View Cambridgeshire LSCB Manual View Cambridgeshire LSCB Manual
View Working Together to Safeguard Children View Working Together to Safeguard Children

1.2.3 Case Recording

AMENDMENT

This procedure was revised in April 2019.


Contents

  1. Introduction
  2. Key Principles of Case Recording
  3. Content of Case Records
  4. Timeliness of Recording
  5. Correspondence
  6. Recording Case Notes on ICS
  7. Genograms and Chronologies
  8. Recording Visits to Children
  9. Children in Need (CIN) Codes
  10. Recording Outcomes
  11. Retention of Records


1. Introduction

This document outlines the requirements for the accurate recording of information relating to children and their families and incorporates the key learning from audits and service user feedback.

Effective recording, ensuring comprehensive and accurate information, safeguards service users, staff and the Council. For service users, it ensures their 'story' is clear and detailed and there is a comprehensive basis for case planning. Staff are accountable for the work they do and it is important that this is reflected in individual case records. The Council provides services based on assessed need and relies on accurate recording to ensure effective provision to individuals and wider service planning.

Individual children's records may be read by the child, their family, by other professionals and by outside agencies such as Ofsted and should be written with this in mind.


2. Key Principles of Case Recording

Children's Services records should be child-centred and the views of children should be specifically sought, usually by seeing them alone, and recorded within case records. A range of tools or media may be used to engage with children and these, too, should be recorded.

The Team Manager is responsible for effective case management, including ensuring that a child's record is up to date and accurate, whilst all staff are responsible for maintaining good case recording of the work they undertake. Managers are responsible for ensuring that each child's file fully reflects the child, their needs, the concerns and risks and the direction of the case.

Further, all managers are responsible for auditing and ensuring the quality of case records within their line management. This is supplemented by the regular auditing programme.

Case records should be sufficiently detailed and complete to inform planning and decision making to ensure good practice with the child and their family. They should not record absolutely everything but must cover the salient points. Records must be written promptly (see Section 4, Timeliness of Recording) and any notes should be simultaneously destroyed (confidential waste).

With too little information, it may not be clear why decisions are being made, plans formulated and actions completed. With too much information, it may not be clear what is significant, making it more difficult for a clear picture of the child's 'journey' to be understood.

Every assessment and decision must be informed by the views of the child as well as the family. Children should, wherever possible, be seen alone and there is a general duty to ascertain the child's wishes and feelings regarding their needs, situation and the provision of services. It is important to understand the needs, strengths and resilience of the individual child when planning services and to engage with them in a manner with which they feel comfortable and at ease. Where English is not their first language or their communication abilities are limited, the onus is on the worker to facilitate their involvement in age-appropriate discussion.

Some ICS exemplars pre-populate information. This can save considerable time, but staff are still responsible for ensuring that the information that has been pulled through is accurate and up to date. This may mean removing some of the pre-populated data so that the exemplar is current.

When copying and pasting from one child's record to another it is very important to ensure that only information that is relevant to that child's record and current circumstance is included in their record. The inclusion in a child's file of information pertaining to another child can be misleading, upsetting for the child/family and is potentially a breach of data protection rules.

If managers make a decision to significantly change the trajectory of a case, the rationale for this decision should be clearly recorded on a case note under 'Manager Comments.


3. Content of Case Records

Children's Services records should:

  • Be clearly written in plain, uncomplicated English;
  • Distinguish between fact and opinion;
  • Make clear when events took place and who was present;
  • Be written as soon as possible after the event (see Section 4, Timeliness of Recording);
  • Evidence that (and how) any statutory duties have been undertaken;
  • Record timescales that have been set and who agreed them; include management oversight where these are not adhered to;
  • Record decisions, who made them and the rationale for them;
  • Be clear who was present and whether children were seen on their own or with siblings and/or parents present;
  • Clearly record the child's voice, including their wishes and feelings and any observations to evidence these, noting where an interpreter was used or the child's communication is limited, perhaps through disability;
  • Include periodic information on the child's development, so that progress can be monitored to ensure outcomes are improving;
  • Include a range of different views of all those with an interest in the child, including, the child's parents, carer(s), the case worker and other professionals;
  • Be individually signed off by the worker, confirming that the record is complete and accurate;
  • Contain evidence of how the manager has supported and, where appropriate, challenged the worker's views of the case and how and when key case decisions have been made. Also where advice/input has been received from a clinician and how this has been used;
  • Where a document/record constitutes an updated version of a previous document/record, the worker must explicitly differentiate between original and new content, including the date of each element.


4. Timeliness of Recording

Recordings should be made promptly and where possible immediately following the action or contact. The following timescales must be met:

  • Home Visits to be recorded within 5 working days (where there are no child protection concerns or significant incidents);
  • Home visits to be recorded within 2 working days where a significant event has occurred or a child is the subject of a Child Protection Plan;
  • Significant or urgent events must be recorded on the same day. If necessary, a brief note covering the key issues should be finalised within 2 working days;
  • Strategy Discussions must be recorded on the same day they occur and must include the Police, Health and other professionals' information pertaining to the child;
  • Child protection investigations (S47 enquiries) to be completed and recorded in the Single Assessment within 15 working days;
  • TM oversight of each Section 47 must be recorded on a case note within 1 working day of the SW completing the Section 47;
  • CIN/Core Group/LAC Review plan should be recorded and distributed within 10 working days and evidenced on ICS that these have been distributed and to whom. Any meeting chairperson should make it clear at the start that the minutes will not be verbatim. Where appropriate, this should also be stated in covering letters to families, accompanying notes of a meeting. For CIN and Core Group meetings, there may not be separate minutes with key issues being recorded within the amended Plan;
  • All Single Assessments should be completed within the timescale agreed at the outset with their line manager and shared with the family. The manager should track progress at day 20 and 35 and it is expected that all assessments are completed by day 45;
  • All correspondence (sent and received) should be recorded on ICS as a case note within 5 working days and any document added to Wisdom (see Section 5, Correspondence);
  • Updating any information on ICS regarding the child's details, placement, legal status, etc. should be completed within 1 working day. This includes changes to address and telephone number;
  • Dates and outcomes of key meetings and events (TARP, Legal Planning meetings, Court hearings, etc.) must be promptly recorded to ensure key decisions are evidenced on file.

No recording must be more than 10 working days out of date. If there is a risk of this happening, the worker should discuss it immediately with their line manager, so any action/support can be agreed. This should subsequently be monitored through supervision.


5. Correspondence

All relevant correspondence must be recorded onto the child's electronic file. The content of telephone conversations, emails and texts should be included in a case note, including details of the sender and date/time received. Letters and other 'hard copy' documents must be scanned and a case note created to state content, date of correspondence and where the information can be located.

This must be completed within 5 working days.

Previous letter templates should not be 'overwritten' as addresses etc. may have changed.

If in any doubt, the address should be confirmed with the service user before sending a letter and consider whether the information might be sent as an email, or email attachment.

Confidential information should not be sent by email to 'non-secure' email addresses. Care should be taken to avoid including identifying information in email exchanges with service users.

If the contents are confidential/ sensitive, the worker should discuss with the recipient the use of Managed File Transfer to ensure safe receipt by email.

Only in exceptional circumstances should letters be sent by recorded delivery, but where this is used, the tracking number should be noted by Business Support and subsequently checked to confirm that the item has been signed for.


6. Recording Case Notes on ICS

Every case note entered on ICS must have a case note event type using the correct date. This ensures that the case note can clearly be seen within the child's chronology and, by ticking the 'significant events' box the worker can ensure the information is pulled into the case note chronology.

Case notes should be used:

  • To record every visit.
    If a visit is a Statutory Visit this must be stated using the relevant drop down box:
    • Case worker visit;
    • Case worker visit child seen;
    • Child seen alone/baby awake (CP stat visit);
    • LAC/CP stat visit (children subject to dual plans);
    • LAC statutory visit;
    • Care Leaver statutory visit;
  • To record the receipt/sending of correspondence (see Section 5, Correspondence);
  • To record the distribution of invitations to meetings and meeting minutes;
  • To note of any other work completed. For example, the completion of a genogram or chronology and where this is stored (Wisdom);
  • To record case discussions (and their outcome) with others, including managers.

The drop down event type selected must reflect the activity. For example if it concerns a letter received, the event type would be 'correspondence'; for home visits it should be stated if child has been seen, and if this was alone.

The subject box also gives the reader insight into the case note without needing to open it fully.


7. Genograms and Chronologies

Genograms

Genograms and ecomaps are required for every family open to Children's Services. They should be started as soon as a family become 'open' and then built on as the case progresses. They can be separate or a single, combined document.

  • They can be hand drawn, or created using Word, or Genopro;
  • They are most effectively completed with different family members, broadening the scope of information gathered;
  • They should cover at least three generations and may involve more than one family;
  • A key should be used to indicate the most significant close/ hostile/ stressful relationships, including those between family members and between key family members and involved professionals/ services;
  • Circles are put around those who live together;
  • Agencies/services involved and key themes (e.g. alcoholism) should be included around the outside of the genogram if a separate ecomap is not being compiled;
  • The worker should include themselves and their Team in the genogram, naming key people involved;
  • Genograms and Ecomaps should have a 'go to' person identified as the person to contact if there is an emergency out of hours;
  • Genograms an ecomaps should be dated and this revised whenever they are updated;
  • They should be revisited and updated regularly (every 3 months or so);
  • It is important to keep a check on the information on the genogram as it can quickly get out of date as family members or professional involvements change;
  • Question marks should be used for 'unknowns' rather than leaving blanks;
  • They should be saved to and stored on the child's file.

Chronologies

Chronologies provide a key link in the chain of understanding needs/risks, including the need for protection from harm. Setting out key events in sequential date order, they give a summary timeline of child and family circumstances, patterns of behaviour and trends in lifestyle that may greatly assist any assessment and analysis. They are a logical, methodical and systematic means of organising, merging and helping make sense of information. They also help to highlight gaps and omitted details that require further exploration, investigation and assessment.

Where a new case does not have an existing chronology, past events can be summarised with more detailed attention being given to the past twelve months.

  • Preparing and maintaining the chronology is the responsibility of the allocated social worker/lead professional. Multi-agency core groups are responsible for completing an integrated chronology. The Assessment Teams are responsible for completing/updating an integrated chronology from available sources as far back as possible in the child's life. A case that enters MASH will have a summary of involvement compiled by the MASH Navigators;
  • Chronologies must be updated and used at these points:
    • Upon receipt of a case by the allocated social worker or lead professional;
    • For Single Assessments;
    • For Conference as a stand-alone document;
    • At closure or transfer;
    • For Court;
    • If a significant event takes place, to consider risk and strengths, and to inform further decision making both within individual supervisions, case discussions and for TARP, LPM, etc.
  • Location of Chronology:
    • It will be a stand-alone document in the child's Assessment folder in Wisdom (for social care) or in the electronic family file (for Early Help);
    • For an active case, it will be on the lead child's folder. Any related children will have the chronology passed over from IFD and a note that the master chronology is in the lead child's folder with the name of that child;
    • At the point of closure or transfer, the full, completed chronology will be copied to all related children, replacing the holding document. Each child must be considered separately, as their lived experiences will be different, and their chronology should reflect this, particularly if, for example, one child leaves the family.
  • Contents. A chronology is not just a list of events. It is essential to include each critical incident and key decision. It should include:
    • House moves (not an actual address), placement or school;
    • Legal history;
    • Major health issues;
    • Deaths and marriages of family members if it directly affects the child;
    • Referrals, key decisions and major stages in social care involvement (e.g. conference, closure, TARP);
    • Periods of non-cooperation – these can be grouped together over a period of time;
    • Any other incident that might impact the child's experience – e.g. parent going to prison, DV incident where the police are called, sudden change in child's behaviour, repeated episodes of self-harming, etc.
    • Also, consider including relevant information about parents' own experiences – for example if they were in care themselves as a child.
  • Format. The chronology template is in Word which should be added to and uploaded to the child's case record as the chronology builds. The purpose of completing in this way is to not only provide a consistent approach but to produce a document that it clear, succinct and purposeful. If Care proceedings are initiated, the Word format is set up so that two columns can be removed, leaving the Court approved chronology format.


8. Recording Visits to Children

It is very important that children are seen regularly whether they are looked after, on CP Plans or children in need. The child should normally be seen within 5 days of allocation and there are minimum frequencies for each type of case:

LAC:

Normally six weekly, though also within the first week of a new placement starting. Where a child has been in placement for more than a year and the plan is for them to remain there until they are 18, the frequency of visits could be reduced to 12-weekly. However, this is a decision that can only be made at a LAC Review and subsequent reviews will check that this arrangement remains appropriate.

There are additional requirements for Placement with Parents and Placement with Connected Persons placements.
CP: Where children are the subject of Child Protection Family Plans, they must be seen by the social worker at least every two weeks, and by a member of the Core Group every 10 working days.
CIN: Children supported through CIN Family Plans should be seen at least every four weeks. Children with disabilities who are open to a Team rather than a Team are to be seen at least every 12 weeks.
Care leavers: Arrangements are the same as for LAC whilst young people remain looked after. Once they are over 18, visits are arranged according to the young person's circumstances. See Local Offer for further details.

It is important to be clear that these are the minimum frequencies and there will always be situations that require more frequent visits to respond to particular needs or current events.

Children should be seen alone to enable them to talk in confidence about their situation, but also to aid the development of a trusting relationship with their social worker. They might sometimes be seen with their siblings, but should also be seen individually on some occasions.

It is important to see children in their 'home' setting, not least because this allows observation of their relationship with their caregivers and others in the household. Each child's bedroom should be viewed regularly. It can also be helpful to see children elsewhere, for example in school, to give them opportunity to talk away from key adults.

Recording. To ensure that time is well spent and direct work is most effective, it is important to have a plan for what is to be accomplished by each visit. It is also essential that visits are recorded clearly and concisely. There is a new template on ICS for recording visits that will also help with their planning:

For Social Care, this is not a new exemplar, but a format for recording within the existing box on ICS to which new guidance notes have been added.

For Early Help, it provides a structure for recording visits and the following additional information is also required: Who was present, including their roles; Whether the child was seen and seen alone; Where the visit took place.

The template comprises five key elements for all visits, with some additional details according to the type of case/visit being undertaken:

  • Purpose of visit (see chart below);
  • Observations/significant recent events / discussion (inc carer/keyworker update);
  • Analysis/Reflections (risks, protective factors, complicating factors);
  • Child's voice/views;
  • Future actions (by family/carer/social worker) to progress plan.

Purpose of visits: The following additional issues should be addressed according to case type:

Purpose of visit: Record against each of the following according to case type:
LAC/ Care Leaver CP S47 CIN
Progressing requirements of Care/ Pathway Plan (inc. permanence) Progressing requirements of CP Family Plan; issues from Core Group Progressing investigation: risks, protective factors; Safety/Family Plan Progressing requirements of CIN Family Plan; issues from CIN Meeting
Accommodation seen;
Placement suitability
Home conditions; bedrooms seen
Relationships with carers;
Family contact;
Social relationships
Family relationships (inc extended family/support network)
Education, Health (inc emotional wellbeing), wider welfare
Additional needs, EHC Plan, Care Package, etc.
Life Story Work/ progress child's understanding of reasons for LAC Child's understanding of concerns / their experience


9. Children in Need (CIN) Codes

CIN codes are used within Panel 3 of the Social Care Referral Form to state the reason that the child / young person is open to Social Care. It is essential that the code is correct and in line with the work being carried out with the child and their family.

To ensure all cases are coded correctly the CIN code must be changed if the reason for involvement changes. This must be considered within supervision and the code updated promptly.

More than one CIN code can be applied and if a CIN code is no longer applicable, an end date can be given.

Changes to the CIN code(s) should be made when a change in the main reason for Social Care involvement has been identified. Any change on ICS should be initiated by the TM and changed by the TM or the Business Support.

For more information regarding CIN codes, see Factsheets for ONE for Social Care (ICS).


10. Recording Outcomes

The outcomes on ICS must be completed to evidence the process of assessments and social work intervention. The ICS outcomes link to data performance therefore it is important that these are accurate and completed in a timely manner to demonstrate the work being undertaken.

See How to Record Outcomes Linked to the Social Care Involvement.


11. Retention of Records

The case record must be kept secure, and any necessary steps taken to ensure that information contained in it is treated as confidential, subject only to statutory rights of access or court orders granting access.

When adoption is the plan for the child the responsible local authority may transfer a copy of the child's case record (or part of that record) to another adoption agency when it considers this to be in the interests of the child, and a written record must be kept of any such transfer (s.4 The Adoption and Care Planning (Miscellaneous Amendments) Regulations 2018, amending s.49 of the Care Planning, Placement and Case Review (England) Regulations 2010).

The Data Protection Act/ General Data Protection Regulation applies to both paper/manual and electronic records.

The retention of a child's record will depend upon the nature of involvement of the local authority with the child and family: see Retention of Records.

Important Note: The Independent Inquiry into Child Sexual Abuse requires all institutions to retain their records relating to the care of children for the duration of the Inquiry under Section 21 of the Inquiries Act 2005. There is therefore an obligation to preserve records for the Inquiry for as long as is necessary.

(See letter to Chief Executives of Local Authorities).

End