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2.1 Recording Standards

SCOPE OF THIS CHAPTER

This document contains the standards, expectations, roles and responsibilities for case recording applicable to Children’s Social Care staff and managers. The standards relate to both the timeliness and the quality of the recording.

This guidance was rewritten in June 2017.


Contents

  1. Introduction
  2. Ownership of Case Records
  3. Basic Information
  4. Case Notes
  5. Correspondence
  6. Documents
  7. Genogram
  8. Ecomaps
  9. Chronology
  10. Case Summary
  11. Case History
  12. Change of Allocated Worker


1. Introduction

Achieving a high standard of case recording is a key professional responsibility of all social work staff. This was emphasised by Lord Laming in his report into the death of Victoria Climbié:

'The case file is the single most important tool available to social workers and their managers when making decisions as to how best to safeguard the welfare of children under their care. It should clearly and accessibly record the available information about the child and the action that has been taken on the case to date. Reference to the case file should be made at every stage of the case and before any significant decision is made.'


2. Ownership of Case Records

Case records should be viewed as the property of the subject child. They are also the property of City of York Council (CYC), and form the record of CYC Children’s Social Care’s involvement with that child. We have both a professional and statutory duty to maintain that record to the highest standards.

The ‘story’ of the authority’s involvement should be easily accessible and reflect the highest standards of professionalism. Remember that the child’s record may at some point be read by the child themselves. Case records should be maintained and written with this in mind.

This means that:

  • Information should be complete (to the extent that this is possible) and accurate;
  • Spelling, grammar and use of language should be of a high standard and accessible;
  • Records should be kept up to date;
  • Management oversight of cases should be easily identified; and
  • The authority’s plans for assessment and intervention in the child’s life should be easily identified and the reasons for decisions made should be clear.


3. Basic Information

The allocated worker is responsible for ensuring that all basic details are correctly inputted onto Mosaic (the electronic case recording system). Any changes to basic details should be updated by the allocated worker on the same business day that the change becomes known.  When a case is reallocated it becomes the responsibility of the new allocated worker to check and ensure basic details are correct.

In particular it is important that the allocated worker ensures that:

  1. All Personal Relationships are recorded accurately (including birth parents, partners, siblings, grandparents, aunts and uncles). It is the allocated worker’s responsibility to obtain missing information, particularly in relation to absent birth fathers;
  2. Addresses, phone numbers, email addresses etc are kept up to date;
  3. Ethnicity, nationality, preferred language and religion are recorded; and
  4. Professional relationships are recorded accurately. In particular the primary allocated worker in any case must be identified by selecting “Allocated Worker” from the drop down list in Mosaic.

Team managers are responsible at the point of allocation, reallocation or case transfer for ensuring that the professional relationships are recorded accurately.

In the circumstances where a case is transferred between teams and the transferring manager is not aware at that stage who the new allocated worker will be in that team, the team manager for the new team will be the “Allocated Worker” until a suitable allocation can be made.


4. Case Notes

4.1 General

Case notes should always be written with an awareness of the likely audience, which includes:

  • The child;
  • Parents and carers (on occasion);
  • Other case workers (both now and in the future);
  • Case managers;
  • Case auditors;
  • Senior managers;
  • Inspectors;
  • Lawyers; and
  • Judges.

Due to the range of potential readers case notes should be written in formal, but clear, language.

It should not be assumed that the identity of those mentioned in case notes will be understood by the reader. Individuals mentioned should be properly identified through a title or job role (for adults), first name and second name, and where relevant or not obvious, by their relationship to the subject child. Once identified in this way at the start of a case note, less formal naming of people using just first name or first and second name for children and some other professionals, or title and second name for adults (and some other professionals e.g. some medical professionals, Police officers) can be used for the remainder of that case note.

Information about third parties should be kept to a minimum and information provided by third parties should be identified as such.

Case notes should:

  • Provide a brief record of case activity undertaken by any of the case workers within children’s social care;
  • Be easy to read and convey a range of information including who was present (both family members and professionals), whether anyone left or joined the visit or meeting and where the activity took place;
  • Identify the purpose of any visit (e.g. home visit to discuss changes to safety plan, arising from latest missing episode);
  • Record the outcomes achieved during the visit / meeting (e.g. new safety plan agreed and signed, see MASP dated 23.01.17).
  • Clearly differentiate between fact, opinion and hypotheses;
  • Be succinct and should not duplicate information contained elsewhere, but should instead cross reference that source, e.g:

    “Assessment session carried out at Clifton Children’s Centre with Mrs Mary Jones. Issues covered: Routines, Children’s needs. Tools used: “Needs Jigsaw” See SA dated ..... for details”.

Where a case note references an attached document or completed form within Mosaic, it is expected that the form or document has already been written up or uploaded.

4.2 Format

  • Title - The 100 character title of a case note within Mosaic should provide a very brief description of the type of activity, who was involved/present and what the purpose was. For example if “Type of Note” selected is “Visit”. The Title may say:

    “Home visit to Mrs Mary Jones to share updated assessment for review CP meeting”
  • Date and Time - Date and time are mandatory fields. These fields default to the time of entry. Staff entering case notes must ensure that these fields are an accurate reflection of when the activity took place.
  • Significant Event - Unlike previous recording systems, completing this field is not mandatory, however this box must be ticked for a case note to be automatically included in the Mosaic Chronology. Please see Section 9, Chronologies for further guidance on what constitutes a “Significant Event”.
  • Note - This section needs to be well formatted, please use a double “return” at the end of a paragraph for there to be a proper space when viewed on screen or printed.

    If the purpose of the visit needs further detail than was possible in the Title, the case note should start with this.

    If there are too many people involved or present at a visit to mention in 100 characters then others present should be mentioned in the next (or opening) line of the main note.

    The main note should be succinct. Case notes should be written in plain English. Jargon and social work cliché, should be avoided, e.g:

    “I advised mum that it was her responsibility to safeguard the children.”

    Would be better worded:

    “I went through the child protection plan in detail with Mrs Jones and emphasised the expectations of her within this as the children’s mother.”

    It is acceptable to use bullet points or numbered lists, if for example setting out a list of topics discussed in a visit.

    Each case note should conclude with an outcome, such as action points agreed, document shared, copy of assessment delivered in person.

4.3 Exceptions

Contact and Referral - All enquiries in relation to a Contact and Referral need to be written up within the “Contact and Referral” form not in case notes.

S.47 Enquiries - Outcome of consultation with other professionals and decisions and actions and outcomes from these should be written up in the “Outcome of S.47 Enquiries” form.

Statutory Visits - Statutory visits to Children in Care and children subject to Child Protection Plans should be written up using the relevant forms in the CYPIC and Child Protection Workflows.

Timeliness - Case notes in relation to child protection enquiries or child protection incidents should be written up within 24 hours of the event. This includes notes relating to child protection matters contained within forms such as “Outcome of S47 Enquiries”.

All other case notes should be written up within 5 working days of the event.

Where handwritten contemporaneous notes have been made these should be securely destroyed once typed up unless the event was of such significance that it may become a matter that is subject to litigation in which case legal advice should be sought and the hand written note scanned and uploaded to documents in Mosaic.

4.4 Quality Assurance

Managers will routinely quality assure case notes in terms of timeliness and quality. This will be undertaken in the course of monthly QA and audit activity as set out in the Quality Assurance Framework. Any issues arising will be discussed with individual social workers within supervision sessions, and any remedial actions required agreed and recorded in worker supervision records.


5. Correspondence

Correspondence is either ‘incoming’ or ‘outgoing’ and can be from or to either other professionals or service users.

Correspondence takes two main forms;

  • Letters (transmitted either electronically or in ‘hard copy’ format); and
  • Email.

Correspondence can also be either ‘internal’ or ‘external’. Nearly all internal to Children’s Social Care ‘correspondence’ (recommendations, management decisions, notifications etc) takes place within Mosaic workflow. It is anticipated that any additional correspondence will be exceptional, not routine or the norm. For the purposes or this procedure, correspondence with other functions or directorates of the Council will be regarded as external.

5.1 Letters

Incoming correspondence in the form of letters should be scanned (if received in hard copy) and saved under the attachments tab of the documents section of the relevant Mosaic record. The following naming format for professional correspondence should be used:

  • Letter_in_ agencyname _ professionalname _ddmmyy;

    or for service users:
  • Letter_in_relationshiptosubjectchild_personname_ddmmyy.

Response letters should follow the exact same format using the preface ‘out’ in place of ‘in’.

Incoming and outgoing letters should be cross referenced in case notes adding a very brief note of the purpose, or subject matter, of the letter.

5.2 Email

Most correspondence takes place in the form of email. Due to the easy access and nature of electronic communication a great deal of this correspondence is not formal and does not contribute in any meaningful way to assessment, decision making, planning, implementation or review processes and as such does not need to form part of the social work case record.

Where significant information is being shared or decisions, plans or outcomes communicated, it is important that this is both captured in the relevant sections within Mosaic workflow but also that the source material (email) is also stored within the case record.

However, even significant and relevant (from the perspective of the case record) emails tend to be informal in nature and can be difficult to fully decipher later. In order to avoid pitfalls associated with this the process for recording should be as follows:

The content of the email should be copied and pasted into a word document with a standard header containing the following information:

  • Name of Correspondent;
  • Professional role / Relationship to Child/ren (if relevant);
  • Agency (if relevant);
  • Date sent;
  • Name of addressee;
  • Professional role of addressee;
  • Agency (if different from CSC and forwarded on).

The naming format should follow the format outlined above for letters (including identifying whether the email is incoming or outgoing) but replacing ‘letter’ with ‘email’.

Incoming and outgoing emails should be cross referenced in case notes adding a very brief note of the purpose, or subject matter, of the email.


6. Documents

There a number of forms and documents that are not currently built as forms within Mosaic. These include legal documents, assessment tools and minutes of external meetings and specialist or expert assessments. The following documents where used/relevant to the case must be uploaded to the relevant Mosaic record on the same working day as received or completed:

  • Completed Assessment Tools Used (e.g. Graded Care Profile, DASH, SDQ etc);
  • Legal Documents:
    • Letters Before proceedings;
    • Pre-proceedings meeting minutes;
    • SWET (Initial and Final);
    • Other Social Work Statements;
    • Other statements (including other professionals and other parties and interveners);
    • Guardian’s reports;
    • Expert Assessments or Reports;
    • Threshold Documents (including findings sought);
    • Final Judgement (if transcribed);
    • Legal Orders (eg. ICO, CO, PO);
    • Legal Care Plan (interim and final).
  • Minutes from External Meetings:
    • MARAC (Redacted to remove information about other families/non professional third parties);
    • MAPPA (Redacted to remove information about other families/non professional third parties).
  • Letters of Authorisation for Holidays.

The following format for saving the file should be used:

  • Code_SubCode_DocumentDescription_DateofDocument.

Examples of possible Main Codes would include: Assessment, Legal, Minutes.

Sub-Codes are the specific document (or meeting)  name e.g. InitialSWET, DASH, MAPPA.

Document Description is optional and will for example allow for two identically named documents to be differentiated from one another e.g. where a letter before proceedings has been sent to each parent separately, or the same assessment tool has been used with more than one parent/carer separately.

For example A letter before proceedings will use:

  • Main Code: ‘Legal’;
  • Sub Code: ‘letterbeforeproceedings’;
  • Document Description: ‘lettertofather’;
  • Date: ‘ddmmyyyy’;
  • So: legal_letterbeforeproceedings_lettertofather_15052017.


7. Genogram

Genograms are a visual means of representing the family tree and relationships within a family that help readers of other case records to understand the structure and make up of the family at a glance. However the Genogram is also an essential working tool for use in undertaking assessments and direct work. Completing a genogram can fulfil a number of functions:

  • Identifying intergenerational patterns within families;
  • Identify sources of risk or support;
  • Finding out about family makeup;
  • Starting to identify identity and whereabouts of absent birth fathers;
  • Identify potential alternative carers for children;
  • Finding out about the family's history;
  • Finding out how much of the history individual family members know.

Mosaic automatically generates genograms from the family relationship information that has been inputted by the social worker. It is essential therefore that this information, including the specific relationships between individuals, is accurate. If there are conflicts in the information recorded Mosaic will not draw the genogram and will display and error message. It is the child’s social worker’s responsibility to ensure the accuracy of this information and to correct any errors (see Section 2, Basic Information).

7.1 Procedure

When a ‘contact and referral’ is received the social worker will ensure that all relationships known at this stage or identified during enquiries are inputted into Mosaic. The social worker will also update and, where necessary, correct any relationships already recorded where there is an existing record for the child.

Each allocated worker after this initial contact will ensure that any new relationships, or information about existing relationships where there had been gaps, are inputted into Mosaic.

It is good practice for the allocated worker to make regular use of the genogram in assessment work and direct work with children and parents, carers and significant relatives.


8. Ecomaps

An ecomap shows the network of people around the subject of the ecomap diagrammatically. The subject will usually be a child or young person but can also be a parent or carer. Family, friends and professionals are included.

As with genograms, ecomaps both provide a visual representation of relationships as well as being a direct work tool.

The Child (or other subject) is placed at the centre of the diagram. Each person and organisation that forms a part of the child or young person's network is named and placed within a circle.

Where there is a connection between the subject of the ecomap and an individual or organisation the nature of the relationship is illustrated by a line drawn between them.

  • An unbroken line illustrates a strong or close relationship;
  • A line of dashes illustrates a weak relationship;
  • A stressful relationship is illustrated by a dotted line.

Ecomaps are very useful in obtaining and providing an overview of the complexity of the network of family, friends and professionals.

Ecomaps can be used to help identify and illustrate patterns and actual and potential areas of conflict in the child's (or other subject’s) relationships.

Ecomaps can also be used to identify current interventions and to plan other or future interventions.

8.1 Procedure

Ecomaps should be used by any social worker undertaking an assessment. Consideration should be given to doing ecomap work within the direct work with the child or young person as well as with their parents or other carers. It is also good practice to use ecomaps when assessing potential carers such as foster carers and special guardians.

With older young people and adults it may be appropriate to describe the task and ask them to complete the ecomap for themselves and then to use it as a basis for discussion and exploration of issues.

Mosaic does not generate ecomaps. The ecomap should be drawn within a word document and uploaded to mosaic using the naming structure:

  • Main code: assessment,
  • Sub-code: Ecomap,
  • Document description: name of subject of ecomap,
  • Date: ddmmyy

See also Section 5, Correspondence.


9. Chronology

9.1 Introductory practice guidance:

Chronologies can serve a number of purposes; they can be a useful way of gaining an overview of events in a child or a young person's life. They can also give an overview of major developments in Local Authority and Children’s Social Care and other agency involvement and significant interventions. Essentially a chronology lists in date order all the major changes and events in a child or young person's life.

A Chronology can help structure information to inform analysis and decision making and should be used by practitioners as an analytical tool to help them to understand the impact, both immediate and cumulative, of events and changes on the child or young person's developmental progress.

Although a Chronology should draw on various sources of information such as previous social work files and information from other agencies, the child or young person and his or her family should be involved in the process of completing the Chronology. The involvement of family members provides an opportunity to check the accuracy of information, and it can assist the social worker in obtaining family members’ perspectives on particular events and to develop an understanding of their impact on individuals in the family.

A Chronology should be factual. Where the factual basis has not been verified or there is a dispute about the facts. This should be noted within the chronology.

A Chronology can contain information from the following two different categories, life events, professional interventions.

Life Events - The type of changes and life events that should be included in a chronology include:

  • Births and deaths of subject child, parents, primary carers and siblings;
  • Changes in the family composition;
  • Changes of address;
  • Changes of placement/carers;
  • Educational establishments attended;
  • Changes in the child or young person's legal status;
  • Any injuries suffered;
  • Any periods of significant illness;
  • Periods of hospitalisation;
  • Other significant medical treatment;
  • Missing episodes and outcomes;
  • Any Offences/Convictions of the child or a significant family member;
  • Other significant events and changes in the circumstances of the child and family.

Professional Interventions - Professional agency information that should be included in the Chronology includes:

  • Previous Children’s Social Care activity;
  • Details of referral and referral source and outcome;
  • Allocation and case closure;
  • Assessment outcome and management decisions;
  • S.47 enquiries and outcome;
  • Periods subject to child in need plan, child protection plan or periods in care and main areas of need or risk associated to each;
  • Public Law Legal interventions and outcomes.

Events should be recorded against the actual date that the event took place, e.g.:

1.5.17 - Care Order application filed

5.9.17 - Care Order made

In circumstances where the social worker becomes aware of an incident some time after the event, the actual date of the event should be recorded, not the date that the social worker became aware of it unless the date of the social worker becoming aware is of some material significance in terms of the impact on the child (for example where information about a significant incident has been withheld or the incident or development concealed).

Chronologies should provide an easily viewed brief overview of important events and developments. It should not contain lengthy or detailed information. There are multiple opportunities for the full record of events to be recorded elsewhere, e.g. assessments, social work statements, case history, case notes etc. 

9.2 Procedure

A Chronology should be started in every case that progresses to a Single Assessment. It should be first created at the point that the decision is made to undertake a single assessment and be updated throughout the period of children’s social care involvement with the child or young person.

Within Mosaic it is possible to have multiple Chronologies to meet different needs (e.g. simple life events chronology to use in a direct work session with a parent or child, or brief chronology of professional involvement). Each Chronology can be given a different name.

The minimum expectation is that there should be a Chronology on the child’s record that combines life events and professional interventions and that this is kept up to date at all times. This Chronology should be clearly named “Main Social Work Chronology”.

Whilst it is possible within Mosaic to start a new chronology from the end of an existing Chronology, it is good practice to keep the Main Social Work Chronology of a particular episode of involvement open and running throughout the period of involvement and only close it at the point of case closure.

Mosaic will auto generate Chronologies based on a specific time period (or the entire record if not specified) drawing from selectable categories of information or activity within Mosaic. Mosaic will pull into this Chronology any case notes that have been identified as significant events. Other case notes can be added manually to the Chronology.

The basic auto generated Mosaic Chronology is only a starting point and will need editing in order to ensure that only the most significant and salient details from case notes, and that the specific relevant details from work steps and forms are captured. Detailed Mosaic Guidance on how to edit the Chronology is being produced separately and will be distributed and saved with other Mosaic guidance.

9.3 Analysis of Chronology

As currently configured the Mosaic Chronology function does not allow for a column for the outcome and/or social work analysis of impact of a particular entry to be included. However, when an assessment is being written or updated it should make reference to events within the chronology and capture the social workers analysis of the impact on the child and family of particular events and developments.

Chronologies are a required element within the SWET. The basic details for this can be copied and pasted from the PDF output that is produced when a chronology within Mosaic is exported to print. The section on the impact on the child will need to be completed within the SWET as this is not currently generated within the Chronology functionality on Mosaic.


10. Case Summary

A case summary provides a summary of events, changes and work undertaken by key professionals over a period of time.

10.1 Using a Case Summary

Case summaries support effective practice in a number of ways. They can:

  • Support work with families - Completing or sharing a summary with a family offers an opportunity to reflect on progress over the period covered by the summary and to discuss achievements as well as any difficulties or stresses being experienced;
  • Offer an opportunity to involve families in recording - Completing or sharing the summary with family members can provide an opportunity for family members to record their views or to have their views recorded;
  • Support the implementation of the plan for the child or young person -The summary should be directly related to the aims and objectives for the child or young person as stated in the child's plan. The summary can be a useful tool to set out the tasks necessary to achieve the objectives;
  • Monitor progress - The summary should include details of interventions and the practitioner's and family's view of their effectiveness. Summaries can be used to support supervision;
  • Assist team working - Case summaries can help to ensure continuity and are an important source of information for colleagues and supervisors in the absence of the case holder;
  • Aid analysis - Writing a case summary provides practitioners with an opportunity to reflect on the effectiveness of interventions and to review progress towards agreed goals.

Case summaries should be completed at regular intervals, at least every three months and when cases are closed or transferred.

Case summaries should be related to the overall objectives for intervention with the child or young person and their family and should include:

  • What contact the practitioner has had with the family, including when the child or young person was seen;
  • Information from other key individuals and agencies on their involvement with the family during the period covered by the summary;
  • Any resources provided to the family, including the practitioner's time, how these resources where used by the family and their outcome;
  • The practitioner's analysis of progress towards the specified objectives and whether these should be modified in any way;
  • The young person's and families views of progress [1].

1 Write Enough: Effective Recording in Children’s Services, Steve Walker, David Shemmings, Hedy Cleaver, online resource (http://www.writeenough.org.uk/default.htm)

10.2 Procedure

Mosaic provides the opportunity to complete periodic case summaries. This function is built into the ‘History’ tab on the person summary screen. This is an open text box. There is no template, no specific format and no workflow associated with it.

All open cases should have a case summary completed every three months.

In order to ensure that the key elements of a good quality case summary are captured the following headings are to be used:

  • Period Covered (From: ddmmyy, To: ddmmyy);
  • Significant Events or Changes:
  • Summary of Work Undertaken:
  • Practitioner’s Analysis:
  • Young Person’s / Family’s Views:


11. Case History

Mosaic has a detailed in built case history function. This is built into the ‘History’ tab on the person summary screen. The case history consists of a detailed list of all activity in the case, including case notes. This list is filterable and searchable. There is no opportunity to edit the information pulled into the Case History, or to add anything manually.


12. Change of Allocated Worker

Where there is to be a change of worker it is the responsibility of the existing worker to bring all records up to date before transfer. Where the worker is leaving the authority the relevant line manager must ensure that the records are up to date before the worker leaves.

End