Case Recording Policy and Staff Guidance

Records must be kept on all children and young people. The home’s records represent a significant contribution to the child’s life history, including what happened to them and why certain decisions were made. It is important that all staff are familiar with the home’s policy on record keeping and understand the importance of accurate, respectful and objective recording.

The child’s case record will usually be developed from notes taken by workers during the course of a Key Session or other meeting. These notes may be used directly, or as a result of such information being in a report or court statement.

The Family Court, in the case of RE M and N (Children) (Local authority gathering, preserving and disclosing evidence) advised that social workers/practitioners must make contemporaneous notes which form a coherent, contemporaneous record.

The notes should be legible, signed and dated and record persons present during the meeting/conversation in question. The notes should be detailed and accurately attribute descriptions, actions and views etc. In some instances, sketches/diagrams may be helpful in establishing the veracity of explanations given, e.g. with regard to how injuries were sustained, etc.

Note: These original notes might need to be disclosed in a court.

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 managements systems must comply with data protection principles (i.e. all staff members have an individual user name / log in). 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.

Storing Electronic Information

• Always store electronic information on a shared network drive, EDRM, or case management system (as appropriate);
• Never store information on a computer hard drive;
• Consider the content of the information you are storing and if access restrictions are needed;
• Apply the same care to the management of electronic records as you would with paper records.

Storing Information in your Offices

• Securely store records you need to access on a regular basis within your offices;
• Ensure records which are stored in one place (such as a storage room) are located away from water sources and other threats;
• Mark records with an anticipated disposal date to avoid accidental disposal;
• Label folders and boxes with a clear description of the contents and the responsible owner;
• Regularly review storage areas to ensure records past their retention period are disposed of.

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

Children and young people should be told what data / information is contained in their records.

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.

Staff are expected to help children living in the home to access and contribute to the records kept in relation to them.

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 participated in the meeting/conversation, should usually complete the record.

Any hard copy records must be signed (not initialled) 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 ensure its accuracy.

Records of decisions must show who has made the decision as well as the basis on which it was made.

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.

Children and young people 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’.

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, children and 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.

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.

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.

Records should be updated from detailed notes made contemporaneously as soon as practicable after information becomes available or as decisions or actions 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 clearly and concisely, using plain language, 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.

Thought should be given to the use of language in relation to Children in Care.

Professionals need to understand that not everyone speaks the same language as them and for the children and young people in our care it can feel complex and overwhelming and sometimes even embarrassing as there can be a lot of stigma attached to some of the terms used by professionals.

For more guidance, please see: TACT Language that Cares which summarises research with children and young people and contains a suggested list of terms / vocabulary to help ensure that the language used by practitioners is accessible, clear and sensitive to children and young people in our care.

Use of technical or professional terms, jargon and abbreviations / acronyms 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 (not initialled) 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.

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. Local authorities have 1 month to respond to any such requests and, if any such request is received, the authority should take reasonable steps to establish if the data is accurate and rectify the record if necessary.

Records must distinguish clearly between assessments, judgements and decisions. Records must also distinguish between first-hand information and information obtained from third parties. Records must reflect the distinction between fact and opinion. Although it is admissible to record opinion, it must be recorded as such and not presented as factual. Records must be signed and dated by the author of each written entry.

The overall responsibility for ensuring all records are maintained appropriately rests with 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 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 stored securely and must be tamper proof.

Any paper files should be stored in a locked cabinet in an office which only staff/carers have access to.

Records of Additional Measures 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.

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 cannot 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, 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.

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.

Retention Schedules:

• These are guidelines which explain how long certain types of records need to be retained for;
• They include a description of the function the records support (rather than being a list of file types);
• Retention schedules are based on legislation, best practice and business requirements;
• Retention schedules are regularly reviewed;
• Make sure you refer to the correct retention schedule before disposing of any records.

Click here to view Derbyshire Children’s Services – Retention of Records which explains the legal requirements for the retention of Children’s Social Care records.

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.

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.

Any files/logs/paperwork must not be destroyed, and each home should plan with the Operations Manager / Head of Service Disability Resources and Business Services staff a routine / process for storage in the home and timescales for information going to off-site storage.

Any boxes and information ideally should be stored together (e.g. Daily Logs, Communication Books etc.), listed and dated with a contents sheet in the box and a copy in the home, so if needed for reference all the information is together for ease.

Children’s Files: Should always be kept in a locked cabinet whilst the child or young person is living in the home. The main file needs to be kept up to date with numbered archive files, if needed. Only keep the latest up to date information in the child’s main file and avoid duplication.

On Discharge: The file needs to be taken to the child’s area office to the social worker. The files should be checked by the key carer with a contents list (including any page numbers) in or on the outside of the file and a copy should be held at the home in a file marked “Children and Young Peoples Returned Files”. The file needs to be signed for by the person receiving the file and kept as a receipt in the home and signed off by the manager.

Information should be kept from one full inspection to the next as evidence for the Ofsted inspector.

Homes files such as Incident Forms and Complaints/Representations should be archived annually from one year to the next, but kept on site until Ofsted have inspected.