Case Recording Policy and Guidance

REGULATIONS AND STANDARDS

Guidance on Chapter 5 of the Regulations – Policies, Records, Complaints and Notifications

The Children’s Views, Wishes and Feelings Standard

The Leadership and Management Standard

The Care Planning Standard

SCOPE OF THIS CHAPTER

This chapter provides policies and guidance on case recording.

RELEVANT CHAPTERS

Access to Records Procedure

Care and Placement Plans Procedure

Log Book and Diary Recording Procedure

AMENDMENT

In June 2017, a note was added into Section 17, Records Must Usually be Retained After Closure, to remind all staff no children’s social care records should be destroyed while the National Independent Inquiry into Child Sexual Abuse is on-going.



Contents

  1. Records Must be Kept On All Children
  2. The Design of Records and Forms Must be Approved
  3. Children and their Families Must be Informed about their Records
  4. The Practitioner Primarily Involved Should Complete the Record
  5. All Relevant Information about Children and their Families Must be Recorded
  6. Children and their Families should be Involved in the Recording Process
  7. Information about Children/their Families should be Shared with Them
  8. Directors/Registered Managers Must Monitor Information held in Confidential Section of Records
  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. Directors/Registered Managers Must Oversee, Monitor and Review Records
  14. Records should be Kept Securely
  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

Regulations regarding information to be included in the case records of children accommodated in children’s homes are listed under schedule 3 of the Children’s Homes Regulations 2015.

Records must be kept on all children: in the form of paper files but computer records (information recorded electronically must be able to be reproduced in a legible form), audio or video recordings may also be kept.

Information held in electronic records must accurately reflect the corresponding information recorded within paper files.

Records held on paper may extend to more than one volume. Where more than one volume exists, the dates covered by each volume must be clearly recorded on the front cover.

Each Childhood First Community offers twenty four hour care; therefore it is vital that an event that occurs during the night is also properly recorded signed and countersigned. There will be particular procedures to follow at each community which will be made explicit to all staff responsible for recording.

Also see Care and Placement Plans Procedure.


2. The Design of Records and Forms Must be Approved

Records and forms must be designed to fit their purpose and used consistently across the organisation.

The design of all records and forms must be approved by the organisation before coming into use.


3. Children and their Families Must be Informed about their Records

Children and their families have a right to be informed about the records kept on them, the reasons why and their rights to confidentiality and of access to their records.

See Confidentiality Policy.

Information must be provided in a form that children and their families will understand - in their preferred language or method of communication. An interpreter will be provided if needed.


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 has participated in the meeting/conversation, must complete records.

Where this is not possible and records are completed or updated by other people, it must be clear from the record has provided the information being recorded and who is producing the record. Preferably 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 and their Families Must be Recorded

All visits, meetings or appointments made in relation to children must be recorded, stating who was present or seen, the relevant discussions which occurred, actions or decisions taken and by whom; the reasons for taking any decisions should also be recorded.

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


6. Children and their Families 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 in a way that is appropriate to their age and level of understanding.

They should be asked to provide information, express their own views and wishes, and contribute to assessments, reports and to the formulation of plans.

Generally, they must be asked to give their agreement to the sharing of information about them with others - but there are exceptions.


7. Information about Children and their Families should Normally be Shared with Them

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

For example, where the sharing of the information may place the child or another person at risk, 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), information 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. Directors/Registered Managers Must Monitor Information in the Confidential Section of the Child's File

Directors/Registered 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 Directors/Registered 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 or, at the latest, within 24 hours.

Where records are made or updated late or after the event, the fact must be stated as a 'Late Entry' in the record, and the date and time of the entry must be included.


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

Records must be written concisely, in plain English, and must not contain any expressions that might give offence to any individual or group of people on the basis of race, culture, religion, age, disability, or sexual orientation.

Use of technical or professional terms and abbreviations must be kept to a minimum; and if there is likely to be any doubt of their meaning, they must be defined or explained.


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.

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

Records must distinguish clearly between facts, opinions, assessments, judgements and decisions. Records must also distinguish between first hand information and information obtained from third parties.

See Confidentiality Policy.


13. Directors/Registered Managers Must Oversee and Monitor all Records

The overall responsibility for ensuring all records are maintained appropriately rests with Directors/Registered Managers with day to day responsibility, delegated to other staff as appropriate.

The Director/Registered 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

All records held on children must be kept 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.

Other day to day records, such as Daily Logs, The Diary 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 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 for 75 years from the date of birth of the child or 15 years from the date of death in the case of a child who dies before the age of 18.

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.