Recording in residential care
The regulatory requirements set out in Volume 4 of the Children
Act 1989 Regulations and Guidance means than practitioners
working in residential care must keep a different set of records
from their fieldwork colleagues. In addition records in residential
child care must facilitate continuity of care among the staff
team; that is they must establish a common shared memory about
the young person, their needs and activities.
The purpose of records in residential care is to:
- Provide a record for the young person of their time at
the residential home;
- Contribute to the development, implementation and review
of the plan for the young person;
- Identify and respond to the young person's needs;
- Assist in recognising and establishing patterns in the
young person's life and/or behaviour;
- To support the provision of consistent, high quality care
- To demonstrate that the residential home meets the regulatory
Types of records
There are three different types of records that should be
maintained within a residential unit:
These are records that the unit is required to keep to demonstrate
effective management and good practice. Examples of administrative
records include an accident book, a sanctions log, a record
of medication. Full details of these records are set out in
the Children Act 1989 Regulations and Guidance, Volume 4.
These are records that support the daily running of the unit,
such as the unit log and in some units a 'hand-over' book.
The young person's file
This is where detailed records relating to the young person
Managing records in residential care
The complexity of recording in residential care means that
it is essential to have a clear procedure for recording within
the unit. All staff, including Agency and sessional staff
should know the procedure. The procedure should set out:
a) the purpose of each type of record used in the unit
b) the content of each record
c) the relationship between different records within the unit
d) the relationship between records held within the residential
unit and the fieldwork record.
Principles for recording in residential care
Record keeping within residential units should take account
of the following principles:
- Recording should be shared with, or at the least accessible
to, the young person;
- Young people should be encouraged to contribute to their
- Recording can be used as a tool to support the work being
undertaken with the young person;
- The main or primary record within the residential unit
is the young person's file;
- Key information about the young person must be recorded
in their file and other records should cross reference to
the young person's record;
- Recording should support the flow of information between
the residential unit and the fieldwork practitioner.
A framework for recording in residential care
Residential units will already have developed recording procedures
and practice. The following framework provides a model of
how recording in residential care may be structured in line
with the principles outlined above.
These records should be brief and factual. It will not be
appropriate to cross-reference these records to more detailed
records in the young person's file. However, in some situations,
for example, in the case of accidents or where a young person
is missing from the unit, a more detailed record should also
be made in the young person's file.
The relationship between the unit log and the young person's
file is central to effective recording in residential care.
The unit log provides an ongoing record of events within the
unit. It helps to establish a common memory among the staff
The records kept in the unit log support the day to day management
or running of the unit. It should record any information that
needs to be immediately available to other staff. The unit
log should contain a brief record of events that occurred
during a shift and any events that have been planned.
It is of course likely that many, if not all, of these events
will involve one or more young people. The unit log, however,
is not the appropriate record to report details about an individual
young person. To use the unit log in this way will create
difficulties for young people to access information about
For a young person to have access to recording about them
in the unit log records about other young people will have
to be removed, which in practice will mean having to photocopy
excerpts from the unit log for the young person. To make information
accessible to the young person, the information in the unit
log will also have to be recorded in the young person's file.
This doubles the amount of recording required and increases
the risk of information being missed from the young person's
All records in the unit log should therefore be brief, dated
and timed and signed. Where detailed information about a young
person has to be recorded, this should be done in the young
person's file and the entry in the unit log should refer the
reader to the young person's file.
This can raise practical difficulties where the young people's
files are kept in a different part of the unit. One way of
overcoming this issue is to have an 'active' file that is
kept securely alongside the unit log and which contains a
section on each young person with a number of detailed records.
These are then used to record any detailed information relating
a young person. Completed records on individual young people
are then regularly transferred to their file. These records
can be easily shared with the young person, by removing them
from the file, and the file can be used to support hand over
and unit meetings.
Example unit log (Microsoft
The young person's file
Each young person in the unit must have their own individual
file, even where several young people from the same family
are living in the unit. The Young Person's file should contain
copies of the young person's Care Plan and other 'Looking
After Children' materials. The file should include a section
that contains all the detailed records made by the unit relating
to the young person. There should be section for correspondence
and a 'Not Yet Cleared Section', which contains any letters,
reports or other information which have not been cleared for
sharing with the young person.
For an example of
a detailed record click here
To go to exercises on recording
skills click here
The young person should be encouraged to contribute to the
record. Their contribution may include their own observations
or where they disagree with an entry in the file.
The young person's file should include regular summaries
that are completed by the young person's nominated key worker
and to which the young person should also contribute.
Case summaries should be used to support work with young
people. Case summaries can be used to:
Support direct work with young people
Completing a summary with a young person offers an opportunity
for the young person to reflect on their progress over the
period covered by the summary, and for staff to acknowledge
the young person's achievements and discuss any difficulties
they may be having.
Offer an opportunity to involve young people in recording
The summary can provide an opportunity for the young person
to write information for their file or to have their views
Support the implementation of the plan for the young person
The summary should be directly related to the aims and objectives
for the young person as stated in the Care Plan, Review and
Assessment and Action Records. The summary can be a tool to
breakdown larger objectives into smaller tasks.
Communicate plans and objectives that require a whole team
The summary can be used to identify actions or approaches
that need to be adopted or supported by all the staff team
to achieve specific objectives or outcomes for, or with, the
young person. A copy of the summary should be kept in the
'active' file to ensure that members of the staff team are
aware of the current issues and objectives for the young person.
Facilitate communication between the residential unit and
Copies of each summary should be sent to the fieldworker.
This will enable the fieldworker to keep up to date with the
young person's progress in the unit and help to ensure that
all the elements of the plan remained synchronised.
Monitor progress and assist in the preparation of reports
If regular summaries have been made the information they
contain can be readily brought together into a report, for
a review for example.
A summary should usually be completed at monthly intervals.
However, the frequency of summaries should reflect the needs
and circumstances of the young person. For example, if a young
person has only recently become looked after or moved into
the unit, then weekly or fortnightly summaries may be more
appropriate. Alternatively, for young people who are placed
long term and are settled in a unit, bimonthly or quarterly
summaries may be more appropriate to their needs.
For an example
of a case summary record click here