Support Record Keeping and Pre Trial Therapy Policy

Support Record Keeping and Pre Trial Therapy Policy

 

1. Introduction 

1.1. Devon Rape Crisis & Sexual Abuse Services (DRCSAS) has a responsibility to a number of stakeholders in relation to the information it records about the support received by the people who use our services.

1.2. This policy is to be read in conjunction with the following policies and procedures;

  • Data Protection Policy
  • Data Security Policy
  • Data Retention Policy
  • Confidentiality and Anonymity Policy
  • Privacy Notice for People Who Use Our Services
  • Service User Record Request Procedure

1.3. This policy has been drawn up in support of our accreditation with Blue Star and following best practice training on the recording of support notes.

1.4. In writing this policy, we have been mindful of both our legal responsibilities, our professional duties and our fundamental values of providing control, safety and empowerment to the people who use our services.

1.5. This policy refers only to the notes/case recordings made as part of our support services. This includes all support offered (counselling, EMDR, group work, specialist support work, trauma stabilisation and advocacy) where a person receiving support is named and their data stored in line with our data protection policies.

 

2. Principles

2.1. Given the nature of the support we offer, note taking must strike an appropriate balance around providing effective and safe support, whilst not prejudicing the rights and options of the people who use our services.

2.2. It is well understood that one of the barriers to seeking support is a fear about how the support received may be perceived by a third party, for example the Police, Crown Prosecution Service, Social Care application or Family Court.

2.3. The fear and trauma which can result from sexual violence may also deter people from using our services for fear of any kind of breach of confidentiality including authorities having access to records.

2.4. We understand that we are in a position of trust about the information we record when a person receives support. It is important to us that we get this right and that we record information which is both helpful to guide the support and not detrimental to our relationship with the people who use our services.

2.5. We recognise that there are potential issues around keeping very detailed records about the support provided and received by people who use our services.

These can include:

  • Record keeping takes time and resources
  • Excessive record keeping reduces our ability to protect third party information (the names and details of others who may be discussed in support)
  • Long notes may not be easily condensed when requests for third party information are made
  • Very detailed notes may be contradictory as support work continues which may undermine options

 

3. Note taking purposes

3.1. Devon Rape Crisis and Sexual Abuse Services takes support notes for the following purposes;

  • to support the choices of people who use our support regarding whether or not they wish to report what happened to the Police;
  • to evidence the impact of rape, sexual violence and abuse;
  • as part of our ethical responsibilities, quality assurance and practice standards;
  • to safeguard anyone at risk. Including identifying risks and recording any actions taken;
  • to monitor and evaluate progress;
  • to assist the recall of useful information to staff and volunteers so to improve the quality of our services or approaches;
  • to assist information-sharing and partnership working with other agencies;
  • to records any sharing of information to third parties, with or without consent to protect both service users and the organisation;
  • to support decision-making about a course of action.

 

4. Informing People Who Use Our Services

4.1 To support transparency employees and volunteers must ensure that people who use our services are aware of how we use their information. This is contained in our privacy notice for people who use our services.

4.2. We layer this information to ensure we are transparent. Our privacy notice is available on our website, a link is made to it on our referral forms and support workers should discuss this during their contracting and support planning conversations at the beginning of support.

4.3. All of our policies relating to data protection are available on our website or on request.

4.4 Blue Star accreditation, which demonstrates our commitment to effective pre-trial note keeping and note disclosure, has supported us to produce an information leaflet that assists us with discussing third party record requests with people who use our services. Employees and volunteers are encouraged to use this leaflet.

 

5. What is included in all support records?

5.1 All support records should include;

  • Activity monitoring, including attendance and cancellations. The type of support received and the duration. Details of who provided the support.
  • Brief notes including the theme of the work covered in the session and the impact of what happened
  • Reviews of progress, evaluation forms and feedback forms. Outcomes and impact monitoring.
  • Formulation, nature and impact of the trauma, needs and risks
  • Support plans including goals and hopes of the person receiving support
  • Referral forms
  • Letters and correspondence including emails, texts and telephone calls on the client file concerning the client
  • Contracts and agreements
  • New disclosure reports
  • Safeguarding reports, including what action was taken

 

6. What makes a good case recording?

 6.1. Notes must be;

  • accurate
  • factual
  • concise and minimal
  • objective and based on the facts disclosed, with no opinion, speculation, subjective statements or interpretations.
  • based on themes, statements and observations not be influenced by personal feelings, bias or prejudice. Note takers should be self-aware of how their perceptions of events and conversations might impact on their ability to record information and provide an account to others. Do not hypothesise, evaluate, or diagnose.
  • clear and understandable
  • written as if they might be inspected by the individual that they are about
  • sufficient, with no abbreviations or jargon
  • respectful and not unnecessarily intrusive
  • consistent
  • structured, consecutive and in chronological order
  • written as soon as possible after the events to which they relate and on the same day unless there is any substantial reason otherwise.
  • without names of others if at all possible
  • provided using general areas addressed rather than detailed process recording

 

7. First Disclosures

 7.1. A first disclosure happens when someone in support makes their first disclosure of rape, sexual abuse or sexual violence.

7.2. Therapy and support may increase the ability of the person receiving support to disclose incidents that could previously be recalled but were actively and deliberately kept from coming to mind due to shame and avoidance.

7.3. If a person in support discloses events for the first time to the worker or volunteer support worker, then all of the details need to be fully documented.

7.4. The support worker would be considered a “First Disclosure Witness” and could be asked to make a witness statement if the victim chooses to report an offence to the police.

7.5. Whilst it is very unlikely, a support worker may have to give evidence in court regarding this first disclosure and it is the notes that are taken by the worker that becomes an extremely valuable source of evidence for the prosecution case and the people who we support.

7.6. When taking a disclosure, support workers should avoid using leading questions or discussing the evidence which the individual or any other witness will give. They should ask open questions such as what happened; who did this; when did this happen and how did it occur. They should not encourage the person making the disclosure to endlessly extend their account of the incident which they have experienced, they are simply looking to record the facts of the disclosure.

7.7. It is absolutely acceptable to offer general reassurance and support to someone making a disclosure during this difficult process and it should be remembered that our principal role in offering a support service is ensuring the wellbeing of the person we are supporting. This is of paramount importance above anything else.

7.8. Support workers should avoid the use of jargon and take care to use language that will not be perceived, if repeated by the person making the disclosure as evidence of the witness being instructed.

7.9. Where appropriate, the support worker may seek the consent of the person making a disclosure to refer to an Independent Sexual Violence Advisor (ISVA) for an options meeting or to ensure a more complete disclosure is made. However, care should be taken not to silence the person making the disclosure through the support workers avoidance, reticence or lack of ability. If in doubt a support worker should seek support from their line manager or the Head of Service Delivery.

7.10. It is good practice for the support worker to provide the person making a disclosure with a copy of their first disclosure notes, or read them through, so that they can check them for accuracy. If appropriate these notes should be signed by the person making the first disclosure.

 

8. Pre-Trial Therapy and Support

8.1. DRCSAS provides pre-trial therapy and support. As most people accessing our support services make a self-referral and have not reported their sexual abuse to the police at that point, it should be understood that most support provided by the Charity is ‘pretrial’ and all support should be delivered with this in mind.

8.2. Through the Blue Star training and accreditation, DRCSAS have a suite of useful guides and resources to guide effective pre-trial therapy and support which should be used to support this policy objective and the effective provision of pre-trial therapy.

8.3. The Crown Prosecution Service produces Pre-Trial Therapy Guidance and this is kept under review and written with legal requirements in mind. This should be read in conjunction with this policy.

8.4. DRCSAS do not provide the following types of support in a pre-trial support setting;

  • Interpretive psychodynamic psychotherapy
  • Therapy involving the rehearsal of past abusive events
  • Therapy using hypnosis or which endeavours to recall lost or hidden memories of past abuse
  • Group therapy where the specific recounting of abuse takes place and the client may adopt the experiences of others taking part in the therapy