HSCB Topic Group – 23 March 2009Item 2 – Paper 1

HERTFORDSHIRE COUNTY COUNCIL

SCRUTINY TOPIC GROUP

23 MARCH 2009

Hertfordshire SAFEGUARDING CHILDREN BOARD: ANNUAL REVIEW 2008-09

Author:Teresa DeVito

HSCB Business Manager

Telephone: 01992 555077

This report was submitted prior to publication of Lord Laming's review of child protection. A further note will follow, setting out any relevant issues for the Topic Group arising from Lord Laming's review.

1.PURPOSE OF THE REPORT

To update members on the workand progress of the Hertfordshire Safeguarding Children Board (HSCB)

2.CONTEXT

2.1The Hertfordshire Safeguarding Children Board (HSCB) was established on 1 April 2006 in accordance with the statutory requirement in Section 13 of the Children Act 2004, which required all Local Authorities to replace their existing Area Child Protection Committee with a Local Safeguarding Children Board (LSCB). LSCB’s became responsible for co-ordinating the contributions of key local organisations for safeguarding, and promoting the welfare of children, and for ensuring that work undertaken is effective.

2.2The HSCB is the key statutory mechanism for agreeing how the relevant organisations in Hertfordshire will cooperate to safeguard and promote the welfare of children in that locality, and for ensuring the effectiveness of what they do.

2.3The work of the HSCB is part of the wider context of children's trust arrangements that aim to improve the overall well being (i.e. the five Every Child Matters outcomes) of all children in the local area, with a particular focus on aspects of the `staying safe' outcome.

2.4The core objectives of a LSCB, set out in Section 14(1) of the Children Act are:

(a)to co-ordinate what is done by each person or body represented on the Board for the purposes of safeguarding and promoting the welfare of children;

(b) to ensure the effectiveness of what is done by each such person or body for that purpose.

2.5The HSCB has a clear responsibility "to ensure in discussion with the Children's Trust Partnership that all planning and commissioning of Children's Services within the Local Authority area, takes account of the need to safeguard and promote children's welfare”. (Working Together 2006)

2.6Working Together to Safeguard Children is a national document and provides a framework within which agencies and professionals work together to safeguard and promote the welfare of children. It was updated in 2006 to replace the earlier 1999 version.

2.7Working Together 2006 details further guidance about the relationship between the LSCB and the Children's Trust arrangements, stressing the importance of a strong working relationship whilst emphasising that the LSCB must be able to exercise its unique statutory role effectively: must have a clear and distinct identity within the children's trust governance arrangement: and should not be subordinate or subsumed within the children's trustarrangements in a way that might compromise its separate identity and independent voice.

2.8The relationship between the HSCB and the HCTP has been further strengthened through the HSCB chair sitting on the Children’s Trust Board with a standing agenda item on safeguarding.

2.9A number of national initiatives have influenced both the structure and working processes of the HSCB, or will do so in the future:

  1. The 2006 Priority Review‘Local Safeguarding Children Boards: A Review of Progress committed the Government to a stocktake of progress to be undertaken in autumn 2008. This stocktake is due to be completed by spring 2009 and will focus on, governance and accountability, engagement of partners, universal, targeted and responsive safeguarding, assessing LSCB impact, Child Death Review Panels and Serious Case Reviews (SCR’s)
  1. The 2008 Joint Chief Inspectors' Report, and further practice examples and intelligence obtained through Joint Area Review Reports and networks of LSCBs. The Government has published its response to the Joint Inspectors' Report and this contains further guidance on increasing the influence of LSCBs.
  1. Aself-assessment toolkit, ‘Challenge and Improvement’ tool published in July 2008 by the DCSF was developed to assist LSCBs in improving their effectiveness.
  1. The implementation of the National Children's Plan, PSA 13 and the National Staying Safe Action Plan all contain significant implications for LSCBs and the way that they work. The structure and performance of the HSCB therefore needs to be considered within the context and development of these important national initiatives.
  1. Finally, and most significantly, the tragic events surrounding the death of baby "P" in Haringey in 2007 will have implications for LSCBs nationally. The Joint Area Review ordered by the Secretary of State on Haringey's Children's Services, with particular reference to safeguarding, has been published. This will have significant implications for the work of LSCBs and governance. Lord Laming's urgent review of LSCBs was due to report in February 2009. This may lead to legislative changes.

3.Outcomes of the Joint Area Review

3.1The effectiveness of the HSCB and its safeguarding arrangements were evaluated within the Hertfordshire Joint Area Review (JAR) in 2007 and judged inadequate.

3.2The JAR concluded that:

Arrangements for safeguarding children and young people are inadequate and arrangements to ensure safe staffing are weak.

3.3Recommendations specifically for the HSCB were:

  • Ensure clarity of roles and responsibilities within HSCB
  • A lack of accountability and performance management in HSCB

3.4All members of the HSCB have agreed and signed Compacts which outline both the individual and agency roles and responsibilities. There is currently an induction package being produced for new members to ensure clarity of role and outline the business of the HSCB. Recommendations from a Development Day in December 2008 resulted in changes to the content of the Board agenda and papers presented. Any advice or good practice arising from the national stocktake will also be considered in making further amendments to promote effective and efficient working practice.

3.5To ensure that the priorities of the Board are managed effectively, a number of multi-agencysub-groups have been established to develop and monitor clear work programmes.

The sub groups are:

  • Improving Outcomes
  • Policy & Procedures
  • Safe Staffing
  • Training & Development
  • Data
  • Audit & Analysis
  • E Safety
  • Serious case Review
  • Child Death Review Panel

3.6All of the Board’s sub-groups work to agreed terms of reference, with clear lines of reporting to the Board. All of the chairs of the sub-groups are Board members

3.7While the HSCB has a role in co-ordinating and ensuring the effectiveness of local individuals and organisations’ work to safeguard and promote the welfare of children, it is not accountable for their operational work. All Board partners retain their own existing lines of accountability for safeguarding and promoting the welfare of children by their services. The HSCB does not have a power to direct other organisations. The HSCB is not an operational body or one that delivers services to children, young people or their families. Its role is co-ordinating and ensuring the effectiveness of what its member organisations do, and to contribute to broader planning, commissioning and delivery.

3.8Members of the Board are named, to ensure consistency and continuity and have a strategic role in safeguarding within their organisation. Statutory organisations that are required to co-operate in the operation of the HSCB and have shared responsibility for the effective discharge of its functions are set out in s13(3) of the Children Act 2004, but include:

  • District councils
  • Police
  • Probation Service
  • Youth Offending team
  • Strategic Health Authorities and Primary Care Trusts
  • NHS Trusts
  • Connexions
  • Child & Family Courts Advisory & Support Service

3.9The budget of the HSCB was set up in accordance with the national guidance offered at the time that LSCBs were established. The guidance provided exemplars of total budgets for LSCBs and the contributions made by each member organisation.The HSCB budget has been established at a level that enables it:

  • to provide administrative and organisational support for the Board and its sub-groups, and those involved in policy and training;
  • to take forward training and staff development as set out in the HSCB Training Plan
  • to drive forward its day-to-day business including its co-ordination and monitoring and evaluation roles;
  • to fund specific operational requirements: in particular, the HSCB's Child Death Review function; the funding of the revised Child Protection Procedures, resources for undertaking Serious Case Reviews and the quality assurance and audit functions for which it is accountable.

3.10The HSCB will set out its budget requirements to deliver its business plan, and accountabilities, as they develop following new national guidance.

4.Serious Case Reviews (SCR)

4.1When a child dies, and abuse or neglect is known or suspected to be a factor in the death, the HSCB should always undertake a SCR. The purpose of serious case reviews is to:

  • establish if there are lessons to be learned from the case about the way in which local professionals and organisations work together to safeguard and promote the welfare of children
  • identify clearly what those lessons are, and how they will be acted upon, and what is expected to change as a result
  • as a consequence, improve inter-agency working and better safeguard and promote the welfare of children

4.2SCR’s are not inquiries into how a child dies or who is culpable. That is a matter for Coroners and criminal courts to determine.

4.3Each service that has had involvement with the child undertakes a separate management review of that involvement. An overview report brings together and analyses the findings of the various reports and makes recommendations for future actions. The overview report writer must be totally independent of the case and of HSCB. The SCR should be completed within four months and sent to Ofsted for a judgement on the quality and content.

4.4Ofsted can judge SCRs to be inadequate not necessarily because of any shortcomings in practice. The judgements relate to a number of factors including timeliness, format, and contributions of different agencies,therefore SCR’s need to be carefully monitored from beginning to end.

4.5In accordance with the letter and guidance sent to LSCB’s by Beverley Hughes Minister of State for Children, Young People and Families, following the Baby P case and subsequent investigation in Haringey in December 2008all SCR’s judged inadequate were to be re-reviewed by an independent chair and a report sent to DCSF and Ofsted evaluating progress on actions by an independent report writer. HSCB reviewed its one inadequate SCR.

4.6 The independent report was completed at the end of February 2009 and highlighted progress and noted:

The overall outcome of the review is a positive one. The report shows that HSCB has made significant progress and changes to structures, processes and systems since the death of RD in November 2006.

The report also shows progress made by the HSCB in striving to improve the quality of future SCRs by reviewing, updating and further developing procedures, support systems and guidance for undertaking SCRs and Individual Management Reviews.

4.7In addition a review has been undertaken by the HSCB of SCR recommendations and their implementationfrom the last two years. Following this review the HSCB has taken the following action:

  • reviewed the local guidance and templates for the completion of individual management reviews which support the process in line with the Ofsted descriptors to include explicit quality standards;
  • establishing a clear protocol with partner agencies to ensure the IMRs are undertaken by appropriate senior managers within their agencies in accordance with this revised guidance and within the required timescales;
  • is in negotiation with the Safeguarding Adviser from the Government Office East to provide training to senior managers within partner agencies on the completion of IMRs to the required standard;
  • reviewed the commissioning of independent overview reports to ensure that they are provided in accordance with the Ofsted standards;
  • included in the programme of multi-agency training, seminars to promote the lessons to be learned from both the Hertfordshire SCRs, other SCRs and national research. In addition a multi agency conference has been planned in May for up to 200 staff to further promote the lessons learned
  • The recently announced national study of SCRs, complementing the wider 'stocktake' of LSCBs, will feed into this plan for improvement.

4.9Research is showing that child deaths are increasing and that the significance of domestic abuse and a relationship with other problems such as parental substance misuse and mental ill health increase risks of harm to children.

4.10SCR’s are very resource intensive, complex and require careful planning and management. The impact of a SCR is often limited or not sustained. The challenge is to make use of lessons and turn them into sustainable improvements in practice with a robust auditing pattern and to develop a stronger learning culture and to consider ‘near misses’ as well as SCR’s and to ensure that learning is embedded throughout all the agencies.

4.11The cost of SCR’s is rising. The guidance from DCSF in December 2008 outlined the independence that SCR’s must have in relation to chairing a SCR and the overview report writer. Consideration should also be given to quality assuring and supporting the report writers from all agencies preparing a report. There is also a cost implication to any practice or policy changes that arise out of a SCR.

4.12Currently HSCB has two SCR’s that are ongoing and two under consideration by the SCR sub group.

5.Child Death Overview Panels

5.1Chapter 7 of Working Together to Safeguard Children sets out the procedures to be followed when a child dies. There are two interrelated processes for reviewing child deaths (either of which can trigger a serious case review):

  • A rapid response by a group of key professionals who come together for the purpose of enquiring into and evaluating each unexpected death of a child
  • An overview of all child deaths (under 18 years) in the Local Safeguarding Children's Board (LSCB) area(s), undertaken by a panel.

5.2Child Death Overview Panels (CDOP)became mandatory in April 2008 and is responsible for reviewing information on all child deaths, and is accountable to the LSCB Chair.

5.3The Panel needs to make a decision on the degree to whicheach death is considered preventable. It is important torecognise that this categorisation is to inform any efforts toreduce childhood deaths, it does not in itself carry anyimplication of blame on any individual party, but simplyacknowledges where factors are identified which, had theybeen different, may have resulted in the death beingprevented.

5.4The Panel must also identify anylessons to be learnt, recommendations to be made oractions to be taken in response to the review of the death. The overview panel will have theadvantage of being able to review each individual childdeath in the context of other deaths of children in their area,and to be able to identify any potentially contributoryrecurrent themes, circumstances, or possible limitations inservice provision by one or more agencies.

5.5This will allow the overview Panel the opportunity to developlocal recommendations to help reduce childhood deaths,for inclusion in annual reports, and where appropriate,specific ad hoc recommendations (e.g. dealing with particular road or environmental factors).

5.6Challenges in setting up CDOP

  • New knowledge and skills
  • Professionals unprepared – lack of training or understanding of processes
  • Complex working together arrangements
  • Emotionally challenging
  • Infrastructure to respond to requirements
  • IT
  • Disclosure issues
  • Interface with Rapid Response process
  • Agreeing what constitutes ‘preventable’
  • Identifying and disseminating lessons
  • Wide range of professionals involved

6.Statutory guidance on making arrangements under Section 11 of the Children Act 2004

6.1“The support and protection of children cannot be achieved by a single agency….Every Service has to play its part. All staff must have placed upon them the clear expectation that their primary responsibility is to the child and his or her family.”

Lord Laming - Victoria Climbié Inquiry Report,

6.2Improving the way key people and bodies safeguard and promote the welfare of children is crucial to improving outcomes for children. In his report into the death of Victoria Climbié, Lord Laming concluded that “the suffering and death of Victoria was a gross failure of the system”. Section 11 of the Children Act 2004, therefore, places a duty on key persons and bodies to make arrangements to ensure that in discharging their functions, they have regard to the need to safeguard and promote the welfare of children.

6.3Via an audit under S11 agencies are asked to review their current policies, procedures and practices, analyse the current state of safeguarding and promoting children’s welfare within their bodies and decide what steps are necessary in order to implement the Guidance. These arrangements will help agencies to create and maintain an organisational culture and ethos that reflects the importance of safeguarding and promoting the welfare of children. The key features of the audit are:

  • Senior management commitment to the importance of safeguarding and promoting children’s welfare;
  • A clear statement of the agency’s responsibilities towards children available for all staff;
  • Having a clear line of accountability within the organisation for work on safeguarding and promoting the welfare of children;
  • Service development that takes account of the need to safeguard and promote welfare and is informed, where appropriate, by the views of children and families;
  • Staff training on safeguarding and promoting the welfare of children for all staff working with or (depending on the agency’s primary functions) in contact with children and families;
  • Safe recruitment procedures in place;
  • Effective inter-agency working to safeguard and promote the welfare of children;
  • Effective information sharing.

6.4The key people and bodies that are covered by the duty are:

  • local authorities, including district councils5;
  • the police;
  • the probation service;
  • NHS bodies;
  • Connexions;
  • Youth Offending Teams;
  • Governors/ Directors of Prisons and Young Offender Institutions;
  • Directors of Secure Training Centres;
  • The British Transport Police.

6.5The section 11 duty means that these key people and bodies must make arrangements to ensure two things. Firstly, that their functions are discharged having regard to the need to safeguard and promote the welfare of children, and secondly, that the services they contract out to others are provided having regard to that need.