Learning from Practice

Looking at practice, and understanding not only what happened but also why things happened as they did can help to identify and build on good practice and potentially identify lessons which can enhance future responses.

As a city, Leeds is continually striving to ensure it is the best city to grow up in, and that it is a child friendly city. This is supported through organisations and individuals learning from, and building upon practice in order to provide the best services for children, young people and families. This includes identifying good practice and replicating it, as well as identifying where practice could be improved.

The LSCP Learning and Improvement Framework identifies how this is undertaken with regards to multi-agency practice, and how learning is disseminated across the city. The Framework includes statutory review processes, other review processes, practitioner learning events, listening to children, young people and their families and listening to practitioners.

Individual agencies have a responsibility to consider how their services can be shaped to reflect the learning.

The reviewing of practice in relation to individual circumstances is an integral part of the LSCP Learning and Improvement Framework (LIF) which demonstrates how learning will be identified, disseminated and implemented in practice within a multi-agency context in order to improve outcomes for children and young people and their families within Leeds.

Looking at practice, and understanding not only what happened but also why things happened as they did can help to identify and build on good practice and potentially identify lessons which can enhance future responses.

In order to achieve this the LSCP has adopted a restorative learning culture whereby through high support and high challenge we identify circumstances to understand learning, drive forward and embed best practice. Safeguarding reviews are one part of this process and within Leeds can take many different forms.

The LSCP strongly believes that all reviews, and associated processes, are about considering the details of a particular case, looking at how decisions were informed and actioned based on what was known at the time, identifying good practice along with any potential opportunities for practice development and improvement.

We also acknowledge it is essential that where possible and appropriate practitioners are involved in review processes. The perspectives of practitioners are important to this process and they will always be conducted with the utmost integrity, in a supportive learning environment and without fear of being blamed. The focus will be on learning and supporting change as appropriate moving forward.

Appreciative Inquiries

Appreciative Inquiry is a method which focuses on understanding, defining and celebrating good practice. It looks at what is good and seeks to understand what has happened with a focus of what works well and valued practice.

Cases which involve aspects of good or challenging multi-agency safeguarding practice are put forward by partner agencies, in order to learn from these.

Further information about the Appreciative Inquiry process can be found via the One Minute Guide

Should you have a case which you think has some learning which could be sought through an Appreciative Inquiry, initially discuss this with your line manager and designated safeguarding lead and then contact the LSCP Business Manager via LSCP.info@leeds.gov.uk

Reviewing Serious Child Safeguarding Incidents

The Local authority has a duty to notify both the National Child Safeguarding Review Panel and its statutory safeguarding partners when they know or suspect that a child has been abused or neglected, if:

(a) the child dies or is seriously harmed in the local authority’s area, or
(b) while normally resident in the local authority’s area, the child dies or is seriously harmed outside England.

This should be notified by the local authority within 5 working days of them becoming aware of the incident. The full LSCP SCSI notification process is available on request from LSCP.info@leeds.gov.uk

In addition the LSCP has a duty to identify and review serious child safeguarding cases which, in their view, raise issues of importance in relation to their area.

What is a Serious Child Safeguarding Incident (SCSI)?

A Serious Child Safeguarding Incident (SCSI), as defined by Working Together to Safeguard Children 2018 is a circumstance whereby:

  • abuse or neglect of a child is known or suspected and
  • the child has died or been seriously harmed.

What does serious harm mean?

Working Together to Safeguard Children 2018 defines serious harm as that which “includes (but is not limited to) serious and/or long-term impairment of a child’s mental health or intellectual, emotional, social or behavioural development. It should also cover impairment of physical health. This is not an exhaustive list. When making decisions, judgment should be exercised in cases where impairment is likely to be long-term, even if this is not immediately certain. Even if a child recovers, including from a one-off incident, serious harm may still have occurred.”

In addition to the definition with Working Together 2018, additional definitions of serious harm include:

“Serious harm” means death or serious personal injury, whether physical or psychological (Sct 224, Criminal Justice Act 2003)

Serious bodily injury or harm is the serious physical harm caused to the human body. It usually refers to those injuries that create a substantial risk of death or that cause serious, permanent disfigurement or prolonged loss or impairment of the function of any body part or organ (US Legal; https://definitions.uslegal.com/s/serious-bodily-harm/).

LSCP Review Advisory Group (RAG)

The LSCP Review Advisory Group (RAG) consider all notifications and oversee the next steps, be that the initiation of a Rapid Review as per statutory guidance (see below) or the recommendation of another type of learning review process.

RAG membership

The RAG consists of representatives from the LSCPs three statutory partners, Health, Local Authority and Police and is chaired by the LSCP Independent Chair.

How to raise a potential Serious Child Safeguarding Incident (SCSI)

If a practitioner is aware of a circumstance which they feel should be considered as a Serious Child Safeguarding Incident (SCSI) they should discuss this with their designated safeguarding lead. If the Safeguarding Lead is in agreement, they should contact the LSCP Business Manager via lscp.info@leeds.gov.uk. The LSCP Business Manager will then discuss this within the LSCP RAG who will decided if they recommend a notification or a learning process.

The Safeguarding Lead and/or practitioner will be informed of the outcome of this consideration at the earliest opportunity.

Rapid Review

Following the notification of a SCSI to the National Child Safeguarding Panel and the LSCP Statutory Partners there is a requirement for the Statutory Partners to undertake a Rapid Review within 15 working days of the notification.

What is the purpose of the Rapid Review?

The purpose of the Rapid Review is to:

  • look at the circumstances of the SCSI,
  • identify and act upon immediate learning, and
  • consider if there is additional learning which could be identified through a wider Child Safeguarding Practice Review (CSPR) (see below).

Through the Rapid Review process partner agencies will be asked to provide information they have with regards to their interactions with the child and their family, and specifically in relation to the SCSI. This will be considered by the LSCP RAG which will allow them to consider learning and make a recommendation as to whether or not further learning would be identified through a CSPR.

The final decision with regards to initiating a CSPR lies with the LSCP Executive, and following the recommendation from the LSCP RAG they will consider the information and make a final decision.

The LSCP must notify the National Child Safeguarding Panel of the outcome of the Rapid Review within the 15 working day timeframe.

What is the Rapid Review Process?

Serious Child Safeguarding Incident
  • The Local Authority inform the National Panel of Serious Child Safeguarding Incident within 5 working days of becoming aware of incident
  •  A copy of Notification is also provided to the LSCP Statutory Partners (LSCP Exec) for information.
Within 2 working days of notification
  • Relevant agencies are requested to provide information in relation to the child, their family and the Serious Child Safeguarding Incident within 5 working days.
Within 5 working days of agency request for information
  • Completed Initial Scoping and Information Sharing Template returned by agencies and then shared with those attending the Rapid Review meeting.
Between 7 and 13 working days of receiving the referral
  • Review the facts of the case presented in the documentation
  • Agree any further immediate action if required
  • Consider the case against the criteria for Child Safeguarding Practice Reviews
  • Complete the Rapid Review Template and agree the recommendation
  • The Rapid Review Form is provided to the LSCP Executive for consideration
  • LSCP Executive decide whether a CSPR should take place based on the information and recommendation provided.
Within 2 days of the Rapid Review meeting
  • The Rapid Review and final decision is sent to National Panel
  • Agencies are informed of the outcome of the Rapid Review.

Child Safeguarding Practice Review

Within the update of Working Together to Safeguard Children 2018 Serious Case Reviews (SCRs) were replaced by Child Safeguard Practice Reviews (CSPRs), and are undertaken if recommended following a Rapid Review.

Their purpose, at both local and national level, is to identify improvements to be made to safeguard and promote the welfare of children and should seek to prevent or reduce the risk of recurrence of similar incidents. 

Working Together to Safeguard Children 2018 provides greater autonomy to Multi-agency Safeguarding Partnerships with regards to how a CSPR is undertaken, and will differ for each review depending on the circumstances of the SCSI. In order to support the review process the LSCP has identified a set of principles for undertaking reviews which can be found in the SCSP Framework (available on request from LSCP.info@leeds.gov.uk).

Other review processes

The LSCP continuously strives to ensure and embed a learning culture at heart and will, where appropriate, take all opportunities to review circumstances in order to identify and learn from good practice and areas where practice could be strengthened.

If a circumstance does not meet the criteria for a CSPR the LSCP RAG may recommend that a local review is undertaken which may take many different forms including a single agency review, an appreciative inquiry, a practice learning set or a form of auditing.

Dissemination of learning

As part of the learning cycle dissemination of learning and responding to that learning is key. The LSCP has a Learning and Improvement Framework which identifies how learning is disseminated and acted upon both within single and multi-agency arenas. This is undertaken in a timely way and monitored by the LSCP Business Unit and the LSCP RAG.

Further Information

LSCP SCSI Notification Process - available on request from LSCP.info@leeds.gov.uk

CSPR Framework - available on request from LSCP.info@leeds.gov.uk

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