Recording of Information
Good record keeping is a requirement under the Data Protection Act 2018, which is the UK’s implementation of the General Data Protection Regulation (GDPR) (European law).
It is essential to facilitate the effective safeguarding of Adults at Risk and also to demonstrate that service users’ cases are managed effectively and efficiently, and that safeguarding decisions and actions in individual cases are taken or pursued lawfully and without maladministration.
Accurate, complete, current and professional records provide evidence – for good or bad – about the management of a given case. Where a case is managed well, good records are the first line of defence to query or challenge poor quality records, however, immediately put an organisation on the defensive, as a well-managed case will have little proof, while a poorly managed case will have holes in the story where allegations and assumptions can go unchallenged.
The Human Rights Act 1998 brought into English law a distinct and different approach to thinking about rights, responsibilities and remedies. Also, courts appear increasingly willing to hold local authorities and individual practitioners to account. In addition, documentation in relation to the safeguarding adults process can be central in providing supported evidence when making referrals to the Disclosure and Barring Service Barred list. In light of this, the importance placed on keeping detailed, accurate records is crucial.
Record keeping is an integral part of professional practice and should assist the process. It demonstrates accountable actions and helps to focus work. It is essential to ‘evidence’ actions and decision making through record keeping. Simply stating the decision and action taken without giving the reasoning behind this is not acceptable. Evidencing decision making, even if the actions taken turn out to be problematic, will help to demonstrate intention.
Best practice in recording is based on key principles of partnership openness and accuracy. All records should be:
- Written to incorporate the adults views and wishes in line with the principles of making safeguarding personal
- Accurate – if mistakes in information have been recorded and remain uncorrected, they are unlikely to be questioned by a new worker. Inaccurate information will be perpetuated inadvertently unless effectively addressed – updates and corrections should be promptly forwarded to those organisations that have originally received shared data;
- Factual – it is essential to record the nature and source of the information;
- What is said, when, where (if relevant) and by whom;
- What was observed, when, where (if relevant) and by whom;
- Opinion, hearsay and third party information must be clearly recorded as such;
- Ethical – all records should be non-judgemental and non-discriminatory. It may be a useful guide to record information with an assumption that the person you are writing about will read it;
- Timely – records should be made as soon as possible after the event
- The Procedure – Record Keeping by all Agencies
Each agency must keep comprehensive records of any work that it undertakes under the safeguarding adults process, including:
- All alerts it receives;
- All Safeguarding Adult Concerns (SAC);
- Enquiries made on behalf of the local authority;
- Any other associated documentation provided under their duty to cooperate with the local authority
The local authority will ensure that comprehensive records are kept which link to any enquiries or referrals made under Sunderland’s Safeguarding Adults Procedures. This information will be stored securely according to agreed procedures.
3.1 What to Record
- all entries must provide factual information e.g., dates, times, names of people contacted and names of any witnesses;
- Any contact with the Adult at Risk of alleged perpetrator must be recorded;
- Record what was said (by the Adult at Risk or the alleged perpetrator) using the person’s own words;
- Use body maps to illustrate any physical injuries;
- All consultations with managers, senior managers, Legal Services, the Police, or Safeguarding Adults Team must be recorded;
- If a decision is made not to contact the Police, it must be clearly recorded who authorised such a decision and on what grounds the decision was made;
- When contacting other agencies, the questions asked and information received must be recorded;
- All telephone calls received and made in relation to the abuse must be recorded, even if there was no reply to outgoing calls
3.2 When Should Information be Recorded?
- Records must be kept from the time that a concern, allegation or disclosure is made, as this constitutes the first stage of an initial safeguarding alert;
- Information should be recorded as soon as possible following any event, contact, or other relevant interaction;
- All records must be dated at the time they were made
3.3 How to Record Information
- Where possible, all records should be typed;
- If this is not possible, they must be written in black ink and writing must be legible;
- Any alterations to records must be made by drawing a single line through the word(s);
- Correction fluid must not be used;
- Where a signatory to these procedures receives updated or corrected personal data for a relevant customer record, the update(s) or correction(s) must be passed to other partner signatories without delay;
- Professionals must be record all information in line with the record keeping guidance and any codes of conduct published by their relevant professional body;
- Best practice is to have adult safeguarding records appropriately classified and afforded security suitable to the classification in place
3.4 Classifying Information
Best practice is for each agency to classify the files, communications and information comprising adult safeguarding records in accordance with the Government Security Classifications. In particular, safeguarding records should be classified as ‘OFFICIAL – SENSITIVE’, with person-identifiable documents and records also attracting the descriptor ‘PERSONAL’. Locally, this is something that is being worked towards with all providers.
3.5 Storing and Filing Information
- All records or files must be stored in accordance with each agency’s own policies and with regard to the Data Protection Act;
- It may be inappropriate to document/store certain safeguarding information in the place normally used for service user records if, for example, the suspected perpetrator or associates may have access to that record e.g. the single record held at an individual’s home or an incident book in a provider service;
- Each agency must ensure there is a protocol in place detailing the length of time for which records are held, in line with national requirements
- Legal Requirements
- Records should not breach a person’s legal rights;
- All agencies should identify arrangements consistent with principles of fairness for making records, available to those affected by and subject to the safeguarding adults process;
- Any person (including the Adult at Risk to whom the information pertains) who asks to see information relating to the safeguarding adults process in line with the Freedom of Information Act should be directed to follow the local authority’s Freedom of Information requests procedure by emailing or writing to Sunderland Council’s Information Governance Team
- Practice Guidance: Recording of Information
- It is the responsibility of the local authority to provide a minute taker at any safeguarding meetings. The decisions taken at all meetings must be recorded. Any enquiries and actions must also be recorded, alongside who is responsible for that action/enquiry and any timescales for completion of the action/enquiry, as appropriate;
- All documentation associated with the safeguarding process must be retained and stored appropriately by the local authority, and/or any partner agencies;
- As part of the Managing Enquiries process (Care Act, 2014) the local authority will ensure that information from Safeguarding Adult Concerns (SAC), statutory enquiries, minutes, action plans or safeguarding plans will be distributed appropriately. Information will be distributed within agreed timescales to ensure that the Adult at Risk is safeguarded. Any delay in sharing information within timescales and the reason for the delay should be recorded;
- Where an external partner has been delegated responsibility for any documentation relating to the safeguarding process they must also ensure this is managed and distributed within agreed timescales and in accordance with their duty to cooperate with the local authority. Any delay in sharing information within timescales and the reason for the delay should be recorded;
- An Adult at Risk should be afforded the opportunity to attend safeguarding meetings in accordance with the principles of making safeguarding personal, unless there are clear reasons why it would not be appropriate for them to be involved. If the Adult at Risk chooses to attend any safeguarding meetings, then they should be afforded the same opportunity to receive minutes, information relating to the content of the minutes, and any other relevant documentation, as anyone else in attendance;
- If a carer, family member or alleged perpetrator is in attendance at any safeguarding meetings, then they should be afforded the same opportunity to receive minutes, or information relating to the content of the minutes, as anyone else in attendance. If they were excluded for any part of the meeting, and/or there are reasons where it would not be appropriate to disclose personal information relating to the Adult at Risk, then it is appropriate to exclude the relevant information from the minutes/documentation before sending them out to the carer, family member or alleged perpetrator;
- Where appropriate the local authority will make arrangements for an appropriate person to provide relevant support and/or an advocate for the Adult at Risk and/or to their carer/family member to understand the content of safeguarding documentation which is made relevant to their case. Where appropriate this support would also be made available to an alleged perpetrator, where they are also an Adult at Risk. This responsibility may be delegated to an external partner or agency
Information sharing of minute and other documents containing information relating to the case may be shared by electronic methods. Where this is the cases, it should be done using appropriate levels of security and encryption. The use of 7Zip software to encrypt information in a manner that is easy to send and receive is recommended. This software is free to download and use and does not require specialist training.