Case Recording Policy and Staff Guidance

Records must be kept on all children: in electronic format or on paper files (information recorded electronically must be able to be reproduced in a legible form) - audio or video recordings may also be kept.

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the child for safekeeping, the amount of money or a description of the valuables, and the dates on which any money is withdrawn, and any valuables are returned.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

9. 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.
10. The name, address, telephone number and the religion, if any, of the child’s parents.
11. The name, address and telephone number of any social worker assigned to the child by the placing authority.
12. 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.
13. The name, address and telephone number of any employer of the child.

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

14. 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.
15. The date and circumstances of any measure of control, discipline or restraint used in relation to the child.
16. 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

17. A copy of any EHC plan or statement of special educational needs in relation to the child.
18. Every school report received in respect of the child while the child is accommodated in the Home.
19. A copy of any plan for the care of the child prepared by the child’s placing authority, and of the Placement Plan.
20. 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

21. 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.
22. Details of any accident or serious illness involving the child while accommodated in the Home.
23. Details of any immunisation, allergy, or medical examination of the child and of any medical or dental need or treatment of the child.
24. Details of any health examination or developmental test conducted with respect to the child at, or in connection with, the child’s school.
25. 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.
26. Any special dietary or health needs of the child.

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

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.

Also see: Care and Placement Plans Guidance.

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 company before coming into use.

See also: Access to Records Procedure.

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.

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.

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 has provided the information being recorded. 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 has been made.

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.

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. Children should be encouraged to keep appropriate memorabilia of the time spent living in the home and staff should help them to record significant life events.

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.

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.

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), this 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.

See Access to Records Procedure for more information.

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.

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.

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 author, the date and time of the entry must be included.

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.

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

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.

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.

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

See: Confidentiality Policy.

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.

All records held on children must be kept securely and must be tamper-proof.

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 measures 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 and in keeping with the principles of good practice laid out in this Chapter.

These records should not be left unattended when not in their normal location.

_{*This can be an electronic record, but this must be accessible to all who have a need to see the record including children to whom the record refers. All records must be in formats that can not be tampered with after the events e.g. bound numbered or electronic entries that are then ‘barred’ so they cannot be amended at a later dates and in a manner that they can be accessed later e.g. for historical investigations.}

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, a manager, who should stipulate or agree how long it is necessary to remove the record, should approve this. 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.

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.

For England, 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. 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 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.

Important Note: The Independent Inquiry into Child Sexual Abuse has said that:

It is now very unlikely that the Chair and Panel will request access to documents relevant to the Inquiry’s Terms of Reference.

Consequently, organisations can plan for destruction or deletion of records that have been retained for the purposes of the Inquiry, which can resume at the end of the Inquiry’s Judicial Review period, currently set for 20th January 2023. However, please consider the following when drawing up disposal plans:

1. Whether any of the records you have retained are likely to be of significant interest to victims and survivors and that your retention schedules meet their needs;
2. The obligation to retain records for other inquiries remains.

Further information about the Inquiry’s moratorium on the destruction of records can be found on the Inquiry’s website.

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

Records must be kept and maintained as specified in Part 1 and Part 2 of Schedule 2 in respect of each place at, from or in relation to which the service is provided.

All records:

1. Relating to individuals must be accurate and up to date;
2. Kept securely;
3. Must be made available to the service regulator on request.

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 company before coming into use.

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.

All records in relation to individuals who use the service should be accessible to the individual and individuals made aware of how to access them.

See:

• Confidentiality Policy;
• Access to Records Procedure.

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.

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.

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 has provided the information being recorded. 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 has been made.

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.

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. Children should be encouraged to keep appropriate memorabilia of the time spent living in the home and staff should help them to record significant life events.

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.

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), this 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.

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.

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.

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 author, the date and time of the entry must be included.

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.

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

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.

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.

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

See: Confidentiality Policy.

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

All records held on children must be kept securely and must be tamper-proof.

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.

Records of sanctions and other measures of control or incidents e.g. where physical intervention is used or if children are absent/missing must be carefully recorded with full details by the staff involved within 24 hours in a record* kept for the purpose.

Other day to day records, such as Contact or Daily Records, should also be kept securely in a manner authorised by the manager and in keeping with the principles of good practice laid out in this Chapter.

These records should not be left unattended when not in their normal location.

_{*This can be an electronic record, but this must be accessible to all who have a need to see the record including children to whom the record refers. All records must be in formats that can not be tampered with after the events e.g. bound numbered or electronic entries that are then ‘barred’ so they cannot be amended at a later dates and in a manner that they can be accessed later e.g. for historical investigations.}

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, a manager, who should stipulate or agree how long it is necessary to remove the record, should approve this. 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.

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.

England

If the registered provider of the closing home:

• Is the registered provider of one other children’s home, the registered provider must transfer each child’s case records which are held in relation to the closing home to the other home;
• Is the registered provider of more than one other home, the registered provider must transfer the case records to the other home which is nearest to the closing home.

If the registered provider is not, or will not continue to be, the registered provider of another home, the registered provider must transfer the case records for each child looked after by the LA to the placing authority for the child who the records relate to.

Wales

The service provider must make arrangements for the records to continue to be kept securely in the event the service closes. In the case of records about a child accommodated in a care home service provided wholly or mainly for children, ensure that the records are delivered to the placing authority when the service ceases to be provided in respect of the child to whom the records relate. Retain records relating to children for fifteen years from the date of the last entry, unless the records.