Case Recording

Untitled Document


Contents

  1. Records Must be Kept on all Children
  2. The Design of Recording Forms
  3. Children and Young People have a Right to 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 in the Restricted Section of the Child's Record
  9. Records Must be Kept Up to Date
  10. Records Must be Written Clearly using Plain Language and Avoid Prejudice
  11. Records Must be Accurate and Adequate
  12. Managers Must Oversee, Monitor and Review Records
  13. Records Should be Kept Securely and Must be Tamper Proof
  14. Removal of Records Must be an Exceptional Occurrence
  15. Records Moved to a New Location Must be Monitored
  16. Records Must Usually be Retained After Closure
  17. Other Records to be Kept by the Home


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 accurate, clear and objective recording.

Case records should reflect children’s lives, their achievements and the work that is carried out with them, and should clearly relate to the plans for their futures. The style and clarity of records should increase the understanding that children have about their histories, background and experiences.

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 (for example if a child / young person or care leaver requests to see their records). Electronic records should be held in a secure database and data management systems must comply with data protection principles i.e. all staff members have an individual user name / log in and password. 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.

Schedule 3 Children’s Homes (England) Regulations 2015 sets out the information to be included in each child’s case records:

Personal details in relation to the child

  1. The child’s name and any name by which the child has previously been known, other than a name used by the child prior to adoption.
  2. The child’s date of birth and sex.
  3. The child’s religion, if any.
  4. The child’s ethnicity, and the child’s cultural and linguistic background.
  5. The child’s address immediately before entering the Home.
  6. The address, and the type of establishment or accommodation, to which the child is to go when the child ceases to be accommodated in the Home.
  7. The dates on which any money or valuables are deposited by or on behalf of the child for safekeeping, the amount of money or a description of the valuables, and the dates on which any money is withdrawn, and any valuables are returned.
  8. The statutory provision (if any) under which the child is provided with accommodation.

Contact details of certain persons in relation to the child

  1. The name (including, where the placing authority is not a parent, the name of an individual who may be contacted), address and telephone number of the child’s placing authority.
  2. The name, address, telephone number and the religion, if any, of the child’s parents.
  3. The name, address and telephone number of any social worker assigned to the child by the placing authority.
  4. If the child attends a school or college—
    1. The name, address and telephone number of the school or college; and
    2. The name and telephone number of the designated member of staff for safeguarding.
  5. The name, address and telephone number of any employer of the child.

Information relating to the care, protection or safety of the child

  1. The date and circumstances of all incidents where a child goes missing from the Home, including any information relating to the child’s whereabouts during the period of absence.
  2. The date and circumstances of any measure of control, discipline or restraint used in relation to the child.
  3. Arrangements for, and any restrictions on, contact between the child, the child’s parents, and any other person.

Plans or reports relating to the child

  1. A copy of any EHC plan or statement of special educational needs in relation to the child.
  2. Every school report received in respect of the child while the child is accommodated in the Home.
  3. A copy of any plan for the care of the child prepared by the child’s placing authority, and of the Placement Plan.
  4. The date and result of any review of the placing authority’s plan for the care of the child, or of the child’s Placement Plan.

Health matters in relation to the child

  1. The name of the general medical practitioner with whom the child is a registered patient, the address of the premises at which the child’s primary medical services are usually provided and the name and address of the child’s registered dental practitioner.
  2. Details of any accident or serious illness involving the child while accommodated in the Home.
  3. Details of any immunisation, allergy, or medical examination of the child and of any medical or dental need or treatment of the child.
  4. Details of any health examination or developmental test conducted with respect to the child at, or in connection with, the child’s school.
  5. Details of any medicines kept for the child in the Home, including details of—
    1. Any medicines which the child is permitted to self-administer;
    2. The administration of any medicine to the child;
    3. The disposal of any medicine.
  6. Any special dietary or health needs of the child.


2. The Design of Recording Forms

Recording forms must be fit for purpose and used consistently throughout the home(s).


3. Children and Young People have a Right to be Informed About and Have Access to their Records

See also Access to Records.

Children and young people should be told what data / information is contained in their records. The records should be available to children, who should be able to contribute to them as they wish, with appropriate support. Staff are expected to help children living in the Home to access and contribute to the records kept in relation to them.

Children and their parents should be supported to understand the nature of records kept by the Home and how to access them.

In particular, they should be helped to understand what data is collected on them, how it is used, who it might be shared with and how long it will be kept for. The most common way to provide information to Data Subjects on what data is collected and how it is used is through a Privacy Notice. Privacy Notices must be easily accessible to children, young people and their families, and should be part of the induction pack given to any new staff members. The Privacy Notice should also be displayed on the staff notice board and / or intranet.

Consideration should be given to summarising the information contained in the Privacy Notice in the Children's Guide which is given to all children and young people when they are first placed in the Home.


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 usually complete the record.

Hard copy 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 the record to confirm its accuracy.

Records of decisions must show who made any decision as well 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'.

Staff should understand their important role in encouraging the child to reflect on and understand their history, according to their age and understanding.

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 Information Sharing Procedure.


7. Information about Children Should Normally be Shared with Them

Information contained in the child's records should usually 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 clearly marked as such in the child's record.

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

See Access to Records Procedure for more information.


8. Managers Must Monitor Information in the Restricted Section of the Child's Record

Managers must monitor information held in the restricted section of the case record, 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.


9. Records Must be Up to Date

All children’s case records must be kept up to date.

As good practice, 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 identifiable.


10. Records Must be Written Clearly using Plain Language and Avoid Prejudice

Records must be written clearly and concisely, using plain language, and with the use of technical or professional terms and abbreviations / acronyms 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.


11. 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.

Every effort must be made to ensure records are factually correct. If a child / young person feels that information in their record is not accurate, they have a right to request that it is rectified. Such request should be responded to within 1 month to and, if any such request is received, the Home's manager should take reasonable steps to establish if the data is accurate and rectify the record if necessary.


12. 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 of control, discipline and restraint taking place within the Home and serious incidents involving children and young people living in 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 to reflect any learning.


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

All records held on children must be stored securely.

Any paper files should be stored in a locked cabinet in an office which only staff 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 while they were missing.

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.


14. 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 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.


15. 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.


16. Records Must Usually be Retained After Closure

The Children's Homes (England) Regulations 2015 stipulate that records in relation to children accommodated in children's homes should be retained securely until the 75th anniversary of the child's birth or, if the child dies before age of 18 years, 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. The Home should maintain a list of records which have been destroyed, the date when they were destroyed and by whom.

Please note - While the 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.

If a Home closes or is taken over by a different registered provider, it is important that children’s case records continue to be stored securely for the required period of time (regulation 36(2)) so that children can access their case records in later life. If the registered provider runs other homes, the case records must be kept in the nearest home (regulation 36(4)(a)(b)). In cases where the Home and its registered provider cease to operate entirely, the case records must be passed to the child’s placing authority (regulation 36(5)) or, as the case may be, the local authority that maintains an EHC plan for the child or the child’s SEN statement.


17. Other Records to be Kept by the Home

Schedule 4 Children’s Homes (England) Regulations 2015 sets out the other records which must be kept.