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2.1 Recording Policy and Guidelines

AMENDMENT

This chapter was updated in September 2016. Amendments were made throughout this chapter in line with local practice, and the chapter should be re-read.


Contents

  1. Records Must be Kept on all Children 
  2. The Design of Records and Forms Must be Approved
  3. Children and their Families Must 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/their Families should Normally be Shared with them
  8. Managers must Ensure that Confidential Information is Identified
  9. Records Must be Legible, Signed and Dated
  10. Records Must be Kept up to Date
  11. Records Must be Written in Plain English and Prejudice Must be Avoided
  12. Records Must be Accurate and Adequate
  13. Managers Must Oversee, Monitor and Review Records
  14. Records Should be Kept Securely
  15. Removal of Records Must be an Exceptional Occurrence
  16. Records Moved to a New Location Must be Monitored
  17. Records Must Usually be Retained After Closure
  18. Use of Computers at Home


1. Records Must be Kept on all Children

Each child must have his or her own electronic case record from the point of referral to case closure; audio, video and digital recordings may also be kept.

Where paper files are also 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.

1.1 The Purpose of Social Care Records:

  • As an agreed record of the agency’s involvement;
  • As a statement of the purpose of the work;
  • As a way of recording plans and monitoring progress;
  • To facilitate communication between agencies and the children and families they serve;
  • To promote continuity throughout a child or young person’s life regardless of whether workers are changed;
  • To provide a documentary record of part of the child’s history. This will help to place important events in the context of the child’s life; their family and wider social networks;
  • To assist in the process of supervision by providing a monitoring tool for managers and to evidence the worker’s practice;
  • To promote accountability between family members and the agency;
  • To enable the consistent collection of information which can be used to determine the quantity and type of resources needed to meet the organisation’s aims. Collection of information is also crucial to deriving data about equality of access to services.


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 by the Policy and Procedures Review Group before coming into use.


3. Children and their Families Must be Informed about their Records

Children and their families have a right to be informed about the records kept on them, the reasons why and their rights to confidentiality and of access to their records.

See Confidentiality Policy.

See also Access to Records Procedure.

Where children have been adopted, see also Access to Birth Records and Adoption Case Records Procedure.

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 the person who directly observes or witnesses the event that is being recorded or who has participated in the meeting/conversation, must complete records.

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.


5. All Relevant Information about Children and their Families must be Recorded

Every child's case record must hold details of the child's legal name, date of birth and any identification number.

It must also include a risk assessment, transfer/closing summary (where appropriate) and a properly maintained Chronology. Chronologies should be completed using the template for analytical chronologies on Wisdom.

All other relevant contacts with children, their families, colleagues, professionals or other significant people must be recorded in the same way, i.e. who was present or seen, the relevant discussions, actions or decisions taken and by whom, and the reasons for decisions. All visits made to a family as part of an assessment should be recorded as visits, as well as informing the assessment record.


6. Children and their Families should be Involved in the Recording Process

Children and their families 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 which are identified in the next section.


7. Information about Children and their Families Should Normally be Shared with them

Information obtained about children and their families should be shared with them unless:

  • Sharing the information would be likely to result in serious harm to the child or another person; 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 the information should not be disclosed.

Where information is obtained and recorded which should not be shared with the child concerned for one of the above reasons, the reasons for restricting access should be recorded on a case file record. All children’s case files are redacted following an access to record request prior to the person being given a copy of their records.

See also Access to Records Procedure.

Where children have been adopted, see also Access to Birth Records and Adoption Case Records Procedure.


8. Managers Must Ensure that Confidential Information is Identified

Managers must monitor confidential restricted information held on case records, ensuring that the reason for it being considered confidential is valid; if not, it should be available to be shared with the child.

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.

In the event of any handwritten documents being produced these should be scanned and saved electronically. 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 two working days.

Where records are made or updated the date the information became known should be recorded in the record and the date and time of the entry is electronically captured.


11. Records Must be Written in Plain English and Prejudice Must be Avoided

Records must be written concisely, in plain English, 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, acronyms, and abbreviations must be kept to a minimum; and if there is likely to be any doubt of their meaning, they must be defined or explained. All names of resources should have a description as to the service they provide for example, Guernsey House Sheffield Care Trust Substance Misuse Service.


12. 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.

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 Confidentiality Policy.


13. Managers Must Oversee, Monitor and Review all Records

The overall responsibility for ensuring all records are maintained appropriately rests with line managers, although the responsibility can be delegated to other staff as appropriate.

The line 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 children must be kept securely.

Children's paper files should normally be stored in a locked cabinet, or a similar manner, usually in an office which only staff/carers have access to.

Other day-to-day records, such as Contact or Daily Records, should also be kept securely in a manner authorised by the manager.

These records should not be left unattended when not in their normal location.

All electronic records must be kept securely and this will include arrangements such as:

  • Password protection;
  • Automatic log out of screens;
  • Logging off computers;
  • Changing passwords on a regular basis.


15. Removal of Records Must be an 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.


16. 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.

The sender should check that the records have arrived at their intended destination.


17. Records Must Usually be Retained After Closure

The member of staff responsible for the case when the case is closed is responsible for ensuring that the file to be retained is in good order and that unnecessary items have been removed, for example, duplicate copies etc.

17.1 Practitioner Diaries

Practitioner diaries represent important documents that detail work carried out and help to ensure accountability. It is good practice to retain practitioner diaries for 3 years.


18. Use of Computers at Home

Staff using computers at home for work purposes should refer to the following pieces of guidance on the Council's Intranet regarding the remote access services:

End