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"It's everyone's job to make sure I'm alright"
Report of the Child Protection Audit and Review

Chapter 5: What leads to success

What leads to sucess
The nature of the problem
Resources
Accountability
Performance management and quality

5.1 Throughout the case audit we saw many examples of good practice. Figure 6 on page 92 provides a summary of effective practice.

The nature of the problem

5.2 When the fieldwork element of the case audit was completed, we examined the emerging global picture of agencies' practice and the outcomes for children. We considered whether practice and outcomes might be affected by:

• the degree of deprivation in the area;
• urban or rural location; and
• the complexity of problems facing families.

5.3 We found that children remain unprotected across both urban and rural areas and across areas of deprivation and areas of relative affluence. Doing well was less frequently evidenced in poorer urban areas, although we found sufficient examples to conclude that it was possible to do well even in the most difficult socio-economic environments.

5.4 The level of problems in a family's life did not appear to affect how well agencies performed, but it did appear to be much more difficult to do well if there was a sex offender living in the family or in close contact with the family.

5.5 We found that the outcomes for children were highly dependent on social work doing well. Where social work performed well, the outcomes were generally good and when they performed less well the outcomes were poorer. Good outcomes were assisted by the work of all agencies, but were less dependent on other agencies.

Resources

5.6 As part of the review we asked staff to log time spent on their activities. Some cases required very little professional input but these were generally cases where no further action was needed after an investigation.

5.7 Most of the children and their parents needed, and were receiving, considerable help from a range of services or were continually coming to the attention of the police or social work. We considered if doing well with difficult cases required a higher level of resourcing. It was very evident that complex, chronic or acute problems required a high level of staff resources from a number of agencies but the level of resources did not appear to be a significant factor in the quality of work. Those cases that were well managed required no more resources than many of the cases that were poorly managed. Some cases which were not allocated designated workers and where decisions had been made not to invest in the family, often took up as much agency time as those cases that had planned sustained interventions. More noticeable, were the different patterns of resource use.

5.8 In good practice cases where there was substantial agency involvement, there was always a skilled social worker who assessed the child and family's needs and who was actively working with the parents and others to change the circumstances for the child. In these cases the social worker had more direct contact with the child and parents and other social care staff, such as home carers, often had less. Other resources were used judiciously for specific purposes and overall the resource use was no higher. In these cases the involvement of other professionals in the work plan was also generally high but, again, in a more focused way and no higher than in those cases that were less well managed.

5.9 In well managed cases time was spent on communicating with other agencies by all practitioners but this was not unduly time consuming, other than in the initial development of the professional network. It was also noticeable in these cases that social workers spent time consulting with other professionals and their line managers and in thinking and planning.

5.10 Better practice was noted with new born babies where planning started before birth and was multi-agency. In these cases there was often as much activity pre-birth as immediately post birth. Clearly it is easier to plan and reflect if a situation is not in crisis and we saw some good examples of professionals acting in anticipation of increased risks.

5.11 These findings might suggest that the key to efficient and effective use of resources lies in:

• anticipation, thinking, planning, reviewing and oversight by all agencies;
• working with families as soon as risks are identified; and
• direct social work with children and their families.

5.12 There are a number of vacancies in children's services across all disciplines as Table 2 shows.

Table 2: Staff vacancies

5.13 Figures on the numbers of posts, or any vacancies, in Sure Start and other programmes are not collated and numbers of police vacancies are held only at local level.

5.14 Different agencies responded to resource constraints in different ways. During the review agencies told us that the lack of psychologists, psychiatrists and counselling services led to the agencies providing these services refusing new cases or maintaining waiting lists. Social work services generally prioritised cases according to a hierarchy starting at the top with children in need of protection, followed by looked after children, children living at home and supervised by the local authority and finally, other children in need. The police, during staff shortages, generally prioritised child protection work and filled posts from other sections. They therefore responded to all 'child protection' referrals quickly and promptly but resource constraints affected the depth of subsequent investigations or the skills of those undertaking them.

5.15 Almost all the agencies prioritised children who were considered to be at risk and describing a child as 'at risk' generally resulted in a more immediate response from agencies. One agency's system for prioritising referrals or cases was not always shared with partner agencies whose staff only became aware of a formal or informal systems operating when difficulties in obtaining a service occurred. For example, in one area Reporters only became aware of social work prioritisation systems when chasing up late reports.

5.16 Both the general lack of social work resources for children and social work vacancies were cited by professionals as reasons for poor performance. It was very evident that few social workers had time to work directly with children and their families and this is noted throughout the audit.

5.17 Social work vacancies were attributed to the unattractive nature of working with children and families in a hostile public and press climate and the migration of children's social workers to the voluntary sector or new projects such as new community schools.

5.18 Many local authority social work staff did tell us that it was difficult working in such a hostile climate, but in their day-to-day work it was the lack of opportunities to directly work with children and their families and the welter of procedures and bureaucracy that frequently frustrated them. Many saw the voluntary sector as attractive because it focused on meeting the needs of children and enabled staff to use their core social work skills of working with children and families.

5.19 During the audit we found severe shortages of social work staff in some local authorities and some teams were as much as 50% under staffed. In these teams the quality of work in those individual cases that were allocated was not necessarily affected. We found some of the best practice in the most understaffed teams, but cases might remain unallocated and therefore recieve no service at all. Although staff were very concerned about cases that were unallocated, they were grateful to line managers for ensuring their own workloads were not excessive.

Accountability

5.20 Agencies working in the field of child protection are accountable to the children and families and communities on whose behalf they act, to the other agencies with whom they work and to their own agencies. Not all accountabilities are clearly defined, or regularly assessed. Where they do exist, accountability mechanisms work in different ways in respect of each professional group and each agency and some work better than others.

Parental and child accountability

5.21 The children and families in the case audit sample needed help to navigate the systems put in place to assist them. Some professionals took a high level of personal and professional responsibility for ensuring that a child was protected or his or her needs met. In many cases the responsibility was an inter-agency one and there was no obvious person of whom it could be said 'the buck stops here'.

5.22 Case conferences demonstrated their accountability to parents by ensuring their presence at meetings and providing them with copies of relevant reports and action plans detailing the work of various agencies. Not all parents had the opportunity of attending case conferences although this has long been considered to be good practice. Even those who did attend often did not receive reports, minutes and plans, or were not given opportunities to respond to them.

5.23 Children rarely attended case conferences and so were unable to use this forum to hold professionals accountable. Professionals exercised accountability for children's welfare through offering services via their parents. They did not always ensure the children obtained those services, however, if parents were unable or unwilling to take them. For example, we saw one case where a psychiatrist closed a case because parents did not bring a child to appointments.

5.24 In other cases, accountability for meeting children's needs came second place to protecting a worker's safety - health visitor services were withdrawn from a family with vulnerable young children following threats to the health visitor; a teacher would not express a view about a child being placed on the child protection register because of intimidation at the case conference.

5.25 There were few mechanisms for ensuring accountability for a child's protection and welfare once an issue of concern had been raised. The structures of agency records did not generally allow for recording the outcomes for children. When we requested information about outcomes, as we did in every case, we received statements that children's names were placed on the register, or a support package had been put in place rather than risks had reduced or needs were met.

5.26 We were concerned that a number of children experienced what we termed the 'round of referrals' with no single individual practitioner taking responsibility for meeting the child's needs or seeking to work together with others to meet them. A number of children in the sample had been referred to services with such long waiting lists that there was little likelihood of them receiving a service in the foreseeable future. Meanwhile, parental or children's hopes had been raised that help would be forthcoming. Having referred to another agency, practitioners did not engage in the work that they expected the other agency to undertake. Social workers, guidance teachers, psychologists and psychiatrists all have some skills in counselling children yet we saw examples of all of these professionals referring children to the others for counselling.

5.27 There is no doubt that staff are under considerable pressure and this may be the underlying reason for the 'round of referrals' that we witnessed. For the same reason agencies were 'screening out' children for services. A child who might need some help could be subject to an assessment process, sometimes an intrusive or lengthy one, in order to determine whether or not a service would be provided. In many cases an early helpful response to meeting need might well have taken less time than it took to deny the child the service. For example, we saw cases where children as young as 4 or 5 had sexually abused other children. Considerable time was spent by a number of agencies in determining if it was a child protection issue and when it was deemed not to be serious enough to call a case conference, the case was closed. In some cases the parents of the abusing children and the children themselves were offered information about sexual development and appropriate touching and play but in others they were not.

Accountability to referrers

5.28 Relatives, the public and staff from a range of agencies are key to identifying children at risk and seeking help on their behalf. The ParentLine study and the case audit demonstrated how dissatisfied many people are when they refer a child to other agencies. Often they believe that agencies 'do nothing'. We know from the case audit that a great deal of work was undertaken in many cases. We also know that this was not always effective and the child still remained at considerable risk. Referrers, seeing lack of progress and without any feedback on what action, if any, was taken, were left with the impression of their referral having no impact. None of the agencies - health, police, education or social work - had systems for feeding back information to referrers or had determined what information might be appropriate to feed back. Moreover, agencies rarely engaged with referrers in a positive way in order to elicit their continuing support as the eyes and ears of the community in protecting its most vulnerable members.

Inter-agency accountability

5.29 Inter-agency accountability is primarily exercised through application of inter-agency agreements or protocols, the most widely used being the inter-agency guidance for child protection enquiries and case conferences prepared by local Child Protection Committees. Although the structures for case conferences varied, as did the quality of written information provided for the conference and emanating from it, this accountability was generally well exercised. Conferences were held according to agreed timescales, reports were prepared, minutes were taken, plans were made and progress was reported on. The case conference model of accountability was an effective one in ensuring all agencies accounted for their work and supported colleagues from other agencies. There was no mechanism however to hold the case conference process accountable for the outcomes for the child. Child Protection Committees do not exercise such a quality assurance role.

5.30 Other aspects of inter-agency accountability were poor. Individual agencies developed policies and procedures which had a great impact on other agencies, but we were told that these were not always fully negotiated with them.

• Police referred all cases of domestic abuse to the Reporter if there were children involved, leading to an increase in referrals that Hearings could not cope with.
• Education and health framed concerns as 'child protection' in order to access resources for a child.
• Social workers formed their own system of prioritising cases thereby not adhering to Hearings timescales or allocation of cases.
• Hearings or courts ordered supervised contact levels between parents and children that social work could not meet.

Agency accountability

5.31 Most professionals are required to work according to agency guidance and a number of systems and procedures have been devised to support staff in this task. In those cases where children are identified as being in need of protection, staff generally work within the guidelines and follow set procedures, the exception being medical practitioners who exercise individual discretion over the extent of their involvement with other agencies and their communications with them.

5.32 Health visitor and social work staff work within agency monitoring systems. Social work and health visitor staff and some clinicians receive supportive supervision from senior colleagues. The model of social work supervision is a helpful one for professionals working in the field of child protection but sometimes it works better in theory than in practice. At best, one social work service supervised staff regularly at all grades, work was properly recorded, line managers had read files and commented on the work and there was clear evidence of staff and managerial accountability coupled with support for staff undertaking a difficult task. At the other extreme we saw one social work service where there was an absence of recording on some files for over a year, where senior social workers had not examined the files during that period and where there was no evidence on the file or in discussions with staff that there was any managerial oversight.

5.33 The extent to which agencies are able to demonstrate accountability in their work with child protection is questionable. We saw few examples, across all agencies, of:

• routine file case audits or examination of practice against expectations;
• records of discussions with staff by line managers;
• sufficiently detailed records to enable a view to be taken about the quality of work or its effectiveness; or
• monitoring of agency practice or reporting mechanisms for senior managers.

Performance management and quality

5.34 Few managers have performance information specifically about child protection activities. The police have outcome targets and information about the levels of arrests, prosecutions and convictions but information about child protection or child safety matters is subsumed within wider categories such as road accidents and assaults. Health services have health outcome targets for children, some of which may relate to abuse or neglect, for example, dental caries are associated with poor diet and education has outcome targets such as the qualifications achieved for children who are looked after.

5.35 The information provided to senior managers about cases of abuse and neglect is usually about:

• the meeting of time targets (e.g. response times, waiting lists, time intervals in the hearing system);
• the volume of work (e.g. numbers of offence investigations, cases or hearings);
• outcomes of decisions (e.g. prosecution/conviction, supervision orders, names being placed on the child protection register).

Very little information is provided about the outcomes for children or the quality of work.

5.36 Occasionally managers at the most senior level engage in discussions about quality and outcomes and also review the work of their staff. We found examples of social work service senior managers inspecting (or commissioning inspections) of child protection cases and these being discussed at senior management meetings.

5.37 The lack of clear performance expectations was an issue raised by the Consultative Group as an area of concern (see Chapter 7). We asked members of the group to bring examples of agency performance indicators. Many organisations did not have any and no agency had a package of indicators from which their agency could give a clear account of their agency's performance in protecting or helping children.

Key Messages:

• Good child protection work is dependent on individual professionals, social work, education, police, medicine and nursing, making judgements, working for the best interests of the child, and being held to account for their work.
• Effective work by all agencies, depends on their working well together.
• Agencies are not good at informing people about the outcome of enquiries or referrals.
• Agency practice lacks regular and rigorous management oversight.
• Agencies lack well developed systems of internal monitoring and accountability.

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