Setting

Florence Kroll, Director of Children’s Services Sophie Linden, Deputy Mayor for Policing and Crime Cressida Dick CBE QPM, Commissioner of the Metropolitan Police Yvonne Leese, Director of Quality and Integrated Governance Anita Erhabor, Designated Nurse for Safeguarding Children Steve Whiteman, Director of Commissioning and Health Protection David Pinson, Head of Commissioning and Health Protection Helga Swidenbank, CEO, Community Rehabilitation Company Kilvinder Vigrus, NPS Divisional Director Emma Clements, YOT Manager

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children missing from home, care or education

Between 12 and 16 February 2018, Ofsted, the Care Quality Commission (CQC), HMI Constabulary and Fire & Rescue Services (HMICFRS) and HMI Probation (HMI Prob) undertook a joint inspection of the multi-agency response to children who go missing, who are at risk of child sexual exploitation and who are at risk of criminal and other forms of exploitation through gangs. The inspection included a ‘deep dive’ focus on a number of cases in which these issues were known to be concerns where children were involved.

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children missing from home, care or education

This letter to all the service leaders in the area outlines our findings about the effectiveness of partnership working and the work of individual agencies in Greenwich local authority.

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children missing from home, care or education

The inspectorates recognise the complexities for agencies in intervening to help children who are at significant risk when affected by the combination of gang affiliation, going missing and child sexual exploitation. Inspectors found that inspection in this area of practice is likely to highlight the significant challenges to the partnership in improving practice. Inspectorates found that traditional methods of assessment, planning and interventions may not always effectively reach or have an impact on this group of children and their families. Cases that were scrutinised by inspectors, particularly in the ‘deep dive’ aspect, involved specific risks and difficulties that make positive change and improved outcomes difficult to achieve and sustain. In addition, many of these children also have mental health and additional learning needs, with an Education, Health Care Plan (ECHP) in place.

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children missing from home, care or education

There is strong partnership working in Greenwich and a shared commitment to improving services for all children at risk of harm. Strategic arrangements for the management and oversight of the multi-agency response to children who go missing and who are at risk of exploitation are well developed. This is high-profile work that has led to increased investment from partners and the development of a number of new and innovative multi-agency approaches, includingthe introduction of the weekly Greenwich Adolescent Risk, Safeguarding and Prevention meeting (GRASP). This multi-agency forum was developed to enable and improve information sharing, enable the earlier identification of risk and provide a ‘real time’ response to emerging concerns. These improvements are leading to increased identification of those at risk and, increasingly, a more effective response to children when these risks are first identified.

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children missing from home, care or education

There is no doubt of the commitment from partner agencies to work together to improve outcomes for this particular cohort of children. The effective work of the Local Safeguarding Children Board (LSCB), strong leadership in many agencies and a shared belief in a partnership approach provide fertile ground for practice to further evolve and improve. However, there is a need to ensure that the operational response from key agencies recognises quickly and consistently the risks posed to these children. Further work is required to fully embed robust practice to ensure that there is timely information sharing to inform assessment and planning. The partnership is aware of the areas that require improvement, and during the inspection demonstrated an openness to continuously improve practice to safeguard children.

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Key Strengths

 Inspectors identified many features of effective leadership in Greenwich. When children are at risk of exploitation or are missing from home and school, there are effective multi-agency arrangements to identify and support them. There are good links between the Greenwich Safeguarding Children’s Board (GSCB), the Health and Wellbeing Board, the Children’s Services Strategic Partnership, the Violence and Organised Crime Unit (VOCU), the Safer Communities Team and other boards. Priorities identified in the Children and Young People Plan are agreed by all the boards and have been adopted by them.

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Key Strengths

 Such arrangements play a key role in enabling the collation and analysis of information from a broad range of services to provide these services effectively. For this reason, there is a good understanding of the local context of older young people, who are largely gang-affiliated, exploiting younger children in organised drug dealing along ‘county lines’.  Partners within the borough have proactively sought additional resources through both the Department for Education (DfE) innovation fund and the Mayor's Office for Policing And Crime (MOPAC) funding. Examples of DfE innovation and MOPAC funded initiatives include: SafeCORE (breaking the cycle of relational domestic abuse); South London Commissioning Consortia for placements for looked after children; training for staff about gang affected young women; workshops in schools to prevent young people becoming involved in gang crime and serious youth violence; and intensive mentoring for

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Key Strengths

young people who are victims , or at risk of becoming victims, of peer-on-peer abuse, violence and exploitation.

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Key Strengths

 Local resources and GSCB funding have also been used creatively to support initiatives that include specialist training for children regarding the safer use of the internet and the commissioning of ‘Chelsea’s Choice’, a theatre production developed by young people to raise awareness of child sexual exploitation, in secondary schools and alternative provision.

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Key Strengths

 Governance arrangements are to be further strengthened following a decision in January 2018 to merge the GSCB Missing Strategic Group with the Child Sexual Exploitation Multi-Agency Strategic Group. This merger supports arrangements to monitor and identify emerging trends or patterns, while further improving information sharing between children’s services, police, the safer communities team and other partner agencies. The panel is co-chaired by the police and children’s services and its work is held to account by the GSCB.

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Key Strengths

 Children at risk from gangs, exploitation and child sexual exploitation have been a priority for the GSCB for the past three years. There is clear evidence of impact from the activity of the board. For example, section 11 audits demonstrate an increased awareness across the workforce of the issues of child sexual exploitation and gang-related exploitation, and an increased confidence in dealing with the issues following training events. Through targeted training and awareness raising, the GSCB has influenced police practice in terms of understanding the issues for young people who are affiliated with and exploited by gangs. Staff across agencies are aware of learning from serious case reviews.

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Key Strengths

 The GSCB undertakes multi-agency ‘deep dive’ audits on individual cases. This activity involves speaking to children, families, carers and professionals to gain a sense of how effectively children have been protected. Consideration is given to how well families have been supported, as well as to areas for improvement. These audits provide more detailed information about the quality of practice than file audits alone. Frontline practitioners across agencies are informed about areas for improvement following reviews, and there is evidence of the chair challenging agencies who do not promptly follow up with actions. The GSCB monitors attendance of professionals at child protection conferences and other meetings and monitors whether reports are provided by agencies. There is evidence of challenge from the chair to partner agencies who do not do this.

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Key Strengths

 Across the partnership, the participation of children and young people is a strength. Case auditing evidences persistent attempts by practitioners to engage with children and to help them to understand concerns.

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Key Strengths

 There is a commitment from the National Probation Service (NPS) to attend GSCB meetings. This ensures that staff are aware of Greenwich safeguarding procedures, including those pertaining to exploitation and going missing. Attendance also builds working relationships across agency boundaries. Staff are expected to participate in at least one of the GSCB joint training events each year. The ‘see the adult, see the child’ GSCB campaign was promoted within the Greenwich NPS team, which encourages a child-centred approach for practitioners who mainly work with adults.

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Key Strengths

 Since 2016, the Metropolitan Police Service (MPS) has made a concerted drive to focus more on child protection, working closely with safeguarding agencies at a pan-London level to improve its responsiveness and thus protect children better. Territorial policing crime fighters’ meetings scrutinise safeguarding activity, and cover a range of areas, including missing persons and child sexual exploitation. These meetings are forums at which senior officers can be briefed and discuss current aspects of child protection and other matters affecting the MPS. At a force-wide level, they have produced a child sexual exploitation 2016 pan-London profile (supported by partnership information) and more recently a London organised crime profile. However, locally there is a lack of analytical capability and currently no local police problem profile in relation to children going missing and child sexual exploitation.

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Key Strengths

 Arrangements at the front door are effective in recognising and responding in a timely manner to risks to children. Referrals into the MASH from partner agencies provide comprehensive information about children, and thresholds are well understood and consistently applied, including for children who are sexually exploited or who have been missing. Police and health services have dedicated staff to check referrals before they are sent to the MASH, ensuring that enough detail is provided to specifically identify risks to children. This enables swifter, better-informed decision-making. Additionally, inspectors saw evidence of timely information sharing by partners, which helps to inform the analysis of risk. For example, the youth offending team (YOS) has a dedicated duty worker who responds to requests for MASH information. This enables relevant information to be shared to inform decision-making and next steps,

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Key Strengths

including for those at risk of exploitation.

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Key Strengths

 Decisions are timely about whether a case will progress for a social work assessment, will pass to early help services or will be closed. They take into account the needs of brothers and sisters who may be gang affiliated, as well as previous family history. Managers sign off decisions and record their rationale and reasoning, which is reported back to the referring agency. This means that partners within the MASH know what level of support children will be given.

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Key Strengths

 When children are identified as being at risk from gangs, child sexual exploitation, criminal exploitation and repeat episodes of going missing, agencies have agreed, through a shared protocol, to a mandatory reporting of these concerns through the MASH. All staff spoken to within the MASH, early help and duty teams are aware of the protocol and understand the high-risk factors associated with this cohort of children. This enables the timely identification of risk and a multi-agency response to address concerns.

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Key Strengths

 Practitioners in the MASH are confident and knowledgeable about their area of business, and support other staff across the borough by delivering training and development sessions. This helps to increase recognition and understanding of the mechanisms used by perpetrators and gang members to engage in exploitative behaviour and expose children to risk.

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Key Strengths

 Effective preventative work is taking place with children to help them understand the risks associated with affiliation with gangs and with child sexual exploitation. For example, the Violent Organised Crime unit regularly delivers awareness sessions in schools to children about the realities of gang affiliations. This innovative work has been aimed at pupils in Years 8 and 9 because research and data has shown that this age group is especially vulnerable to being targeted by gangs. Because the initiative commenced in January of this year, the impact is yet to be evaluated.

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Key Strengths

 A shared approach underpins joint working between the local authority, partners agencies and voluntary organisations, which are commissioned to provide a good range of support to young people who are at risk of gang involvement. Community safety and youth offending teams play an important role in collating and analysing information from a range of sources to better understand and respond to the local picture. This is improving awareness and helps tailor responses to need.  Sexual health services, Charlton Athletic Community Trust, and the Safer London ‘Empower’ project offer creative packages of support designed to prevent children from becoming involved with and at risk from gangs. Charlton Athletic Community Trust runs the universal youth service on behalf of the local authority and offers a variety of diversionary activities. Young people who are at risk of child sexual exploitation are supported by the ‘Empower’ project. This

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Key Strengths

is a new initiative for Greenwich, and will have the capacity to offer intense support to seven young people annually.

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Key Strengths

 Voluntary and community services report positive relationships with the local authority. Thorough commissioning and funding arrangements are in place, and performance of commissioned services is closely monitored. This ensures that services are effective and monies are well directed for maximum impact. Agencies report a strong focus on safeguarding for children. They have a clear understanding of thresholds and know how to make referrals to the MASH and to early help services.

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Key Strengths

 Voluntary agencies are very well informed about the techniques used to exploit children, the fast pace at which this can happen, and how gangs operate within communities. This heightened awareness and recognition has led to an increase in referrals and means that these vulnerable children can be helped more quickly.

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Key Strengths

 The newly re-modelled integrated early help service is developing approaches to strengthen responses to children who are affiliated with gangs or exploited, or where child sexual exploitation is an issue. Recognising the very serious impact of exploitation, good consideration has been given to developi a range of practice models, including systemic family work, restorative-based practice and trauma-informed practice. This work is still at an early stage and it is too soon to measure impact. However, the work is evidence based and research based and there is a track record of the interventions that are reducing risks to children.

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Key Strengths

 Strong arrangements are in place to ensure that children missing from education (CME) are identified and, where possible, located. Good liaison is in place with the MASH when children are missing from education. The CME team is diligent in their efforts to locate children, for example by checking with housing colleagues, health colleagues and other local authorities.

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Key Strengths

 The procedures of the Fair Access panel ensure that when young people are not attending school full-time, they receive high-quality alternative provision that meets their needs. A well-commissioned range of provision is available for young people to access across the borough when it is clear that mainstream schooling is not suitable or they have been temporarily excluded. At present, 243 pupils are registered to receive elective home education. The elected home education officer works closely with social work colleagues to ensure that all safeguarding processes are robust and any concerns are highlighted at the earliest opportunity.

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Key Strengths

 There is a calm and reflective approach to leadership in children’s social care and a commitment to learning and developing child-focused practice. Performance management and a wide range of audit activities are well embedded, leading to the identification of areas for improvement and action plans to address the issues.

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Key Strengths

 Senior managers in children’s social care have developed an environment in which social workers can provide a high-quality service to children and their families, with a key focus on knowing children well and understanding their wishes and feelings. Children’s views are well captured and help inform planning. Professionals know children well and are committed to their welfare. Visits are regular and children are seen alone and are able to express their views, which are evident in reports and work completed with them.

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Key Strengths

 Workloads are manageable and social workers receive regular, supportive supervision and management oversight of their work. This enables social workers to undertake direct work with children and build trusting relationships. The workforce is generally stable and staff are happy to work in Greenwich.

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Key Strengths

 Political support from elected members and the leader of the council has ensured that resources for children’s services are protected. Leaders are focused on and committed to children and see them as a priority in the borough.

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Key Strengths

 The safer communities team has a project officer dedicated to working on youth violence, vulnerability and exploitation who works closely with the VOCU as well as children’s services staff and schools. The project officer gives advice to caseworkers and schools on gang-related risks and through this work gathers and interprets information to update a constantly developing picture of overall gang dynamics and related risk factors. This overview is shared with partners to inform decisions on operational tactics, service development and commissioning.

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Key Strengths

 A clear commitment is shown by the local borough police to developing a resilient and co-ordinated structure in which to safeguard children. This is evident by the numbers of police staff working within the MASH and local police safeguarding teams. The MPS has an internal media campaign, ‘Spot It to Stop It’ (with the strapline ‘Think Child, Think Safeguarding’). The messaging concentrates on four themes: child sexual exploitation, child abuse, missing children and child criminal exploitation. This demonstrates the high profile given to these issues by the police.

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Key Strengths

 The police have recently recognised a number of gaps in the way that they were identifying and responding to criminal exploitation and ‘county lines’. They have worked with the missing person, child sexual exploitation and the violent and organised crime unit (VOCU) teams to develop clearer awareness and a stronger response to the issue. However, the force has some information technology limitations that frustrate the visibility of information, and the MPS is seeking to overcome these through the introduction of the new Met Integrated Policing Solution (MIPS) system.

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Key Strengths

 More locally, a method has been introduced to identify individuals of concern in the area to ensure that information is linked and more visible through the use of the crime recording system (CRIS). In addition, the safer communities team has a youth violence, vulnerability and exploitation project officer, who assists in gathering intelligence from partner agencies in order to identify and manage children and young people at risk of gang exploitation, as well as with other contextual safeguarding.

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Key Strengths

 There is a strong commitment by health leaders to the multi-agency partnership and to improving services for children who are exploited or missing. This includes contribution to the work of the safeguarding children board and to local strategic groups, such as the ‘MASE’, the ‘Missing’ and the violence against women and girls groups, where the designated professionals play a key role in the development of strategy and practice.

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Key Strengths

 There are clear and responsive integrated health safeguarding governance processes involving commissioners and providers that have been effective in improving safeguarding practice in health services. This responsiveness is evident in the improvements seen in frontline practice since a health safeguarding inspection undertaken in 2017. Commissioners have made good progress in ensuring that frontline services for young people meet their needs, as is illustrated by work in The Point, as exemplified below.

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Key Strengths

 Health leaders assure the quality of safeguarding work through a range of activities. These include a regular scheduled audit programme, which has demonstrated improvements in practice. Safeguarding professionals from the two principal providers of health services for children contribute to the local operational panel that directs work with children at risk of exploitation. This ensures that information is shared and decisions are made by health staff with appropriate expertise and seniority from both the acute and community services.

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Key Strengths

 Training on the risks and issues around child sexual exploitation and other forms of exploitation is embedded within existing safeguarding training programmes. All GPs and pharmacists in Greenwich that are commissioned to provide sexual health services are accredited as ‘You’re Welcome’ services. They receive training on the issues around child sexual exploitation as part of this process. For this reason, referrals have been received from local pharmacies about young people potentially at risk of child sexual exploitation.

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Key Strengths

 There is good oversight of decisions made about children and young people at risk in the acute hospital services. Weekly multi-disciplinary safeguarding meeting in the Accident and Emergency department reviews concerning presentations from the preceding week and any follow-up action are agreed. The weekly maternity safeguarding meeting reviews the plans put in place by the community midwives for vulnerable pregnant teenagers who may be at risk of child sexual exploitation or gang-related activities. These cases can be discussed and reviewed at any stage of the pregnancy and are normally discussed on more than one occasion.

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Key Strengths

 Greenwich local authority has maintained a strong YOS. Frontline YOS staff are positive about the service and describe good training opportunities and supportive managers. Staff demonstrate a strong value base and high level of commitment to building relationships with young people. Inspectors saw examples of staff determined to remain in contact and trying to engage vulnerable children who were involved in gangs or at risk of exploitation in work to reduce the risks to them. Staff understand that building trusting and meaningful relationships is especially important with this group of children.

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Key Strengths

 There are effective systems in place for sharing information and reviewing work with young people. For example, inspectors observed a youth offending service health workers’ forum in which information was shared and cases discussed to ensure that children are receiving the support they need. Greenwich local authority has not reduced the services available to the YOS model. The team continues to include social workers, nurses and specialist support workers, who are providing a coordinated service for children.

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Key Strengths

 The YOS has worked with Greenwich University to develop training videos around criminal exploitation and ‘county lines’ for a range of professionals. Trauma-informed practice training has been delivered to all YOS staff, and was funded through a bid to MOPAC. Staff are able to describe how the training had impacted on their practice, for example by leading to them having a better understanding of trauma and responding better to traumatised children. Additionally, restorative justice practice with cases involving sexually harmful behaviour has been developed and has improved outcomes for families, including improved relationships and reduced numbers of family breakdowns.

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Case study: highly effective practice

The local area pays good attention to commissioning and delivering services that connect with what young people want, reflect the daily challenges they face and professionals actively work together to promote their engagement.

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Case study: highly effective practice

The Point offers a welcoming space for children and young people to share their concerns and helps reduce risks to their safety and well-being. Children and young people are able to access a range of youth, care and health services under one roof during one visit. This model of support promotes timely access to a range of services, and increases opportunities for sharing information and early intervention for young people at risk of sexual or criminal exploitation. The approach to identifying and meeting need is holistic, with a lead professional sensitively co- ordinating the involvement of other relevant professionals. Joint training and monthly multi-agency reviews enable shared learning about what works best for each child and young person, enabling consistent approaches and effective tracking of risks.

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Areas for improvement

 The understanding and response to risk is variable across all of the agencies, and for some children not sufficiently explored or known because information sharing is not robust enough. This means that decisions are sometimes made without the benefit of all available information. On occasion, it has taken too long for information to be gathered from all agencies when it is already known that a child is involved with, for example, ‘county lines’ activity. This has led to a small number of delays to inform planning for the children.

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Areas for improvement

 When a new concern is referred to children’s social care about a child whose case is already open, it is not always prioritised to lead to a timely response. This may delay the completion of assessments when information from all agencies cannot be gathered. This in turn can inhibit swift action to help children when circumstances change or risks escalate.  While many assessments are thorough, timely and accurately reflect the issues for the child and family, some others do not include enough analysis of historic factors or multi-agency information, which would enrich the understanding of the child’s situation. Assessments do not always include sufficient analysis of the complex and dynamic nature of children’s needs and the impact on children and their families.

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Areas for improvement

 While multi-agency plans are in place for children at risk from child sexual exploitation and exploitation from gangs, they do not always evidence a strong enough grip or focus to allow services to keep pace with changing events in a young person’s life. The complexity of these particular issues are not always recognised in plans and are therefore not making enough difference for children and their families.

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Areas for improvement

 There is a lack of analytical capability within the borough police, which hampers the police’s ability to research and analyse a range of information and data sources. This means that, for example, there is currently no supporting local police problem profile in relation to children going missing and at risk from exploitation. There is more to do to understand the extent and nature of child sexual exploitation and children going missing, as at present police practice and awareness is under-developed.

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Areas for improvement

 While senior health staff attend multi-agency strategic meetings, the contribution of leaders to the GRASP meeting observed during the inspection was less effective. The contribution of safeguarding practitioners who attended the meeting was limited and did not add to the decisions made during the meeting. Information that ought to have been made available by both health trusts was not provided at the meeting and so the situations of the children under discussion were not fully understood.

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Areas for improvement

 The attendance of health practitioners at child protection conferences is variable. When practitioners do not attend, reports are not always provided, and this impairs the ability of the conference to make fully informed decisions. There is then a failure to inform assessment, planning and the appropriate delivery of services to meet the needs of those children at risk of exploitation. In addition to this, reports and documents from conferences are not always included in health records. This means that health practitioners are not fully aware of emerging concerns or progress made on plans for children at risk of exploitation.

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Areas for improvement

 Community health services support children through universal and early help services to identify emerging risks of exploitation. However, there is no specific emphasis on exploitation as a significant priority issue and the low numbers of referrals of missing or exploited children to the MASH from health services reflect this. Additionally, work needs to be undertaken with child and adolescent mental health services staff to further develop the understanding of exploitation and the links with mental health.

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Areas for improvement

 The MPS has a central pan-London audit function which has examined cases thematically. Themes include child sexual exploitation and missing children. These audits are designed to identify good practice and areas for learning and improvement. The MPS safeguarding performance dashboard provides information both for frontline staff and managers on a range of safeguarding areas. While it holds comprehensive information on missing children, it is less well developed for examining or auditing the theme of child sexual exploitation.

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Areas for improvement

 It is a positive step that missing and exploited children have been a priority for the GSCB for three years. The GSCB has a business plan that identifies tasks and actions to be completed by agency, sub group or individual as well as timescales for completion. It is acknowledged, however, that it is not always possible to link action taken by the board with improved outcomes for children and young people and the impact on frontline practice. Case Study: areas for improvement.

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Areas for improvement

Inspectors found that schools are communicating with all relevant agencies to proactively identify risks when children are missing from education, including in some cases when young people have associated with gangs. However, the local area does not consistently provide alternative education quickly enough for children on education, health and care plans (EHCP) when they have been excluded from school. This means that some young people have had extended periods during which they have not attended school.

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Areas for improvement

In one case considered, decision-making had been mostly appropriate to the level of risk presented, although these risks were not always addressed in a timely manner. For example, the child had been out of school for 18 months, which placed them at risk of exploitation, gang involvement or criminal behaviour. The EHCP was also delayed, potentially contributing to increased risk.

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Areas for improvement

Thorough, prompt and comprehensive risk assessment completed by the school in the case had accurately identified risks of child sexual exploitation, going missing and potential gang involvement, reflected in escalating criminal behaviour. However, a key risk not sufficiently identified was non-school attendance. The young person had not attended school for some considerable time and was therefore left unsupervised in the community while their parents were at work.

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Areas for improvement

The young person has recently started attending other specialist provision. However, they are not yet accessing a full curriculum and it is too soon to say if this new education placement will prove successful in helping to reduce risk-taking behaviours.

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Next steps

The director of children’s services should prepare a written statement of proposed action, responding to the findings outlined in this letter. This should be a multi- agency response involving NPS, CRC, the police, the clinical commissioning group and health providers in Greenwich local authority.

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Next steps

The response should set out the actions for the partnership and, where appropriate, individual agencies.

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Next steps

The director of children’s services should send the written statement of action to ProtectionOfChildren@ofsted.gov.uk by 16 August 2018. This statement will inform the lines of enquiry at any future joint or single agency activity by the inspectorates.

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Ofsted Care Quality Commission

YvetteStanley National Director, Social Care Ursula Gallagher Deputy Chief Inspector

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HMI Constabulary HMI Probation

Wendy Williams Her Majesty’s Inspector of Constabulary Helen Mercer Assistant Chief Inspector

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