Quality Assurance, Learning and Improvement Framework
Introduction Working Together to Safeguard Children (Department for Education, March 2013) identifies a number of principles that should be applied by all LSCB s in relation to learning and improvement. This framework was developed in consultation with partners and coordinated by the Quality Standards and Case Review Sub-Group on behalf of Bracknell LSCB. In order to maximise the opportunity for synergy and support and challenge the development of this framework a short-life start and finish group was set up between the Berkshire LSCB s. This Framework will bring together a number of functions of the various sub-groups within Bracknell but also those that operate on a pan-berkshire basis. This document will later identify in what areas of the business of the board we work alongside neighbouring LSCB s and how this work will inform learning and improvement on a local level. Professor Eileen Munro, in her review of child protection, stated that in order to move towards a system that promotes the exercise of professional judgement, local multi-agency systems will need to be better at monitoring, learning and adapting their practice. This framework aims to outline the role of the LSCB in evaluating local safeguarding practice, promoting multi-agency learning, and facilitating improvement. General aims of this framework include: Enabling professionals and organisations to reflect on the quality of their services Facilitate or coordinate learning between organisations Highlight good practice so that multi-agency partners know what works well Identify how we will ensure a rigorous, objective analysis when areas for improvement are identified so that partner agencies are aware of what and why, so that lessons are learnt across local agencies Engage multi-agency partners in the work of the Board so that together we have a greater understanding of local practice Identify the range of reviews that will be carried out (including that of cases which do not meet statutory criteria) Bring together the data and other information collected by the Board so that there is lasting improvements across organisations Listen to and respond to the voices of children, young people and their families and the children s workforce. Andrew Ellery, Quality Assurance Officer, 2014 1
Scope This Framework applies to Bracknell Forest Local Safeguarding Children Board. It has been designed in consultation with partner agencies and such agencies are encouraged to implement the principles of this Framework within their own organisations. Underlying Principles The below are the principles upon which this Framework has been developed. Although slightly adapted for the purpose of this Framework, they relate directly to the principles that Working Together (2013) states LSCB s and partner agencies should apply to all reviews: We will promote a culture of continuous learning and improvement across the organisations, identifying opportunities to draw on what works and promote good practice The approach taken to Quality Assurance, Learning and Improvement should be proportionate according to the scale and level of complexity of the issues being examined Serious Case Reviews will be led by individuals who are independent of the case under review and of the organisations whose actions are being reviewed Professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith The involvement of families, including surviving children, must always be considered Improvements will be monitored and followed up so that agencies make a real impact on improving outcomes for children. Andrew Ellery, Quality Assurance Officer, 2014 2
Sub-Groups of the LSCB All of the LSCB sub-groups have a responsibility for challenging the practice of all agencies. The below table contains the possible sources of learning, linking to the relevant sub-group: Name of sub-group Learning and Improvement Sub-Group (LIA) Early Intervention (EI) Child Sexual Exploitation (CSE) Aims To maintain the Quality Assurance, Learning and Improvement Framework. To coordinate the Serious Case Review and Child Protection Incident Review processes To carry out multi-agency audits and monitor section 11 returns and updates. To monitor the Common Assessment Framework and the impact this is having on families. To monitor the overall effectiveness of the Early Intervention Hub. To develop a multi agency strategy and action plan for addressing child sexual exploitation which focuses on prevention, identification, support and prosecution Quality Assurance, Review, Learning and Improvement Method Single agency audit; multi-agency audit; training/learning event participant feedback; partnership review/child protection incident review; local section 11 returns; dataset; inspection; quality assurance; peer review; self-evaluation; multi-agency scrutiny/challenge; analysis of training feedback; benchmarking; annual report; Outcome (e.g. action plan, raising awareness material, development of courses etc). Action plans Monitoring of action plans SCR Recommendations Service development/change Learning events Andrew Ellery, Quality Assurance Officer, 2014 3
Pan-Berkshire Sub-Groups Child Death Overview Panel (CDOP) Section 11 (S11) Training To take an overview of all child deaths with a view to identifying any matters of concern affecting the safety and welfare of children in the Berkshire area; any wider public health or safety concerns arising from a particular death, or from a pattern of deaths in the Berkshire area; any case giving rise to the need for a Serious Case Review. Review and evaluate S11 returns of the full three yearly audit of S11 Children Act 2004 in order to make an assessment of agencies compliance with the duty to safeguard. Review and evaluate the organisations mid-term status of compliance against the three yearly full audit, and provide support as needed. Ensure that safeguarding training is monitored effectively and delivered to agreed standards. Ensure that safeguarding training and learning provision is responsive to local and national needs. Identification of themes, trends and modifiable factors; Provide data to the Department for Education to inform national analysis of child deaths; Pan-Berkshire section 11 returns; Views of practitioners, students and volunteers; Newsletter Annual report Findings inform local Joint Strategic Needs Assessment Action plans Development of training Improvement of training delivery Analysis of trainer and participant feedback Andrew Ellery, Quality Assurance Officer, 2014 4
Policy and Procedures To develop policies and procedures in the areas of child protection and safeguarding. To review research and guidance on the protection of children, along with issues arising from serious case reviews and ensure that the Boards are advised about revisions to policies and procedures. To act on feedback from workers on the translation of policies, procedures and protocols into practice. Andrew Ellery, Quality Assurance Officer, 2014 5
Serious Case Reviews Regulation 5 of The Local Safeguarding Children Boards Regulations 2006 sets out the criteria for conducting a review of serious cases. Serious Case Reviews (and other case reviews/audits) are a core function of the board and will be conducted in a way which: Is proportionate, independent and promotes a culture of learning and improvement Recognises the complex circumstances in which professionals work together to safeguarding children Seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did Seeks to understand practice from the viewpoint of the individuals and organisations involved at the time rather than using hindsight Is transparent about the way data is collected and analysed Makes use of relevant research and case evidence to inform the findings Where possible includes direct feedback from frontline staff and those who access services. With particular reference to Serious Case Reviews and in order to contribute to learning and improvement on a local and national level, we will publish SCR Overview Reports and the response from the LSCB. The LSCB annual report will examine the impact of Serious Case Reviews. When the criteria for a Serious Case Review has not been met, a Child Protection Incident Review/Partnership Review or a single agency review will be carried out. On the 17/10/14 the Learning and Improvement subgroup received a report outlining the findings from a survey carried out after a serious case review. The subgroup accepted that the below findings should inform any future serious case review or partnership review methodology; 1. That group sessions facilitated by the SCR Overview Report Writer are split so that practitioners and managers meet separately. 2. Group sessions used to gather information should not include others who have not been part of the case. They can attend subsequent sessions where lessons are shared. 3. Group sessions should not be too large. 4. Consider the environment where group sessions will be held so that it enhances learning. 5. An SCR Reference Group should meet regularly to monitor progress and accuracy. 6. The SCR Reference Group updates all involved as soon after their meetings as possible so that everyone remains communicated with about updates and any issues. 7. Learning material be shared with agencies who at present will not send practitioners to learning events. Andrew Ellery, Quality Assurance Officer, 2014 6
8. The LSCB will produce guidance for all involved about the SCR process so that those who have not previously been involved feel clear about what to expect. This will include brief information about each step of the process (e.g. agency report, interviews, information gathering group sessions etc.). 9. Realistic approximate timescales to be agreed by the Reference Group once the Learning and Improvement Group and Independent Chair have decided a notification meets the threshold for a SCR. This can then be negotiated with the Overview Report Writer. 10. To invite a legal advisor to the Reference Group where there is likely to be differences in opinion about how best to obtain information. This is particularly in reference to those who may not have capacity to agree to their records being disclosed. Section 11 Audits Section 11 of the Children Act 2004 places a duty on a range of organisations and individuals to ensure their functions, and any they contract out to others, are discharged having regard to the need to safeguard and promote the welfare of children. Working Together (2013) helpfully lists organisations that have these duties and they include: Local Authorities and District Councils NHS organisations including CCG s, NHS Trusts, NHS Foundation Trusts etc The police, including police and crime commissioners and the chief officer of each police force in England The Probation Service Governors/Directors of Prisons and YOI s Youth Offending Services Statutory Adult Social Care Services (usually within Local Authorities) Children and Family Court Advisory and Support Service Housing and Environment Health (usually within Local Authorities) One of the criteria for good within the Ofsted Inspection Framework and Evaluation Schedule, around the Effectiveness of the Local Safeguarding Children Board states; In addition, inspectors will consider how effectively the LSCB evaluates and monitors the quality and effectiveness of the local authority and statutory partners in protecting and caring for children, including the provision of improvement advice. In addition to providing improvement advice and guidance to statutory partners through the Business Manager, Chair, members and other employees of the Board, Bracknell LSCB aims to provide advice to non-statutory partners who do not have a statutory obligation to provide evidence of their compliance with Section 11. An example of how this will be achieved is the preparation for a series of community lunches arranged in partnership with Bracknell Forest Voluntary Action membership organisation. These lunches will provide an opportunity for voluntary, community and faith groups to engage with the LSCB and at the same time enable Andrew Ellery, Quality Assurance Officer, 2014 7
the LSCB to begin to establish the quality of safeguarding in unregulated nonstatutory services/organisations/groups. Minutes of meetings and any promotional material will be used as evidence of the LSCB s provision of improvement advice. Bracknell Forest Section 11 arrangements The Learning and Improvement Sub-Group will coordinate the Section 11 arrangements for services operating solely in the Bracknell Forest area. This will include Section 11 audits from the Local Authority, YOS, Schools, Early Years, other providers etc. A panel of three will be convened in order to scrutinise section 11 audit returns or the yearly update reports. The panel will consist of: An employee of the LSCB A partner agency representative who is a member of the LSCB Executive One person with sector specific knowledge Where possible they will bring a practitioner to be involved Pan-Berkshire Section 11 arrangements The pan-berkshire Section 11 Sub-Group considers returns that relate to more than one LSCB and Local Authority returns. With reference to Local Authority returns, panel feedback from this sub-group will then be passed to their own LSCB. This sub-group will ask organisations to carry out an audit against the Section 11 standards once every three years, with a mid-term review. In time for the mid-term review, the Section 11 sub-group panel will request that organisations inform them as to whether their circumstances have changed and the impact this is having on compliance. The panel will also request information about how organisations are progressing against their action plans. Child Death Overview Panel The Child Death Overview Panel (CDOP) operates on a pan-berkshire basis covering six unitary authority areas. They have a responsibility to review information on all child deaths in Bracknell and are accountable to the LSCB Chair. The CDOP reviews all child deaths, with the exception of legal and planned terminations, and babies who are stillborn. With reference to learning, improvement and quality assurance they have a duty around; Determining whether the death was deemed preventable, that is, those deaths in which modifiable factors may have contributed to the death and decide what, if any, actions could be taken to prevent future such deaths Making recommendations to the LSCB or other relevant bodies promptly so that action can be taken to prevent future such deaths where possible Identifying patterns or trends in local data and reporting these to the LSCB Where a suspicion arises that neglect or abuse may have been a factor in the child s death, referring a case back to the LSCB Chair for consideration of Andrew Ellery, Quality Assurance Officer, 2014 8
whether an SCR is required; agreeing local procedures for responding to unexpected deaths of children Annual and Quarterly Reports Annual and quarterly reports will be submitted following an agreed process and presented in an agreed format. These will include, among others; Independent Reviewing Officers report Child Protection Chairs report MAPPA report MARAC report Missing children report Report from Broadmoor Hospital Complaints report LADO report Reporting will inform the LSCB Annual Report and Business Plan. Information obtained through the quality assurance activity described within this framework will also inform the Annual Report, providing a rigorous and transparent assessment of the performance and effectiveness of local services. In order to implement the LSCB Quality Assurance, Learning and Improvement Framework, the below are the expected single agency responsibilities Contribute to the development of an annual audit programme for the LSCB, to include single agency audits that individual agencies will own and complete, feeding back findings. Lead agencies involved in cases will obtain feedback from those accessing services and staff. Feedback will inform any audits analysis and actions. Ensure that frontline staff are involved in the development and evaluation of internal training. Ensure that feedback from frontline staff is routinely analysed. Analyse data that is presented to the LSCB, providing evidence of work done and outcomes expected/achieved. Inform the board of any Inadequate Ofsted inspection (or equivalent from other inspectorates) in relation to safeguarding. Involve children, young people, families and frontline practitioners in audits and improvement work. Ensure that the workforce is suitable recruited, qualified and equipped to safeguard children. Provide staff with adequate supervision and support, and access to safeguarding training. Ensuring that their staff are competent to carry out their responsibilities for safeguarding and promoting the welfare of children. They are responsible for Andrew Ellery, Quality Assurance Officer, 2014 9
creating an environment where staff feel able to raise concerns and feel supported in their safeguarding role. Offering their staff mandatory induction, this includes familiarisation with child protection responsibilities and procedures to be followed if anyone has any concerns about a child s welfare. Ensuring that all professionals have regular reviews of their own practice to ensure they improve over time. Releasing staff to assist in delivering multi-agency learning as well as attending multi-agency learning. Ensuring that all staff have evidence of suitable safeguarding training. They are also responsible for ensuring evidence of updated safeguarding learning. Agencies are responsible for responding to audits under Section 11 of the Children Act 2004. Agencies are responsible for reporting on their compliance and quality of single agency work Single Agency Audit Outcomes of single agency audits will be presented to the Learning and Improvement sub-group. Outcomes will in turn be presented to the Board via the sub-groups reporting. Agencies will continue to provide notifications of significant incidents and any reviews they undertake in relation to children and young people. This is in addition to their responsibilities for alerting the Board of cases that may meet the criteria for Serious Case Reviews. Multi-agency LSCB Audit The role of the LSCB is crucial in determining the attitude of agencies towards improving practice on a multiagency basis. Effective partnership working through the LSCB, a robust and systematic approach to quality assurance and the modelling of a cycle of continuous learning through constructive challenge will establish a culture which will permeate through to front-line practice. Undertaking multi-agency audits is a resource intensive activity but will pay dividends in terms of service improvement if conducted in a robust manner. Multi-agency audits should be conducted in a spirit of open learning with the intention of further improving outcomes for children. Action points from audit will be rooted in practice, so any changes arising are more likely to be owned and complied with by practitioners. Using audit as a cycle of improvement and not as a way of allocating blame will also have a beneficial effect on everyday interactions between practitioners from different agencies and will encourage challenge on live cases to take place in an open-minded way. Some examples of themed multiagency audit completed so far include: Prolonged engagement with services (2011) Domestic abuse (2012) Under 1 s (2012) Andrew Ellery, Quality Assurance Officer, 2014 10
Substance misuse (2013) Child Sexual Exploitation (2013) Qualitative and Quantitative Information Quantitative Information Qualitative Information The Board will collate data from partner agencies through the multiagency dataset. A comprehensive multi-agency dataset will be used by the LSCB to monitor performance and benchmark where necessary. This information will inform qualitative auditing and the Boards priorities going forward. The principles of collating quantitative data are: It should be multi-agency Collating the data should be achievable for partner agencies To ensure it is built upon information currently collated The data should be simple to use, analysed by partner agencies, and interpreted in a straightforward manner It should include formal safeguarding data, but also other data that can inform partner agencies about the journey children take and early help offered. It is the responsibility of partner agencies to analyse their data and report on this when appropriate. This is likely to be through quarterly, 6 monthly and annual reporting. Partner agencies will commit to engaging in audit activity through the Learning and Improvement Sub-Group. Qualitative audits are an essential tool through which the LSCB will scrutinise the work of agencies. Such audits are the means to begin understanding the nature, quality and impact of local service delivery to children and families. The priorities of the board, audit outcomes, data collected, agency reporting and LSCB notifications will inform the scope of audits. The principles underpinning the collation of qualitative information are: Multi-agency in terms of challenge but the focus of audits can be on a number of agencies or single agency Achievable in the aims of pieces of work Methods will vary depending on the piece of work Service user focused and will evaluate the quality and effectiveness of their experiences based on the child s journey. Involving Children and Young People The LSCB expects partner agencies to meaningfully involve children, young people and families in their quality assurance activity and for them to contribute to learning; this is a key principle of Working Together. During audit and case review activity, the involvement of children, young people and families will be explored and scrutinised by partner agencies represented. The principles relating to involving children are: The LSCB will be satisfied that partner agencies have a clear understanding of the collective needs and concerns of children and young people in the area Andrew Ellery, Quality Assurance Officer, 2014 11
Partner agencies and the Board will operate in a way that allows for the meaningful contribution of children and young people, whether this be direct or indirect The experiences of children and the journey they take through various systems is what should inform, drive and develop improvement activity. The involvement of children and young people needs to be addressed at the following levels: Strategic Involvement Operational Involvement Special Groups Individual Experiences Membership of/representation on LSCB Contribution to annual report and business plan Links with other key groups and plans such as the Health and Wellbeing Board, Corporate Parenting, Children s Trust etc Contribution to the work of sub-groups Contribution through Quality Assurance systems e.g. questionnaires, surveys and interviews Links to, and involvement with, specific participation groups run by partner agencies Through direct and indirect input to case audits Through presentation to LSCB and other forums, annual conference and workshops Advising partner agencies on what good looks like Involving Frontline Staff The involvement of frontline staff needs to be addressed at the following levels, both within the LSCB and partner agencies: Strategic Ensuring frontline staff know the role of the LSCB, the work of the Board, membership and its priorities How they can contribute to reports submitted to the Board and how they can contribute to the LSCB business plan Ensure they know how they can meet the Chair and other members of the Board LSCB events are embedded into local learning and development opportunities Operational Actively nominating frontline staff to engage in the work of sub-groups Included in audits and evaluations Ensure they know how they can shape and evaluate local and multiagency training Engaging frontline staff in developing the priorities of the board. This may be achieved through partner agencies engaging staff in team meetings or by publishing a consultation Andrew Ellery, Quality Assurance Officer, 2014 12
Individual Ensure there are methods to capture individual experiences of frontline staff e.g. comprehensive supervision systems Through Board membership, access to frontline staff will enable particular sub-groups to ascertain the quality of individual work. Frontline staff will become familiar with how work is evaluated and understood by the LSCB The Board should create opportunities for staff to present work to the Board as evidence of good practice Partner agencies need to ensure that they appropriately feedback learning from case file audits and other Quality Assurance processes Enhancing and Embedding Learning The responsibility for embedding learning does not rest solely with the LSCB. It is also the responsibility of individual agencies to identify and implement learning for their own organisations. The LSCB has an overall aim of identifying themes and ensuring these are aligned with the LSCB priorities. Partner agencies as learning organisations need to be clear about how to use a variety of sources of learning to drive improvements in their agencies. Organisational learning is a dynamic process; learning needs will inform the LSCB s wider strategic planning. The Board and partner agencies expect learning to be embedded in a number of different ways. This can be through any of the following: Training o Single day courses o Multi-day courses o Brief workshops/seminars o E-learning Topical promotional material aimed at professional audiences o Cue cards o Posters o Leaflets o Newsletters and e-bulletins Conferences o Internally delivered o LSCB conferences o Externally commissioned expert speakers Access to research Action Learning Reviewing/adapting/writing policies and procedures Community, Voluntary and Faith Sector engagement events Andrew Ellery, Quality Assurance Officer, 2014 13
Evaluating the Impact of Learning It remains the responsibility of the Training Sub-Group to evaluate the impact of training. This should include feedback from those undertaking training opportunities, feedback from those delivering training, and feedback from line managers as to whether courses have impacted positively on service delivery. This can largely be identified through the changing outcomes of Training Needs Analyses. Feedback and associated actions will inform and strengthen future training strategies. Other Sub-Groups also have a role, for example the Learning and Improvement Sub-Group have a role to play in auditing cases that are in line with the priorities of the business plan. This will assure the Board and partner agencies that work being carried out is leading to improved practice. Role of the Learning and Improvement Sub-Group To own, review, promote and develop the Quality Assurance, Learning and Improvement Framework. Membership should be senior officers from respective partner agencies. Provide a report to inform the LSCB annual report outlining the extent, nature and findings of all audit activities in the area. Provide challenge to sub-groups around methodology adopted in evaluation, consultation, audit/review, and other Quality Assurance activity. Provide guidance around methods of disseminating learning Oversee Serious Case Reviews, Child Protection Incident Reviews/Partnership Reviews and resulting action plans. Oversee local Section 11 process and learning from pan-berkshire Section 11 processes. Andrew Ellery, Quality Assurance Officer, 2014 14