1.5 Case Recording

2.1 Overview

2.2 Definition of a Case Record in Children and Families

2.3 Ownership of Case Records

2.4 Purpose of Recording

Recording is intended to be a dynamic tool to support and promote good practice, decision-making and outcomes and to demonstrate activity and accountability through the following:

• To provide clear, accurate and up to date information about the child’s situation and social care involvement which is available to support decision-making at all times whether or not allocated workers are available;
• To enable reflective practice, and as a tool for analysis, decision-making and planning;
• To demonstrate and be accountable for decisions taken and actions carried out with the reasons behind them;
• As a source of personal information to share with the child, now or in the future, to help them understand what has happened in their lives - “the child’s story”;
• To promote joint working with the child, young person, family and partner agencies (even though partner agencies do not have access to Protocol);
• To ensure continuity, effective transfer and/or joint working with Children and Families;
• To enable the work to be monitored, audited and evaluated;
• To provide evidence as appropriate in the child’s interests.
  
  

2.5 Principles and Values

2.6 Legal Requirements

Case records must comply with and reflect the following:

• Data Protection Act 2002 which requires personal information to be kept securely, used only for the purposes it has stated, to be up to date and accurate, sufficient and relevant and kept only as long as necessary. The person who the record is about is called the Data Subject and the agency holding the record is called the Data Controller. The “data subject” has a right a) to be informed about the nature of the record and b) to access it under specified circumstances;
• Human Rights Act 1998 which enshrines a right of respect for individual private life and for family life which must be reflected in practice and in the record;
• The Isle of Man Safeguarding Board Procedures, Principles of Case Recording Procedure is mandatory guidance for all agencies working with children and young people. It is compatible with all aspects of this policy. It specifically includes several requirements for recording including the recording of interviews with children and young people and recording when information is shared;
• Race Relations Act 2004 - This Act places a duty on public authorities to ensure that their functions are carried out with due regard to the need:
  1. To promote equality of opportunity, and good relations, between persons of different racial groups; and
  2. To eliminate unlawful racial discrimination.

It is unlawful for a person, on racial grounds to treat another person less favourably than he treats or would treat other persons. These requirements clearly affect case recording.

• Freedom of Information Act 2015 - The purpose of this Act is to enable persons who are resident in the Island to obtain access to information held by public authorities in accordance with the principles that:
  1. The information should be available to the public to promote the public interest; and
  2. Exceptions to the right of access are necessary to maintain a balance with rights to privacy, effective government, and value for the taxpayer.

These requirements clearly affect case recording.

2.7 Confidentiality of Case Records

Case records contain personal data and sensitive information and therefore must be kept strictly confidential. This means that electronic records must be password protected. Contents must not be available to or disclosed to anyone without consent of the subject of the record other than to: the individual the record concerns as appropriate, employees and partner professionals with appropriate permissions to access them solely in order to provide a service or for management and quality assurance purposes or as directed by a Court.

Any sharing or electronic record with others via email should be password protected.

2.8 Information Sharing

3.1 Overview

3.2 Recording Requirements in Children and Family Service

3.3 Electronic Recording

All children and young people who receive a service will have an electronic file. Information completed on paper such as information from service providers, letters and specialist reports will be uploaded to the Protocol electronic record. This will primarily hold all ICS documentation, demographic information and running Case Notes. In addition to these, documents prepared electronically within Department of Health and Social Care must be uploaded to sit with the child/young person’s electronic Protocol record e.g. Court Reports, Secure Panel paperwork, minutes of meeting held outside the ICS processes, letters etc. There is no requirement to print off and hold in the paper file such documents, or ICS documents unless the practitioner wishes to for taking to meetings or other purposes. Emails which support a decision or action may be either, printed and added to the child’s file, or uploaded onto the relevant record.

3.4 Protocol and the Integrated Children's System (ICS)

The Integrated Children’s System is a framework to support practitioners and managers in the key tasks. It is made up of four elements which are updated as required:

• NARRATES, the framework for assessment, planning, intervention and review is informed by a child’s developmental needs, their health, education, emotional and behavioural, social, self-care and resilience. In addition it is informed by parental support and a robust approach to identifying risk, protective factors and impact on children. Active use of NARRATES within Protocol will make it more likely that the significance of the information will be understood and used to promote good outcomes;
• A set of data requirements to contribute both to individual case planning and the information required to plan and deliver children’s services. This data is used for the Performance Management Framework meetings held monthly;
• Templates (i.e. formats with guidance) for Contact, Referral and Information, NARRATES, including Strategy Discussion, Outcome of Section 46 Enquiries, Care Orders and Conference/Review documentation (i.e. Pre Meeting/Conference Reports, Chair’s Reports and Minutes) for Looked After children, children subject to Child Protection Risk Action Plans and Children with Complex Needs Plans, Adoption Plans and Pathway Assessment/Plans for relevant client groups;
• Protocol is a web-based IT system which has been designed to support the Department to record and manage the volume and complexity of information collected in the course of work with children and families. Guides to most commonly used parts of the system are available in the ICS Manual.

Within Protocol the following screens and functions are particularly important for the Social Worker to maintain and use in working with the family:

• Relationships which shows family and other significant relationships to the child, significant adults in the life of the child (such as parents’ partners not living in the child’s home);
• Involvements which shows the ‘professionals’ involved from Department of Health and Social Care (including the Allocated Social Worker) and ‘key agencies’ - professionals from other disciplines, with their contact details;
• Case Notes are the “running record” for recording details of decisions, contacts, visits, incidents, third party information, supervision and other relevant information. These can be added from a variety of places on the system;
• Additional. Via this tab disabilities can be added and Legal Status changes that are not associated with Looked After status - these are added via the Looked After screens and are automatically pulled through to this screen. The location and details of paper files held are also recorded via this screen;
• Identity. Ethnicity, Nationality, Language and Religion are all recorded here. Ethnicity must be entered before a child can be made Looked After or the subject of a Child Protection Risk Action Plan on the system;
• Risks. If a person is known to pose a risk to children it can be recorded here by those with the appropriate level of access. When attempts are made to link this person with any child on the system an Alert will be visible warning of the potential risk. MAPPP discussions, allegations made against the person and hazards (e.g. dangerous dog owner) and offences committed are all found on this screen;
• Chronology. In conjunction with the History tab this tab can be used to build a Chronology of significant events for the child to assist with understanding patterns of life events to assist in assessment and planning. See Chronologies and how Protocol can be used to produce a chronology for each child.
  
  

3.5 Recording Out of Hours

3.6 Roles and Responsibilities in Case Recording

All staff have a responsibility to contribute to records in accordance with this Policy, Procedure and Best Practice Guidelines. Particular responsibilities are:

• Initial Response Team: To receive and record the details and basic information about Contacts and Referrals and pass to the Team in a timely manner;
• The Allocated Worker: To record all aspects of their work with and on behalf of the child and family and manage the case record overall within requirements and best practice, ensuring the child and the child’s interest are kept central throughout. Case Notes must be recorded on Protocol within 5 working days of the event/s being described or within 1 working day if a significant risk is identified;
• To maintain the Chronology appropriately and to record key processes of Assessment, Care Planning, Review and statutory visits within timescales and using correct formats so that they contribute to proactive case management and accurate performance measurement. Where there is a set timescale for production of such documentation as prescribed in Departmental policy these must be adhered to where possible with reasons recorded as to why this was not achieved where necessary;
• Team Secretaries, Independent Reviewing Officers and Conference Minute Takers: To assist professional staff in adding and amending essential information to ensure it is accurate and up to date. To manage arrangements for meetings set up on Protocol e.g. Core Group, LAC Reviews, CP Conferences including entering minutes taken. To enter/retrieve other case information as requested by the Allocated Worker, or managers;
• To ensure that case records are maintained according to this policy, procedure and guidance including all essential family and household information and all aspects of management from referral to closure; to record decisions they make with intended outcomes and the reasons behind them; to record details of discussions and actions agreed with partner agencies, including the Police; to authorise NARRATES and plans and other templates on Protocol; to complete ‘file fit for purpose’ audits on Protocol; to monitor all cases for which they are responsible in supervision to ensure cases are being actively managed and recording is being maintained;
• Senior Team Manager (IRT) and Head of Statutory Social Work Services: To ensure that discussions and decisions they make are recorded on the child’s record with reasons. To ensure that minutes of any meetings chaired outside of ICS processes are uploaded onto the child’s record;
• Senior Independent Reviewing Officer and Independent Reviewing Officers. To record Outcomes of LAC Reviews and CP Conferences on Protocol and to ensure minutes from such meetings are completed, authorised and distributed. To ensure that discussions and decisions they make are recorded on the child’s record with reasons. Timescales for the production of such documentation must be adhered to or reasons for non-compliance recorded.
  
  

3.7 Alterations to Records

3.8 Recording about Adults on a Child's File

3.9 Records of Service Users who are also Employees

4.1 Best Practice Overview

If you can always answer yes to all of these questions it is likely that you are already recording to a high quality and standard.

• If I were “run over by a bus” would somebody reading this record quickly have a complete and vivid picture of this child or young person’s circumstances and be able to use the information to take suitable further action in the child’s interests?
• Are the following essential aspects clear?
  • The factors contributing to need and risk;
  • The protective factors;
  • The impact on the child;
  • The decisions made with evidence and reasons?
  • Who else is in the family, household and wider network?
  • The contacts with the child and family and whether the child has been seen alone;
  • The views of the child or young person and their parents and Carers;
  • Which partner professionals are involved and how they can be contacted.
• Do the content, language and tone demonstrate socially inclusive practice and is it suitable for the person concerned to read?
• Is the record in the right formats and maintained securely?
• Is there an up to date child’s Chronology?
• Is there evidence of supervision and management oversight?
• Does this record overall reflect the work of an accountable professional using sound professional judgment?

4.2 Structure of Case Records

• Individual record for each child or young person: Every child receiving a service will have their own record which includes contact, assessment, planning, services provided and review. Family information may be duplicated provided it is relevant for each child;
• Essential information: Full personal details of the child or young person and their family and household and services in contact are essential and must be gathered as an early a stage as possible and changes and additions made immediately as they are known. Non-resident parents must be included and/or a statement made regarding their whereabouts. Details of members of the household who are not related must also be included and may be essential information to ensure that any potential risk to a child from others can be identified. Changes of address and services such as school must be made immediately;
• Up to date: New information will be added as soon as possible and within the timescales for assessments and planning or review meetings and formal proceedings. Events and issues which indicate risk or have a significant impact and new essential information such as a new member of a household and/or significant adult such as parent’s partner who lives elsewhere must be recorded as soon as practicable. Other information such as accounts of regular visits will normally be recorded within 5 working days;
• Comprehensive: Full personal details of the child or young person and their family and household are essential. This must include non-resident parents or parent’s partners. Full details of contacts and interventions from referral to closure must be included. Full details of all contacts and interventions from referral to closure must be included. In the event of parent's partners being involved, consent to information sharing will need to be sought;
• Outcomes focused: The aim and intended outcomes must always be specifically stated at each stage of planning and used to measure progress at review and in supervision;
• Informed by evidence and balanced: This means stating the basis for actions or decisions and including positive and negative factors including those which challenge the current viewpoint. “Evidence” includes direct observation, verifiable information, knowledge of likely impact on a child or information about “what works” from experience, theory and research;
• Fact differentiated from professional opinion. The difference between an observed and / or verifiable fact and the author’s interpretation or view about its meaning must always be clear. For example “The garden was not safe for a toddler” is an opinion. It would be expressed factually as “There was no gate to the garden” Based on this evidence your opinion, could be expressed as "... so that K could run out into traffic and in my view it was not safe for her to play there even if supervised”;
• Fact differentiated from an allegation: The difference between an observed and / or verifiable fact and an unsubstantiated allegation by a third party must always be clear and the source attributed. For example an allegation could be expressed as “C informed me that J goes to G’s house when not at school.” The author could add an interpretation or view about its meaning for example. ”If true J could be at risk of further abuse so I will investigate immediately”;
• Relevant: Information will be selected according to professional judgement to contribute to the holistic picture and to decision-making;
• Includes a Chronology of significant events which clarifies the pattern of life for the child over time. For further guidance see separate guidance on Chronologies;
• Reason for each visit or meeting specified - e.g. “Visit to R to clarify if she needs a supporter at the Review”. This will provide focus and is a requirement of the Climbie report 2003 (Recommendation 34);
• Key topics, themes and decisions clearly identified. For example “When J and I met we discussed her next visit home. I summarised by acknowledging J’s feelings of anger. We decided to write a letter to her father”;
• Source of information stated. Direct observations must start “I observed that... Information or allegations from others needs to be clarified;
• Using correct formats. The Protocol templates must be used for the key processes such as Assessment, Strategy Discussion / Meetings and Care Orders. This enables information to be shared and accessed by those with permission and need to know. Protocol is also used for essential information and Case Notes.
  
  

4.3 Content which Reflects Best Practice

• Reflect the “voice” of the child or young person. Direct communication with and/or observation of the child, whether this was alone and his or her wishes, feelings and views must be recorded prominently. It must also be demonstrated how the child’s views were used to inform decision-making - for instance “During our one to one session, T drew a picture of what had happened and told me she did not want to go back...This informed the decision for T to move”;
• ... and the family and carers. While the focus must remain on a good outcome for the child, the record must reflect where and how this is being achieved through work with and support for parents and carers in their parenting role. However the record must always keep focus on the needs and outcomes for the child;
• Outcomes. An outcome is expressed as the effect on the well-being of an action on the child or young person for instance “L will take K to her hospital appointments” (action) so that her epilepsy is controlled (consequence) and she can live a normal life for her age” (outcome). An outcome is not a decision or an action or a service, say for example after a NARRATES is completed and an outcome for next steps is chosen. A way to clarify what is a genuine outcome is to think of it in terms of the child’s welfare rather than a professional intervention. It is essential that all plans, interventions are geared towards an intended outcome and that this is explicitly recorded and used to measure progress;
• Analysis. This is the “making sense of” or drawing out the “meaning” of all the information available for the child or young person and their family as a basis for deciding future actions. The critical thinking involved in analysis enables you to move beyond a list of issues to examine the interaction between them, any cumulative effect and the protective factors and determine the risks and needs to be addressed;
• Decision - making process and accountability. Significant decisions affecting plans and possible outcomes for the child, who made them and the reasons behind them must be made explicit so that that accountability is clear and in later life the young person will be able to understand the basis on which important decisions were made which affected their lives;
• Where significant decisions are made outside formal meetings or supervision they must still be recorded in the above detail and for the above reasons as a Case Note on Protocol;
• Inclusive practice. The language and actions reflect respect and consideration for each individual and for diversity and difference regardless of circumstance. For example “S learns best using visual information due to her learning disability so I took photographs and used them to explain”. Children and Families will always need to link to other policies, processes and procedures, e.g. Joint Protocol for parents with cognitive impairment;
• A co-ordinated approach with partner agencies and teams. This will show in the records through appropriate information sharing, joint plans, prompt responses etc. “I contacted JN, social worker in Mental Health Services for P’s father and we agreed to undertake a joint assessment”.
  
  

4.4 Recording Style

• All the following aspects will demonstrate professionalism and contribute to the validity of the account in formal proceedings:
  • Concise - i.e. in as few words as possible needed to cover the main points and ensure the “story” and the issues can be easily read and understood while also ensuring that all necessary information is included. In some circumstances bullet points can help to clarify the elements of a situation or observations;
  • Plain English Language will be straightforward without jargon or acronyms or where they are inevitable they will be explained in full at the first use in each report. This will aid understanding for anyone else who needs to read it and enable the person it concerns to understand it at a later date;
  • Accurate spelling and grammar demonstrating professionalism. A spell check is available for all electronic formats;
  • No colloquial figures of speech for instance “the children” rather than “kids”;
  • Neutral language for instance “H said that G left the house for the second time this week after an argument” rather than “G stormed out in one of his usual tempers”;
  • Names and job roles where relevant written in full so that all individuals and their actions can be easily identified at any time. Professional staff to be referred to as “F. N., Health Visitor…” rather than “Frankie...;
  • Signed legibly with full name, role and dated. This is particularly important in paper records. It is recorded automatically in electronic formats.
    
    

4.5 Recording in Specific Situations

• Recording individual or one-to-one work. Important interactions and insights may be revealed in work sessions that must be recorded to contribute to understanding of the child’s views and to planning. While it may be difficult to record every moment the essence must, at least be captured in a summary. Direct quotations can be powerful in conveying meaning;
• Enquiries under Section 46 must be fully recorded on Protocol including the reason for the enquiry, who participated and the decision with reasons. Further guidance is available, see NARRATES Professional Operational Guidance (April 2016);
• Report writing for evidence. Reports used in evidence in any formal proceedings must demonstrate all aspects of this recording policy, procedures and practice guidance.
  
  

4.6 Use of Recording Tools

• Click here for more information about Genograms;
• Genograms: These are Family Trees or pictorial and readily understandable representations of family relationships which when developed with individuals or family groups are a potentially powerful vehicle for assessment and decision-making through identifying and reflecting on relationships, issues and feelings. They can be used with young people and adults and can deepen understanding of the family dynamics for both family members and professional workers. Used positively and sensitively a genogram can be a therapeutic tool for exploring past or present relationships and events. The commonly used symbols and conventions used in genograms are found in separate guidance notes provided;
• Their uses include understanding and identifying any one or more of the following:
  • Family composition over two or more generations;
  • Households and changes in households over time;
  • Family relationships - biological, by marriage or association and emotional;
  • Aspects;
  • Family members who are estranged, have lost contact or not usually mentioned;
  • Medical and genetic issues especially inherited characteristics;
  • Family patterns such as mental ill health, domestic abuse or “secrets”.
• Where genograms have been written on a separate document, they must be scanned in and attached to the child’s Protocol record.
• Ecomaps: This is a relationship map or representation of the networks and social world surrounding a person or family group especially the individuals, services and the sources of support. Ecomaps can be used creatively as an assessment, decision-making, reflective or therapeutic tool in similar ways as a genogram. They are created by the person placing themselves at the centre and drawing or placing objects such as buttons, or directing others to do so, to represent people and/or agencies and/or supports etc around them. In a straightforward way they can help to identify someone’s network and as a reflective or therapeutic tool the “people” can be placed symbolically at distances to represent someone’s perceptions of how emotionally close, accessible or supportive they are;
• Where Ecomaps have been written on a separate document, they must be scanned and attached to the child’s Protocol record.
• Assessment tools (in addition to NARRATES). These include the series of Scales and Questionnaires and others developed for gathering and for facilitating the organisation and analysis of information for assessment and therapeutic purposes;
• Where assessment tools have been completed on a separate document they must be scanned and attached to the child’s Protocol record. The Strengths and Difficulties Questionnaire is available electronically on Protocol;
• “Write Enough” an interactive site about recording in social care may be of further benefit at Write Enough website.

5.1 Structure

Each record must demonstrate it is:

• A full individual ‘stand-alone’ record for each child receiving a service;
• Up to date information added as soon as possible;
• Outcome focused with outcome expressed as the effect on a child’s well being;
• Informed by evidence including knowledge from observation, theory and research;
• Fact differentiated from opinion or allegation. Sources of information stated;
• Concise but sufficient to ensure and evidence sound decision-making;
• Reasons for contacts with families specified and key topics/issues identified;
• In the correct format and includes a Chronology.

5.2 Content

Case recording must reflect best practice by demonstrating it is:

• Focused on the child or young person and reflects their ‘voice’;
• Clearly identifying risk, protective factors, need and impact in all decisions;
• Reflecting views and issues for parents/carers while not losing sight of the child’s needs;
• Analytical and shows critical thinking leading to decision-making;
• Accountability for decisions and actions;
• Demonstrating inclusive practice;
• Joined up and demonstrated partnership working.
  
  

5.3 Style

A professional and accessible style is essential which is in:

• Plain English without colloquial language, jargon and with acronyms explained;
• Correct grammar, spelling and punctuation;
• Neutral language;
• With names and job roles given in full;
• Attributed to the author and dated.

7.1 Policy

Effective reviewing and closure of cases will ensure that:

• Positive changes in families are acknowledged;
• Services continue to be directed at those in greatest need;
• The information on the Team’s workload is kept accurate.

Therefore a case will be considered closed to Department of Social Care when the following steps have been completed:

• A review of the child’s circumstances show that the intended outcomes of social care intervention are achieved and the child’s welfare is assessed to be appropriately protected and promoted. A Team Manager has agreed and countersigned the record outlining this assessment; routinely this will be located on the Closure Record. Alternatively, that there are no statutory powers for Department of Health and Social Care to remain involved and the young person or family are refusing to accept services from social care. This must be clearly recorded on the case file;
• The child (as appropriate), young person, family and other agencies involved have been informed in writing of the closure and the reasons for this decision;
• Where appropriate, clear arrangements are in place for another/other agencies to continue to support the child and family and this must be recorded on Protocol;
• The child is returning to being a Child with Additional Needs;
• A closing summary giving details of work undertaken and reason for closure is on the case file - this is found on the Closure Record on Protocol;
• The case file is up to date and complete;
• The Referral has been closed on Protocol.

The following additional steps must have been taken prior to closure on cases where there have been allegations of deliberate harm to a child.

• The child has been seen and spoken to alone (where appropriate);
• The child’s Carers have been seen and spoken to alone;
• The accommodation in which the child lives has been visited;
• The views of all the professionals involved have been sought and considered;
• A plan for the ongoing promotion and safeguarding of the child’s welfare has been agreed and is recorded on the child’s case file.

7.2 Procedure