Learning from reviews

We are committed to supporting practitioners and organisations to improve practice and achieve the best outcomes for children and young people.

Reviewing professional practice, alongside personal reflection, allows for the identification of learning and best practice. Reviews can range from case audits and best practice reviews, through to lessons learnt and serious case reviews (SCRs) and can be undertaken using a range of methodology. However the purpose is the same, to identify how to achieve the best outcomes for children and young people.

The following information provides a summary of learning from multi-agency reviews. The learning highlights specific themes and identifies how practitioners can implement the learning to improve practice. 

 


Joint Targeted Area Inspections (JTAI) - Domestic Abuse
 

Themes

  • Domestic abuse and violence
  • Holistic picture
  • Engagement with children, young people and families
  • Responding to children’s individual needs
  • Abuse in relationships between young people
  • Joint working
  • Forced marriage

 


Summary

 

Joint Targeted Area Inspections are carried out by Ofsted, the Care Quality Commission (CQC), Her Majesty’s Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS)  and Her Majesty’s Inspectorate of Probation. The inspections look at multi-agency arrangements and take a ‘deep dive’ approach to look at responses to neglect for children and young people. In preparation for a possible inspection in Leeds, a multi-agency working group meets monthly to discuss the theme, and carry out multi-agency audits of relevant cases. Seven audits were carried out on the domestic abuse themes during 2017/18, and the findings are detailed below.



Key learning and practice improvements

 

Holistic picture

  • Where parents have been victims of domestic abuse in previous as well as current relationships, this context is not always fully explored, and full information about previous relationships may not be shared between agencies. This can mean that decisions about risk are not informed by the full context.
  • Where there has been domestic violence in previous relationships, it is important that considerations of contact arrangements for children with their birth fathers is informed by intelligence about associated risks.
  • In some cases, referrals were dealt with as isolated incidents, without consideration of what the accumulation of referrals means for wider patterns of risk.
     

Engagement with children, young people and families

  • Practitioners were persistent in their efforts to engage with children and young people and to build relationships, and agencies supported those relationships with flexible arrangements.
  • Information about contact between victims and perpetrators is often based on self-report, which can result in over-optimistic assessments of risk.
  • Parents have often been offered a range of support and interventions over a number of years, but their engagement with that support can be inconsistent.

 

Responding to children’s individual needs

  • Social workers knew the individual children in sibling groups well, and identified and responded to their individual needs.
  • Individual plans for young people were in line with their specific needs, for example keeping one child on a plan when risks were still present for them but not for their siblings, and making individual placement decisions in line with the needs and wishes of children and young people.


Abuse in relationships between young people

  • Parents who are under the age of eighteen are still children; their needs as children should be considered, in addition to their needs as parents.
  • Young people in abusive relationships often have a history of having witnessed domestic abuse in their family home. Practitioners and services need to consider how to break the intergenerational cycle of abuse, and to consider how this can affect young people’s perceptions of their own situation.
  • Careful consideration needs to be given to transition to adulthood; domestic abuse services for adults are very different to those available to under eighteens.

 

Abuse in relationships between young people continued

  • Many young people in abusive relationships (both victims and perpetrators) may have unmet emotional needs. In a number of the cases, young people were offered therapeutic support but declined it or did not consistently engage; social workers felt they may not have been ready to address these needs.
  • Consideration needs to be given to joint discussions about risk, when both victim and perpetrator are under eighteen. They are likely to have different key workers who may need to share information about the young people as a couple, in addition to their individual needs.


Joint working between agencies

  • Good identification of risk and appropriate referrals to the social work service had resulted in appropriate responses.
  • Incomplete information received and unknown reasoning behind decision making communicated for families who had moved to Leeds from other areas had hindered risk assessment and planning processes.


Forced marriage

  • Joint working between police and social work at the early stages is critical in order to ensure appropriate and co-ordinated responses.
  • In the case considered, forced marriage risks were not picked up at the earliest opportunity; initial responses focused on the risks of missing education, and whether services could intervene in relation to this. 
  • There is the potential that forced marriage risks may  be identified earlier for a young woman rather than a young man. Practitioners need to be open to forced marriage being a risk for both male and females.
  • Consideration should be given to the impact of placing an age limit on Forced Marriage Protection Orders and whether cases should remain open on Child in Need plans, in order to support the enforcement of the orders.
  • Managing engagement with families in relation to forced marriage needs careful consideration; the general principles of openness with families and presumptions that extended families will be involved in the care of children and young people need to be approached with an awareness of the potential for escalating the risks.

Your next steps

Share and discuss this learning with colleagues, and consider the implications for your practice including:
Ensure a holistic picture is obtained to inform risk assessments and planning.
Consider how you can be flexible to ensure consistent relationship building and support for children, young people and families

 

  1. Ensure individual needs are considered and responded to, especially within sibling groups.
  2. Remember that parents under the age of 18 are also children and their needs as children should be considered.
  3. When sharing information (within or across boundaries) ensure that information is complete and the reasoning behind decision making is recorded.
  4. Be open to the fact that forced marriage can affect both males and females.
  5. Understand the implications and guidance in relation to family engagement in known or suspected cases of forced marriage.

Click the image below to download a printable version of this review:

 


Joint Targeted Area Inspections (JTAI) - Neglect

 

Themes:

  • Parental difficulties
  • Chronic neglect
  • Responding to children’s individual needs
  • Joint working between agencies

Summary

 

Joint Targeted Area Inspections are carried out by Ofsted, the Care Quality Commission (CQC), Her Majesty’s Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS)  and Her Majesty’s Inspectorate of Probation. The inspections look at multi-agency arrangements and take a ‘deep dive’ approach to look at responses to neglect for children and young people. In preparation for a possible inspection in Leeds, a multi-agency working group meets monthly to discuss the theme, and carry out multi-agency audits of relevant cases. Six audits were carried out on the Neglect theme during 2017, and the findings are detailed below.

 


Key learning and practice improvements

 

Parental difficulties

  • Parental difficulties in relation to alcohol and substance use, domestic abuse and mental and physical health problems were present in a number of cases, of which two included young carers.
  • Working with parents to access support with their own trauma and emotional health can result in improvements in their ability to care for their children and reduce practitioners’ concerns. 
  • A focus on parents’ needs and risks may however obscure a clear focus on how the needs of parents impacted on the children.


Chronic neglect

  • Whilst recent referrals had generally been dealt with effectively and robustly, many families had long histories of social work involvement, with patterns of interventions followed by improvement, case closure and subsequent deterioration. Parents’ engagement with services was often sporadic.
  • Long histories of chronic neglect were not always recognised, robustly responded to or escalated in a timely way.
  • Comprehensive analytical chronologies are important in identifying and responding to chronic neglect, rather than taking a more episodic approach.
  • When intervention in relation to neglect is not timely or effective enough, it can have a damaging effect on children’s development, and a delay in acting can result in children and young people falling further behind at school.


Responding to children’s individual needs

  • Social workers knew the individual children in sibling groups well, and identified and responded to their individual needs.
  • Individual plans for young people were made in line with their specific needs, for example in a group of siblings one child remained on a plan as risks were still present for them but not for their siblings, and making individual placement decisions were made in line with the needs and wishes of children and young people.

 

Joint working between agencies

  • Good identification of risk and appropriate referrals to the social work service had resulted in appropriate responses.
  • Incomplete information received and unknown reasoning behind decision making communicated for families who had moved to Leeds from other areas had hindered risk assessment and planning processes.
  • Effective communication and planning when arranging appointments will remove potential barriers faced by families such as travel, cost and clashes with other commitments.

Your next steps

 

Share and discuss this learning with colleagues, and consider the implications for your practice including:

  1. Recognise the role of young carers and ensure that their needs are assessed and appropriately responded to.
  2. Be aware of the potential for losing focus on the needs of a child when providing support for parents—this should be balanced.
  3. Ensure a chronological analysis of neglect rather than episodic.
  4. Ensure individual needs are considered and responded to, especially within sibling groups.
  5. When sharing information (within or across boundaries) ensure that information is complete and reasoning behind decision making is recorded.
  6. When arranging appointments consider the needs of the family in attending e.g. timing, travel, cost and clashes with other commitments.

 

Click the image below to download a printable version of this review:

Learning from reviews



Appreciative Inquiry:
strong & effective early help planning

 

Themes:

  • Child and family centred approach
  • Early Help 
  • Getting the basics right
  • Professional confidence & mutual respect
  • Strengths-based approach to learning

Summary

 

The LSCP is piloting Appreciative Inquiry (AI) as an approach to supporting Safeguarding Practice Reviews (Working Together 2018) and to help us understand, define and celebrate good practice in Leeds. This Appreciative Inquiry is our first one focussing specifically on good practice and relates to early help planning in respect of a young child who has a hearing impairment. 


Key learning and practice improvements

 

Child and family centred approach:

  • Parental confidence is enhanced by working in partnership, effective lead practitioner support and the knowledge that their child’s needs are being met.
  • High-quality information sharing and communication leads to confident and inclusive planning.

 

Early Help:

  • Shared commitment to the Early Help approach strengthens practice and outcomes.
  • The role of lead practitioner is key in ensuring effective multi-agency early help.
  • Effective early help involves investment and commitment.
  • The early help approach can make a real difference for the parent and child.

 

Getting the basics right:

  • The Team Around the Family (TAF) includes family members and practitioners, all with a different role to play.
  • Team stability, accessibility and visibility make a difference to all involved. 
  • Technology can enable participation, for example Skype and conference calls.
  • Responding promptly to changing circumstances.

 

Professional confidence & mutual respect:

  • A work environment that embraces learning, development and high quality safeguarding support and supervision influences professional confidence and judgement and  flexibility of approach. 

 

Strengths-based approach to learning:

  • Focuses on what is good:  we can do more of this.
  • Helps to build practitioner confidence and affirm core values.

Your next steps

 

  1. Share and discuss this learning with colleagues.
  2. Ensure children and families are central to planning.
  3. Regularly review and ensure that you are “getting the basics right.”
  4. Consider how technology can support practice.
  5. Think about how strengths based learning can support practice in your area of work.
     

Click the image below to download a printable version of this review:

Leeds Safeguarding Children Partnership Learning from Reviews


 


 

Child B Serious Case Review

 

Themes:


Summary

 

Child B was a 14 year old child looked after by the local authority who lived in a children’s home in Leeds. Tragically, he died in August 2015 after climbing a tree, where he got his neck caught in a rope that was hanging from the tree. An inquest was held in November 2016 which arrived at a narrative verdict.

Although the exact circumstances of Child B’s death were unknown, Leeds Safeguarding Children Board commissioned a Serious Case Review (SCR). The undertaking, management and implementation of risk assessments was a key theme addressed by this SCR.


Key learning and practice improvements

 

Risk assessments:

  • Involve children and young people in the development and monitoring of risk assessments.
  • Remember that risk is dynamic and changeable and assessments should be reviewed at an agreed frequency, be relevant and kept up to date.
  • Share risk assessments (and on-going updates) widely with other relevant agencies and in any review processes.
  • Ensure risk assessments include details of the action to be taken if a young person is in a risky situation and the carer(s) present cannot resolve the situation safely.
  • Managers should ensure that practitioners comply with a young person’s risk assessment.
  • Practitioners should know how to deal with emergency and be aware of their agency's procedures.


 

Attendance at meetings:

  • Agencies and practitioners should take responsibility for knowing the date, time and venue of the next review meeting and ensure attendance.

 

Positive relationships:

  • Create a safe environment to allow the identification of, and response to concerns.
  • Provide space and time for the child or young person to talk.
  • Reassure the child or young person that they can talk to staff.

Your next steps

 

  1. Circulate and discuss the issues of this bulletin within your team.
  2. Review and ensure that your risk assessment practice for children and young people is effective, timely and relevant.
  3. Make sure you are proactive in knowing when review meetings are taking place and ensuring attendance.  
  4. Build positive relationships with children and young people, providing time and space to talk.

 

Click the image below to download a printable version of this review:

Leeds Safeguarding Children Board - Learning lessons from reviews

 



 

Thematic Learning from Leeds Safeguarding Reviews

 

This brief is based on the findings from 4 safeguarding reviews undertaken by Safer Leeds and LSCP, to learn lessons and improve future responses to safeguarding incidents.

These reviews (some of which will be published) all focused on incidents whereby a level of domestic violence and abuse was evident. Click on the image to expand the view to a printable version.

 

LSCP Learning Lessons Review