10.3 Case Recording

Part 1: Record Standards Policy

Executive Summary

This policy sets out a framework of standards for electronic and paper recording within Adult Services which will apply to practitioners and managers in Adult Services.

• high quality recording is essential to the delivery of effective adult services;
• the production of case records is governed by national data protection legislation together with guidance from the Health and Care Professions Council and the Care Quality Commission;
• accurate recording is essential from first contact to case closure;
• all staff involved in managing records will receive the necessary training and formally acknowledge their duty of care with regard to records.
• the case record is the main record of involvement with and service to someone who uses services arranged by the Council;
• record keeping is central to the processes of assessment, decision making, service planning and delivery, which ensure that providers meet the expected standards of service;
• information from case records will inform the review of services to individuals and decision making for commissioning and policy development.
• case records must provide accurate, factual, verifiable information and specify where they are based on direct observation by the staff member;
• case records are essential to effective safeguarding services requiring accurate and detailed recording of ongoing work including risk assessments and safeguarding plans. This will be scrutinised during inspections of Adult Services;
• effective recording should promote an effective working partnership with service users and carers through the construction of shared records wherever possible. Records should show evidence of how information has been shared with the user and access promoted;
• decisions made in supervision should be clearly recorded as an integral part of the main case file;
• each service user will have a separate case file recording every contact and decisions taken with clear recording of the assessment, care plan and the service and standards of services provided. The feelings and wishes of the service user and carer and will be recorded along with any management authorisations;
• the case / key worker is responsible for ensuring that the case record is to the required standard, complying with this policy and any additional guidance;
• routine monitoring and auditing of case records will be undertaken by operational managers on selected files or cases against the records checklist in Appendix 1: Case Records Checklist – Quality of Record of Referral, Assessment, Planning and Review;
• senior managers will support supervisors monitoring case files and formally monitor selected case records against the records checklist in Appendix 1.

1.1 Policy statement

Bedford Borough Council is committed to the provision of high quality recording as essential to delivery of Adult Services in the following ways by ensuring that:

• the standard of case recording will meet national and local policy requirements;
• high quality case recording will be an essential part of the planning and delivery of services;
• records include the views and wishes of service users in the design of services they receive;
• case records are an essential part of supervision for all staff;
• recording can be used as evidence for staff and managers to justify explain and account for their actions;
• information from case records informs the review of services to individuals and decision making for commissioning and policy development.

1.2 Legislative framework

1.2.1 Legislation

• National Health Service and Community Care Act 1990 / Care At 2014: the local authority has the duty to assess the need for community care services decide whether to provide services as a result of that assessment and to involve health and housing agencies where needed to provide services;
• Data Protection Act 1998 regulates access to and disclosure of personal and sensitive data held both manually and electronically.
• Human Rights Act 1998: Article 8 of the Convention includes a right to respect for an individual’s private life thus reinforcing the principle of non-disclosure laid down in the Data Protection Act;
• judgement of the European Court of Human Rights 1989 (Gaskin vs UK) which found a local authority to be in breach of the Human Rights Act for failing to grant access to records;
• Crime and Disorder Act 1998 permits information to be disclosed to the police, probation, health and the local authority for the purpose of preventing crime and disorder.

1.2.2 National Guidance

• Health and Care Professions Council Standards of Conduct, Performance and Ethics, Section 10, You must keep accurate records;

1.3 Relevant policies and procedures

• Bedford Multi-Agency Safeguarding Adults Procedures: accurate case recording is particularly important in safeguarding vulnerable adults and this policy identifies standards in recording alerts, and minutes of case conferences;
• Bedford Customer Records Management Policy: how records will be managed for accessibility and confidentiality;
• Supervision policy: standards in recording of supervision sessions;
• Bedford Handling an Incident Policy: includes need to know policy and procedure and identifies records which are to be made of specific incidents and referred to the Executive Director;
• Operational Procedures relating to care management process, single assessment process, CPA process
• Bedford Access to Records Policy: a person’s right to access their records and the correction of inaccuracies;
• Bedford Disclosure Of Personal Records Policy: the circumstances in which confidential records can be disclosed. Local authorities have a general duty in common law to safeguard the confidentiality of personal information under which they hold in connection with their social services function. Any disclosure of personal and sensitive information should only be carried out within this policy;
• Your Right to see your Record: leaflet for service users and carers advising them about their right to have access to their records.

1.4 Definitions

Assessment
Assessment is the process whereby the needs of an individual are identified and their impact on daily living and quality of life evaluated”. The objective of the process is to determine the needs and/or eligibility of a person for health or social care services and any other services (e.g. housing, benefits that may be needed to maintain their independence).

Capacity
A person’s capacity is their ability to make particular decision at the time it needs to be made. Lack of capacity may be due to impairment of, or disturbance in the functioning of, their mind or brain.

Care and support plan
A care and support plan is details of how the needs of a person receiving self directed care might be met.

Care management
Care management is the process of tailoring services to a persons needs from first contact, assessment and review to termination of the case.

Care plan
A care plan is details of services, which are directly provided to a person following assessment of their needs.

Case audit
A case record audit is the systematic appraisal of the record using the Case Record Checklist.

Case records
For the purpose of this guidance, case records are defined as the main record of involvement with, and service to, someone who uses services arranged by Bedford Borough Council. This may be held electronically, in hard copy, or in some combination of these.

Case record checklist
Is the form for systematically assessing whether the case record is complete, with all relevant documentation and evidencing the required quality of service

Commissioning
The Department of Health document “An introduction to Joint Commissioning” 1995 defines commissioning as the “strategic activity of assessing needs, resources and current services and developing a strategy of how to best make use of available resources to meet needs”

Eligibility
People are eligible for services if they have needs which entitle them to services within the council’s eligibility criteria which are the full range of needs that will be met by the council taking their resources into account.

Performance and quality management systems
Performance and Quality Management systems monitor the extent to which services are meeting individuals’ needs

Provider agencies
Provider agencies delivering services to an individual directly, on a contract or by direct agreement with a person who is self funding

Referral
A referral is when a first contact to Social Services requires further investigation or assessment to see if the person is eligible for services. It is at this point of recording a referral against a person on SWIFT that the person becomes the Service User.

Review
A review is an examination of needs and services provided by a care or support plan that must include a (formal) re-assessment of need.

Risk
The level of risk is the likelihood of harm occurring in a situation. This could include the service user, and anyone having contact with them including carers, staff members or the general public.

Safeguarding procedures
Safeguarding Procedures are the multi – agency response that is made to every adult who is eligible for services and whose independence, well-being is at risk due to abuse or neglect.

Self-directed care
Self-directed care is where care and support and resources are provided for the individual within an agreed care and support plan to meet the agreed outcomes however they choose.

Service user 

The service user is the person for whom the service has been provided.

Supervision
Supervision is the formal process of management and support provided by a manager to a member of staff.

Third party
A third party is anyone other than the service user about whom there is information in the case record and who may need to consent before their information is disclosed.

Unsubstantiated and un-attributable information
Unsubstantiated and un-attributable information is Information that cannot be verified by reference to facts or has been provided anonymously.

1.5 Background

This policy has been produced to ensure that case records in Bedford Borough Adult Services meet the Care Quality Commission recording standards. Case records have come under greater scrutiny during recent inspections of local authority safeguarding services. Effective safeguarding services require accurate and detailed recording of ongoing work including assessments and safeguarding plans. This includes high quality strategy meeting and case conferences minutes, together with evidence of supervisory oversight by managers recorded on the main case file.

This policy framework establishes a set of standards for electronic and paper records held by Bedford Borough Adult Services which will apply to practitioners of all levels, to managers in monitoring the standard of recording and administrative staff in recording minutes of meetings and case conferences.

It is critical to acknowledge and incorporate into everyday practice that:

• the record is present;
• the record can be accessed;
• the record can be interpreted;
• the record can be trusted;
• the record can be maintained through time.

All staff that create, use, manage or dispose of records have a duty to protect them and to ensure that any information that they add to the record is necessary, accurate and complete.

All staff involved in managing records will receive the necessary training and formally acknowledge their duty of care with regards to records.

Record keeping is central to the processes of assessment, decision making, service planning and delivery and is an integral part of the service to service users and carers. It is recognised that good recording supports good practice in a number of ways:

• ensures that the practitioner and agency have met the expected standards of social care;
• supports effective partnerships with service users and carers;
• assists continuity when workers are unavailable or change;
• provides documented evidence and account of the department’s involvement with an individual service user;
• provides an historical perspective and evidence for planning and allocating resources at an individual and strategic level;
• facilitates reflection, analysis and planning;
• supports the formulation of risk assessments and risk management plans;
• supports supervision and professional development.

Good case recording helps to focus the work of staff ensuring a documented account of their involvement with individual service users, families and carers. It is essential for continuity of service when workers are unavailable and for managers to monitor actions. It is additionally a major source of evidence for investigations, enquiries and the management of complaints. Over the past 25 years, inadequate or unclear case records have often been cited as a factor in cases with tragic outcomes.

Best practice in recording is based on key principles of partnership, openness and accuracy. Effective recording is part of the total service to the user; it promotes an effective working partnership with service users and carers. This includes constructing and sharing written records. Gaining clearance to share information provided by another person with service users in the normal course of day-to-day work is an effective way of ensuring that access to records is minimised.

All Adult Services staff should tell service users why and when information is to be transferred or exchanged between different parts of the service and with provider agencies. They should secure their agreement to this process and ensure that this is clearly recorded. This is an important aspect of people’s rights and should mean that, when service users have access to their records, the contents are an accurate record.

Working in this way should promote greater diligence of recording. Fact will need to be distinguished from opinion, issues discussed, the actions agreed and the reasons for decisions made, should be succinctly recorded.

Case records will need to contain evidence of the assessment and a statement of objectives for the work to be done. There should be a balance between running records and periodic summaries and reviews. Records should show evidence of how information has been shared with the user and access promoted. This could include copies of key records being given to the user or signatures on file to show that these have been discussed with the service user.

Equally, Adult Services managers need to demonstrate a commitment to case recording as an important part of the service to users and carers and to ensure that policy and procedures are established. The commitment should be explicit and reflected in recruitment, induction, training, performance appraisal, auditing, monitoring and review.

Throughout the process of assessment and intervention and the writing of the record, management oversight should support work and ensure accountability. Decisions made in supervision are a significant part of the record for service users and they should be clearly recorded and held on the main case file as an integral part of the record.

Safeguarding case records are the main source of evidence of the experience of people who use services who may have been subjected to abuse. It will also be essential to record risk assessments carried out when establishing self directed care arrangements and to ensure that the necessary assessments of capacity and best interests are recorded where there are any issues of capacity.

Case records may also provide additional evidence for commissioning, workforce development and performance and quality management systems; they therefore may contribute to the evidence base for the capacity to improve judgement.

1.6 Recording Standards

The Case Record

Case records are official records, which are called by courts, coroners, inspectors and investigators in the event of a significant issue arising. Upon such requests there will be no opportunity for correcting, editing or adding to the content of case records. Thus, what is written at any one time is what will be regarded as the whole of the record and anything, which has not been recorded, is likely to be viewed as not having happened. Therefore good record keeping is essential if Bedford Borough Council is challenged to evidence that all decisions made were not taken unlawfully or with mal administration. Both electronic and paper records will be accurate, up to date and secure. The following standards will apply equally to both.

Clarity, coherence and evidence base are important factors for recording on paper or on an electronic system. It is the quality of recording that allows case records to provide a clear account of individual cases.

Each service user will have a separate record. Essential key components of each record will ensure that:

• every contact concerning service users is recorded. All entries should identify purpose of visit; meeting or telephone contact should be recorded daily
• there is an accurate initial referral for each initial referral for each episode on care which has sufficient information attached;
• any decisions taken are recorded and clearly identified;
• that the evidence on which decisions is based is clearly shown;
• there is clear evidence on the record showing when copies of key documents (e.g. assessments, support plans, reviews and minutes of meetings) are supplied to service users or carers;
• the feelings and views of the service user are recorded on file under clear headings;
• the full name and job title of the member of staff making the record are clearly identifiable at appropriate points;
• the assessment of the person’s eligibility for services will be clearly recorded and identifiable, and the content of the assessment and review of needs will be in accordance with care management and local processes;
• records will show that service users and carer:
  o have been consulted;
  o have had their views recorded; and
• Adult Services have been informed of decisions and plans where the service user agrees to this information being disclosed or where the carer has significant involvement in their care.

Case summaries must be kept up to date to provide an accessible overview of each case.

Records must indicate appropriate authorisation from managers. Where a decision has been reached that includes details of legal advice received, the name of the person offering the advice and the date of the advice must form part of the record.

The content of case records should be:

• accurate and to the point;
• up to date;
• relevant;
• easy to read and in plain English;
• easily understood by the service user / carer;
• recorded within 48 hours of the event (records should be made soon after the event);
• in relation to any record relating to a safeguarding investigation all events must be recorded as soon as the event has occurred and within 24 hours.

All service user and carer files will have the following information:

• an accessible data sheet with accurate key personal information;
• risk information, which identifies for those who may not know the service user how to identify and manage risk;
• an accurate initial referral with sufficient information on each period of service;
• a record, which demonstrates a holistic assessment, has been completed;
• a support plan / personalised budget which set out the detail of all support for the service user with expected outcomes;
• all files have review records at the frequency required by their changing needs.

There must always be good reason for recording and continuing to hold any information on service users and third parties and workers must always distinguish between fact, judgement and unverifiable information.

The amount of information collected and recorded must be the minimum necessary for the particular purpose, but be complete. The record must contain all essential information appearing to be relevant relating to a particular decision or purpose.

Information recorded must be accurate and relevant and the content of case records will include the feelings and views of the service user, carer, direct observation descriptions by the worker and factual, verifiable information.

In each case any non factual information (including opinions or assumptions) must be clearly identified and recorded in a separate sentence or paragraph to factual information.

Unsubstantiated and un-attributable information will be recorded on the file only if it is judged to be of current or possible future significance. The status of this information must be absolutely clear. Attempts should be made to check its accuracy as quickly as possible and to record the outcome.

All decisions must be recorded indicating who was involved in the decision making, what information was taken into account and the reason for the decision. This includes judgements, assessments or evaluations that have been reached:

• a collective view of the service user’s circumstances by more than one professional or volunteer (for example a case conference);
• where they have been agreed with the client.

Where there is unresolved disagreement with a service user about the recorded information this should be recorded, stating the area for disagreement.

There will be occasions where ‘detailed’ recording will be required and is likely to be used to cover what might be seen as significant events, for example safeguarding adults. It should be noted that, even where a detailed recording is required, this should still be as concise as possible.

All documents associated with case records should clearly have a written signature of the individual responsible for creating the document and be signed off by the responsible line manager. This includes assessments, reviews, and letters etc. that have been completed by the individual worker.

All assessments, support plans and reviews must have the signature of the service user / carer or nominated legal representative who has the legal authorisation to sign on behalf of the service user.

1.7 Records Standards Responsibilities

Adult Services managers need to demonstrate a commitment to case recording as an important part of the service to users and carers and to ensure that policy and procedures are implemented. The commitment should be explicit and reflected in recruitment, induction, training, performance appraisal, auditing, monitoring and review.

Managers will clearly relay to staff expectations and requirements relating to case records and the systems in place to monitor standards. Those systems include:

• discussions on the quality of the recording and the content of files with the team manager as part of regular supervision and a recording of the discussion and decisions entered in to the file using the supervision pro forma;
• routine monitoring by managers of case records and efficiency of case recording practice, through regularly auditing selected files or cases against the checklist in Appendix 1 as set out in more detail below;
• compliance with relevant legislation regarding the monitoring of case records, for example the CQC’s Fundamental Standards.

The case / key worker is responsible for ensuring that the case record is kept up to the required standard and complies with the policy and procedural guidance on care records.

Part 2: Case Recording Auditing Standards

2.1 Introduction

The auditing of case records is an essential component of the management of service quality. The aim of the auditing procedure is to develop a culture in which adult services records are regularly examined and that this is seen as a routine method of management assessment and feedback to staff as to the quality of their work and service delivery.

2.2 Objectives of Auditing

The objectives of auditing are to implement the procedure by using the Case Record Checklist (see Appendix 1) to identify whether:

• the file is up to date, contains all the relevant documentation and that the documentation has been properly completed;
• the quality of the data recorded on file is relevant, useful for future decision making and reflects good practice.

2.3 Principles

Reading case records and making judgements about work done is a fundamental part of improving service delivery to our customers and to evaluate the quality of the work we undertake.

Time spent on the reading of case records must be proportionate to its relevance to national standards and outcomes as well as to the purpose of the record inspection.

The reading of non-safeguarding case records must relate to both national and local standards and outcomes and must include capacity for improvement where appropriate.

Case records should not be considered as the only source of evidence of outcomes for people who use services and their carers.

Managers should not feel constrained to limit their inspection to one case record especially if the case record identifies potential issues with case recording.

2.4 Why do we read case records of people using services?

• Case records contribute to the evidence of people’s experience of using services and that of their carers.
• Analysis of case records can reveal whether the management of casework and the quality of safeguarding investigations is providing positive outcomes for people who use services and their carers.
• Case records demonstrate how well the Council understands and addresses the needs of their diverse populations and ensure equality of opportunity and outcomes.
• Safeguarding case records are currently the main source of evidence of the experience of people who use services who may have been subjected to abuse and their carers.
• Case records may provide additional evidence about commissioning, workforce development and performance and quality management systems.

2.5 Case Record Checklist

Purpose
The Case Record Checklist is designed to assure high quality performance in recording and filing (to include electronic records and paper recording) throughout the care management process including Single Assessment Process and adults safeguarding. This will enable continued monitoring of all activities relating to core personal data, all assessments of needs, care planning and reviewing

Benefits

The continued use of the Case Record Checklist will provide evidence of current practice existing within Adult Services. Further benefits will extend to:

• improving staff competence;
• informing the supervision process;
• contributing to team plans;
• identifying further individual training needs;
• improving service delivery;
• monitoring performance through regular management reports.

This Case Record Checklist should be used for all audits except those relating to safeguarding adults investigations; there is a separate safeguarding adults audit process to use for this.

Auditing Record Standards
This guidance applies to all case records however a separate audit process exists for safeguarding investigations which is detailed in the SOVA Toolkit for lead investigators and managers.

All records must be audited using the case record checklist attached to this policy in Appendix 1.

All team managers (including senior practitioners / operational managers) are required to audit a minimum of two randomly selected cases (per supervisee) prior to each supervision meeting with supervisees. During the supervision session all managers will clearly identify case record issues with the supervisee and implement an action plan accordingly.

• A record of those cases audited by line managers will be made available for checking with their line managers in supervision. Where actions are required, these will be recorded on the supervision form with the required dates.
• Service managers will inspect three cases per month of each of their teams within their service responsibility using the case record checklist. Any issues identified from those cases inspected will be discussed with the member of staff and line manager with an appropriate action plan. It is the responsibility of the service manager / head of service to monitor the execution of the action plan and outcomes.
• Assistant directors will inspect three cases per month within their service division using the Case Records Checklist in Appendix 1.
• Where there are consistent concerns about the standard of recording or where there are significant failings in the standards of records it is the responsibility of the line manager to escalate such concerns to the service manager / head of service where an appropriate action plan will be implemented and when required disciplinary action to be taken.
• Periodic audit inspections will be independently carried out by the Performance, Policy and Practice Improvement Unit and the outcomes of the inspections will be relied to the worker / line manager and service manager / head of service. A summary of periodic inspections will be made to the Senior Management Team and actioned.
• The Adult Services Senior Management Team will receive a quarterly report on the number of audits completed per team based on:
  o supervisor (including senior practitioners / operational managers);
  o service manager;
  o assistant directors.

This report is available for daily monitoring on the current SWIPE information system and updated on a daily basis.

Completing the Case Record Checklist

All management staff with a supervisory responsibility are required to audit a certain number of records each month, using the Case Record Checklist.

The Case Record Checklist is available on the Social Care Database, in Profile Notes on the selection of Print options. It is necessary to be in the client’s record in order to complete and attach an electronic version of this document. Once the document has been completed, save in line with current procedures and store in the Adults Record Audit Folder in the X shared Drive.

All Case Record Checklists will be stored in the X Drive Adults Record Audit Folder in line with the current naming convention for all documents.
The file naming convention is a standard way all Adult Services client information should be saved. It is: Swift ID_Surname_Initial_date (yymmdd)_description.

• Click Save. Once saved, the name of your document will appear at the top left corner of the screen.
  After saving the Case Record Checklist to the X Drive, record a Profile Note in SWIFT and attach the checklist to it. In Profile Notes, select the appropriate Profile Note type:
• Adult – Audit Supervisor’s checked & completed (to be completed by Senior Pracs and Operational Managers);
• Adult – Audit Service Manager checked & completed;
• Adult – Audit Assistant Director checked & completed;
• Adult – Audit Independent Auditor checked & completed (to be completed by Performance Unit and External Assessors) Record the date of completion into the date field, complete the other fields in line with current business process and save.

To attach the Case Record Checklist to the Profile Note, use the Attachments button.

Attaching Documents to Profile Notes

• Click the Attachments button. The attachments window opens.
• Click in the next blank line in the Attachment Name list.
• Click Find.
• Use the File Open window to locate the document you saved earlier.
• Highlight the document and click open.
• Your document will now appear in the attachments list. Click Back.
• You will receive a message confirming that the attachment has been made. Click OK to return to Profile Notes.

Note: If you are attaching more than one document to a record, click Back to exit the attachments screen in between attaching them. If you do not, the first document may be overwritten with the second attachment.

• It should be noted that any continuing practice under-performance highlighted by use of the Case Record Checklist should be addressed in supervision and in the supervisee’s PDR as necessary. This will enable appropriate training to be identified and will establish whether there are grounds for invoking the capability procedure.
• Collective practice under-performance highlighted by use of the Case Record Checklist in supervision should be addressed in the Team Plan e.g. where specific applicable Performance Indicators are being adversely affected.

Performance Reporting

It is critical that all Case Record Checklists undertaken must have a Profile Note completed to confirm that an audit has occurred. Information recorded here is extracted to produce a monthly Performance Management report for the Executive Director of Adult Social Services.

Appendix 1: Case Records Checklist – Quality of Record of Referral, Assessment, Planning and Review

Click here to view Bedford Case Records Checklist

• – End –