Case Recording

Untitled Document


Contents

  1. Records Must be Kept on all Children
  2. The Design of Recording Forms
  3. Children and their Families Must be Informed About and Have Access to their Records
  4. The Practitioner Primarily Involved Should Complete the Record
  5. All Relevant Information About Children Must be Recorded
  6. Children Should be Involved in the Recording Process
  7. Information about Children Should Normally be Shared with Them
  8. Managers Must Monitor Information Held in Confidential Section of the Child's File
  9. Records Must be Legible, Signed and Dated
  10. Records Must be Kept Up to Date
  11. Records Must be Written in Plain English and Prejudice Must be Avoided
  12. Records Must be Accurate and Adequate
  13. Managers Must Oversee, Monitor and Review Records
  14. Records Should be Kept Securely and Must be Tamper Proof
  15. Removal of Records Must be an Exceptional Occurrence
  16. Records Moved to a New Location Must be Monitored
  17. Records Must Usually be Retained After Closure


1. Records Must be Kept on All Children

Records must be kept on all children. The home’s records on each child represent a significant contribution to their life history, and it is important therefore that all staff are familiar with the home’s policies on record keeping and understand the importance of careful, objective, and clear recording.

Some records may be kept electronically (Regulation 38) provided that this information can be easily accessed by anyone with a legitimate need to view it and, if required, be reproduced in a legible form. Electronic records should be held at the individual home in accordance with data protection principles. IT systems should ensure the safe storage of these records and business continuity planning should be in place to prevent loss or damage to them.

For more information, please see Regulations 35-39 which detail the records that must be kept in children’s homes.


2. The Design of Recording Forms

Recording forms must be fit for purpose and used consistently across the organisation.


3. Children and their Families Must be Informed About and Have Access to their Records

Children and their families should be informed about the records kept on them, and supported to understand the nature of records kept by the home and how to access them.

Staff are expected to help children living in the home to access and contribute to the records kept in relation to them.


4. The Practitioner Primarily Involved Should Complete the Record

The practitioner primarily involved, that is by the person who directly observes or witnesses the event which is being recorded or who participated in the meeting/conversation, should complete the record.

Records must be signed and dated by the author of each written entry.

Where this is not possible, and records are completed or updated by other people, it must be clear from the record who provided the information being recorded and who is producing the record. In this situation, the originator should read and sign the record.

Records of decisions must show who has made the decision and the basis on which it was made.


5. All Relevant Information About Children Must be Recorded

All visits, meetings or appointments made in relation to children must be recorded, stating who was present or seen, a summary of the discussion, any actions agreed and decisions taken and by whom. The reasons for reaching any decisions should also be clearly recorded.

All other relevant contacts with children, their families, colleagues, professionals or other significant people must also be recorded. When recording such contacts, it will be necessary to state who was present or seen, a summary of the discussion, any actions agreed or decisions taken and by whom. The reasons for taking any decisions should also be recorded.


6. Children Should be Involved in the Recording Process

Children must be routinely involved in the process of gathering and recording information about them. They should feel they are part of the recording process, and be encouraged to see the home’s records as ‘living documents’.

On a regular basis, all children and young people should be supported to contribute to their records in a way that reflects their voice, views, wishes and feelings. Children should also be encouraged to keep appropriate memorabilia of their time spent living at the home and to record significant life events.

Generally, young people must be asked to give their agreement to the sharing of information about them with others - but there are exceptions. See Confidentiality Procedure.


7. Information about Children Should Normally be Shared with Them

Information obtained about children should be shared with them unless to do so would place them or others at risk of harm.

For example, where the sharing of the information may place the child or another person at risk of harm, or where the Police request that information should be withheld in order to enable them to investigate or prosecute a serious offence.

Where information is recorded which should not be shared with the child concerned, it should be placed in the Confidential Section of the child's file and a note of the lodging of the document should be recorded.

Where records contain information about third parties (for example, other family members or other children), this cannot usually be shared, unless permission is gained from the person concerned. In such cases efforts must be made to separate the information relating to third parties from that concerning the child/parents.


8. Managers Must Monitor Information in the Confidential Section of the Child's File

Managers must monitor information held in the Confidential section of files, ensuring that the reason for holding it there is valid; if not, it should be shared with the child and/or moved to another section of the file.

However, before sharing any information previously deemed to be confidential, the manager must take all reasonable steps to consult the originator and take account of their views and wishes.


9. Records Must be Legible, Signed and Dated

If possible, manual records should be typed or handwritten in black ink and all records must be signed and dated. Those completing computerised records must show their name and the date when the recording was completed.

Any handwritten records must be produced so that readers not familiar with the handwriting of the writer can read the records quickly and easily. It must be possible to distinguish the name and post title or status of the person completing the record. If there is any doubt of the identity of the writer from a signature, the name should be printed.


10. Records Must be Up to Date

Records should be updated as information becomes available or as decisions or actions are taken as soon as practicable ideally, within 24 hours.

Where any records are subsequently amended this must be clearly marked.


11. Records Must be Written in Plain English and Prejudice Must be Avoided

Records must be written concisely, in plain English, and use of technical or professional terms and abbreviations must be kept to a minimum.

Staff should record information on individual children in a non-stigmatising way that distinguishes between fact, opinion and third-party information. Information about the child must always be recorded in a way that will be helpful to the child.


12. Records Must be Accurate and Adequate

Care must be taken to ensure that information contained in records is relevant and accurate and is sufficient to meet legislative responsibilities and the requirements of these procedures. Information recorded on individual children should be in a non-stigmatising way that distinguishes between fact, opinion and third-party information.

Every effort must be made to ensure records are factually correct.


13. Managers Must Oversee, Monitor and Review Records

The overall responsibility for ensuring all records are maintained appropriately rests with the registered manager.

The Manager should routinely check samples of records to ensure they are up to date and maintained as required and, if not, that deficiencies are rectified as soon as practicable.

Records of Incidents taking place within the home should be regularly reviewed by the manager of the home in order to examine trends / identify patterns of behaviour and to enable staff to reflect, learn and inform future practice. Where necessary procedures and staff training should be updated.


14. Records Should be Kept Securely and Must be Tamper Proof

All records held on children must be stored securely.

Children's files should normally be stored in a locked cabinet, or a similar manner, usually in an office which only staff/carers have access to.

When a measure of control, discipline or restraint is used in the home, a record must be made within 24 hours. Records must also be kept detailing all individual incidents when children go missing from the home, including any information relating to the child’s whereabouts during the period of absence.

Other day to day records such as Contact or Daily Records should also be kept securely in a manner authorised by the manager.

Records should not be left unattended when not in their normal location.


15. Removal of Records Must be an Exceptional Occurrence

Records should not normally be taken from the location where they are normally kept.

If it is necessary to remove a record from the home, this should only be with the approval of a manager, who will stipulate how long it the record can be removed for. The manager must also be satisfied that adequate measures are in place to ensure the security of the record(s) whilst they are removed.

For example, records must never be left in unattended vehicles.

The authorisation for a record to be removed must be recorded, and those who may have need to see the records should be informed of their removal.

The manager must then ensure the record is returned as required/agreed.


16. Records Moved to a New Location Must be Monitored

Where records are moved to a new location, the date of transfer should be clearly recorded by a Manager.

The same person should check that the records have arrived at their intended destination.


17. Records Must Usually be Retained After Closure

Records must be retained until the 75th anniversary of the child’s birth, or if the child dies before age 18, for 15 years from the date of death.

When a file is closed, the date for its destruction should be put on the cover and on the computer record. Records should be destroyed on the relevant date unless the person concerned has been re-referred. Each home and team should maintain a list of records which have been destroyed, the date when they were destroyed and by whom.

Please note - While the National Independent Inquiry into Child Sexual Abuse is on-going, no children’s social care records should be destroyed. See Independent Inquiry Website for full details.