SCOPE OF THIS CHAPTER
This chapter covers the requirements within chapter 4 of Working Together to Safeguard Children 2015, which describes the way that professionals and organisations protecting children need to reflect on the quality of their services and learn from their own practice and that of others. It explains the requirements for an integrated local learning and improvement framework.
1.1 Learning and Improvement Framework
Working Together 2015 requires that the Local Safeguarding Children Board maintain a shared local learning and improvement framework across those local organisations working with children and families.
This local framework covers the full range of single and multi-agency reviews and audits which aim to drive improvements to safeguard and promote the welfare of children. The different types of review include:
- Serious Case Review (see Serious Case Reviews Procedure);
- Child death review (see Chapter 5: Child death reviews of Working Together 2015: a review of all child deaths under the age of 18;
- Review of a child protection incident which falls below the threshold for a Serious Case Review;
- Review or audit of practice in one or more agencies.
1.2 Purpose of Local Framework
The aim of this framework is to enable local organisations to improve services through being clear about their responsibilities to learn from experience and particularly through the provision of insights into the way organisations work together to safeguard and protect the welfare of children.
The framework should be shared across all agencies that work with families and children. Working Together states that 'This framework should enable organisations to be clear about their responsibilities, to learn from experience and improve services as a result'. (WT p65)
This should be achieved though:
- Reviews conducted regularly;
- Such reviews to encompass both those cases which meet statutory criteria (i.e. Serious Case Reviews and child death reviews) and cases which may provide useful insights into the way organisations are working together to safeguard and protect the welfare of children;
- Reviews examining what happened in the case, why it did so and what action will be taken to learn from the findings;
- Learning from both good and more problematic practice about the organisational strengths and weaknesses within local services to safeguard children;
- Implementation of actions arising from the findings which result in lasting improvements to services;
- Transparency about the issues arising and the resulting actions organisations take in response to the findings from individual cases, including sharing the final reports of Serious Case Reviews with the public.
Reviews are not an end in themselves, but a method to identify improvements needed and to consolidate good practice. The LSCB and partner organisations will translate the findings from reviews into programmes of action which lead to sustainable improvements.
There is considerable local discretion as to what the Learning and Improvement Framework will look like in any area. It will need to take into account the LSCB structure and partnership arrangements and aim to be as inclusive as possible.
Local learning and Improvement framework arrangements will need to develop shared audit tools, processes for capturing the views of service users and a system for sharing learning with the wider workforce.
1.3 Principles for a Culture of Continuous Improvement
There should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, so as to identify what works and what promotes good practice.
Within this culture the principles are:
- A proportionate response: According to the scale and level of complexity of the issues being examined i.e. the scale of the review is not determined by whether or not the circumstances meet statutory criteria;
- Independence: Reviews of serious cases to be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed;
- Involvement of practitioners and clinicians: Professionals should be fully involved in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith;
- Offer of family involvement: Families, including surviving children, should be invited to contribute to reviews and be provided with an understanding of how this will occur;
- The child to be at the centre of the process;
- Transparency: Achieved by publication of the final reports of Serious Case Reviews and the LSCB's response to the findings. The LSCB annual reports will explain the impact of Serious Case Reviews and other reviews on improving services to children and families and on reducing the incidence of deaths or serious harm to children. This will also inform inspections;
- Sustainability: Improvement must be sustained through regular monitoring and follow-up so that the findings from these reviews make a real impact on improving outcomes for children.
There is an understandable focus on Serious Case Reviews given the profile of this type of review, however it should be remembered that they are not the only process that should drive learning and improvement. LSCB's should pay equal or greater attention to the dissemination processes for learning giving consideration to:
- The need to reach a multi-agency audience;
- An understanding of adult learning;
- The on-going training and development needs of certain professional groups.
Clearly one approach will not be suitable for all learning and every agency; a range of learning opportunities should be provided that could include: inter-professional discussion forums, specific dissemination events, thematic presentations (combining the learning from several different reviews) and the uses of LSCB newsletters to produce factsheets on specific topics.
1.4 Nottingham City and Nottinghamshire Learning Improvement Framework
The Nottingham City and Nottinghamshire Learning and Improvement Framework has been developed in accordance with Working Together to Safeguard Children 2015 statutory guidance. It applies to local organisations who work with children and families across Nottingham City and Nottinghamshire and is governed by the Nottingham City and Nottinghamshire Safeguarding Children Boards (NCSCB/NCSB). It sets out the principles under which the framework should be applied, and more detailed guidance about the processes involved are referenced where appropriate.
PurposeThe framework described within this chapter seeks to enable organisations to be clear about their responsibilities to learn from experience, act and secure improvement of services as a result.
Learning and Improvement model
The model below sets out the component parts of the NCSCB/NSCB Learning and Improvement Framework
Improving practice relies on seeking learning from as many sources as possible and triangulating information in order to underpin the Boards' identification of priorities for their Business Plans. This will include:
- Gathering information from children and families;
- Analysis of performance data on a range of activity from early help through a child's journey in the child protection process;
- Feedback from frontline staff;
- Section 11 audits;
- Reports on agencies' critical issues;
- Learning from inspections and thematic reviews.
Multi Agency Audits
The NCSCB and NSCB will develop each year Multi Agency Audit programmes, with the aim of providing assurance to their respective Boards of the quality of safeguarding services in Nottingham City and Nottinghamshire. In addition, any areas of good practice will be identified and shared and areas for development will result in recommendations and action to improve practice.
The multi agency audit programmes will be developed taking into consideration:
- Priorities detailed in any national or local guidance;
- The implementation of new policy, procedure and practice guidance including any developments relating to those children described as vulnerable in Working Together 2015;
- Issues identified through NCSCB / NSCB processes including Serious Case Reviews, the review of Child Deaths and the Risk Register.
The NCSCB and NSCB will ensure that the level and depth of multi agency audit is sufficient to provide the necessary assurance of safeguarding practice and that partner agencies are involved appropriately, including the involvement of front line staff. Wherever possible the views of children, young people and their families will be incorporated into audit work. In addition to agency representatives, additional support will be provided in relation to issues such as domestic violence, substance use, learning disabilities and mental health. Not all auditors will undertake each audit.
Reports of audit activity will be made to the NCSCB / NSCB Boards on a regular basis, and these will include any emerging issues that need to be addressed.
An analysis of these reports will be published in the Board Annual Reports, and will inform the Business Plan priorities for the following year.
The Annual Reports will highlight the following:
- Safeguarding issues emerging from the audits;
- Good practice and areas for development within multi agency safeguarding work;
- The expected process by which this will be disseminated and how actions and monitoring of their impact will be managed within each agency.
Each LSCB has in place a full Terms of Reference document for their Multi Agency Audit Process, and recognises the contribution they make within their Quality Assurance Frameworks and Impact Evaluation documents.Single Agency Audits
In addition the NCSCB & NSCB have an expectation that each partner agency of the board will undertake their own internal audits of safeguarding activity.
Partner agencies are to determine the focus of these audits based on their own self assessments of safeguarding practice (including Section 11 compliance) and learning from Serious Case Reviews. These may cover the implementation of policy and procedures; line management arrangements, training and supervision; and the quality of specific safeguarding interventions. Analysis of the results of the audits should lead to recommendations for future practice development, and be reported to the appropriate LSCB Board.
Learning from Case Reviews:
The aim of all types of learning review is to enable professionals and organisations protecting children to reflect on the quality of their services, and learn from their own practice and that of others. The processes ensure that good practice is shared and that when cases have poor outcomes, the lessons can be learnt and actions identified to ensure that services can be improved to reduce the risk of future harm to children.
The following review processes form part of the Learning and Development Framework:
Child Death Reviews:
These are conducted by the Child Death Overview Panel (CDOP). The multi-agency panel reviews each death of a child normally resident in the area – there are separate CDOPs for Nottingham City and Nottinghamshire.
The panels collect and collate information relating to each child death to determine if the death was preventable and identify any modifiable factors which may have contributed to the death. If there are any such factors, the panel will make recommendations to the Local Safeguarding Children (LSCB) so that action can be taken to prevent such deaths in the future where possible. The panels also analyse local data to identify any patterns or trends and alert the LSCB accordingly. If there is a suspicion that neglect or abuse may have been a factor in the death, the panel will refer the case for consideration for a Serious Case Review.
The panel is also responsible for agreeing local procedures for responding to unexpected deaths and ensuring appropriate support is in place for those affected.
All learning identified is shared widely both on a local and national scale and findings are reported to the LSCB for dissemination within partner agencies.
Serious Case Reviews (SCR):
The purpose of an SCR is to advise local agency partners on lessons to be learned from serious cases with a focus on both good and poor practice. An SCR must always be conducted if:
- Abuse or neglect of the child is known or suspected; and
- The child has died; or
- The child has been seriously harmed and there is cause for concern as to the way in which agencies have worked together to safeguard the child.
If an agency feels a case meets the criteria for an SCR, they must make a referral and the Board will gather the relevant information for the case to be considered by the Standing Serious Case Review Sub-Group (SSCR). The SSCR will make a recommendation to the Independent Chair of the LSCB who will then decide whether an SCR should be carried out or whether an alternative type of review would be more suitable.
Other multi-agency reviews:
If a case does not meet the criteria for an SCR but it is felt that there is some learning that can be identified from it in order to improve practice, then an alternative multi-agency learning review can be held. The process will be agreed according to the needs of each individual case and described in the terms of reference. It will be facilitated by an independent manager who has had no involvement in the case.
One option for consideration includes a case discussion resulting in an interactive analysis of the practice undertaken. Such a discussion would:
- Explore all relevant aspects of practice in the case;
- Test out some of the initial conclusions reached in relation to specific issues;
- Identify changes to practice to bring about improved outcomes for children; and
- Summarise the key learning points and make recommendations.
The case discussion is a real opportunity to engage front-line staff in identifying and implementing learning. To maximise this, the event will always be managed to avoid apportioning blame. The event will generally be structured as follows:
- An introduction setting out the ground rules etc;
- A discussion of the trigger incident in which each agency is invited to contribute to reflect their involvement;
- An open ended discussion focusing on the practice and what would have made a difference;
- An analysis to inform the report to the NCSCB/NSCB.
Single agency reviews:
Many agencies have procedures which involve conducting a single agency review when an incident has occurred. Whilst these reviews take many forms, it is expected that the agency will ensure that the Board is appropriately notified when they are undertaken, and of any learning identified which it would be helpful to share across partner agencies (for example, a resulting change to their multi-agency working practice). The learning should be shared with partners through the relevant LSCB representatives. It is crucial that all agencies are aware of learning and improvements to practice so that local safeguarding practice can continue to improve and evolve, and that this can be monitored.
National and Regional Learning
Both Boards maintain a live link with the regional group of LSCB's, which allows them to contribute to and benefit from shared learning, activity and research. This informs local developments and practice.
Findings from published Serious Case Reviews nationally are also reviewed, through reference to the repository established by the National Association of LSCB Independent Chairs and the NSPCC, to identify any improvements in practice required locally.
To ensure that specific areas for improvement in practice, or learning from good practice identified from reviews, audits and other sources is effectively disseminated, the NCSCB and NSCB will:
- Establish and monitor clear communication channels within Board structures and across all partner agencies;
- Require all Board Sub Groups and partner agencies to identify and report on actions identified to promote improvements in practice;
- Make clear what improvements in practice are required, and how this might be evidenced;
- Identify priorities in the Board Business Plans to reflect the key learning from the previous year;
- Organise a range of learning opportunities to support the dissemination of learning, such as seminars, newsletters, meetings of safeguarding leads;
- Put in place a number of methods for evaluating the effectiveness of the dissemination of learning such as feedback from newsletters, hits to web pages, event evaluations.
To evaluate and review the effectiveness of the Learning and Improvement Framework, it is important to gather some evidence of the impact of learning and it's dissemination, on practice and outcomes for children and young people.
In the context of an Impact Evaluation Framework adopted by both Boards, the NCSCB / NSCB will develop a range of methods for collecting evidence of improvements in practice, including:
- When actions to improve practice are identified by partner agencies or Board sub groups, the outcomes that would provide evidence of their effectiveness are clearly spelt out and monitored;
- The use of themed multi agency audits;
- Drawing information from other quality assurance processes (E.g. Section 11 audits);
- Using post course or learning event questionnaires;
- Monitoring the impact of actions from Serious Case Reviews;
- Outcomes of inspections and peer review.
Each Board will use their Performance Management and Quality Assurance practices to contribute to the evaluation of the impact of identified improvements in practice.