Recording

Records must be kept on all young people. The Service’s records on each young person represent a significant contribution to their life history, and it is important therefore that all staff are familiar with the Service’s policies on record keeping and understand the importance of accurate, clear and objective recording.

Staff should record information on individual young people in a way that does not stigmatise and distinguishes between fact, opinion and third-party information. Information about the young person must always be recorded in a way that will be helpful to the young person.

Case records should reflect the young person’s life, their achievements and the work that is carried out with them, and should clearly relate to the plans for their future. The style and clarity of records should increase the understanding that young people have about their histories, background and experiences.

Staff should understand their important role in encouraging the young person to reflect on and understand their history, according to their needs. Staff should keep and encourage young people to keep appropriate memorabilia of the time spent living in supported accommodation and help them record significant life events (when the young people wish to do so).

Some records may be kept electronically 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 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.

Information and documents to be included in each child’s case records (Schedule 2  Supported Accommodation (England) Regulations 2023):

Personal details in relation to the young person

1. The young person’s name and any name by which the young person has previously been known, other than a name used by the young person prior to adoption;
2. Date of birth and sex;
3. Religion, if any;
4. The young person’s ethnicity, cultural and linguistic background;
5. The address immediately before being admitted to the supported accommodation;
6. The address, and the type of accommodation, to which the young person is to go when they are discharged from the supported accommodation;
7. The dates on which any money or valuables are deposited by or on behalf of the 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 under which the young person is accommodated in the supported accommodation.

Contact details of certain persons in relation to the young person

9. The name of an individual who may be contacted at, and the address and telephone number of the accommodating authority;
10. The name, address, telephone number and the religion, if any, of the young person’s parents;
11. The name, address and telephone number of any social worker assigned to the young person by the accommodating authority;
12. If the 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 young person.

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

14. The date and circumstances of all incidents where a young person goes missing from the premises used as supported accommodation, including any information relating to the young person's whereabouts during the period of absence;
15. The date and circumstances of any measure of restraint used in relation to the young person;
16. Arrangements for, and any restrictions on, contact between the young person and their parents, and any other person.

Plans or reports relating to the young person

17. A copy of any Education, Health and Care Plan for the young person;
18. Every school or college report received in respect of the young person while the young person accommodated by the supported accommodation undertaking;
19. A copy of any relevant plan prepared for the young person;
20. The date and result of any review of any relevant plan for the young person.

Health matters in relation to the young person

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

Recording forms must be fit for purpose and used consistently throughout the Service.

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 young people, who should be able to contribute to them as they wish, with appropriate support. Staff are expected to help young people living in the Service to access and contribute to the records kept in relation to them.

Young people and their parents should be supported to understand the nature of records kept by the registered person and how to access 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, 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 Young Person’s Guide/Welcome Pack which is given to all young people when they are first placed in the Service.

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 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 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.

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 Service’s records as 'living documents'.

Staff should understand their important role in encouraging the young person to reflect on and understand their history.

On a regular basis, all young people should be supported to contribute to their records in a way that reflects their voice, views, wishes and feelings. Young people should also be encouraged to keep appropriate memorabilia of their time spent living at the Service and to record significant life events.

Generally, 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 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 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 young person concerned, it should be clearly marked as such in the young person’s record.

Where records contain information about third parties (for example, other family members or other children or young people), this cannot usually be shared with the 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 young person/parents.

See Access to Records Procedure for more information.

The registered person 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 young person and/or moved to another section of the file.

All young people’s case records must be kept up to date and signed and dated by the author of each entry.

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 young people in a non-stigmatising way that distinguishes between fact, opinion and third-party information. Information about the young person must always be recorded in a way that will be helpful to the 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 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 and, if any such request is received, the registered person 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 person.

The registered person 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 restraint taking place within the Service and serious incidents involving young people should be regularly reviewed by the registered person 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 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 restraint is used in the Service, a record must be made within 24 hours. Records must also be kept detailing all individual incidents when young people go missing from the Service including any information relating to the 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 registered person.

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 Service, 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.

Young people’s case records should be retained securely until the 75th anniversary of their birth or, if the young person dies before the 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 Service should maintain a list of records which have been destroyed, the date when they were destroyed and by whom.

If a Service closes or is taken over by a different registered provider, it is important that young people’s case records continue to be stored securely for the required period of time so that young people can access their case records in later life. If the registered provider runs other settings, the case records must be kept in the nearest setting. In cases where the setting and its registered provider cease to operate entirely, the case records must be passed to the young person’s accommodating authority.

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.