Case Recording

Records must be kept on all children/young people. The Home's records on each child/young person 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.

Case records should reflect children/young people’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/young people 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/young person's case records:

Personal details in relation to the child

1. The child's/young person'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/young person's date of birth and sex.
3. The child's/young person's religion, if any.
4. The child's/young person's ethnicity, and the child's/young person's cultural and linguistic background.
5. The child's/young person's address immediately before entering the Home.
6. The address, and the type of establishment or accommodation, to which the child/young person is to go when the child/young person 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/young person for safekeeping, the amount of money or a description of the valuables, and the dates on which any money is withdrawn, and any valuables are returned.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/young person is provided with accommodation.

Contact details of certain persons in relation to the child/young person

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/young person's placing authority.
10. The name, address, telephone number and the religion, if any, of the child's/young person's parents.
11. The name, address and telephone number of any social worker assigned to the child/young person by the placing authority.
12. If the child/young person 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/young person.

Information relating to the care, protection or safety of the child/young person

14. The date and circumstances of all incidents where a child/young person goes missing from the Home, including any information relating to the child's/young person'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/young person.
16. Arrangements for, and any restrictions on, contact between the child, the child's/young person'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/young person.
18. Every school report received in respect of the child/young person while the child/young person is accommodated in the Home.
19. A copy of any plan for the care of the child prepared by the child's/young person'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/young person, or of the child's/young person's Placement Plan.

Health matters in relation to the child

21. The name of the general medical practitioner with whom the child/young person is a registered patient, the address of the premises at which the child's/young person's primary medical services are usually provided and the name and address of the child's/young person's registered dental practitioner.
22. Details of any accident or serious illness involving the child/young person while accommodated in the Home.
23. Details of any immunisation, allergy, or medical examination of the child/young person and of any medical or dental need or treatment of the child/young person.
24. Details of any health examination or developmental test conducted with respect to the child at, or in connection with, the child's/young person's school.
25. Details of any medicines kept for the child in the Home, including details of—
    1. Any medicines which the child/young person is permitted to self-administer;
    2. The administration of any medicine to the child/young person;
    3. The disposal of any medicine.
26. Any special dietary or health needs of the child/young person.

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

See also Access to Records.

Children and young people should be told what data / information is contained in their records. The records should be available to children/young people, who should be able to contribute to them as they wish, with appropriate support. Staff are expected to help children/young people living in the Home to access and contribute to the records kept in relation to 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 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 participated in the meeting/conversation, should usually complete the record.

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 confirm its accuracy.

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

All visits, meetings or appointments made in relation to children/young people 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/young people, 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/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'.

Staff should understand their important role in encouraging the child/young person 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.

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.

Information contained in the child/young person'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/young person 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/young person concerned, it should be clearly marked as such in the child/young person'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/young person, 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 of young person/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/young person and/or moved to another section of the file.

All children/young people’s case records must be kept up to date.

As good practice, records should be updated as information becomes available or as decisions or actions are taken as soon as practicable ideally, within 24 hours.

Where any records are subsequently amended this must be clearly identifiable.

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.

Staff should record information on individual children/young people in a non-stigmatising way that distinguishes between fact, opinion and third-party information. Information about the child/young person must always be recorded in a way that will be helpful to the child/young person.

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. 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.

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/young people must be stored securely.

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

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/young people go missing from the Home, including any information relating to the child/young person'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.

Records should not be left unattended when not in their normal location.

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.

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.

The Children's Homes (England) Regulations 2015 stipulate that records in relation to children/young people accommodated in children's homes should be retained securely until the 75th anniversary of the child/young person's birth or, if the child/young person 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. The Home 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/young people'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/young people 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/young person'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/young person'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.