that consent to share information has been sought at the first point of contact or where this is not possible at the earliest opportunity thereafter and signed;
• Always record that the 'consent for information-sharing' document or any other type of 'fair processing notice' is signed and added to the record;
• Always record the level of consent the person gives to share information and how information will be shared with them routinely. If consent has not been gained or you are in any doubt about whether to disclose information, consult with your manager and, if necessary, seek advice from the Information Governance & Assurance Team;
• Always record that wherever information has been shared without express consent that there are specific, exceptional and or justifiable reasons to do so;
• Always record that information has been given about how to make a complaint or appeal or that a specific leaflet has been given to the person, advocate or carer;
• Always record that the person has been told that they have a right to see and contribute to their record;
• Always record when children /young people, families and carers at initial have been given a leaflet on "access to your personal records" at the first point of contact, or as soon as possible thereafter;
• Always record when information is shared as well as information that has been shared without express consent that there are specific, exceptional and justifiable reasons to do so. It is important to have an auditable record of when information has been shared, detailing what was shared, with whom, for what purpose and when. It is also important to make sure that the information being shared directly relates to the reasons given for gathering it;
• Always record when information has not been shared;
• There are times when it is not appropriate to share information owing to identified risks. This decision needs to be authorised by a manager, with the decision and the reasons for making it being added to the record.

The sooner activities and events are recorded the more accurate they are likely to be. Timely recording and accurate records support Children's Services in legal proceedings and help colleagues to have access to the information they require if the worker is absent.

• Records should be completed within three working days or in line with the relevant statutory guidance by the individual undertaking the task or activity;
• Where work is undertaken to assess whether a child, young person or adult may be at risk of significant harm, or to protect them from this, all relevant information must be recorded if at all possible within the same working day and at the latest within 24 hours;
• Duty work should be recorded within 24 hours;
• Records must be completed to ensure that adequate information is available electronically to the Emergency Duty Team in order to ensure the effective management of risk outside office hours;
• Emergency Duty Officers must ensure that all necessary information is passed to daytime staff, via the electronic system;
• As a general principle, records should be updated as information comes in or as decisions or actions are taken.

Children's Services undertakes a range of assessments and shares these assessments and plans with children, young people, families and carers, who can also request to see the other information the Council holds about them. Staff need to record with this in mind and also ensure that information is communicated in a way that everyone can understand:

• Be clear, concise and written in plain English using correct grammar and spelling;
• Use full names, titles, designations and relationships;
• Avoid using jargon or abbreviations;
• If a technical or medical term is needed, make sure that it is followed by an explanation the person will understand;
• If handwriting in paper form, make sure that black pens are used and that the writing is legible. Do not use highlighters;
• All records produced by Children's Services are formal so do not use slang or over-familiar language;
• Use the electronic recording systems (Mosaic) and this includes scanning in documents received and any signatures gained;
• Any documents that are to be sent out to children, young people, families and carers should be in Arial font 11 unless other communication methods are needed;
• Blocks of upper case letters and bold text should be avoided as this is more difficult to read;
• Information should be produced or communicated in a way that meets any specific communication needs of the person receiving it.

The Council should only hold the minimum amount of information that is needed to allow Children's Services to carry out its roles, rather than every piece of information the Department may come across about someone. There is also a need to balance keeping notes brief and to the point with making sure key information is recorded. The purpose and context of the activity should guide the length and detail of the recording:

• Information recorded must relate to the work being done with someone and not contain information that has no relevance to the situation;
• Recording should capture sufficient and purposeful information. For example, 'all tasks completed' or 'no concerns' would not inform anyone what actual work has been carried out or how the person is;
• The use of bullet points is acceptable.

In the course of working with children, young people, families and carers, practitioners may discover that information recorded within the paper file and/or the electronic record is inaccurate. Service users and others may also disagree with opinions or judgements that are in their records. If, as a result of new information, a member of staff finds that a piece of factual information within a record is inaccurate, this should be discussed with their line manager, who should record their agreement to action being taken to correct but not remove the record. The agreed change should be noted in the case notes and also wherever the information occurs in the case record. This includes both the paper file and the electronic record. Amendments to paper records should make it clear where a change has been made, with the date, and leave visible the information that has been corrected. Where the inaccurate information has been passed on to others, they must also be told about the correction.

In order to show the basis for Children's Services' decision-making, it is important to be clear about the difference between facts and opinions. This includes how information received from others (third parties) is recorded.

1. Fact
   
   A fact is a piece of information that can be shown to be accurate, for example, "John has a deep red, circular mark on his forearm". Not all information which is presented as being a matter of fact can be accepted at face value. For this reason, it is important to record the source of the information and any relevant supporting evidence. In John's case, for example, it would be important to note whether the report of the red mark came from a teacher who has seen the mark or from the parent of another child who has been told about it second-hand;
   
   
2. Opinion
   
   An opinion is a view expressed by someone about the significance of certain pieces of information. Opinions may be based on various foundations. At one end of the spectrum, someone may be "talking off the top of their head". At the other, they may be expressing a view formed after a structured analysis of a wide range of evidence. In the second case, the opinion given would be better described as a judgement (see below). Thus, for example, the parent of another child may express the opinion that the mark on John's arm is a cigarette burn because she knows his parents smoke, but a paediatrician, on the basis of John's medical history and a direct examination of the mark, may form the "professional opinion" that it is a chicken pox scab that has been picked and become infected. Where opinions are recorded it is important to distinguish these from statements of fact, and to include any available information about the basis of the opinions;
   
   
3. Assessment
   
   Assessment is a process of gathering information and analysing its significance. This is done by gathering information from different sources and perspectives and analysing it by reference to relevant knowledge (for example, research evidence), guidance and Children's Services policy;
   
   
4. Judgement
   
   A judgement is made when information has been analysed according to relevant considerations. Wherever judgements are recorded the evidence on which they are based should be made clear;
   
   
5. Decisions
   
   Decisions are statements about actions that will be taken.
   
   

Common descriptive words such as 'aggressive' need to be supported by further information to explain why they are being used, as they can mean very different things to different people. For example, this could range from someone raising their voice to threatening or carrying out physical violence.

The Council's commitment to equalities-based and anti-discriminatory practice should be demonstrated in all case recording practice. Recording should be child centred and an open, transparent and true record. Record using appropriate and respectful language inclusive of anti-discriminatory and anti-oppressive language with respect and sensitivity to difference in culture, language, ethnicity, 'race', age, gender, disability, sexual orientation, religion and sensory impairment. Be aware of and avoid language that stereotypes or labels people.

All records should be stored as securely as possible in order to avoid potential problems such as misuse or loss. This applies equally to photographic or electronic records as well as manual ones. Children, young people, families and carers have a right to be assured that the information the Council has about them is kept safely and for only as long as it is required. This is also a legal requirement.

• Only staff who have a legitimate need to access a person's record in their capacity as a Council employee should do so;
• Personal information in any form should be kept securely so that people who are not authorised to view it do not have access to it;
• Records should be kept for a period in line with the Council's Retention Schedule available on the Councils intranet.

Although every member of staff is responsible for making sure their recording meets the Children's Services' standards it is important that recording is monitored and audited to acknowledge good individual and team practice and to identify areas for improvement. Supervisors and managers at all levels are responsible for overseeing the quality of case recording through the supervision process, quality assurance audits and when signing off documents and records.

In cases where consent to share information has not been obtained the Council will require alternative lawful grounds to share personal information. For example:

• If an individual is believed to be at serious risk of harm;
• If there is evidence of serious harm or risk of harm to others;
• If there is evidence of a serious health risk to an individual;
• If the non-disclosure of information would significantly prejudice the prevention, detection or prosecution of a crime;
• If instructed to do so by a court;
• If, as part of a best interest decision relating to sharing information, the person does not have the capacity to consent under the Mental Capacity Act (2005);
• If an Independent Mental Capacity Advocate has satisfied the relevant requirements to access information without consent.

Where information-sharing is being considered without consent it is important staff discuss this with their line manager, seek approval from the relevant Information Asset Owner and, if necessary, seek advice from the Information Governance & Assurance Team before a disclosure is made. In exceptional cases it may be appropriate to consult with the Caldicott Guardian. The Caldicott Guardian is a senior person responsible for protecting the confidentiality of service user information and enabling appropriate information-sharing across health, social care and other partner agencies.

In all cases where personal data is shared then the information must be relevant for the purpose for which it is being shared and be accurate at the time of disclosure. It is important to remember to disclose the minimum amount of information. It is also important that the information is shared securely.

Staff need to ensure that information-sharing decisions are recorded, whether or not it is decided to share information. If information is shared, staff need to record the following information:

• What information has been shared?
• With whom?
• For what purpose?
• How was the information shared?

Staff should also inform the person to whom information relates that information has been shared about them, if they have the capacity to understand, or if they do not have capacity, then any person acting on their behalf must be informed.

However, there may be some circumstances where it may not be appropriate to inform the service user or other person at the time of the disclosure of the information, for example, police investigations or where the safety of a child or adult may be compromised. Any decisions to delay informing service users or others should also be written in the record, stating the reason(s) for the delay and the name of the person making that decision.

Further information and advice is contained in the Walsall Information Sharing Protocol.

When sharing any personal information or sensitive personal information both internally and externally it is important to ensure such information is classified correctly. The Council has adopted central government's Protective Marking Scheme. The majority of information within the Council will be 'Unclassified', 'Protect' or 'Restricted'. The definitions are:

Unclassified to be used when information is in the public domain.

Protect if loss or unauthorised access:

• Would cause short-term inconvenience, harm, distress to one person or organisation;
• Would cause short-term embarrassment to the Council;
• Would not lead to legal action.

Within Children's Services examples of where you would use the 'protect' marking would be:

• An individual's personal data (for example, name, address, date of birth and contact details);
• Information received from health colleagues marked 'NHS Protect'.

Restricted' if loss or unauthorised access would cause:

• Substantial inconvenience, harm, distress to one or more people/organisations;
• Substantial and sustained embarrassment to the Council and/or other public services;
• Lead to a fine, prosecution, compensation.

Within Children Services examples of where you would use the 'restricted' marking would be:

• When personal data and sensitive data are combined (for example, name combined with details of health condition (medical records);
• Information received from health colleagues marked 'NHS Confidential'.

If e-mails containing personal and sensitive personal information need to be sent, outside of a secure system, documents must protected via other means such as being password-protected. Request that the recipient makes contact via the telephone to obtain the password. On the rare occasions when this is not possible, ask the recipient to confirm receipt by return and send the password separately. The password needs to be individual to that document.

Alternatively you should identify an alternative secure email address to send the information to.

More information is available on the intranet.

All Council staff may only access information in order to carry out their job role within the Council. This includes personal data of others. Staff should only access personal information as required by their job role and not in any other circumstances. Unauthorised access will lead to disciplinary action and may also be a criminal offence under the UK General Data Protection Regulations (UK GDPR) and Data Protection Act 2018 or Computer Misuse Act 1990.

Employees must ensure that information and equipment are kept securely. In particular, Council information covered by the UK General Data Protection Regulations (UK GDPR) and the Data Protection Act 2018 must be kept secure at all times and must not be accessible to other household members.

Managers must be satisfied that all reasonable precautions are taken to maintain confidentiality of material in accordance with the requirements of the Council's Data Protection and Information Security policies as outlined above.

Employees must discuss with their manager taking information covered by the UK General Data Protection Regulations (UK GDPR) and the Data Protection Act 2018 out of the office for work elsewhere.

Information Governance & Assurance Team:
Telephone: 01922 650 970
Email: informationmanagement@walsall.gov.uk.