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Annual Report on Safeguarding Arrangements 2018-19

Introduction

Everyone in Devon shares a commitment to and responsibility for safeguarding children. Statutory responsibility rests with the three safeguarding partners: the Clinical Commissioning Group (CCG), the local authority and the police, who come together to lead Devon Children and Families Partnership (DCFP).

DCFP is required to publish its Multi-Agency Safeguarding Arrangements (MASA), which it did in November 2018 – the second partnership in the country to do so. It must also publish a report, at least annually and this report must be independently scrutinised before publication. This is DCFP’s first annual report. Mark Gurrey, an independent consultant, agreed to provide independent scrutiny for our annual review and this report. The detail of the activity undertaken to provide independent assurance is set out in appendix one.


Achievements in 2018/19 and priorities 2019/20

We published a three-year Children and Young People’s Plan (CYPP), the accompanying outcomes framework is at final draft stage. Future reports will include an outcomes data appendix and our new partnership website is operational. We feel confident that we are embedding a partnership system that is responsive to the complexity of Devon (outlined in our MASA) and the nature and scale of the safeguarding challenges locally. New provider arrangements for Children’s Community Health services are operational. We have overseen major developments in involvement (parents and young people).

The review found that:

“Over £150k has been invested and new staff brought in to bolster this crucial area of work. Building on the previous engagement service, there is now activity to widen the scope of user participation both for children and young people (through mechanisms like the children in care council, the Special Educational Needs and Disability (SEND) workstream and the youth parliament) and crucially with parents and carers. The Children’s Plan benefitted from considerable consultation with children and young people and the next ‘take over’ day will now include all partners in Devon not just the Council as previously…..work has already begun on engaging with parents of children who have special education needs and/or are disabled but the intention is to expand that to include parents of children in need, those on child protection plans and those in care.”

There are five key areas of impact for children and families:

1. We further strengthened Early Help, Multi-agency Safeguarding Hub (MASH) and the interface between statutory services and early help, ensuring that more families, more often receive the right service at the right time

2. We have responded positively to the challenge of the 2018 SEND Inspection and are able to evidence impact from the actions we have taken.

3. We launched the Adolescent Safety Framework (ASF). The review found:

“a substantial piece of work designed to radically refocus service provision to young people at risk (of criminal exploitation, of child sexual exploitation, of substance misuse etc) where the source of the risk is extra-familial. It builds on ‘contextual safeguarding’ approaches and sets out a theoretical approach to the work; a new model of multi-agency coordination; clear pathways for assessment and provision and a toolkit for use by partnership professionals…..it is a comprehensive and well-constructed approach and one that DCFP will want to closely monitor and support as needed.”

4. We completed development work on sexual abuse, with the impact to be tested next year. The review found:

“a completed and comprehensive plan to drive forward work in this area. This has been well received and important to ensure the work is maintained and impact felt.”

5. We progressed development work on teenage suicidal ideation. The review found:

“there are a series of actions, picked up from one of last year’s rapid reviews, relating to suicide ideation. The actions are comprehensive and most will sit with the Quality Assurance Development Group (QADG) to coordinate and deliver.”


Key priorities for 2020/21

  • SEND, in particular responding to autism, and corollary challenges of emotional health and well-being and mental health and speech and language development. This will incorporate learning from the 2018 review which explored radicalisation risk and preventative interventions in relation to young people with autism.
  • Further work to embed neglect practice toolkit. 2018/19 saw a lot of development work in relation to neglect. Impact was tested in 19/20. The partnership was not satisfied that the toolkit was sufficiently informing frontline practice. Activity is scheduled for January 2020 with learning dissemination for March 2020. The review found that:

“in Devon as elsewhere, long standing and chronic neglect remains one of the most significant challenges needing to be addressed if outcomes are to improve for children in the County. The Neglect Strategy and associated tool kit is one of the key strands within the Children’s Plan (under the ‘Feel Safe’ theme). Thus far, 257 practitioners have received the training on the use of graded care profiles, however the implementation of graded care profiles needs accelerating. The numbers of children subject to child protection plans for neglect has reduced to a level comparative to others.”

  • From our two rapid reviews in 19/20 we have identified deeper understanding of coercive control and mitigating risks that arise in Elective Home Education (EHE) as key development areas.
  • Assessing the impact of the Adolescent Safety Framework.

Governance and leadership

Changes in governance are detailed on the website, and you can view a structure chart of the DCFP including all sub-groups here.

The review found:

“a positively developing culture within the partnership characterised by a commitment to work together and to be ready to scrutinise and be scrutinised…. relationships at executive level were good; robust and mutually supportive and challenging. The leadership work over the last 12 months has been successful in moving the group to a more effective and purposeful position than applied in either the DSCB or the Alliance. DCFP Executive is now chaired by the Police lead. This is a welcome development in that it distributes the leadership of the partnership more than hitherto.

Similarly, at locality level, managers all described effective and engaging local partnership networks both inside and outside of the formal locality meetings. Attendance and commitment is generally good and all were positive about the increasing development of partnership being ‘the way we do things around here.'”

DCFP has been exploring how best to respond to significant changes in the health landscape and emerging thinking about Local Care Partnerships (LCP). For children, the DCFP Executive and its Locality Partnerships will be responsible for the functions envisaged for LCP. The lead provider for Children’s Community Health Services will represent health provider functions on the Executive and during 2020 Locality Directors will consider the options for the further development of Locality Partnerships to meet the future challenge.

DCFP’s progress in relation to the Expert Reference System which we described in our MASA faltered, largely attributable to the challenges we have encountered in resourcing the partnership’s back office. This remains an outstanding element of our governance review, to be resolved in 2020.


Practice evaluation

During Winter 2018/ 2019 DCFP worked with Research in Practice to develop a practice evaluation model based on appreciative inquiry (AI). The review noted that:

“the appreciative inquiry approach developed under the Early Adopter initiative has not progressed as was originally hoped. There are completed AI materials publicly available and it is clear that some of the underlying philosophy within them is gaining some traction across the partnership.”

The tools developed from AI work are published here. The principles of AI have underpinned the work of the Child Safeguarding Practice Review (CSPR) Group and one CSPR has been completed using an AI approach; this will be published in 2020.

DCFP has a case resolution protocol however this is used rarely. Each agency is reporting confidence that the timely resolution of issues between agencies is well embedded with MASH, the Locality Partnerships and Locality Directors creating the conditions for this to be effective both at early help and child protection.

During 2018/19 Serious Case Reviews, Rapid Reviews and Local Child Safeguarding Practice Reviews (LCSPR) were undertaken. The learning from these reviews in relation to coercive control and Elective Home Education risk has informed work plans for 2020.

Since publishing our MASA, DCFP has completed three Rapid Reviews:

Rapid Review One

In February 2019, a Rapid Review into the death of a young person from a drugs overdose, opened up questions of adolescent neglect. The review was completed in a timely way. A plethora of reviews have explored neglect and it was judged unlikely that the case would open up new learning. The partnership decided to conduct its CSPR in the case through an AI to explore creating the conditions for effective practice in neglect to flourish. The AI was published in January 2020. The AI didn’t evince ‘new’ learning about neglect but the experience of being involved in the AI was described as transformational, both for the AI facilitators and for the AI participants. The clear move from a culture of accountability (often experienced by practitioners as blame) to a culture of learning, coupled with a detailed and thoughtful examination of good practice seem to be key to this transformation. However, it is still very early in the implementation of the national and local reforms of Working Together 2018 and it would be premature to draw conclusions from this first practice example.

Rapid Review Two

In July 2019, a Rapid Review was undertaken following the death of a six-month old child. At the time of the Rapid Review, it was unclear that abuse or neglect were factors in the death. Nevertheless, a history of Children’s Services involvement with an older child, led to the decision to undertake a Rapid Review, which was concluded in a timely way. There were three key areas of learning:

1. Devon has an excellent, public health led Domestic and Sexual Violence and Abuse (DVSA) strategy, developed and introduced in 2016/17. We are not confident that we have sufficiently integrated learning about coercive control across the system. There is stronger evidence that coercive control is shaping police thinking and therefore their interventions, but this is less evident in other professional groups.

  • This has been built into the partnership’s learning and development plan for 20/21.

2. The complexity of access to records for public health nursing, coupled with staff shortages, led to a new birth visit taking place without reviewing records in advance; hence the history of domestic abuse did not inform the practitioner and parental accounts were taken at face value. This learning has been highlighted in another recent case and actions taken to ameliorate the risk.

  • An assurance report was presented to the Partnership Executive in January 2020, updating on the positive progress that has been made.

3. The decision, by Children’s Services, to end the older child’s child in need status and close the case was made without multi-agency discussion and without consideration of a step across to Early Help. Other professionals involved did not challenge this, suggesting some professional passivity. This passivity is also often evident, more generally, in responses to MASH decision-making.

  • An audit was undertaken in the Locality to test the prevalence of single-agency decision making and action taken across the county to further strengthen step across to Early Help.
  • MASH has taken active steps to strengthen questioning practice, actively seeking partners’ feedback and building a culture that welcomes questions and challenge.

At its January 2020 meeting the CSPR group will consider toxicology findings and decide what if any further learning can be excavated and what if any further action to commission.

From a process and practice perspective this case is a compelling example of the value of Rapid Reviews. The uncertainty about the cause of death would have delayed a decision on SCR. The Rapid Review, though intensive in the 15 days, can be completed and learning acted upon months before the threshold question can be answered.

Rapid Review Three

In July 2019, a Rapid Review explored the learning about two children withdrawn from school for Elective Home Education (EHE) in December 2018. The Rapid Review summary notes:

“The number of EHE children in Devon has more than doubled in the last five years and in the last year there has been a further 25% increase. On 30.7.19 there were 1518 registered cases and 231 unregistered cases. The total number of cases for 18/19 was 1922 registered and 260 unregistered. Many more of these children have SEND and/or safeguarding concerns. We have seen the 70/30% balance of lifestyle choice/non-lifestyle choice completely reverse over time; only 30% of EHE are now judged to be lifestyle choice. There has been no corresponding increase in resource to match the volume and complexity of cases with inevitable consequences for quality. The legislative bias favouring the right of parents to EHE leaves the right of children to an education and to be safeguarded compromised. The local authority cannot insist on seeing EHE children or visiting the home to ensure they are safe and well. It does not even require parents to engage with the local authority in a meaningful way or enable professionals to inspect work completed by children to ensure they are receiving a suitable education.”

The outcome of the Rapid Review has been some myth-busting about, and a clearer understanding of, the local authority’s powers in EHE across the partnership and a clear strengthening of partnership between MASH and EHE. EHE cases will not automatically meet threshold for a social care response, but the changed profile of EHE nationally and locally requires us to ensure vulnerable children are not being missed. The joint MASH/EHE work is designed to close the gap.


In relation to Rapid Reviews, the review found:

“The rapid review process in Devon expects partners to go through a staged process – what has happened; what is the background to the event(s); what are the emerging lessons; what if anything, more might we need to learn about and what is the most effective way of getting to that learning. DCFP are currently producing short, well focussed and analytical rapid reviews and their use and impact was spoken of positively. They are demonstrating a clear and effective understanding of the new process and it is clear that the final reports are both well received, widely circulated and well used locally.”

The key outcome envisaged within the changes set out in Working Together 2018 are that case reviews should be conducted in much quicker and more focussed ways than hitherto and that the gaps between an incident and the learning contained therein and the dissemination of that learning should be considerably narrowed. There is evidence that that is the case in Devon and will need to be sustained. DCFP approach to rapid reviews and any LCSPRs should be maintained and developed and the partnership should continue to focus on quick and effective ways of identifying and disseminating learning from individual cases.

This emerging good practice will be further supported through workshops with LCSPR Group, Practice Development Group (PDG) and QADG planned for Spring 2020 facilitated by Research in Practice.


The MASA sets out a clear expectation that any independent scrutiny commissioned by DCFP must add value to that already in place and that carried out by safeguarding partners in the delivery of their statutory duties. The partners determined that the benefits of retaining the chairing of the Executive (and other component parts of the partnership) by safeguarding partners and the increased sense of ownership that would bring, outweighed the benefits of independent chairing. DCFP judged that scrutiny of safeguarding in a large and complex area like Devon anyway requires more than can be reasonably be provided by one scrutineer regardless of their background or expertise.

Since publication of the MASA, some aspects of the partnership and or individual agencies have been formally reviewed by regulators or inspectors.

  • December 2018 SEND Area Inspection (Ofsted CQC). Written Statement of Action approved August 2019
  • May 2019 Ofsted focused visit Children in Need
  • Summer 2019 Partners in Practice team diagnostics for social work teams
  • HMICFRS inspected Devon and Cornwall Police in July 2019, report to be published January 2020.
  • The Atkinson Secure Children’s Home, whilst not falling within the definition of secure institutions set out in Working Together, has also been subject to an Ofsted inspection and is rated ‘good’ in all areas.
  • The four short breaks residential units, which transferred form Virgin Care to Devon County Council (DCC) in April 2019, are also subject to Ofsted inspection. They have been judged as follows:
    • Meadowpark (September 2019) – Requires Improvement
    • Hillcrest (December 2019) – Requires Improvement
    • Welland House (December 2019) – Good
    • Barnes (December 2019) – Good
  • 41 schools were inspected and only one of these was judged ineffective for safeguarding. We are working with this academy and the Regional School’s Commissioner to support the necessary improvements.

The DCC Overview and Scrutiny Committee has continued to meet, advised by an external safeguarding expert. And the Office of the Police and Crime Commissioner (OPCC) and the non-executive directors of the CCG continue to provide the levels of challenge and scrutiny required of them.

The PDG and QADG are the engine room for practice improvement. There is some good evidence of their impact however the independent review notes:

“the assurance plan needs to be agreed as a matter of urgency, a programme of case/practice evaluations needs to be agreed and that the approach to Section 11 is reviewed and streamlined.”

This is agreed and will be taken forward by the partnership.


Workforce development

The Partnership has continued to invest significant resources in multi-agency learning and development to complement single agency initiatives

The priorities for workforce development set out in the MASA have been reviewed and amended in line with the CYPP. Find more information about workforce development here.

As examples of reach, the Adolescent Safety Framework Briefing Sessions were attended by 175 multi-agency practitioners with more planned from March 2020 and 100 practitioners were trained in reducing parental conflict with further events planned from March 2020. From 1 January to 31 December 2019, 5087 people were trained through the DCFP programme. This includes statutory and voluntary sector staff with a range of courses including child protection, neglect, adolescent risk. Participants report that the training has impacted on their practice through assessment of risk, awareness of need, helping to open honest conversations, enabling parents/carers to take ownership of areas that they need to work on.


User involvement

Children’s voice and influence in the work of the partnership has been a priority development area through 2018/19 with additional investment made to a 12-month post from DCFP to work alongside the additional resources the Council has committed to expand this team.

  • Three “Big Lunch” workshops, attended by 10% of the care leavers “in touch” with Devon, were held across different localities in Devon as part of the celebration of National Care Leavers Week (October 2019).
  • Members of Devon’s Youth Parliament organised a climate change forum attended by over 100 young people aged 11-16 to come together from across the county. The full day of activity included workshops, tree planting and provided an opportunity to ensure that the voice of children and young people is heard in the development of the Devon Carbon Plan.
  • Children in Care Councils were revised and revamped moving to a locality-based model to enable more children in care to attend and participate. The number of children in care and care leavers who are actively engaged with activity undertaken by the participation team has steadily increased.
  • The development of the forum for parents and carers of children with SEND in Devon continues to be a high priority for us as we seek to ensure meaningful engagement on matters of co-design and co-production. The forum is being supported by Somerset Parent Carer Forum as a host organisation until they are ready to set up as an independent charity in Summer 2020.
  • The Local Maternity System (LMS) Board have been engaging widely on the Maternity Strategy for Devon, with events in 2019 hosted either by the LMS or by the recently established Maternity Voice Partnership. A social media page “Better Births in Devon” has 328 members and the page is used to debate matters, seek views and give/receive information.
  • In August 2019, the CCG brought together parents of children and young people with autism to hear their views on and suggestions as to how best to improve the services and support available. Through its engagement on the NHS Long Term Plan, the CCG commissioned a local voluntary organisation to discuss and seek views on the emotional health and wellbeing of children and young people.
  • Services and organisations across Devon were encouraged and supported to take part in the national Takeover Challenge day on 29th November 2019. This was positively embraced and resulted in a range of exciting opportunities created for children and young people.

Funding and support

The independent review commended partners for:

“having established equal funding contributions to support DCFP. This is one of the few and possibly the only partnership in the country where this is the case. That said, I acknowledge it has been a significant leap in contributions especially from the Police and there is I understand some doubt about whether that is sustainable for 2020-21 and beyond. Whilst acknowledging the difficulties for one agency covering four local authority areas, it is to be hoped that the funding level can be sustained as a real and concrete expression of the equal responsibilities placed on safeguarding partners under the new arrangements.

Since the review, ongoing commitment from the three Safeguarding Partners has been secured to the costs of the partnership support. The partner’s will also make a resource available for multi-agency training and are committed to continue to do this into 2020/21.


Conclusions and recommendations

The independent reviewer has recognised, in lots of areas, our continuously improving practice as well as areas of innovative practice. In his view, we are meeting the challenge of Working Together 2018 well.

The independent reviewer’s biggest reservation about the MASA is the very wide scope of the comprehensive agenda set out in the CYPP and the risk that “the Exec could default to only monitoring the plan’s progress, processing papers and reports…as too many Local Safeguarding Children Boards (LSCB) did”.

He goes on to suggest that:

“the DCFP Executive take direct ownership of and responsibility for one or two specific areas of safeguarding and ensure that their collective efforts have a demonstrable impact on front line practice. The Executive should ensure they are sighted on current practice, including examples of good work, understand what needs to happen both in terms of leadership and investment to improve practice and oversee positive changes throughout the course of 2020.”

This is agreed and will be taken forward by the partnership.

The second area of reservation for the reviewer concerns independent scrutiny of partnership working. The reviewer recommends that:

“DCFP commissions some external independent scrutiny work during 2020 with a clear focus on partnership working. It should look to build on the approach being developed within rapid reviews and through their appreciative inquiry work that scrutiny should be explicitly learning focussed, should include areas of good practice as well as ones of concern and should be conducted in a way that enables quick and effective dissemination to front line practitioners”.

This is agreed and will be taken forward by the partnership.

The independent review recognises that DCFP is still at an early stage of development and is probably more advanced than most nationally.


Appendix one: independent review

Mark Gurrey undertook the independent review between October and November 2019. He interviewed:

  • Lead Member Children’s Services Devon CC
  • Chief Officer Children’s Services DCC
  • Head of Service Education DCC
  • Head of Children’s Social Care DCC
  • Chief Superintendent and DCFP Executive Chair
  • Head of Commissioning DCC
  • Interim Deputy Chief Officer NHS Devon CCG
  • Head of Safeguarding NHS Devon CCG
  • Safeguarding Lead Babcock (externally commissioned school support services)
  • Primary Head Teacher
  • 3 of the 4 Locality Area Managers Early Help
  • Manager, Quality Assurance and Reviewing Service

The reviewer read minutes of the DCFP Executive, the Practice Review Group and all other associated groups within DCFP architecture. The reviewer considered the rapid reviews and the LCSPR. A Summary of his findings is below:

Strengths

  • Good progress since inception – ‘hard yards completed’
  • Partners describe a positive culture and clearly value DCFP
  • Relationships are good and mutually supportive
  • More purposeful than in the past
  • Chaired by Police – spreads leadership
  • Tri-partite funding
  • Mirrored at locality level – partnership is the way we do things around here
  • Detailed and comprehensive Children’s Plan produced
  • DCFP becoming a recognised and valued brand

Areas for Development

  • The Children’s Plan is substantial in content – a danger that Exec could default to only monitoring its progress, processing papers and reports…as too many LSCBs did
  • All partners must take a shared responsibility of the agenda.
  • The gaps in the Partnership Support Unit have had a significant impact on progress
  • Resolve longer term funding base

Acknowledgements: DCFP would like to thank Mark Gurrey Independent Reviewer for his observations and recommendations. The partnership is committed to independent scrutiny and welcomes the insight and experience that has informed the review, which is expected to further strengthen an already flourishing partnership.


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