SCRs, Inspections and LSCBs

1. SCRs, Inspections and LSCBs Kathy Bundred Government Office for London Safeguarding Team

2. SCRs, Inspections and LSCBs • Notifications 2009 • Recent SCRs Action plans • Inspection findings • Implications for LSCBs

3. Notifications 2009 • Local authorities rather than LSCBs • London historically under notified Serious Incidents • 51 over 12 months • 24 boroughs • 61 children and young people • 21 under 1 year • 8 aged 1-3 years • Diverse ethnicity • Eighteen SCRs confirmed or in process from these notifications

4. Reasons for notifications 2009 • NAI, abuse or neglect • Suicide • Accidents • Death from natural causes • Teenagers and young adults who had suffered serious and sustained abuse over a number of years • Killed as a result of arson • Young people involved in serious crime including murder

5. Serious Case ReviewsApril 2006 – September 2009 In 47 London SCRs: • 60 child victims in incident leading to review & a further 30 children in the same household • 62% (29) families a child died Ages • 35% children under 1 • 23% 1- 5 • 13% 6 -10 • 17% 11 -15 • 11% of children aged 16 & over Gender • 62% boys

6. Some statistics • 34% of families white British • Approx 15% involved new immigrants, from Africa, Asia and Eastern Europe • 19% Child Protection Plan and13% CIN • 17% Looked After Children • 21% multiple referrals • but1/3 families not known to children’s services

7. Nature of Abuse • Neglect a serious issue in 27% of cases • In 13% children & adults part of an unidentified network of sexual abuse • 17% of mothers experienced sexual abuse and/or exploitation as children • A number of mothers involved with their partners when still minors

8. Mental health, domestic violence, drugs and alcohol Of the families: • 60% had a parent with mental ill health • In some instances psychotic illness only apparent after child’s death • 47% domestic violence including some fatal domestic violence • 26% included adult with identified history of violence other than DV • 23% Alcohol misuse • 28% Identified drug misuse • 1 in 4 of these families (3 families in total) had an adult drug dealer in family

9. Mobility & Housing • 40% highly mobile • 47% had arrears or facing eviction • 13% in dispute with neighbours • 9% women forced to move because of DV • 6% language difficulties • Some young people known to care system had multiple placements all over the country

10. Disruptions To The Early Mother-Child Relationship • 21% Problems with anti-natal care - late booking & missed appointments, anxiety or domestic violence during pregnancy • 32% Issues such as prematurity, post-natal depression, feeding difficulties • Some babies experienced drug withdrawal

11. SCRs – some more common themes Chronologies/history taking an issue in several SCRs • Professionals in this case also often failed to build on what they already knew, or what had happened previously and then to interpret new information in the light of it. This led to them treating each new injury as an isolated event instead of part of a pattern which might also have implications for the safety of other children in the home.

12. Common themes– persisting with a failed solution • The proposed solution of the department, engagement of the voluntary organisation was flawed as there had already been concerted attempts to offer family support and health services which had been persistently refused. The organisation had no clear brief and so far as can be established no track record of success in dealing with such concerns: the non engagement with the organisation lasted through the entire year, though there is no clear documentation as to how persistent it was in its efforts • Despite this, reliance continued to be placed on it as late as December • The department should have called ‘time’ on this approach .

13. SCR –common themes 3 • Fractures or bruising to infants should always be viewed as suspicious • Low level persistent neglect may mask lethal neglect and physical and sexual abuse • Thresholds either not explicit or not understood leading to multiple referrals or non referrals • Children who go missing quickly become at risk • Professionals are often over optimistic despite evidence of danger signs

14. SCR Action plans – procedures/work processes • Checks on whether children known should be replaced by consultations with duty social workers • Supervision decisions recorded on case files • Need for effective supervision in all agencies – supervision not sufficiently probing • Need for case file audits • CP conferences and quoracy – right people present • Roles of QA units in overseeing CP processes including core groups • Legal advice – and mechanisms for raising concerns • Raising concerns in agency and inter-agency

15. Inspections • 19 no notice inspections of assessment and duty so far • 3 announced inspections of Safeguarding and LAC • London generally coming out better than elsewhere but some common themes • Few priority actions but several areas for development

16. What is going well in many LSCB areas • Good morale implied in most and specifically noted in nine unannounced inspections • Engagement of children and parents • Management oversight and support generally positive • Inter-agency working • Good prioritisation and thorough CP assessments • Responsive management • Regular audits

17. Areas for development • Delays for non CP referrals • Inconsistent quality of initial and core assessments • Variable analysis • High caseloads noted in seven inspections • Thresholds not always clear • CAF processes not usually well developed • Staff turnover front line and first line management • Inconsistent quality of supervision • Performance management /audit underdeveloped

18. Supervision • Supervision by managers is inconsistent, not fully recorded and does not follow the council’s supervision procedures. • The supervision arrangements for social work staff is not of a consistently high standard. • Supervision records for some practitioners are insufficiently detailed and of variable regularity. • While all social workers and social work assistants have satisfactory access to supervision, opportunities for reflective analysis of case work practice are insufficient. 􀂃

19. Performance management • Performance management and audit not robust • Quality of analysis and evidence based practice not strong in core assessments • No systematic audit of front line processes • Case file audits and QA processes insufficiently developed • ICS, case file audits and QA processes not sufficiently developed • Delays in decisions, poor planning and management oversight • Access to performance management information not readily available

20. Implications for LSCBs – practice questions • How good is the attendance of key agencies at conferences and core groups? • Do assessments and plans involve key family members including fathers and any new partners? • Do assessments and plans recognise the significance of family history? • Are health professionals equipped and supported to identify risk especially with babies and young children? • Are ante- natal services identifying high risk families? • How good is inter-agency working including working with adult services?

21. Implications for LSCB • LCSB needs to be well informed about performance –current performance data, any lessons from CDOP, notifications • Performance data from council and from partners should be benchmarked against other similar LSCB areas • Pay attention to inspection findings- own and similar areas • Ensure SCR action plans are progressed • Promote effective audit programme and ensure audit informs training and improved practice • Training programme for staff and managers • Need effective support and challenge within and between agencies and LSCB should model/facilitate

22. And finally…implications for LSCBs – the importance of the workforce • Staffing levels, vacancies, staff turnover are all matters for the LSCB – what impacts on staff morale will impact on children and families • Manageable caseloads • Supervision arrangements – policy and compliance and ensuring time for reflection Because…. Good organisational arrangements and culture are important in ensuring children are safeguarded.