Salford Children's Services Procedures Manual Salford City Council website

3.3.2 Recording

SCOPE OF THIS CHAPTER

This chapter is for children in Residential Care.


Contents

  1. Introduction
  2. General
  3. Young Person’s Residential File
  4. Important Event Sheet
  5. Diary
  6. Log Book
  7. Sanctions Book
  8. Admissions & Discharges Register
  9. Restraint Log 
  10. Visitors Book
  11. Menus
  12. Fire Book
  13. Accident Book


1. Introduction

Accurate and careful case records are an important part of residential childcare. They are essential documentation of events in a child’s life and important tools in measuring a child’s progress, wishes, feelings and needs. Recordings must include not only the significant events in a child’s life but a brief record of day to day activities, problems and achievements. It is also vital to include all communications with individuals outside of the residential home including social workers, family members and schools.

The case record in the home is of primary importance to the child because it will contain information about his or her life at a time when the family relationships are strained, disrupted or destroyed. It becomes the child’s ‘memory’ in lieu of parents’ recollections. Details which at the time may appear trivial, may become very significant as the child grows up and needs to look back to piece together and make sense of a disrupted childhood.

Whilst it is important that written records are maintained it is useful to recognise the importance of other types of records. For example photographs can be an important part of building positive self-images as well as recording events, activities and achievements. School reports, certificates, pictures, birthday cards are also important elements that should be kept as part of a child’s case records.

Good records are required for the following reasons:

  1. To ensure continuity and consistency:
  2. To support effective social work practice:

    a record of assessments, plans, contracts, agreed areas of intervention, targets, aims, objectives, outcomes and evaluation.

  3. To ensure accountability and protection:
    • a record of life history.
    • to ensure compliance with Children’s Services policy, legislation and appropriate use of resources.
    • to ensure oversight of cases through effective supervision.
    • to ensure that all representatives or complaints are responded to appropriately and that appropriate changes are made to meet the needs of the children and young people wherever necessary.
    • to justify actions in case of subsequent inquiry.


2. General

Records should be clearly and concisely written in black ink. All recordings should be signed (not just initialled) by the author. Records should be factual, avoiding opinions, judgemental statements, jargon and colloquialisms. Mistakes should be crossed out neatly, but never use Correction Fluid.

All recordings should be made in a book that has had the pages pre numbered. Pages should never be removed. All recordings must be kept safely and securely.

The Registered Manager must take the responsibility for ensuring the quality of recording. All recordings should be reviewed at least monthly and countersigned by the Manager.


3. Young Person’s Residential File

Following admission, a residential file must be created for a young person, following the standard format. The Keyworker has responsibility for maintaining the file. Records for siblings shall not be amalgamated although a degree of cross reference and duplication will result.

Any requests for information or documentation to be forwarded by social workers should be recorded and dated at the front of the file.


4. Important Event Sheet

Date of Incident Event/Incident
Occurrence/achievement		 Cross Referenced
Reports/PE etc		 Signed and Dated

Guidance on the use of Important Event Sheet:

  1. This recording sheet will be used as a quick reference of important events in the history of a young person’s time in residential care. It will be a useful tool for preparing review reports and monthly summaries.
  2. It should be filed in the section marked PE’s.
  3. The record should be kept up to date by the keyworker and checked and signed during supervision by the supervisor.
  4. A brief description of the event/incident should be made and it should be cross referenced to a more detailed recording where appropriate.
    (PE/incident reports/absconding book etc).
  5. The following events should be recorded, but this list is not exclusive
    • Admissions/discharge
    • Change of school/social worker/keyworker/other
    • Important meetings; reviews, child protection meetings, planning mtg/parents evenings etc
    • Restraints and sanctions
    • Missing From Home. Arrests/charges/convictions
    • Achievements in school
    • Important appointments - Doctors/hospital/optician/dentist/school
    • Incidents (all incident reports should be listed) inside and outside the home
    • Serious events, bullying, family events, decisions regarding contact, any illness, periods spent in hospital - episodes of self harm - joining any groups/clubs/societies.


5. Diary

All staff must be encouraged to make regular use of a central diary to ensure good communication and that appointments are attended. No set format is prescribed but in a busy home a day to a page diary is probably best and staff should initial entries.


6. Log Book

Time
Event
Signed

A day to a page diary should be used. The log book should be used to give a brief outline of the activity in the home. Personal information should not be recorded here, that should be recorded on a young persons Personal Event Sheet.

Recordings should include:

  • Staff on duty including any agency or relief staff.
  • Time staff arrive and depart
  • Any visitors/purpose of visit
  • The time any part of the building is secured or unlocked
  • Time the home is settled at night
  • Key events of the day

In those homes where a waking night is employed it is usual to have a separate day and night log book. A night log must be kept if waking night staff are used on a very temporary basis.


7. Sanctions Book

(See Sanctions Procedure).

Young person’s sanction
Reason for sanction
Duration of sanction
Staff issuing sanction Staff on duty
Young person’s comment Young person’s signature
Reason if not signed by young person
Manager’s comment Manager’s signature
Young person completed sanction Yes   No  
If No please give reason:   
Date Sanction Imposed Brief details/reason YP Comments Managers Signature

All sanctions must be countersigned by a senior member of staff within 48 hours. The Registered Manager should examine the sanctions book regularly to ensure that sanctions are being used appropriately.


8. Admissions & Discharges Register

Ref No Date of Admission Full Name DOB Age Sex Admitted from
Emergency/Planned Social Worker Legal Status Discharge To (Must include an address) Discharge Date

Above tables to be spread over 2 A4 pages.

This register must be kept up to date, with entries being made on day of admission or discharge.


9. Restraint Log

(See Physical Intervention Procedure).


10. Visitors Book

(See Visitors to the Home Procedure).

All homes should have a Visitors Book and it should be made easily available and all visitors should be asked to sign in.


11. Menus

No set format is required. However, there needs to be written evidence that meals have been planned, that young people know what food to expect and that there is a record of what has actually been eaten if different.

Menus should indicate where special diets have been catered for.


12. Fire Book

Date of practice drill Nature of practice drill Persons taking part Hypothetical location of fire Time of alarm
Time of completion of drill Means of escape used and tested Fire apparatus tested First aid equipment checked Remarks

This should be completed following a planned or unplanned fire drill and when equipment has been tested.

Fire procedures for the home should be filed in the front of the book.


13. Accident Book

Online form on Salford’s Intranet.

The accident should be recorded by a member of staff on duty on the intranet immediately. Print a copy before submitting the form. The copy must then be put into a file for future reference.

End