Q Family Local Safeguarding Children Board Response Document

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ISLE OF WIGHT SAFEGUARDING CHILDREN BOARD

RESPONSE TO THE Q FAMILY SERIOUS CASE REVIEW

Introduction

1. The case was considered by the Isle of Wight Local Safeguarding Children Board (IOWSCB) at its serious case review subgroup on 16 October 2013 under Regulation 5 of the Local Safeguarding Children Board Regulations 2006. The subgroup found that this case met the criteria for a serious case review and agreed the commissioning arrangements in order to meet the requirements of such reviews as laid out in HM Government Working Together to Safeguard Children, 2013

2. Working Together 2013 allows LSCBs to use any learning model consistent with the principles in the guidance, including systems based methodology. Alan Bedford an independent safeguarding specialist, was commissioned as the lead reviewer to complete the work using a systems-based methodology to ensure full participation by the front line practitioners who had been involved with the family.

4. As the case was so large, and covered nearly two decades, it was decided that it would

be an unnecessary use of agency resources to study the whole case in detail as in the

traditional model of SCRs. To think through a way forward, a scoping day was held,

chaired by the independent reviewer, with around 30 involved staff.

5. The conclusion of the scoping day was to focus on themes of how the family impacted

on professional staff (and what could be done better with similar families in future) and

on some key turning points in the case, rather than the whole case history. The

independent reviewer worked with agency staff and documents to elaborate on these

areas of focus. The staff group was reconvened to consider the draft findings and

contributed to the learning and how things could be done better. In total 40 staff

contributed to the review process.

6. To support the process there was a reference group of senior staff from involved

agencies which the reviewer used as a sounding board, and where necessary to

facilitate any stumbling blocks in the process. The SCR sub group quality assured the

final draft before presentation to the Board

7. As part of the review the LSCB and each agency involved provided a report on what has

already been put in place as a result of their learning from this review, or has improved

since the events described. This can be found in Section 8 of the report whats better

now updates from agencies.

Lessons Learned

8. Below are the recommendations from the report which the LSCB has considered. The

responses provided are the Boards collective view about how it has or will discharge its

responsibility for assuring the quality of child protection systems on the Isle of Wight.

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Recommendations have been clustered together to give a view of the IOWSCB where it

was felt appropriate to do so.

Recommendation 1: That in complex long term cases there is time to step back and reflect,

away from the heat of current crises

IOWSCB View

9. Each agency will have a different definition of what constitutes a complex long term

case. IOWSCB recognises that it is important to share and acknowledge this differing

definition across all partners. This will enable and encourage an open dialogue and

practitioners will feel confident to raise their concerns and discuss these with their

colleagues. This is the foundation for creating the level of understanding required in

order to facilitate effective multi agency working.

10. The use of supervision, particularly reflective supervision, is accepted by IOWSCB as an

area requiring improvement in most agencies. Each agency recognises the need to

support staff and give time for supervision. Work is underway across he NHS trust to

enhance their existing supervision policy and childrens social care introduced a

revamped policy earlier in the year. IOWSCB will continue to promote a culture of

reflective practice as part of its on-going improvement journey.

IOWSCB Actions

11. An audit will be undertaken, led by the performance and quality assurance subgroup,

on the quality and regularity of supervision in all agencies, and the type of supervision

used. This will be completed by May 2015.

12. A resolution will be found to the on-going challenge of sharing information securely

across partners. This will be led by the business management group and

recommendations presented to the February 2015 meeting of the IOWSCB.

13. The business unit will explore the feasibility of licensing all agencies to use the same

chronology software to facilitate a straightforward merging of information for complex

cases. This will be completed by January 2015.

14. The business management group will develop guidance for shared supervision of

practitioners in complex cases, similar to that used by the youth offending team. This

will be completed by March 2015.

15. The serious case review subgroup will review its processes and if necessary terms of

reference to ensure that it receives information about complex cases so that lessons

from good practice can be shared. This will be completed by January 2015.

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Recommendation 2: That the impact of aggressive parents is understood, and staff are

supported with this so that they become resilient in face of the pressures

IOWSCB View

16. Intimidating and aggressive adults directly impact on the effectiveness of the

interventions and support being provided to our most vulnerable children and their

families. This can deflect practitioners away from their child centred approach as they

seek to find ways of coping with volatile situations. Staff need support to be resilient in

the face of aggression and to be actively encouraged to discuss the impact this is having

on both the children and themselves.

17. The re-introduction of multi-agency training on the Island, and specifically the

Sandstories workshops, is having a positive effect in equipping staff to deal with conflict

in a proactive way. A joint approach to working with hostile parents should be part of

the agreed multi-agency intervention plan. This will improve the sharing of knowledge

and understanding on individual cases and demonstrate a unified approach to the

family.

IOWSCB Actions

18. The performance and quality assurance subgroup will agree a mechanism for agencies

to alert each other about complaints received to improve information sharing and

responses to hostile families. This will be completed by February 2015.

19. The workforce development group will undertake an audit of single agency training

provided in relation to conflict management/dealing with hostile families. The group

will also ensure that this topic is included in the 2015/16 training plan. This will be

completed by April 2015.

Recommendation 3: That the value of history is high, that records are easily accessible,

and that assessments always take the full history into account.

Recommendation 7: That the resolution of a current problem does not prevent the

consideration of the long term wellbeing of the children.

Recommendation 8: That there are clear processes in place for multi-agency discussion of

chronic cases without necessarily a single trigger event

IOWSCB View

20. The context within which practitioners were working over the period of time covered is

accurately described in this report. However, much has changed on the Island,

particularly over the last 18 months since the Department for Education issued an

improvement direction following an inadequate Ofsted inspection. A key development

has been the introduction of Hants Direct and the multi-agency safeguarding hub

(MASH) in partnership with Hampshire Childrens Services. This has vastly improved the

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response for contacts made to and referrals received by childrens social care and

ensuring full history is taken into account to enable a long term view to be considered

when the assessment is undertaken.

21. The MASH makes sure there is a consistent approach to taking case history for all

referrals and enables the triangulation of information at a central point. Detailed

assessments are undertaken based on wider historical research and access to multi-

agency records. There is still some work to do to ensure there is consistent access to

adult services records and to address the challenges that the remote access to NHS

trust records can bring.

22. Improvements are continuing across all agencies around record keeping through the

sharing of best practice across schools, for example, and revising processes to allow

better sharing of information between midwives and GPs. All children open to

childrens social care have a plan of intervention which is regularly reviewed and

updated. Permanence planning is now included from the point of referral.

23. The meetings between health, social care and police to discuss chronic chases, or cases

where difficulties have arisen offer regular opportunities for multi-agency discussions

that are not triggered by any specific event.

IOWSCB Actions

24. The use of the same chronology software (see para 2.5) will facilitate and improve

information sharing in complex cases. This will be completed by the business unit by

January 2015.

25. The performance and quality assurance subgroup will review its audit tools to include

looking at the use of the resolving professional disagreements policy, the effectiveness

of information sharing and the use of historical intelligence in assessments. This will be

included in the 2015 audit plan.

Recommendation 4: That optimism in the face of changing evidence will sometimes

happen and needs to be addressed through good supervision and case review

IOWSCB View

26. A degree of optimism is always necessary when working with children and their

families. However, the risk is that staff become acclimatised to presenting risks and

optimism over-rides the need for a re-assessment. IOWSCB expects all partners to have

in place robust supervision policies which are regularly tested and reviewed. Childrens

social care undertake monthly audits to test how effectively their updated supervision

policy is being implemented.

27. There is evidence from recent multi-agency audits and learning lessons events that the

concept of professional challenge is becoming embedded. The joint meetings held with

health, social care and police senior managers allow the sharing of different views on

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cases and resolution to be achieved in complex, long terms cases. IOWSCB envisages

that the leadership demonstrated through these interactions will be replicated in every

tier of management across all agencies.

IOWSCB Actions

28. The performance and quality assurance subgroup will lead on the implementation of a

multi-agency peer assessment of supervision. This will test the use and quality of

supervision in all agencies and how practitioners are challenged where there is undue

optimism. This will be completed by September 2015.

Recommendation 5: That challenge is valued, and modelled by supervisors and managers

by both giving and receiving challenge well.

IOWSCB View

29. The culture of fear that was prevalent in agencies on the Island across most of the life of

this case is clearly evident throughout this serious case review. A change of culture and

attitude has been evolving over the last 12 months in the context of professional

respect and reflecting progressive practice. It is accepted that this will take time to fully

embed and the senior leaders who are members of IOWSCB will continue to contribute

to this important culture change by modelling this behaviour.

30. Quarterly partnership meetings take place involving the NHS trusts safeguarding team,

and senior managers from childrens social care and the police. This has and will

continue to support the use of challenge and the shift away from the belief of blame.

The implementation of IOWSCBs learning and improvement framework in December

2013 puts practitioners and their managers at the heart of identifying and

implementing system change.

IOWSCB Actions

31. IOWSCB will continue to support a culture of positive, professional challenge through

the content and learning outcomes of the multi-agency training that it commissions.

This will be reflected in its 2015 training plan.

32. Through its board development day IOWSCB will ensure strategic managers are

equipped to contribute to the continued creation of a culture of challenge and are able

to model appropriate behaviours. The development day will be held by March 2015.

33. The performance and quality assurance sub group will evidence and test individual

agency understanding, ownership and expectations around giving and receiving

challenge through its multi-agency audit plan and review of Section 11 compliance.

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Recommendation 6: That the escalation procedures to resolve inter-professional and inter-

agency disputes are understood and used.

IOWSCB View

34. There is evidence from recent multi-agency audits and learning lessons events that the

local escalation procedure (resolving professional disagreement policy) is well

embedded in practice. Single agency child protection processes reference this

procedure and are underpinned by revised internal processes. Staff attending the

learning lessons events are reminded about the policy and how to use it.

35. There is a clear recognition that multi agency approaches work best where there is

challenge as part of the dialogue. Partners understand the importance of hearing

different agency viewpoints and how this improves outcomes for children and young

people. Challenge and escalation are no longer perceived as a hostile action and staff

are pro-actively supported to stop being passive.

IOWSCB Actions

36. The performance and quality assurance subgroup will monitor the use and effectiveness

of the application of the local escalation procedure through its multi-agency audits and

the quarterly performance reports provided by each agency.

Recommendation 9: That, whilst valuing the contribution of parents to conferences, there

are clear processes in place to ensure staff can have some time to discuss their views

without the parents being present.

IOWSCB View

37. As part of the Ofsted improvement plan childrens social care have reverted to the

traditional style of case conferences. Parents and carers are and will continue to be an

essential part of creating and delivering the agreed intervention plan for the children.

This partnership approach is seen as being at the core of achieving effective and

sustainable outcomes from case conferences on the Isle of Wight.

38. The current case conference process allows for professionals to alert the chair in

advance if they wish to have a confidential discussion should they have concerns about

the impact that the information they will be sharing may have on the parents/carers

present. Agencies attending the conference can ask the conference chair to join this

discussion. Additionally, there are clear criteria in the 4LSCB safeguarding procedures

against which the conference chair would decide whether or not it is appropriate to

exclude either parent or carer from all or part of the conference.

IOWSCB Actions

39. The Hampshire and Isle of Wight workforce development group will, as part of the

refresh of the IOWSCB training plan, seek to include workshops or include in relevant

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courses roles and responsibilities of practitioners before, during and after child

protection conferences and review conferences. This will be completed by April 2015.

40. Childrens social care will be asked to confirm and evidence that it has effective training

in place for its independent reviewing officers and conference chairs. This will be

monitored through the quarterly independent reviewing officer report that is to be

considered at the performance and quality assurance subgroup. This will be actioned

by March 2015.

41. Childrens social care will review the invitations sent out for conferences to ensure

agencies are reminded they can hold a confidential slot and that the conference chair

can be invited to join this. This will be actioned by January 2015.

Recommendation 10: That childrens social care would, other than in the most exceptional

circumstances, convene multi-agency meetings to discuss major concerns by other

agencies, and that the procedural requirement for the LSCB to rule on any dispute is

understood.

IOWSCB View

42. All children open to childrens social care will have a multi-agency intervention plan

in place, and these are regularly reviewed. The current multi-agency safeguarding

procedures include the need to hold a strategy discussions and convene strategy

meetings where there are perceived or actual safeguarding concerns.

43. Understanding of the term complex case does differ across agencies however the

introduction of locality hubs on the Island allows the opportunity for practitioners to

take cases there for discussion if they have any concerns. It will be important for the

locality hubs to be well attended and supported by all partners.

44. Any organisation can convene a multi-agency meeting to discuss specific cases.

Childrens social care can attend where the case is not open to them to give advice

and share information but this should not be a route for referrals.

45. Childrens social care will always convene a multi-agency meeting to discuss major

concerns raised by other agencies about open cases. The regular meetings between

childrens social care, health and police senior managers are used to discuss open

cases and agree appropriate courses of action. Additionally, the escalation policy is

well embedded and offers opportunities for appropriate professional challenge

where needed.

IOWSCB Actions

46. IOWSCB to promote the new locality hub arrangements across all partners to ensure

there is a good understanding of what they are there to do, and that agencies

regularly attend and support the meetings. This will be actioned by February 2015

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47. The 4LSCB safeguarding procedures will be reviewed to make sure there is clarity

about who can convene meetings where there are concerns about complex cases.

This will be actioned by February 2015

Recommendation 11: That the contradictory evidence from children about an allegation or

disclosure does not lead to a failure to consider what is happening overall in the childrens

lives

Recommendation 12: That contradictory evidence is considered as a possible indicator of

abuse rather than something that disproves it

IOWSCB View

48. Contradictory information should not be a reason to dismiss an investigation or case

but rather actually be expected. Hampshire Police ensure information and wider

evidence gathering is used to test, corroborate or dispel allegations so that an

informed, transparent and reliable picture is produced.

49. Professionals are encouraged and expected to demonstrate appropriate professional

curiosity regarding the overall case/family circumstances. This will lead to holistic

analysis and assessment (including risks) and consider the reasons for contradictory

evidence where this occurs.

50. The use of the child and family assessment in childrens social care and the

requirement for chronologies are a key component of the Islands improvement

journey. This will ensure there is a clear thinking, child centre approach for all cases.

Practitioners start with the premise of believing the child or young looking beyond

the current allegations and seeking to understand what lies beneath what is

currently happening.

51. The multi-agency risk assessment conference (METRAC) is a good example of the

Police working in partnership with a range of agencies to assist in managing the risk

of highly vulnerable children and young people where there are no criminal

investigations or proceedings underway.

IOWSCB Actions

52. The IOWSCB training offer for the childrens workforce on the Island is being

reviewed to include assessment and management of risk. Delivery of updated

training courses will commence in April 2015.

53. The effectiveness of METRAC and its impact on improving outcomes for children and

young people will be tested through the performance and quality assurance multi-

agency audit programme in 2015.

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Additional IOWSCB actions

54. IOWSCB disseminated information from this case through a series of learning lessons events held in October 2014. It will work with the Hampshire and Isle of Wight workforce development group to ensure the lessons are incorporated into Level 2/3 IOWSCB endorsed safeguarding training and training for newly qualified social workers.

55. The above actions will form of an action plan which will be monitored by the IOWSCB serious case review subgroup with exception reporting to each Board meeting.

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ACTIONS ARISING FROM RECOMMENDATIONS

Action Lead Target date

1. An audit will be undertaken on the quality and regularity of supervision in all agencies, and the type of supervision used.

Performance and quality assurance subgroup

31 May 2015

2. A resolution will be found to the on-going challenge of sharing information securely across partners

Business management group

28 Feb 2015

3. Explore the feasibility of licensing all agencies to use the same chronology software to facilitate a straightforward merging of information for complex cases.

IOWSCB business unit

31 Jan 2015

4. Develop guidance for shared supervision of practitioners in complex cases, similar to that used by the youth offending team


31 Mar 2015

5. Review processes and if necessary terms of reference for the serious case review subgroup to ensure that it receives information about complex cases so that lessons from good practice can be shared.

Serious case review subgroup

31 Jan 2015

6. Agree a mechanism for agencies to alert each other about complaints received to improve information sharing and responses to hostile families.


28 Feb 2015

7. Undertake an audit of single agency training provided in relation to conflict management/dealing with hostile families, and will also ensure this topic is included in the 2015/16 training plan

Workforce development group

30 Apr 2015

8. Use same chronology software (see action number 3) to facilitate and improve information sharing in complex cases.


31 Jan 2015

9. Review audit tools to include looking at the use of the resolving professional disagreements policy, the effectiveness of information sharing and the use of historical intelligence in assessments


30 Apr 2015

10. Implement a multi-agency peer assessment of supervision. This will test the use and quality of supervision in all agencies and how practitioners are challenged where there is undue optimism.


30 Sept 2015

11. Support a culture of positive, professional challenge through the content and learning outcomes of the multi-agency training that it commissions


30 Apr 2015

12. Ensure strategic managers are equipped to contribute to the continued creation of a culture of challenge and are able to model appropriate behaviours.

IOWSCB board members

28 Feb 2015

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Action Lead Target date

13. Evidence and test individual agency understanding, ownership and expectations around giving and receiving challenge through its multi-agency audit plan and review of Section 11 compliance


31 Dec 2015

14. Monitor the use and effectiveness of the application of the local escalation procedure through its multi-agency audits and the quarterly performance reports provided by each agency.


31 Mar 2016

15. As part of the refresh of the IOWSCB training plan, seek to include workshops or include in relevant courses roles and responsibilities of practitioners before, during and after child protection conferences and review conferences.


30 Apr 2015

16. Confirm and evidence that it has effective training in place for its independent reviewing officers and conference chairs. This will be monitored through the quarterly independent reviewing officer report that is to be considered at the performance and quality assurance subgroup

Childrens social care 31 Mar 2015

17. Review the invitations sent out for conferences to ensure agencies are reminded they can hold a confidential slot and that the conference chair can be invited to join this.

Childrens social care 31 Jan 2015

18. Promote the new locality hub arrangements across all partners to ensure there is a good understanding of what they are there to do, and that agencies regularly attend and support the meetings

IOWSCB board and subgroups

28 Feb 2015

19. 4LSCB safeguarding procedures to be reviewed to make sure there is clarity about who can convene meetings where there are concerns about complex cases.

4LSCB procedures group

28 Feb 2015

20. Review the IOWSCB training offer for the childrens workforce on the Island to include assessment and management of risk


30 Apr 2015

21. Effectiveness of METRAC and its impact on improving outcomes for children and young people to be tested through the multi-agency audit programme


31 Mar 2016

Documents

Q Family Local Safeguarding Children Board Response Document