1 Social work recording
1.1 What do we mean by social work recording?
We mean all the written material contained in the social work files of people using social work services. Social work files may be wholly or partly electronic or they may be in hard copy.
Recording is a crucial part of day to day social work practice and takes up a substantial amount of practitioners' time. Recording involves:
- writing down the work you do;
- noting the progress people make towards their desired outcomes;
- including the views of the person;
- analysis and assessment; and
- the life history of the person and its interpretation.
Good records are an essential tool for practitioners to reflect on their on going work with people and plan future work. When shared with the person whose file it is they encourage transparency.
Recording is also part of the code of practice for social services workers 1 published by the Scottish Social Services Council ( SSSC). The purpose of this code is to set out the conduct expected of social service workers and to inform people using social work services and the public about the standards of conduct they can expect from social service workers. Recording comes under section 6:
'As a social service worker you must be accountable for the quality of your work and take responsibility for maintaining and improving your knowledge and skills.'
'Maintaining clear and accurate records as required by procedures established for your work.'
1.2 What is the purpose of social work recording?
- documenting the involvement with the individual;
- informing assessment and care planning;
- enabling practitioners to review and reflect on their work;
- assisting practitioners to identify any patterns;
- ensuring accountability of staff;
- meeting statutory requirements;
- providing evidence for legal proceedings;
- enabling continuity when a new worker takes over the case;
- providing performance information;
- forming a biography - for example, for a looked after child to read at a later date to provide them with their history;
- providing evidence for inquiries or reviews; and
- assisting partnership working between workers and people using their services.
1.3 Good recording should:
- be drawn up in partnership with the person whose record it is;
- record the views of the person whose record it is, including whether they have given permission to share information;
- be an accurate up to date record of work, which is regularly reviewed and summarised;
- include a record of decisions taken and the reasons for these decisions;
- include a chronology of significant events; 2
- be evidence based and ethical;
- separate fact from opinion;
- incorporate assessment, including risk assessment where appropriate;
- include an up to date support/care/action plan; and
- record race/ethnicity, gender, religion, language, disability.
1.4 Information sharing
Data protection legislation has given people who use services greater access to what is written about them. Front line workers must bear this in mind when they are writing in their files. This can require some professional sensitivity when workers write down what they consider the necessary information about a person they should be aware of how it would feel for that person to read what they have written.
Effective joint working depends on practitioners regularly sharing personal information with other agencies. Practitioners should be open and honest with the person (and/or their family where appropriate) from the beginning about why, what, how and with whom their information will, or could be shared. Practitioners must seek people's agreement to share their information, unless it is unsafe or inappropriate to do so.
Information sharing has a key role in the assessment and management of risk. The Multi-Agency Public Protection Arrangements, for example, place a duty on agencies to co-operate with the responsible authorities (Police, local authorities, the Scottish Prison Service and the Health Service) and this includes information sharing.
Social work services have information sharing protocols in place with guidance for practitioners. National guidance is provided on the Scottish Government website and there is a helpful pocket guide produced as part of HM Government information sharing guidance. 3
1.5 What practitioners say about recording
Despite recording being a key part of social work practice, front line staff often experience it as a tedious chore that gets in the way of practice rather than enhancing and enabling it. Practitioners often express the view that actually 'doing the work' is more important than 'writing it down.' Practitioners often complain that they now spend too much time in front of computers and that this is not why they came into social work.
Research 4 into social workers' attitudes to, and experience of recording found it to be a topic which provoked many strong and ambivalent feelings. Other issues reported were:
- lack of training in recording;
- variable standards in recording practice;
- some difficulties in reconciling the readership of files - in particular around sharing recording with people using services; and
- the view that recording had become a 'tick box' form filling task in recent years.
Feedback from local practitioner forums in Scotland reflected similar issues. Generally the forums welcomed this guide on recording, recognising good recording as core to social work. Staff found it hard to prioritise recording over other demands on their time, for example, home visits. Further, they were not always clear what level of detail should be recorded. They understood this depended on the type of work being done and the risks involved but wanted more clarity about this. For example making decisions on particular cases where summaries would be sufficient. They also said that forms or templates to be applied to recording were constantly changing. Electronic recording was welcomed by some and criticised by others. Some considered electronic files were inherently better organised, easier to read and accessible to other workers. On the other hand some practitioners found recording systems with a number of different fields and headings, though easier to complete, were harder to read than a traditional paper file.
1.6 Electronic recording
SWIA found electronic recording systems were being used to different degrees across Scotland. Some councils used primarily electronic records, others primarily paper ones. Most councils used a mix of electronic records and paper files and many were in transition. Not all staff had access to PCs and this was sometimes a barrier to good recording practice.
Some electronic systems were not designed to be printed out yet manual records remained in place. This could lead to neither record being complete with the danger that information could become fragmented or lost. During the transition from paper to electronic recording it is essential that staff cross refer between paper and electronic records. Information sharing and access are particularly difficult to arrange when the information is split between electronic and paper systems. Staff should be provided with clear guidance about what information should be recorded and where.
Lord Laming notes in his follow up report in March 2009 5:
"There are definite advantages to electronic record keeping in place of the previous often inaccessible paper files. Technology offers the potential for professionals to share information more effectively, to make information more accessible, and to use systems to manage the workflow of children's services."
He goes on to suggest that despite practitioners and managers being committed to the principle of electronic systems they had some concerns about their design. He heard from staff of fears that professional practice and judgements were being compromised by some recording systems. He found a wide variation of systems in England, some of which supported practice and some which did not.
There is no doubt that performance information can be gathered more easily from electronic recording systems. However care must be taken to ensure that both the casework and the management information functions can be served by the system in place. IT strategies need to be clearly linked with recording policies to ensure any developments in recording systems support professional practice.
To aggregate information from individual files, there needs to be some uniformity in what is recorded and in what form. Electronic records make this much easier. However front line staff complain that all too often they are asked to record information not immediately relevant to their day to day work with the person.
Accuracy in case recording is of fundamental importance whether the records are electronic or paper. A person's name spelt incorrectly or one digit being wrong in a date of birth can be replicated across the system with serious consequences. Information must be regularly checked for accuracy.
Recording in joint or integrated teams posed some difficulties. Practitioners in integrated teams sometimes had to record information about the people they were working with in two different formats. For example, information had to be entered on both the social work and the health system and neither accepted the other's agreed format. Some staff did not have easy access to both systems. In best practice, integrated teams agreed jointly what core information was required and allow practitioners to record the same information in both systems.
Advantages of electronic recording
- you can find information more easily when there is a crisis;
- no need to interpret illegible, handwritten case notes;
- much easier for you to immediately insert information - even if you are not the allocated worker;
- managers at all levels in the organisation are able to access individual case records relatively easily;
- ease of access for out of hour's staff and other agencies;
- enables information to be gathered about unmet need; and
- easier to set up performance information systems which allow aggregating of information from individual files.
The Scottish Government is developing the 'eCare' framework to enable the multi-agency electronic sharing of personal information using a multi-agency store. From 2009 the eCare framework could be used for electronic single shared assessments for people using community care services. It could also be used by children's services practitioners to share information relating to child protection. Further eCare developments will be the Getting it right for every child multi-agency assessment and within community care to support joint reporting on outcome measures.
The Lanarkshire Children's Services eCare Project designed, developed and piloted the child protection messaging framework for Scotland. Their child protection messaging pilot was the first live electronic information sharing for children in Scotland between social work, health and education using the multi-agency store. Child protection messages help practitioners within and among agencies to easily share information timeously and so enhance working together to protect children from risk of harm.
In summary electronic recording, which is becoming the norm, offers clear advantages for practice. The development of eCare enhances multi-agency information sharing and strengthens joint working. However some social work services are closer to full implementation than others and the transition from paper to electronic systems does pose short term challenges. It is essential that developments in electronic systems are explicitly designed to support professional practice.
1.7 National frameworks
Getting it right for every child
This is a new practice model that is being introduced in stages throughout Scotland. 6 The overarching concept of Getting it right for every child is that of a common, co-ordinated approach across all agencies that supports the delivery of appropriate, proportionate and timely help to all children as they need it. The practice model includes a structure for gathering and recording information on children and their families. This framework ensures that information is gathered in a consistent way which will make it easier for agencies to share what they know and as a result meet children's needs as soon as they are identified.
This new model provides practitioners with a structure for information gathering and should lead to more consistency in children's records. However it will still depend on practitioners' good information gathering and recording skills. This has been demonstrated in the earlier evaluation of the Integrated Assessment Framework pilots. 7 This found that parents and workers were able to see the benefits of the co-ordinated partnership approach in focussing on the child's needs but also drew attention to inadequacies in some of the recording. The report suggested that substantial changes were needed in recording to ensure that factual information was precise and its sources documented. They concluded that more attention was needed to recording the 'what, who, when, where and how of events, household routines, social interactions and networks'.
We found the new practice model to be work in progress and councils had not yet fully embedded the use of this framework. Data sharing arrangements were still problematic in some areas. Where councils and their partners had begun to use a common framework it still tended largely to be a social work document into which they 'cut and pasted' contributions from other agencies. The electronic framework and tools to support delivery are still being developed by Scottish Government.
Single shared assessment
The single shared assessment 8 is a national framework which has been designed to ensure faster access to the health and social care services people need by co-ordinating access through one lead professional.
The single shared assessment seeks information once, through a lead professional who co-ordinates documents and shares appropriate information, co-ordinates all contributions, and produces a single summary assessment of need. The assessment should actively involve people who use services and their carers and should seek to provide outcomes acceptable to them, and to all agencies that are involved.
The single shared assessment applies to 'simple', 'comprehensive' and 'specialist' assessments. 'Simple' assessments apply where needs or a request for services are straightforward and can be dealt with by a low level response. 'Comprehensive' assessments apply where the person has a wider range and complexity of needs. Comprehensive assessments are more likely to involve contributions from more than one agency. 'Specialist' assessments may apply to simple needs of a specific nature or particularly complex needs requiring investigation by a professional with recognised expertise.
Single shared assessment for older people was introduced from April 2003 and extended to all community care groups from April 2004. Although every area has an assessment tool, single shared assessments are not yet fully embedded throughout Scotland. Most single shared assessments are still completed by social work staff, rather than health or other staff. In some areas housing staff have been trained to complete simple assessments. Although progress has been made in some areas, there remain barriers to linking up the electronic systems of the different agencies.
Good recording cannot be achieved simply by providing a framework for practitioners to use. Front line staff also require support to develop their recording skills and the time to produce good quality records of their work.
1.8 The importance of recording - learning from inquiries
Recording is a vital part of the social work task and inquiries into social work service failures over the years have identified it as a significant area of concern. This is true across all care groups.
Here are a few examples from Scotland:
The investigation into the management of the post-release supervision of a sex offender in 2005 9 found that the supervising officer had kept only brief notes which made it impossible for anyone reading them to get an impression of the quality or content of the interactions with the offender. The notes were simply not detailed enough and were not signed every 2 weeks, as they should have been.
"Given the assessed risk posed by the offender we considered that the supervising officer should have kept much better records of the case. The notes often consist of only a few lines, and it is impossible to get an impression of the quality or content of the interactions with the offender. In a case of this seriousness, it is important to keep a full and clear record of all information on the offender and any interaction with third party agencies or individuals relevant to the case. The North Lanarkshire sex offenders' protocol document sets out that a senior social worker will sign case records on sex offenders at two-weekly intervals. There is no evidence in the case file that the senior social worker in the Justice Throughcare team did this." (Page 9)
This led to the following recommendation:
"Senior social work managers should ensure that high risk offender case records are of the highest quality and represent an accurate and thorough account of work with the offender."
In 2003 the Minister for Education and Young People asked the Social Work Services Inspectorate to carry out an inspection into the social work services provided to people with learning disabilities by Scottish Borders Council. This followed the discovery of the physical and sexual abuse of a woman with learning disabilities over an extended period. Within a similar timescale the Mental Welfare Commission carried out an investigation into the involvement of health services in this woman's care and treatment.
The main findings from both investigations include reference to poor standards of recording and a lack of care plans. 10
"Very poor standards of case recording falling well below acceptable practice."
"Lack of care plans identifying the purpose of contact with individuals."
The follow up joint inspection reported in 2005. 11 All staff interviewed during this follow up inspection reported that recording was now a major priority. One social worker said:
"Writing things down is crucial. You have to evidence what you are doing."
However some still found it a challenge saying:
"I sometimes struggle to maintain the standard that is expected of me."
"The amount of paperwork has quadrupled - has become more important than working with people."
The report concludes that there had been a huge drive to improve the quality of case recording and by May 2005 there was a significant improvement in the quality of social work files.
The significant case review into the death of Brandon Muir 12 also has the theme of recording running through the report. The review report notes the effective recording of one social worker (regarding two other children). In these records there was a clear focus on the children's needs and evidence that regular discussions had taken place in supervision between the social worker and team manager. These records were also regularly signed by both staff.
On the other hand the report states:
"However the standard of record keeping was generally below an acceptable standard. …I found examples of important discussions not being recorded on case files. …All agencies need to ensure more detailed recording particularly of critical issues"
The findings of these inquiries highlight the importance of good quality social work recording and the serious implications for people using social work services when recording is not of an acceptable standard. Yet recording does not always receive the attention it deserves. We talked earlier about practitioners having ambivalent views on the importance of recording and not always seeing recording as a core part of the social work task.