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63 <h1 class="h1">
63 Case Recording
63 </h1>
64 <div class="scope_box" style="padding-bottom: 0px; padding-top: 15px;">
65 <h2 class="h3">
65 REGULATIONS AND STANDARDS
65 </h2>
66 <p>
66 <a
href="http://qualitystandards.proceduresonline.com/homes/p_manag_admin_reg.html#chapter_5"
target="_blank">
66 Guidance on Chapter 5 of the Regulations – Policies, Records, Complaints and Notifications
66 </a>
66 </p>
67 <p>
67 <a
href="http://qualitystandards.proceduresonline.com/homes/p_quality_standards.html#ch_views
" target="_blank">
67 The Children's Views, Wishes and Feelings Standard
67 </a>
67 </p>
68 <p>
68 <a
href="http://qualitystandards.proceduresonline.com/homes/p_quality_standards.html#leadership
" target="_blank">
68 The Leadership and Management Standard
68 </a>
68 </p>
69 <p>
69 <a
href="http://qualitystandards.proceduresonline.com/homes/p_quality_standards.html#care_plannin
g" target="_blank">
69 The Care Planning Standard
69 </a>
69 </p>
70 <h3 class="h3">
70 SCOPE OF THIS CHAPTER
70 </h3>
71 <p>
71 This chapter provides guidance on case recording.
71 </p>
72 <h3 class="h3">
72 RELEVANT CHAPTERS
72 </h3>
73 <p>
73 <a href="p_acc_rec.html">
73 Access to Records Procedure
73 </a>
73 </p>
74 <p>
74 <a href="p_care_plac.html">
74 Care and Placement Plans Guidance
74 </a>
74 </p>
75 </div>
76 <h2 class="h2_underlined">
76 <br />
77 Contents
77 </h2>
78 <ol>
79 <li>
79 <a href="#records">
79 Records Must be Kept on all Children
79 </a>
79 </li>
80 <li>
80 <a href="#design">
80 The Design of Recording Forms
80 </a>
80 </li>
81 <li>
81 <a href="#children">
81 Children and Young People have a Right to be Informed About and Have Access to their Records
81 </a>
81 </li>
82 <li>
82 <a href="#practitioner">
82 The Practitioner Primarily Involved Should Complete the Record
82 </a>
82 </li>
83 <li>
83 <a href="#relevatn">
83 All Relevant Information About Children Must be Recorded
83 </a>
83 </li>
84 <li>
84 <a href="#families">
84 Children Should be Involved in the Recording Process
84 </a>
84 </li>
85 <li>
85 <a href="#info">
85 Information about Children Should Normally be Shared with Them
85 </a>
85 </li>
86 <li>
86 <a href="#managers">
86 Managers Must Monitor Information in the Restricted Section of the Child's Record
86 </a>
86 </li>
88 <li>
88 <a href="#date">
88 Records Must be Kept Up to Date
88 </a>
88 </li>
89 <li>
89 <a href="#written">
89 Records Must be Written Clearly using Plain Language and Avoid Prejudice
89 </a>
89 </li>
90 <li>
90 <a href="#accurate">
90 Records Must be Accurate and Adequate
90 </a>
90 </li>
91 <li>
91 <a href="#monitor">
91 Managers Must Oversee, Monitor and Review Records
91 </a>
91 </li>
92 <li>
92 <a href="#securely">
92 Records Should be Kept Securely and Must be Tamper Proof
92 </a>
92 </li>
93 <li>
93 <a href="#removal">
93 Removal of Records Must be an Exceptional Occurrence
93 </a>
93 </li>
94 <li>
94 <a href="#location">
94 Records Moved to a New Location Must be Monitored
94 </a>
94 </li>
95 <li>
95 <a href="#retained">
95 Records Must Usually be Retained After Closure
95 </a>
95 </li>
96 </ol>
97 <h2 class="h2_underlined">
97 <br />
98 1.
98 <a name="records" id="records">
98 </a>
98 Records Must be Kept on All Children
98 </h2>
99 <p>
99 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.
99 </p>
100 <p>
100 Some records may be kept electronically (
100 <a href="http://www.legislation.gov.uk/uksi/2015/541/regulation/38/made" target="_blank">
100 Regulation 38
100 </a>
100 ) 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.
100 </p>
101 <p>
101 For more information, please see
101 <a href="http://www.legislation.gov.uk/uksi/2015/541/part/5/made" target="_blank">
101 Regulations 35-39
101 </a>
101 which detail the records that must be kept in children's homes.
101 </p>
102 <h2 class="h2_underlined">
102 <br />
103 2.
103 <a name="design" id="design">
103 </a>
103 The Design of Recording Forms
103 </h2>
104 <p>
104 Recording forms must be fit for purpose and used consistently throughout the home(s).
104 </p>
105 <h2 class="h2_underlined">
105 <br />
107 3.
107 <a name="children" id="children">
107 </a>
107 Children and Young People have a Right to be Informed About and Have Access to their Records
107 </h2>
108 <p>
108 Children and young people should be told what data / information is contained in their records.
108 </p>
109 <p>
109 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
109 <a href="http://www.proceduresonline.com/resources/glossary-cs/" target="_blank">
109 Data Subjects
109 </a>
109 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.
109 </p>
110 <p>
110 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.
110 </p>
111 <p>
111 Staff are expected to help children living in the home to access and contribute to the records
kept in relation to them.
111 </p>
112 <h2 class="h2_underlined">
112 <br />
113 4.
113 <a name="practitioner" id="practitioner">
113 </a>
113 The Practitioner Primarily Involved Should Complete the Record
113 </h2>
114 <p>
114 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.
114 </p>
115 <p>
115 Hard copy records must be signed and dated by the author of each written entry.
115 </p>
116 <p>
116 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.
116 </p>
117 <p>
117 Records of decisions must show who made any decision as well the basis on which it was made.
117 </p>
118 <h2 class="h2_underlined">
118 <br />
119 5.
119 <a name="relevatn" id="relevatn">
119 </a>
119 All Relevant Information About Children Must be Recorded
119 </h2>
120 <p>
120 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.
120 </p>
121 <p>
121 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.
121 </p>
122 <h2 class="h2_underlined">
122 <br />
123 6.
123 <a name="families" id="families">
123 </a>
123 Children Should be Involved in the Recording Process
123 </h2>
124 <p>
124 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'.
124 </p>
125 <p>
125 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.
125 </p>
126 <p>
126 Generally, young people must be asked to give their agreement to the sharing of information
about them with others - but there are exceptions. See
126 <a href="p_confid.html">
126 Information Sharing Procedure
126 </a>
126 .
126 </p>
127 <h2 class="h2_underlined">
127 <br />
128 7.
128 <a name="info" id="info">
128 </a>
128 Information about Children Should Normally be Shared with Them
128 </h2>
129 <p>
129 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.
129 </p>
130 <p>
130 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.
130 </p>
131 <p>
131 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.
131 </p>
132 <p>
132 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.
132 </p>
133 <p>
133 See
133 <a href="p_acc_rec.html">
133 Access to Records Procedure
133 </a>
133 for more information.
133 </p>
134 <h2 class="h2_underlined">
134 <br />
135 8.
135 <a name="managers" id="managers">
135 </a>
135 Managers Must Monitor Information in the Restricted Section of the Child's Record
135 </h2>
136 <p>
136 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.
136 </p>
137 <h2 class="h2_underlined">
137 <br />
138 9.
138 <a name="date" id="date">
138 </a>
138 Records Must be Up to Date
138 </h2>
139 <p>
139 Records should be updated as information becomes available or as decisions or actions are taken
as soon as practicable ideally, within 24 hours.
139 </p>
140 <p>
140 Where any records are subsequently amended this must be clearly identifiable.
140 </p>
141 <h2 class="h2_underlined">
141 <br />
142 10.
142 <a name="written" id="written">
142 </a>
142 Records Must be Written Clearly using Plain Language and Avoid Prejudice
142 </h2>
143 <p>
143 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.
143 </p>
144 <p>
144 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.
144 </p>
145 <h2 class="h2_underlined">
145 <br />
146 11.
146 <a name="accurate" id="accurate">
146 </a>
146 Records Must be Accurate and Adequate
146 </h2>
147 <p>
147 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.
147 </p>
148 <p>
148 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.
148 </p>
149 <h2 class="h2_underlined">
149 <br />
150 12.
150 <a name="monitor" id="monitor">
150 </a>
150 Managers Must Oversee, Monitor and Review Records
150 </h2>
151 <p>
151 The overall responsibility for ensuring all records are maintained appropriately rests with the
registered manager.
151 </p>
152 <p>
152 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.
152 </p>
153 <p>
153 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.
153 </p>
154 <h2 class="h2_underlined">
154 <br />
155 13.
155 <a name="securely" id="securely">
155 </a>
155 Records Should be Kept Securely and Must be Tamper Proof
155 </h2>
156 <p>
156 All records held on children must be stored securely.
156 </p>
157 <p>
157 Any paper files should be stored in a locked cabinet in an office which only staff/carers have
access to.
157 </p>
158 <p>
158 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.
158 </p>
159 <p>
159 Other day to day records such as Contact or Daily Records should also be kept securely in a
manner authorised by the manager.
159 </p>
160 <p>
160 Records should not be left unattended when not in their normal location.
160 </p>
161 <h2 class="h2_underlined">
161 <br />
162 14.
162 <a name="removal" id="removal">
162 </a>
162 Removal of Records Must be an Exceptional Occurrence
162 </h2>
163 <p>
163 Records should not normally be taken from the location where they are normally kept.
163 </p>
164 <p>
164 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.
164 </p>
165 <p>
165 For example, records must never be left in unattended vehicles.
165 </p>
166 <p>
166 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.
166 </p>
167 <p>
167 The manager must then ensure the record is returned as required/agreed.
167 </p>
168 <h2 class="h2_underlined">
168 <br />
169 15.
169 <a name="location" id="location">
169 </a>
169 Records Moved to a New Location Must be Monitored
169 </h2>
170 <p>
170 Where records are moved to a new location, the date of transfer should be clearly recorded by a
Manager.
170 </p>
171 <p>
171 The same person should check that the records have arrived at their intended destination.
171 </p>
172 <h2 class="h2_underlined">
172 <br />
173 16.
173 <a name="retained" id="retained">
173 </a>
173 Records Must Usually be Retained After Closure
173 </h2>
174 <p>
174 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.
174 </p>
175 <p>
175 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.
175 </p>
176 <p>
176 <span class="bold">
176 Please note -
176 </span>
176 While the Independent Inquiry into Child Sexual Abuse is on-going, no children's social care
records should be destroyed. See
176 <a
href="https://www.iicsa.org.uk/sites/default/files/retention-instructions-and-data-protection-re
quirements.pdf" target="_blank">
176 Independent Inquiry Website
176 </a>
176 for full details.
176 </p>
178 <p>
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179 <br />
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193 </div>
194 <div class="footer_box">
194 W884 [WCAG21 2.1.1/2.1.3 (A/AAA)] Mouse/Pointer event handlers require keyboard equivalents:
When using mouse/pointer event handlers on elements that can be accessed by keyboard, ensure that you provide an equivalent keyboard handler. See WCAG 2.1 Failure F54. <input name="printMe" type="image" onclick="printSpecial()" value="Print this Page"
src="images/icons/print.gif" onmouseover="images/icons/print.gif'"
onmouseout="this.src='images/icons/print.gif'" alt="Print this page"/>
196 <a href="#" onclick="printSpecial()">
196 print
196 </a>
196
196 <span class="darkdivider">
196 |
196 </span>
196
196 </div>
197 </td>
198 </tr>
199 </table>
200 </div>
200 </div>
201 </div>
202 </body>
203 </html>