Recording Policy and Guidelines
REGULATIONS AND STANDARDS
Fostering Services: National Minimum Standards
STANDARD 26 - Records
RELATED CHAPTERS
Information Sharing and Confidentiality Procedure
SCOPE OF THIS CHAPTER
This chapter explains the recording policy of the Agency and clarifies the purpose, format and content of information to be kept on Agency files, on the child's files and on case files relating to foster carers.
Staff, volunteers, panel members and fostering households should understand the nature of records maintained and follow the service's policy for the keeping and retention of files, managing confidential information and access to files (including files removed from the premises). It also explains the systems in place to monitor the quality and adequacy of record keeping and take action when needed.
Contents
- Records Must be Kept on all Carers and their Families
- The Design of Recording Forms
- Carers and their Families Must be Informed about their Records
- The Practitioner Primarily Involved Should Complete the Record
- All Relevant Information about Carers and their Families Must be Recorded
- Foster Carers and their Families should be Involved in the Recording Process
- Information about Children/their Families should Normally be Shared with them
- Managers Must Ensure that Confidential Information is Identified
- Records Must be Legible, Signed and Dated
- Records Must be Kept up to Date
- Records Must be Written Clearly Using Plain Language and Avoid Prejudice
- Records Must be Clear, Accurate and Adequate
- Managers Must Oversee, Monitor and Review Records
- Records Should be Kept Securely
- Removal of Records
- Working with Others
- Use of Computers at Home
1. Records Must be Kept on all Carers and their Families
Each foster carer (and other members of their household) must have an electronic case record from the point at which they express an interest in registering as a carer with the Agency, to the time they leave the Agency.
Where paper files are also kept, information held in electronic records must accurately reflect the corresponding information recorded within paper files.
All records, irrespective of whether they are physical or electronic, should be securely kept and electronic messaging (e.g. e-mails) should also be sent in a secure and safe way so as to preserve their confidential and professional nature (see Section 14, Records Should be Kept Securely).
2. The Design of Recording Forms
Records and forms must be designed to fit their purpose and used consistently across the organisation.
A manager must approve the design of all records and forms before coming into use.
3. Carers and their Families Must be Informed about their Records
Foster carers and their families should:
- Be informed about the records kept on them and the reasons why;
- Enable to have access to these records.
See Information Sharing and Confidentiality Procedure and Access to Records Procedure.
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 and easy to understand and should be part of the induction pack given to any new staff members and foster carers in their induction packs . The Privacy Notice should also be displayed on the staff notice board and/or intranet.
4. The Practitioner Primarily Involved Should Complete the Record
The practitioner primarily involved, that is the person who directly observes or witnesses the event that is being recorded or who has participated in the meeting/conversation should usually complete the record.
Where this is not possible and records are completed or updated by other people, it must be clear from the record which person provided the information being recorded. Preferably the originator should read and sign/endorse the record.
Records of decisions must show who has made the decision and the basis on which it has been made.
See also: Section 11, Records Must be Written Clearly Using Plain Language and Avoid Prejudice and Section 12, Records Must be Clear, Accurate and Adequate.
5. All Relevant Information about Carers and their Families Must be Recorded
All contacts by e-mail, telephone, visits, meetings or appointments made in relation to carers must be recorded, time and date should be recorded, stating who made the contact, who was present and/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 carers, their families, and other professionals o must be recorded. When recording such contacts, it will be necessary to state who was present and/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. Foster Carers and their Families should be Involved in the Recording Process
Foster carers should be routinely involved in the process of gathering and recording information about them.
They should be asked to provide information and contribute to assessments and reports. For example by checking reports are factually correct and signing documents to indicate they agree with their contents.
Generally, they must be asked to give their agreement to the sharing of information about them with others - but there are exceptions. See Information Sharing and Confidentiality Procedure.
7. Information about Children and their Families Should Normally be Shared with them
Children and their parents should be told about the records which are kept and how to access them. See also Access to Records Procedure.
Information contained in the carer's file should usually be shared with them unless:
- Sharing the information would be likely to result in serious harm to the child or another person (for example it relates to an allegation made against the carer); or
- The information was given in the expectation that it would not be disclosed; or
- The information relates to a third party who expressly indicated that the information should not be disclosed.
Where information is obtained and recorded which should not be shared with the carer for one of the above reasons, it should be placed in the 'Confidential' section of the file and the reasons should be recorded after taking advice from a manager.
See also Access to Records Procedure
When sharing a record it is important to record who it was shared with and when. The sharing of all decision-making documents reviews, reports and agreements make it easier for everyone to know what is expected and to work together better.
It is important that case records reflect children's lives and the work that is carried out with them. Case records should reflect children's achievements and 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. They are able to see them, challenge them or contribute to them as they wish, with appropriate support.
8. Managers Must Ensure that Confidential Information is Identified
The Agency managers and relevant line managers must monitor sensitive/restricted information held on the 'Confidential' section of case records, ensuring that the reason for it being considered confidential is valid; if not, it should be available to be shared with the foster carer.
However, before sharing any such information, the manager must take all reasonable steps to consult the originator and take account of their views and wishes. See also Access to Records Procedure.
9. Records Must be Legible, Signed and Dated
Those completing electronic records must show their name and the date when the recording was completed.
If possible, paper records should be typed or handwritten in black ink and all such records must be signed and dated and the pages numbered.
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 Kept 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 of the event.
11. Records Must be Written Clearly Using Plain Language and Avoid Prejudice
Records must be written concisely, in plain English and must not contain any expressions that might give offence to any individual or group.
E-mail communication to colleagues and other professionals (that will be included in the record) should always be completed with the same care and attention. The recording should certainly 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, acronyms and abbreviations must be kept to a minimum; and explained.
See Access to Records Procedure.
12. Records Must be Clear, 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 Information Sharing and Confidentiality Procedure.
13. Managers Must Oversee, Monitor and Review all Records
The overall responsibility for ensuring all records are maintained appropriately rests with managers, although the responsibility can be delegated to other staff as appropriate.
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.
14. Records Should be Kept Securely
All records held on foster carers and the children placed with them must be kept securely.
Any paper files/records should normally be stored in a locked cabinet, or a similar manner, usually in an office which only staff have access to.
These records should not be left unattended when not in their normal location.
All electronic records must be kept securely and comply with the requirements of the Data Protection Act 2018 This will include arrangements such as:
- Password protection;
- Automatic log out of screens;
- Logging off computers;
- Changing passwords on a regular basis.
Where staff are working in an 'agile'/'mobile'/'hot-desking' context, care must be exercised to ensure that records or computers are not left on or overlooked by others.
15. Removal of Records
15.1 Exceptional Occurrence
Records should not normally be taken from the location where they are usually kept.
If it is necessary to remove a record from its normal location, a manager should approve this and should stipulate or agree how long it is necessary to remove the record. 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.
Should the situation ever occur where a file/documents is/are lost or mislaid, this must be reported immediately to the manager and every reasonable effort should be made to obtain their recovery.
16. Working with Others
The Agency will work with the responsible local authority to ensure effective integration of information held in the Agency's case files and those of the responsible authority. On receipt of a written request by a child's responsible authority, the Agency will immediately provide copies of records and documents in relation to the child.
When a foster carer seeks to move to a new provider, the Agency will comply with such a request within one month of receipt of the written request if permission is gained from the foster carer and/or safeguarding concerns should be shared.
17. Use of Computers at Home
Staff using computers at home for work purposes must ensure that they are working within the rules of the 'data protection principles' in accordance with the UK General Data Protection Regulation and the Data Protection Act (2018).
This also applies to staff using laptop computers and mobile devices in the course of their duties.
Should the situation ever occur where a laptop is lost or mislaid, this must be reported immediately to the manager and every reasonable effort should be made to obtain their recovery.