All children should have an individual electronic case record, even though there may be many children in the family.Case records must remain confidential and ensure that they take account of equal opportunities. A good case record will contain accurate, concise recording with clear analysis. Significant events should be reflected in an associated chronology .
- This policy covers all manual & electronic information held, in relation to service users, by the department or by individuals acting on its behalf.
- Accurate recording is deemed an integral part of case management and good practice. It is a priority task and not a secondary activity and case records should be written within 24 hours of the event.
- The case record is used to bring together information from a number of sources to enable effective professional analysis.
- Case recording is monitored as part of the staff supervision process to assist staff in their professional development and for managers to monitor the work.
- Case records will assist continuity when workers are unavailable or change.
- Case records should be signed, dated and professional designation stated.
- Case records should contain: content, the source and the means by which the information was conveyed.
- Case files must include key information relating to the child and their family that will assist in providing a source of evidence for assessment of need, investigation and inquiries.
- Running records for visits should always include:
- nature of contact, date, time, place and the date and time that the record is being written,
- purpose of visit,
- who was present,
- what was discussed,
- what was observed,
- differentiating between fact and opinion,
- decisions taken,
- actions agreed.
- A common language should be used, free from jargon, abbreviations and acronyms, to assist clear recording.
- Closed files are stored & identified through a clear filing system in conjunction with the case closure policy.
- Archived files are organised through a structured system and kept in an identified secure place as identified via the archiving policy.
- Specific recording for looked after children and child protection should be recorded using appropriate episodes in the computer system.
- Any recording of legal advice will be subject to legal professional privilege and should be stored in a separate part of the manual or electronic file. Such information should not be disclosed externally without the permission of the department's legal advisers.
Legal aspects case recording
- It is important to avoid basic factual errors (e.g. getting people's names and dates of birth wrong).
- Basic errors can impact on the trust and confidence between professionals and family members - a parent or carer may well think that if you cannot get the name of their child right then everything else you do is compromised. It is also not going to convey a positive impression.
- The birth certificate is only a starting point because when those with parental responsibility act jointly, they have an absolute right to name and rename their child. This applies to all of a child's names. It is a myth to think that a child's name can only be changed by a legal document (e.g. 'deed poll') - such legal documents are merely evidence of a change of name (although on occasion such evidence may be required - e.g. to issue a passport in a new name and obtaining a legal document is generally advisable to avoid future confusion).
- In reports for Court (or the Tribunal) the child's full name should be as recorded on their birth certificate or subsequent deed poll (or similar) is used on the front page and if the child is known by another name this is set out in detail and explained at the beginning of the report / statement / plan (preferably on the front page). If it is considered more appropriate, it is acceptable to use the most commonly used name for the child throughout the report provided it has been clearly established and set out the registered name at the commencement.
- Remember most if not all documents prepared by children's social care can end up before the court or Tribunal so it is strongly advised that the same rigour on getting names and dates of birth correct is applied in all documents.
- Caution and sensitivity should be exercised in relation to certain ethnic minorities and one must not assume that everyone will have a surname in the 'usual' sense of a family name or that the family name will necessarily come last. The Judicial Studies Board gave advice to Judges on naming and naming systems (particularly in relation to Muslim, Hindu, Sikh and Chinese communities) which it may be appropriate to reference.
- Remember that a child's name occasionally can be the source of dispute between those with parental responsibility If there is a dispute, that should be noted.
- The legal position in relation to how children are referred to when they are looked after is a little more complicated. The surname of a child can only be legally changed (from the registered name) with the consent of all those with parental responsibility or a court order. Accordingly, the Department cannot unilaterally allow a child to be known by a new surname, even if the Department shares parental responsibility. In the absence of the consent of all those with parental responsibility, it would be rare (at least in England and Wales) for a court to agree to a change of surname unless there was strong cogent evidence of the issue of the name impacting adversely on the child's welfare. It is anticipated that the court's in the Bailiwick would adopt a similar approach.
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