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Contents

1. Policy Statement
2. Underlying Values and Principles
3. Equal Opportunities 
4. Bromley Recording Policy
5. Confidentiality Values and Principles 
6. Consultation Values and Principles 
   
   Appendix 1: Security and Confidentiality Undertaking

1. Policy Statement

In Children's Social Care Division, work will always be done to ensure that all children have the best chances in life to achieve their full potential.

This can be summarised under 5 key Every Child Matters outcomes for children and young people:

• Being healthy
  
  All of the Children's Social Care Division children and young people have the right to have their physical and mental health safeguarded and promoted. They also have the right to live a healthy lifestyle.
• Being safe
  
  All of the Children's Social Care Division children and young people have the right to be safe and secure, protected from harm and neglect, and to live in an environment that enables them to develop to their full physical, mental, spiritual, moral and social potential.

• Enjoying and achieving
  
  All of the Children's Social Care Division children and young people have the right to the best possible education and training which meets their identified needs and equips them to live full adult lives. They also have the right to time and support to pursue appropriate leisure interests, especially children acting as young carers.
• Making a positive contribution
  
  All of the Children's Social Care Division children and young people have the right to family life wherever possible and to be supported to take part in community life. They have the right to a continuity of care wherever possible and to develop and preserve their own identities. They also have a right to information and to make choices about their lives, having regard to their age and understanding. Through this they will be enabled to make a positive contribution to the community and to society.
• Economic well-being
  
  All of the Children's Social Care Division children have the right to live above the poverty threshold and to be equipped with the skills and knowledge that will help them overcome socio-economic disadvantage where necessary.

2. Underlying Values and Principles

1. The best interests of the child: All decisions made in relation to children must have, as the first and paramount consideration, the best interests of the child;

2. Assessment, planning and review: Services will be provided to children on the basis of regular assessment, planning, monitoring and review.  For those who are Looked After, this will continue through the transition from childhood to adulthood;

3. Avoiding delay: All decisions in relation to the provision of services to children will be made promptly and within agreed time-scales, having regard to the needs of the child; the achievement of these timescales will be monitored and reviewed;

4. Anti-discriminatory: Children will receive services which take account of their race, culture, language, disability, sexuality and religion;

5. Valuing the family: Children have the right, whenever possible, to be brought up within their own family, either with their parents or relatives;

6. Partnership: In promoting this right, services will be provided in partnership with parents, significant people in children’s lives and with other agencies to assist and support parents in meeting their children’s needs within the family;

7. Listening and taking action: We will promote an ‘open door’ culture for all children, which encourages them to express their views, wishes and feelings; and say what they think about anything which affects them.  We will then do all we can to ensure their views are taken into account when decisions are made about them;

8. Quality services for children: Where services are provided for children, they will be provided by skilled people, committed to meeting children’s needs; in a manner which promotes their educational, physical, emotional, social and psychological development and in an environment where they feel safe, positive and encouraged;

9. Keeping children informed: Children will be provided with a range of accessible information about our services and those which they may require to improve their life chances;

10. Promoting independence: We will help children to be as independent and to take as full and active a part in everyday life as possible;

11. Safeguarding children: We understand that, on occasions, it will be necessary for limits to be placed on the actions of some children for the sake of their welfare or to protect them or others from injury or harm.  Interventions used in these circumstances will be the least restrictive and disruptive compatible with children's well-being;

12. Resolving dissatisfaction: Where children, or others on their behalf, are dissatisfied, we will take steps to resolve their dissatisfaction and provide opportunities for them to complain if they wish;

13. The appropriate looked after placement: Where children are unable to live with their birth family, they will be looked after in family based care or, where appropriate, residential care;

14. Respecting privacy: Looked after children will be treated with respect and afforded privacy; 

15. Permanence: We will ensure a plan exists for all looked after children to achieve a permanent solution for their future upbringing.  Wherever possible, permanence will be secured through a return to their parents’ care or a placement within their wider family but where this cannot be achieved within a time-scale appropriate to the child’s needs, plans will be made for a permanent alternative family placement, which may include adoption, or, for older children, a stable placement which prepares the child for adulthood;

16. Maintaining community links: Where children are looked after away from the family, they will be placed as near to their family home or community as possible unless their needs dictate otherwise;

17. Promoting contact: We will promote meaningful contact between looked after children and their families unless particular circumstances indicate that such contact would not be in their best interests;

18. Monitoring and Review: We will ensure that all looked after children receive regular visits from their social workers for the purposes of monitoring and reviewing the suitability of their placement arrangements.

3. Equal Opportunities

The Children's Social Care Division will ensure that all services are aware of their responsibilities towards both users and staff in promoting an ongoing and critical review of the services they provide.

The Children's Social Care Division and its employees will not discriminate against or disadvantage any child or family on the grounds of colour, race, religion, language, disability, gender or sexuality.  All policies, procedures and practice will reflect this intention. 

4. Bromley Recording Policy

1. Introduction
2. Relevant Legislation
3. Other Relevant Bromley Children's Social Care Procedures
4. Scope of Procedure
5. Aims and Objectives
6. Purpose of Recording
7. Elements of an Effective Record
8. Management Overview
9. Information Technology
10. Message Technology
11. Service User Rights
12. Management of Paper Files

1. Introduction

The way in which events are described in case recording and the language used play an important part in communicating and understanding what has happened or is happening with a child or young person and their parent(s), family members or carers.

2. Relevant Legislation

• The Data Protection Act 1988;
• DOH Guidance to Social Services on the Data Protection Act 1998;
• The Human Rights Act 1998;
• The Social Services Inspectorate 'Recording with Care' standards;
• The Assessment Framework 2000;
• The Children Act 1989 and subsequent Regulations;
• The Adoption Act 1976;
• Adoption Agencies Regulations 1983 and LAC (97) 13;
• Residential Children's Homes Regulations 1991;
• Race Relations (Amendment Act) 2000;
• Freedom of Information Act 2000;
• Fostering Services Regulations 2002.

3. Other Relevant Bromley Children's Social Care Procedures

• Access to Case Records Procedure;
• Complaints Procedure;
• Child Protection Procedures (Click on the button on the left of the screen);
• RAT Procedures;
• Adoption Procedure (section 5.1 of the manual);
• Fostering Procedures (section 4.6 of the manual);
• All Procedures for Looked After Children;
• Supervision Policy;
• Safeguarding and Social Care Division Audit Strategy;
• ICT Do's and Don'ts Procedure;
• Information Sharing Protocol;
• File Structure Guidance;
• Destruction and Retention of Files Procedure.

4. Scope of Procedure

This policy applies to all staff in the Children and Young People Service Safeguarding and Social Care Division.

This policy sets out the Division's requirements and standards for recording in conjunction with the use of CareFirst and the Integrated Children's System. 

5. Aims and Objectives

Case recording is an essential part of our services to children, young people, parents and carers (service users).

Working Together to Safeguard Children 2006 states that: "Good record-keeping is an important part of the accountability of professionals to those who use their services.  It helps to focus work, and it is essential to working effectively across agency and professional boundaries."

This policy aims to promote:

1. Consistency of recording practice;
2. High standards of record keeping;
3. Accurate and up-to-date records of all work undertaken;
4. Anti-discriminatory and anti-oppressive practice.

6. Purpose of Recording

Case Recording:

1. Becomes the major source of evidence for investigations and enquiries;
2. May need to be disclosed in Court proceedings;
3. Assists continuity of service - for example when staff leave or are unavailable;
4. Is an essential tool for managers to monitor the quality of the work and the performance and the effectiveness of services provided;
5. Provides management information for planning purposes;
6. In supporting service users, particularly Looked After Children (LAC), recording becomes the historical and documented report of their life events;
7. Documents how and why key decisions are reached in children and young people's lives.

Good recording should:

1. Demonstrate why interventions take place;
2. The purpose of each intervention;
3. The decisions made and the resulting action;
4. How children/ young people are involved in the decisions that affect them and how their parents, family members and carers have been consulted.

7. Elements of an Effective Record

Accountability

1. All contact with service users must be recorded on CareFirst in the relevant sections;
2. All workers should assume professional responsibility and ownership of their file recording.
3. The author is responsible for the accuracy of the information recorded and should be able to substantiate and discuss their recording, including opinions and actions taken, if required to do so;
4. In the event of two workers being involved in a piece of work, there is joint responsibility for the work which has been undertaken. The workers should agree who will complete the recording of any piece of joint work.  The other worker should complete a short recording on CareFirst stating whether they agree with the other worker's recording, and if not, stating his or her different experiences or opinions about the case. 

Timescales for Recording

a.

The accuracy of records and therefore their usefulness will diminish if not recorded promptly, as recall reduces over time. Therefore: Whenever possible all information on all cases should be recorded by the worker at the time of the events/discussion, or as soon as possible after the event/discussion; Details of all Section 47 investigations must be recorded within 24 hours of the event; Minutes of strategy meetings, core group meetings and visits to children who are subject to a Child Protection Plan must be recorded within 48 hours; Referrals must be recorded as soon as possible after the referral is received and must be fully completed within 24 hours; Initial Assessments completed under the Assessment Framework should be recorded within 10 working days of the visit in line with the duty procedures; All Core Assessments must be completed and recorded within 35 working days following completion of the initial assessment (total of 42 working days from the date of referral); Case recording sheets should be written up within 48 hours; All other recording including detailed records such as visits to LAC, minutes of meetings, must be recorded within 7 days; The change of circumstances form must be completed within 24 hours of the change. (Note that this form is in interim use during the adoption of ICS and may not be used in the future.); All recording must be fully updated before any period of extended leave (i.e. over one week).

b.

If, in exceptional circumstances, the above guidelines cannot be met, it is the responsibility of the worker to discuss this with their line manager. The manager must record on the CareFirst system the reasons for the delay and the new timescale for the recording to be completed.

Accuracy and Clarity

a.	Workers should ensure they record visits, conversations, and impressions as accurately as possible and that their records can stand up to inspection by other parties. When in doubt,  workers should check the accuracy of their recordings with service users and professionals
b.	Workers should ensure that: They have used the correct spelling of names and medical terms; Where information is received on the telephone, they repeat back to the caller what will be recorded on the service users electronic file; Should exact agreement be necessary, that they request the caller to send their information in writing. All new referrals from other professionals and between teams within the Division should be completed in writing. (The only exception is if the information concerns a Child Protection matter, in which case the information can be phoned through to the appropriate duty desk as long as it is followed up in writing within 48 hours.); Workers must ensure that they clearly record who said what and that statements of fact are accompanied by their source and clearly distinguished from any opinions expressed; The reasons and evidence for opinions should be recorded.  Generalisations should be avoided as far as possible.  Workers should not use derogatory words, such as "manipulative" or "inadequate", about service users without explaining their reasoning for using them.  Writers should remember that service users have the right to read what has been written about them; When recordings are made from information supplied by an interpreter or signer, this should be made clear in the recording; Records should not be altered in any way other than by a simple crossing out at the time that a writing mistake has been made. Anything crossed out which affects meaning must be signed and dated. 'Tippex' or any other correction fluid should not be used on paper files; Comments added by workers (for example, to correct a misleading or inaccurate recording) or by service users following access to the file, must be attached to the recording sheet and clearly marked and dated as  a subsequent addition.
c.	Workers should avoid using jargon as far as possible.
d.	Workers should record the full name, telephone number, and place of work of people they contact.
e.	Workers should ensure that when referring to adult service users in any individual recording, they give the family name and position or relationship to the child or young person.  These details might be included in brackets after the first reference to the adult in the recording.

Recording of Visits and Contacts

a.	Every contact with a service user, carer or other professional person, formal or informal must be recorded.
b.	The worker should include headings in all detailed recordings of visits or contacts.
c.	The contents of visits and other contacts undertaken during the assessment process can be recorded as part of the assessment forms in order to avoid duplication.
d.	However, the fact that a visit or other contact has been undertaken must be recorded on the case recording sheet and cross referenced with the assessment forms if the content of such contact is detailed on them.
e.	The above two points do NOT apply to specific concerning incidents; for example, if a child is physically abused, this should be recorded in the "Observations" and other relevant sections in CareFirst.  In addition, such an incident should also be included in the chronology of significant events.
f.	All records of visits or contacts should state clearly: The date of the visit or contact; Who was seen and spoken to; The issues discussed; The purpose of the contact if not carried out under Looked After Children or Child Protection procedures; Service users' views and any disagreements; Any observations made; Any opinion from the assessment of the issues discussed and observations made; Bullet point of agreed tasks and actions for worker and service users to carry out before the next contact; Any progress made in relation to the plan.

The Recording of Decisions

a.	All decisions and the reasons for them, whether made formally in supervision or outside that process, must be recorded on CareFirst.
b.	All decisions during a child protection investigation or the decision to commence care proceedings or accommodate a child should always be recorded and authorised by a manager on CareFirst.
c.	All other decisions taken outside of supervision should be recorded by the worker
d.	It is the supervisor's responsibility to ensure that staff are recording their decisions
e.	Decisions can be recorded in the following ways: By the manager on the Supervision Record; By the manager on the Manager's Action Sheet; By the worker or manager on the Chronology of Significant Events.

Equalities and Diversity in Recording Practice

a.	Recorded information, which can be used to monitor the development of policy and practice, must support practice which is responsive to ethnic and cultural diversity.  For example, the service user's ethnicity, language and religion must be recorded when requested on CareFirst.
b.	CareFirst must show, where it is relevant: How services respected social and cultural diversity; How services were sensitive to the various needs of people in the community; The continuing development of anti-discriminatory practice.
c.	Staff should avoid using stereotypical language and making assumptions based on stereotypes.
d.	Staff have an obligation to learn about the different ethnic, cultural, and religious backgrounds and practices of people they work with, to avoid making assumptions based on stereotypes. Staff should seek appropriate advice on these matters or check with service users when necessary.
e.	The case record must show how service users with language and communication needs were accommodated for to allow fair and equal access to their files.  Where specialist equipment was needed, the case record must show how the service user was helped to use the equipment if they were unfamiliar with the equipment.

Balance

1. Recording should give due weight to both the strengths and vulnerabilities/stress factors of the individuals and families being discussed. 

Recording of Criticisms or Allegations Against Staff

1. It is not appropriate for criticisms and allegations against staff to be recorded on the service user's record, as the record can be accessed by many different parties.  They should be held separately by the Group Manager;
2. Copies of complaints should be held by the Group Manager separately from the service user's record.
3. The fact that a complaint has been made should be noted in the service user's record on CareFirst.  

8. Management Overview

a.	All managers are responsible for ensuring staff have appropriate training and development opportunities to learn and produce high quality professional recording.
b.	Group Managers are responsible for ensuring that case records: Are being used effectively to plan work with service users; Are aiding the assessment and decision-making processes; Reflect practitioners' involvement with service users; Accurately record the progress of the care plan or the work on the service being requested; Are kept in accordance with this policy; and Contain care plans that are outcome focused.
c.	Supervisors should review case files at a minimum of every 3 months.
d.	Group Managers and Deputy Managers should carry out an audit on five randomly selected files every month.

9. Information Technology

a.	The Data Protection Act 1998 places a responsibility on the council to ensure the security and confidentiality of all personal information at all times (Principle 7).
b.	The security of IT systems is the responsibility of the department's IT service. However all staff have a duty to abide by general rules pertaining to the use of systems, especially: i. Not sharing their password to the system; ii. Ensuring that they log out of systems when they go home or leave the computer for any length of time; iii. Ensuring the safety and security of floppy disks in their possession, and of portable computers.
c.	Please see Bromley's ICT Procedure for more detailed guidance.

10. Message Technology

Facsimiles

1. Information that is confidential within the department (for example containing sensitive personal information such as information relating to a medical condition) should not routinely be sent by fax;
2. When sending or receiving faxes containing personal information, staff will need to ensure there is someone standing by the fax machine at both ends in order to guarantee confidential receipt of the fax;
3. All fax messages must include an authorised front sheet, which contains the agreed privacy and confidentiality notice, in case of transmission error.  This is particularly important for highly confidential material;
4. The receipt and transmission of fax messages should be noted in CareFirst; the message should be scanned into CareFirst (once this facility is available), and a photocopy of the fax should be stored in the paper file;
5. The images on certain fax paper fades over time and will eventually become unreadable. Faxes must therefore be scanned into CareFirst immediately and not saved on the paper file to be scanned at a later date;
6. If a worker realises they have sent a fax to the wrong number, they must report this to their line manager immediately so that follow-up action can be taken.   

E-mail

1. Workers should avoid sending messages containing information about a service user via external emails (e.g. to NHS colleagues), as these messages are not secure;
2. Internal email messages should not be included in CareFirst. External email messages (e.g. from health visitors) should be cut and paste into Care First records.

11. Service Users Rights

1. The views of parents, carers, children and young people should be sought at each stage of the decision making process and noted on the record;
2. Parents and children/young people are given the opportunity to record their views, for example on LAC consultations and the assessment framework forms;
3. A child has a right to be protected by the state, so if a decision is made NOT to intervene, the reasons for this must be clearly documented to avoid future negligence claims;
4. Where a local authority departs from right under the conventions (for example by issuing care proceedings, which is contrary to Article 8, the 'Right to respect for family life and private life'), then the reasons for the decision must be explicitly recorded.

12. Management of Paper Files

1. Recordings on CareFirst should not be printed off and put onto paper files. In due course, through CareStore, paper files will be phased out and scanned into CareFirst;
2. Printouts of recordings must be filed in the appropriate sections of the paper files. Loose papers or notes, for example telephone messages, should not be attached or placed in the paper file. Messages should be recorded in the appropriate section;
3. All paper files must be kept in a secure locked cabinet;
4. Paper files in current use will be known as the working file and will not have a volume number;
5. When the file is full, it should be stored and given a volume number;
6. Files should be kept in the filing system at all times they are not actually being used;
7. All files should be returned to the filing system at the end of each working day;
8. No files should be kept in desk drawers and the filing cabinets should be locked at the end of each working day;
9. No file should be taken out of the office without the permission of a manager and a note of the file(s) being made in the team diary;
10. If removed from the office, files must never be left unattended e.g. in a car;
11. Where the files are found to be missing, a record of this should be lodged with the appropriate administrative officer. 

5.  Confidentiality Values and Principles

Each of the following values is summarised in this Section. Also see guidance relating to confidentiality and information sharing, in Information Sharing Guidance - to follow.

5.1	Principles of Confidentiality
5.2	Personal Information is subject to a legal duty of confidence
5.3	Disclosure of confidential information in exceptional circumstances
5.4	Freedom of Information Act 2000

5.1   Principles of Confidentiality

The introduction of electronic case recording has resulted in much greater accessibility to individual records to those involved in a case. This does, however, increase the risk of information being used insensitively or inadvertently being disclosed to someone inappropriately.

See National Information Sharing Guidance

Whilst there is no such thing as a totally safe system it is important to take appropriate measures to safeguard personal information. To help consider how best to record and store this information safely, the Children's Social Care Service has adopted the concept of three different levels of confidentiality. Workers must take this into account when collecting and recording information. The levels of confidentiality are:

5.2  Personal information is subject to a legal duty of confidence

All personal information is subject to a legal duty of confidence.  The legal framework for confidentiality is contained in common law, the Human Rights Act 1998 and the Data Protection Act 1998. All staff are obliged to safeguard information held about our users and are personally responsible for any breach of this statutory responsibility. 

5.3  Disclosure of confidential information in exceptional circumstances

As far as possible, a worker should seek consent before disclosing personal information, even to other care agencies.  If consent is not forthcoming, information can be disclosed in circumstances when the individual’s right to confidentiality is superseded by the need to comply with a statute, court order, where there is a serious risk to public health, a risk of harm to other individuals particularly children or for the prevention, detection or prosecution of crime.  If disclosure is made without consent, a careful record needs to be kept of what has been disclosed.  Also, only the minimum personal information necessary should be disclosed.  Information should not be disclosed to a non-agency body or person without first seeking legal advice. 

Workers are allowed to exchange necessary personal information with other care or health agencies when enquiries are being pursued under Child Protection Enquiries (Section 47 of the Children Act 1989).

5.4  The Freedom of Information Act 2000

Under the Act anybody may request information from a public authority (which includes all local authorities).  The Act confers two statutory rights on applicants:

1. To be informed in writing whether or not the public authority holds the information requested;
   
   and if so
2. To have that information communicated to him/her.

The Act applies to all information whether recent or old.

The Act sets out 23 exemptions from rights of access to information.  If the information is exempt, there is no right of access under the Act.

One exemption relates to personal information.  This means that an application for personal information under the Act is exempt and will not therefore be dealt with under the Act.  A person’s right of access to such information must still be dealt with in accordance with the Data Protection Act 1998. 

Another category relates to information provided in confidence where disclosure would involve an actionable breach of confidence.  This would include information provided by a member of the public about a child protection issue where the provider has provided the information on the basis that anonymity will be maintained. 

The Act therefore does not change the legal position into the principles of confidentiality set out in paragraphs 5.1 to 5.3 above.

6.  Consultation Values and Principles

People’s views should be sought and taken into account in relation to all decisions, which are likely to affect their daily life and their future.

The older and more mature the child is, the more weight can and should be given to their wishes and feelings. 

Unless there are exceptional circumstances, reasonable steps must be taken in all cases to consult the parents.  Exceptions will include where older children with an appropriate level of maturity specifically request that their parents are not consulted and a decision is made to respect their wishes. 

Consultation should take place on a regular and frequent basis with those who need to be consulted and assumptions should not be made about the inability or lack of interest of those who should be consulted.

Where people have communication difficulties of any sort, suitable means must be provided to enable them to be consulted, including arranging access to advocates or representatives who may speak on their behalf. 

If consultation is not possible or is restricted for whatever reason, steps should be taken to ensure those affected are informed of decisions as soon as practicable after they are made, and an explanation for the decision given, together with the opportunity to make a comment and express their views. 

If it is then felt that a different decision may have been appropriate, steps should be taken to reconsider the decision.

If decisions are made against people’s wishes, they should be informed of the decision and the reasons for the decision should be explained.  In these circumstances, the person should be informed of any rights they have to formally challenge the decision, and of the availability of the Complaints or Grievance Procedure.

Appendix 1: Security and Confidentiality Undertaking

See Security and Confidentiality Client Case Records Procedure

End