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1.7 Case Recording Policy and Staff 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.

RELATED CHAPTERS

Access to Records Procedure

Care and Placement Plans Guidance

AMENDMENT

In November 2018, this guidance was reviewed and updated following publication of the General Data Protection Regulations and Data Protection Act 2018.


Contents

  1. Records Must be Kept on All Children
  2. The Design of Records and Forms Must be Approved
  3. Children and Young People have a Right to 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 and their Families should Normally be Shared with them
  8. Managers Must Monitor Information in the Restricted Section of the Child's Record
  9. Records Must be Kept Up to Date
  10. Records Must be Written Clearly using Plain Language and Avoid Prejudice
  11. Records Must be Accurate and Adequate
  12. Managers Must Oversee and Monitor all Records
  13. Records Should be Kept Securely
  14. Removal of Records Must be an Exceptional Occurrence
  15. Records Moved to a New Location Must be Monitored
  16. Records must Usually be Retained After Closure


1. Records Must be Kept on All Children

Also see: Care and Placement Plans Guidance.

Records must be kept on all children: in the form of paper files but computer records, 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.


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 before coming into use.


3. Children and Young People have a Right to be Informed about their Records

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.

See Information Sharing 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.

Any 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 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 made any decision as well as 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.

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 contained in the child’s record should usually 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 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, 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.


8. Managers Must Monitor Information in the Restricted Section of the Child's Record

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.


9. 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.


10. Records Must be Written Clearly using Plain Language and Avoid Prejudice

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.

Use of technical or professional terms 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.


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

See Information Sharing Policy.


12. Managers Must Oversee and Monitor all Records

The overall responsibility for ensuring all records are maintained appropriately rests with the managers with day to day responsibility, 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.

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.


13. Records Should be Kept Securely

All records held on children must be kept 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 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.

*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.


14. 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.


15. 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.


16. Records must Usually be Retained After Closure

Click here to view Nottingham City 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.

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.

End