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Learning from audits / reviews

Serious Case Review

Learning from Stoke-on-Trent serious case reviews (click on the link)

Learning and Improvement Framework

Stoke-on-Trent SCBs Learning and Improvement Framework (click on the link to view the document) was revised in September 2016.  Working Together 2015 requires that 'Local Safeguarding Children Boards' (LSCBs) should maintain a local learning and improvement framework which is shared across local organisations who work with children and families.  This framework should enable agencies to be clear about their responsibilities, to learn from experience and improve services as a result".

Each local framework should support the work of the LSCB and their partners so that:

  • reviews are conducted regularly, not only on cases which meet the statutory criteria, but also on other cases which can provide useful insights into the way partner agencies are working together to safeguard and protect the welfare of children;
  • reviews look at what happened in a case, and why, and what action will be taken to learn from the review findings;
  • action results in lasting improvements to services and processes which safeguard and promote the welfare of children and help protect them from harm; and
  • there is transparency about the issues arising from individual cases and the actions which partner agencies are taking in response to them
  • This cycle of reviewing, will help practitioners to understand what has happened and why, what action needs to be taken to learn from the review and how we can embed the learning into frontline practice

Learning from local case reviews

The SCB carries out a number of multi-agency case file reviews and learning reviews, particularly those cases that link to child protection, child in need and Early Help and Intervention cases.  Activities such as this should not be seen as one off events but as part of the continuous cycle of planning, learning and seeking assurance about the robustness of frontline practice.

The purpose of our review process is to provide a stringent and consistent approach to assessing work undertaken on a multi-agency or single agency basis with a child/young person and their family through a review of case records and discussions with those practitioners who are or have been involved with each case.  We, particularly focus on the safeguarding role of both specialist and non-specialist practitioners, the voice and journey of the child and the outcome of the decision making.

During the review process we aim to:

  • Identify learning points from areas that are working well and those which need improvement.
  • Focus on the outcomes that have been achieved through practitioner / agency involvements.
  • Carry out the SCB function of monitoring the effectiveness of what is done to protect children and promote their welfare.
  • Promote service improvement through identification of key practice issues so that recommendations can be drawn together and action plans implemented.
  • Feed into policy, training, practice protocols, learning and development activity.

It is also important to note that learning from good practice identified through the review audits and how this can be consistently achieved in order to make a difference for children is at least as important as learning from shortcomings.

Learning from Local Reviews-Child Sexual Exploitation & Consent
This briefing has been produced to help professionals to be aware of the lessons to be learnt from a recent child sexual exploitation learning process; it is aimed at all frontline practitioners working with children and their families. The briefing is shown under related files at the bottom of this page.

Latest Findings From Multi agency case file reviews

17 Multi agency case file review

Do all professionals have an understanding of intervention thresholds at all levels?

  • A recent review evidenced a clear misunderstanding of the SCB Escalation Policy which was not acted upon by professionals—where there was a clear history of concerns regarding failure to engage, it is important that professionals challenge/escalate their own concerns.
  • A very clear need was also identified for all professionals involved in supporting a family to escalate concerns when they are denied access to a home environment but believe that conditions are compromising safeguarding arrangements for children or young people.

16 Multi agency case file review

Do all professionals establish the wishes and feelings of children with disabilities?

  • A recent review evidenced a need to review how assessments at all levels consider the ‘Voice of the Child’ when those children have a disability and cannot verbally disclose.
  • A very clear need was also identified for all professionals involved in making and receiving referrals in relation to a child’s disability to also assess all non-disabled siblings as part of that investigation to ensure that they are safe and supported.
  • Consideration should also be given where elder sibling takes lead responsibility for the care of a child with a disability.

15 Multi agency case file review

  • Can all professionals please consider the planning and time of appointments they aware making on behalf of service users or, to visit service users.
  • A recent review evidenced a very clear commitment by all professionals involved in supporting this family to achieve positive outcomes. However, it was clear that at times some professional visits / appointments were clashing leaving the service user feeling overwhelmed and unable to do what was expected of them.

14 Multi agency case file review

  • Professionals must ensure that when working with a family whose first language is not English they provide the family with copies of reports / child protection plans etc. that have been translated into their first language.

13 Multi agency case file review

  • We acknowledged that there are clear cultural differences relating to parenting, attachment and wider safeguarding issues professionals must make sure that diversity does not mask concerns around child protection.
  • Professionals must be aware that in some cultures the surnames are not always the same even though members of family’s are blood related.

12 Multi agency case file review 

  • Excellent evidence of positive multi-agency frontline practice
  • Clear evidence of planned and appropriate interventions fully supported by a robust Child Protection Plan
  • Excellent communication between all professionals involved with the family—evidence clearly upon safeguarding individual members of the family

Good practice

From a multi-agency case file review relating to a child with a disability, the following areas of good practice were evident:

  • Evidence of robust lateral checks to help in the decision making
  • Good multi-agency partnership working
  • The young person’s disability was taken into account when communicating 
  • The young person’s views were listened to
  • Agencies consistently had the same information which was accurate and up to date
  • From a  multi-agency case file review which evidenced some really good partnership working resulting in best outcomes
  • Positive and robust practice across all partner agencies
  • Positive communication between professionals
  • Clear decision making based on good analysis
  • Achieving positive outcomes for children, young people and their families

Latest Findings From National Case File reviews March 2017 (click on the link)

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