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Pitfalls for practitioners 8

The record is disrespectful to the service user

Case recording is part of the service that the local authority provides to the individual service user (1). For the practitioner the case record will be just one of a number of similar records they keep as part of their duties in the agency. For the service user it is their record. Although the practitioner makes the records they are made about, for and ideally with the service user. The case record does not simply provide a documented account of the agencies involvement with an individual service user. For many service users, particularly those looked after, the case record may be the main source of information about significant events, decisions and people in their lives.

The most obvious way in which the record may be disrespectful to the service user is in the way in which the record is written. Failing to differentiate between fact and professional opinion, unsubstantiated opinions and oppressive or discriminatory statements may indicate that the practitioner is not thinking about how the record may affect the service user should they read the file.

In their research on parental perspectives on child protection Cleaver and Freeman (2) reported that it was not uncommon for the spelling of the child's name or dates of birth to be incorrect in reports for child protection conferences or court proceedings. This had the affect of undermining parents' confidence in social services.

It is not simply what is recorded, but the way in which the record is maintained that provides a reflection of the agency and practitioner's attitude towards service users.

The general presentation of the record, papers unsecured or incorrectly located in file, illegible, undated notes or files not being kept safely indicate a lack of respect for the record and its importance to the service user. Research carried out by Satyamurti (3) found that files were left not locked in filing cabinets overnight but were often left overnight in baskets on the practitioner's desks.

The case record is not simply the fieldwork or locality team's file, although this should be considered as the main or central file within the case record. The case record is made up of all the social services records maintained by the agency on an individual. For some children it will include residential, day-care, family placement and foster carer records. It will be important that the case holder is aware of all the different components of the record and maintains within the main file a list of all other records kept on the child and their location. Failing to do this can lead to important parts of the child's record going missing and with it the child's history. A report commissioned by Gloucestershire county council on possible contacts between children in the authority's care and Fred and Rosemary West found that the files on 397 children (17%) previously looked after by the authority were missing (4).

Avoid the Pitfall

  • Try Recording Exercise 4
  • Try Recording Exercise 5
  • Try Recording Exercise 6
  • Try the 'What Constitutes the Record?' exercise
  • When you record ask yourself, 'What would I think if I was the service user and read that?'
  • Ensure that there is a record in the main file which lists where all other parts of the case record are kept.
  • Check out basic details, such as dates of birth and the spelling of names, with parents and the young person at an early stage.
  • Use the Audit Sheet to review your files

References

1. Social Services Inspectorate (1999) Recording With Care Inspection of Case Recording in Social Services Departments. Department of Health, London.

2. Cleaver H and Freeman P (1995) Parental perspectives in cases of suspected child abuse, HMSO, London.

3. Satyamurti C (1981) Occupational Survival. Blackwell, Oxford.

4. Pritchard, M. J. (ed) (1996) In Care Contacts - The West Case. The Bridge, London.

 
 
 
By Steve Walker, David Shemmings and Hedy Cleaver
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