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Recording in residential care

Introduction

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 requirements.

Types of records

There are three different types of records that should be maintained within a residential unit:

Administrative records

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.

Unit records

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 are kept.

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 record;
  • 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.

Administrative records

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.

Unit records

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 group.

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 themselves.

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 file.

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 Word format)

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

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 recorded.

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 response

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 fieldworker

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


 
 

 
By Steve Walker, David Shemmings and Hedy Cleaver
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