The LSCP Learning and Improvement Framework aims to ensure that learning from practice, audits, local and national research is disseminated and embedded through improvements to safeguarding systems alongside training and development opportunities for practitioners across Leeds.
The LSCP Review Advisory Group (RAG) is a significant sub-group of the Executive who provides nominated members from their organisations and is chaired by the Independent Chair. It is responsible for identifying learning in relation to the most serious cases, including Serious Child Safeguarding Incidents (SCSIs), identifying good practice and areas of learning and improvement.
The fundamental purpose of reviewing incidents where children who have either died because of abuse or neglect or where children have been seriously harmed is to learn from those cases to help make improvements to systems that protect children and to prevent other children from being harmed.
A central role is to seek assurance related to actions taken following local learning activities, Rapid Reviews, Local Child Safeguarding Practice Reviews (CSPRs) or National Child Safeguarding Practice Reviews. The RAG can request support from LSCP Subgroups to disseminate learning, undertake quality assurance work to measure impact and to seek assurance that partner agencies use their own internal structures to implement recommendations.
Notifications of SCSIs
Working Together to Safeguard Children 2018 states that the duty to notify Serious Child Safeguarding Incidents (SCSIs) to the National Child Safeguarding Practice Review Panel rests with the local authority. Furthermore, that in making that decision it is an integral part of the decision-making process that they are informed and guided by the views of statutory partners. However, the ultimate responsibility to notify, or not to notify, lies with the local authority, as set out in legislation. There are no provisions within the legislation which permit a local authority to delegate this statutory duty to partners. The local authority remains accountable in law for the decisions made.
The LSCP RAG collectively considers whether an incident meets the criteria for notification as a SCSI, with relevant partner agencies providing information and professional opinions to support the Local Authority decision making. Following the notification of a SCSI by the Local Authority to the National Safeguarding Panel the LSCP through the LSCP RAG will promptly undertake a Rapid Review (The statutory timescale for a Rapid Review is 15 working days).
A Serious child safeguarding incident is defined as:
- Abuse or neglect of a child is known or suspected; and
- The child has died or been seriously harmed.
Cases for consideration are raised to the RAG via partner agencies using the SCSI notification and discussion form developed by the RAG and introduced in May 2022. Prior to that, cases were raised directly with the LSCP Business Unit.
When an agency other than the local authority becomes aware of an incident that appears to meet the criteria for notification, the relevant partners discuss this with their agency’s safeguarding lead (or RAG member) and refer this to the LSCP RAG for a discussion in relation to a potential notification.
Review of Notification Processes
In 2021 The Independent Chair informed the LSCP Executive she required assurance of the notification systems in Leeds and whether all partners were equally able to inform the decision of whether to notify the National Panel of a SCSI. This initiated a review of notification process undertaken by representatives from each of the three key statutory partner agencies, led by West Yorkshire Police and independently scrutinised by the Independent Chair. This review acknowledged that the legal duty and decision to notify a SCSI to the National Panel rests with the Local Authority and this cannot be changed.
The outcome of the review has led to improvements that ensures all statutory partners are informed of any consideration of a notification by the Local Authority and are able to provide information and their professional opinions to inform the decision-making process. In addition:
- All cases for potential notification are first reported to the Independent Chair and the LSCP Business Unit
- All relevant statutory partners (RAG members) are informed of any consideration of a notification by the Local Authority and are encouraged to provide information for consideration via the notification referral form
- Partner agencies are encouraged to refer serious childcare incidents into the RAG for partnership discussion
- Extra-Ordinary RAG meetings are held whereby all statutory partners can share relevant information, their professional opinions and in addition, there is a multi-agency discussion to inform the decision-making process
- Partner agencies are encouraged to invite relevant professionals to discussions to provide additional professional opinion
- The rationale to notify or not, is recorded and shared with all statutory partners in a timely manner.
Since this process has been implemented, all the SCSI cases considered by the RAG resulted in collective discussion and agreement on decisions.
Continuous Improvement and Reflection by Executive and Senior Partners
In the interest of continuous improvement and building on open and transparent discussions, two workshops were facilitated with the LSCP Executive, National Child Safeguarding Practice Review Panel and the three National Safeguarding Reforms Facilitators. This led to further conversations of how differences in opinion can be extremely challenging, recognising that this can be reflective of a strong partnership, mature enough to disagree at times. It also recognised that despite these challenges, a way forward was identified and a mutually agreed set of arrangements were put in place. This is a clear indicator of the Partnership’s ability to be open, transparent, and challenging of each other, and of systems and processes in the interest of children and young people.
Rapid Reviews
A Rapid Review is a multi-agency process which considers the circumstances of a SCSI. The purpose of the Rapid Review is to 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).
The Rapid Review enables safeguarding partners to:
- Gather the facts about the case, as far as they can be readily established at the time.
- Discuss whether there is any immediate action needed to ensure children’s safety and share any learning appropriately.
- Identify immediate learning and consider the potential for identifying improvements to safeguard and promote the welfare of children
- Decide what steps they should take next, including whether to undertake a local Child Safeguarding Practice Review (CSPR).
At every stage of a rapid review, multi-agency meetings are held to ensure all partners within the RAG have an equal opportunity to share their professional opinion and contribute to any decisions. Minutes of these meetings are used to capture the rationale for any recommendations made and shared with the LSCP Executive and the National Panel.
In Leeds, between 01 September 2019 and 31 March 2023, the LSCP have undertaken 16 Rapid Reviews (including a retrospective notification).
- Police referred 9 cases to RAG
- CSWS referred 9 cases to RAG
- Health referred 3 cases to RAG
Of those referred 15 were notified to the National Child Safeguarding Review Panel resulting in a Rapid Review.
Child Safeguarding Practice Reviews were commissioned following four Rapid Reviews, and a CSPR was initiated in relation to a retrospective notification. A joint review has also been undertaken with the Leeds Community Safety Partnership (Safer Leeds) and the Leeds Safeguarding Adults Board to consider learning from a case which did not meet the criteria of a CSPR, but where it was recognised that there was an opportunity for the consideration of joint learning.
The National Panel provides a response to Rapid Reviews submitted by the LSCP and have the authority to agree or disagree with local decisions on whether a case is considered a CSPR or whether a local review is more appropriate. In all cases, the National Panel have agreed with the LSCP Executive decisions. Feedback from the National Panel on Rapid Reviews has been positive with comments highlighting ‘clear recommendations and learning points’ ‘all appropriate learning identified’ and a ‘clear and focussed review’
Examples of Cutting Cross Themes from Learning Reviews.
Professional curiosity – This has been a reoccurring theme that has led to much discussion within the RAG whereby it has been identified a consistent theme. The combination of looking, listening, asking direct questions, checking out and reflecting on the information received has led to missed opportunities to fully understand an individual or family’s situation and what might be needed to support them.
Partnership discussions have been held in relation to professional curiosity to consider good practice, barriers and support required, along with a partner agency survey in relation to how professional curiosity is promoted and supported including within supervision by partner agencies. The findings have been fed into an ongoing piece of work with Safer Stronger Communities and the Leeds Safeguarding Adults Board to develop consistent city-wide resources around professional curiosity.
A Yorkshire and Humber Masterclass series in Spring 2023 will focus on professional curiosity with the findings of the above work influencing the choice of topics and speakers.
Disguised compliance –Reviews demonstrated how individuals were able to sometimes, divert attention from what was happening within the family through appearing co-operative and providing practitioners and agencies with the information requested, and this was not further pursued regarding assurances in relation to how the family were or undertaking what was asked of them. It was acknowledged that this was closely associated with the need for professional curiosity and not taking everything on face value.
This learning has been fed through to the LSCP learning and Development Officers and the work they are undertaking in relation to professional curiosity due to the links between disguised compliance and professional curiosity.
Escalation processes –Reviews have highlighted how in some cases there is a lack of escalation and / or where professionals have attempted to escalate concern have not always been resolved as expected. This has led to ongoing work to understand barriers to implementing the escalation process, namely related to why it is not effectively being used by all practitioners or recorded when used. Issues of confidence and power differentials were identified, and these issues are being taken forward through both training and specific guidance and messages for practitioners across the partnership.
Death of a significant family member –several reviews noted families has recently experienced the death of a significant family member which understandably had an impact. The reviews identified the need to ensure a sensitive balance between supporting families in relation to the grieving process and the provision of bereavement support, alongside the need to monitor plans and assess risk. The impact of a bereavement needs to be considered in all assessments. This learning will be shared with the partnership as part of the presentation of learning from reviews and be fed into the learning and development subgroup
Domestic abuse – The majority of cases identified domestic abuse either historically or in the present. Reviews have identified a need to improve how risks and / or impact on children is assessed. This should include how historical abuse is considered and assessed in relation to the birth of a first child based on the research in relation to pregnancy being a time of heightened risk in relation to domestic abuse. This learning was shared as part of the LSCP Domestic Abuse Review and provides recommendations for the partnership which require monitoring to be assured of improvements.
Different agencies risk assessment processes – One review identified that practitioners are not always fully aware of / fully understand the risk assessment processes used by different agencies or what the identified risk levels / assessment outcomes mean. This was particularly evident in relation to assessment and management of Registered Sex Offenders. The partnership is now considering broader discussions to develop work in this area including a workshop to consider improved multi-agency oversight and management of Registered Sex Offenders currently being developed by police colleagues.
Impact of Covid Pandemic –Reviews identified the impact of the COVID Pandemic ranging from impact on agency capacity and staffing levels which resulted in a lack of consistency of allocated workers for families; differing ways of working which reduced face to face visits and contact; isolation for children from services, schools, and peers; the cancellation of appointments both by agencies and families resulting in longer periods of time between an agency’s contact with a family
Complex health needs – two reviews considered children with complex health needs, identifying the impact for a family of the numerous services and agencies that were involved, along with the co-ordination of numerous medical appointments.. In addition, the need for assurance in relation to access of appropriate medical support when a child is staying out of area was identified, resulting in the LSCP policy for children with complex health needs travelling abroad being updated in November 2022 to include traveling out of area.
Consistent application of safeguarding approaches – Throughout reviews undertaken, the impact of the consistent application of core safeguarding approaches including the Think Family Work Family approach, Was Not Brought Approach, Early Help Approach and Safeguarding being everybody’s responsibility was evident for improving outcomes for children and young people. There have been examples of excellent practice whereby these approaches have been considered and applied, however it was recognised that these approaches were not always consistently applied across the Partnership resulting in the potential for differing responses to situations.
These approaches are continually being promoted across the partnership, and where appropriate reviewed and updated to reflect specific learning.
Taking Learning from Reviews Forward
Following the completion of a review, an action plan is collated and agreed by all the relevant partners. Progress against this is monitored by the LSCP Business Unit with assurance being provided to the LSCP RAG. The oversight of Action Plans is being reviewed and incorporation into the Performance Management Subgroup work plan.
The LSCP Business Unit supports the dissemination of learning through:
- The production of learning sheets which summarise the incident which has been reviewed and the key good practice and learning – this is also provided to partner agency training leads to support them in reflecting lessons within single agency training
- Updating training to reflect learning, including a section in relation to learning from reviews within the LSCP Refresher Training
- Presentation to the LCYPP meeting including requests for partners to disseminate and embed learning internally
- Inclusion in any learning from reviews presentations for example at the LCYPP Bi-Annual Meetings
- Practitioner presentations based on the review and identified learning – consideration is also undertaken with regards to capacity in relation to the number of sessions required to reach the workforce within Leeds.
An annual assurance request of all partners is being considered to seek assurance in relation to how partner agencies are disseminating and embedding learning and identifying the impact and outcomes. This will be introduced in March 2023 and will be overseen by the Performance Management Subgroup, with findings being present to the CYPP on an annual basis.