Setting

Carmel Littleton, Director of Children’s Services, Islington local authority Tony Hoolaghan, Chief Operating Officer for Haringey and Islington Clinical Commissioning Groups Sophie Linden, Deputy Mayor for Policing and Crime Cressida Dick CBE QPM, Commissioner of the Metropolitan Police Curtis Ashton, Head of Service, Targeted Youth Support, Youth Offending and Integrated Gangs Services Kilvinder Vigurs, Divisional Director, National Probation Service London Alan Caton, Chair of Islington Safeguarding Children’s Board LSCB

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abuse in the family in Islington

Between 3 December 2018 and 7 December 2018, Ofsted, the Care Quality Commission (CQC), HMI Constabulary and Fire & Rescue Services (HMICFRS) and HMI Probation undertook a joint inspection of the multi-agency response to sexual abuse in the family in Islington. 1 This inspection included a ‘deep dive’ focus on the response to sexual abuse in the family.

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abuse in the family in Islington

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

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abuse in the family in Islington

This joint targeted area inspection (JTAI) included an evaluation of the multi-agency ‘front door’, which receives referrals when children may be in need or at risk of significant harm. In Islington, all enquiries and referrals are progressed through the Children’s Services Contact Team, which incorporates the multi-agency safeguarding hub (MASH). Alongside this evaluation, inspectors undertook a ‘deep dive’ into the effectiveness of services for a group of children and young people who have suffered, or are at risk of, child sexual abuse in the family environment. Inspectors also considered and evaluated the effectiveness of the multi-agency leadership and management of this work, including the role played by the Islington local safeguarding children’s board (ISCB).

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abuse in the family in Islington

1 This joint inspection was conducted under section 20 of the Children Act 2004. Islington senior leaders hold a strong strategic commitment to the multi-agency partnership and have made significant investments to improve practice and outcomes for children at risk of abuse, including those children subject to child sexual abuse in the family environment. They are successfully driving a significant cultural shift across the partnership by embedding a model of trauma-informed practice. This approach promotes the development of a skilful and confident workforce that builds good relationships with children and their families and keeps children at the centre of interventions. Senior leaders’ positive relationships enable them to critically and respectfully challenge each other, and their strong strategic intent has supported the creation of the Lighthouse, which opened in October 2018. The Lighthouse provides a safe space to support children and young people in their

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abuse in the family in Islington

recovery from sexual abuse or exploitation. This is an important new opportunity for the five north central London boroughs, including Islington, to transform the model of care and support available to children and their families.

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abuse in the family in Islington

This significant development has been supported by the ISCB and partners have good engagement with the board. Their consistent attendance and ownership of the work of the board’s sub groups demonstrate a shared responsibility to improving outcomes for children and help agencies to hold each other to account. ISCB partners have created a learning environment with constructive challenge that drives continuous improvements in operational practice. An example of this is the effective monitoring of partners’ engagement in child protection processes. This has improved information-sharing by strengthening levels of reporting and attendance at child protection case conferences.

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abuse in the family in Islington

While senior leaders hold significant knowledge of and expertise on the impact of child sexual abuse in the family environment and work well together at a strategic level, this is not articulated in strategic plans. There is limited evidence available across the partnership of shared multi-agency needs analysis on the prevalence and profile of child sexual abuse. This means that senior leaders do not have sufficient oversight in monitoring, planning and understanding the risks to children of sexual abuse, or of the lived experience of children experiencing familial sexual abuse in the borough. In the deep dive, the inspectors’ analysis of the children’s experiences identified inconsistency in the quality of operational practice when children are identified as being at risk of sexual abuse.

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abuse in the family in Islington

Staff across the partnership have opportunities to attend a wide range of core and specialist training programmes offered from the ISCB. Local authority senior managers have invested significantly in mandatory training for all staff and managers in the motivational social work practice model, including in trauma- informed practice. While staff receive generic safeguarding training, they do not receive specialist training on child sexual abuse in the family environment and some partner agencies have identified this as an area for improvement.

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Key Strengths

 There is a clear strategic intent, vision and expectation among senior leaders to improve outcomes for all children. Partnership arrangements are purposeful in their drive for innovative practice derived from trauma-informed and relationship- based leadership. Governance arrangements across Islington are strong and inclusive of the Safer Islington Partnership and ISCB working together for a safer Islington. Shared ownership of a ‘Think Family’ safeguarding approach is securing better outcomes for children, young people, adults and families by coordinating the support they receive from all services.

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Key Strengths

 There is a strategic commitment to creating the right working environment and an environment in which children can build trusting relationships, across universal and specialist provision, to increase the likelihood of disclosure when they are at risk of sexual abuse. Investment in a 10-year early help strategy, 2015–2025, encompasses prevention work by Bright Start, early help support services and the roll out of trauma-informed approaches across schools. So far, 11 schools across the borough have benefited from training on trauma-informed approaches, and another eight schools are completing the training this year. Staff report to inspectors that this training has been transformational to the culture in schools, for example by providing a safe space for children to disclose abuse and helping teachers to be professionally curious.

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Key Strengths

 Mature partnerships in the ISCB share good and equal engagement when progressing the board’s priorities, and there is strong engagement in the board’s sub-groups. The creation of a bespoke Education sub-group and a re-focused Missing & Child and Adolescent Exploitation sub-group further ensures a shared commitment and the equal responsibility of agencies to the work of the safeguarding board. Relationships are sufficiently robust for partners to discuss, question and challenge each other when threshold decisions are complex for individual children, and there is a balanced and measured approach to resolutions that are in children’s best interests.

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Key Strengths

 Adopting trauma-informed practice across the partnership demonstrates senior leaders’ unequivocal dedication to the shared belief that building trusting relationships with children and their families, while understanding the impact of trauma, is key to achieving positive outcomes and change for children. This investment in training staff across the partnership demonstrates commitment to providing a safe environment in which children can disclose sexual abuse, as well as commitment to further understanding the needs of those children who exhibit harmful sexualised behaviours. All the inspectorates identified the positive impact of the implementation of trauma-informed practice across agencies and how this contributes to improving children’s outcomes.

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Key Strengths

 The programme of prioritising trauma-informed practice is helping to build the confidence and capabilities of teaching staff and foster carers in promoting a wider understanding of and a targeted response to children’s individual and changing emotional and mental health and behavioural needs. Inspectors saw careful consideration and sensitive engagement in partners working through adverse childhood experiences with children and their families, including those subject to child sexual abuse in the family environment. This work includes Growing Together, an innovative and effective model for supporting a Think Family approach, ensuring that parents with mild to moderate mental health difficulties are supported to recognise and respond appropriately to the emotional and developmental needs of their children.

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Key Strengths

 There is a clear vision by the local police leaders to improve practice and, ultimately, services for children, including those at risk of child sexual abuse. There are clear governance structures for safeguarding within the Central North Basic Command Unit (BCU), which incorporates Islington and Camden police boroughs, with a lead for safeguarding at superintendent level.

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Key Strengths

 Senior police leaders have a commitment to protecting vulnerable children, which is demonstrated by their active engagement in the chairing of the missing & child and adolescent exploitation sub group of the ISCB.

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Key Strengths

 Local authority senior leaders value practitioners and managers across the service. Staff are considered as an important asset, with skills that are key to keeping children safe. The roll-out of trauma-informed and motivational practice models across early help and social work teams is making a positive difference to children’s outcomes. Significant numbers of social workers are trained to deliver best evidence in order to support joint child protection investigations with police, while others hold expertise in Assessment Intervention and Moving On (AIM 2) assessments for adolescents with harmful sexual behaviours. Recruitment and retention of staff is a real strength, and high levels of permanent staff ensure that children benefit from consistent relationships with social workers. Morale is high and social workers want to work in Islington. Social workers are passionate about the children they work with and are effusive when talking about children.

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Key Strengths

 Health leaders in Islington embrace new ways of working and are actively supportive of new models of care to make best use of each other’s capacity and expertise. Senior leaders work closely with partner agencies to secure a joined-up, child-centred response to children and their families. Innovative child-centred work is led and co-delivered by child and adolescent mental health (CAMHS) practitioners in partnership with children’s social care, schools and wider community and voluntary sector organisations. Securing a dedicated CAMHS health practitioner presence in all primary and secondary schools is a significant achievement and ensures a strong, shared focus on the emotional health and mental well-being of children and young people through the different phases of childhood.

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Key Strengths

 It is impressive that the Youth Offending Service (YOS) management board is chaired by the chief executive of the council, and this demonstrates a significant level of strategic support for the service. The YOS board is part of a network of joined-up work and coordination of boards and groups focused on tackling serious youth crime in Islington. Recent analysis of the young people with the most complex offending behaviours provides insight into their lives and helps staff to work constructively with them. There is a high incidence of trauma and adverse childhood experiences (ACE) for these young offenders and trauma-informed practice is supporting interventions with them. There are clear pathways for young people who display harmful sexual behaviour to receive a service.

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Key Strengths

 The creation of the Lighthouse is an inspirational development for children and their families where there are serious concerns about child sexual abuse. Cross- border and multi-agency partnerships have supported the development of the first Child House model, and this has taken commitment, promotion and investment to establish. The Lighthouse is helping to address previously unmet need, so that children and adults can access medical and therapeutic support. This can be provided over time and at a pace that recognises children’s vulnerabilities, rights and choices effectively. Although it is too early to assess the full impact, the service model is firmly rooted in the child’s voice and experience. At the time of inspection, Islington had referred 11 children since the opening of the Lighthouse in October 2018, and has already secured positive interventions for three children.

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Key Strengths

 Detailed care and attention has been given to ensuring that the Lighthouse and its workforce offer a welcoming and inclusive environment that promotes a holistic assessment of children and young people’s diverse physical, emotional and mental health needs. Arrangements recognise effectively the diversity of young people using the service in relation to their age, disabilities, language, faith and cultural needs. For example, careful consideration has been given to the use of interpreters, and the service has established a partnership with a local charity. The service offer includes young people up to the age of 18 years, or 25 if they have learning disabilities, with operating procedures clearly recognising the complex issues of capacity and consent.

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Key Strengths

 Multi-agency public protection arrangements (MAPPA) are appropriately chaired between senior leaders in the National Probation Service (NPS) and the police. Attendance by partners is good and leads to the ability of the representatives to take decisions on behalf of their organisation in managing risk when there are concerns for children’s safety. Services that may not be obvious MAPPA participants, such as those for care leavers, have contributed, where necessary, to recent panels, and this further enhances the understanding of risks to children and young people.

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Key Strengths

 Senior leaders across the partnership demonstrate a shared culture of organisational learning, both individually within their own service areas and more widely as a collective partnership. The ISCB appropriately reviews partners’ practice performance information and audit activity to oversee frontline activity and interventions for children. While there has not been a bespoke focus on children at risk of sexual abuse in the family environment, the ISCB has been pivotal in supporting and promoting the roll-out of trauma-informed practice and the Lighthouse developments to meet the needs of children at risk of and subject to sexual abuse.

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Key Strengths

 The local authority takes a considered and proactive approach to learning, and shows a willingness to continuously develop services and operational practice in order to enhance children’s outcomes effectively by utilising a comprehensive quality assurance framework. This includes biannual practice weeks when senior managers join teams and immerse themselves in operational practice. Reports from regular audit activity and service users, including children’s views, feed into the monthly practice and outcomes board and the senior management team to ensure regular, detailed oversight of practice. Outcomes of reports, including core quality assurance activity, appropriately inform training and staff development.

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Key Strengths

 The Metropolitan Police Service (MPS) has a dedicated inspection team that provides assessments of the quality of investigations, undertaken on a thematic basis, with findings disseminated to senior officers in order to raise awareness and improve the quality of investigations. Operation Beat provides information to local officers in relation to high-risk and very high-risk registered sex offenders. However, these officers remain unaware of those offenders categorised as medium-risk and low-risk. In addition to this information-sharing, a chief inspector chairs a monthly meeting with the sergeants from the Camden and Islington MASH teams in order to consider any issues of concern for children and to support consistency in the quality of practice.

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Key Strengths

 The Clinical Commissioning Group’s governance and oversight of the quality and performance of local NHS providers, including the review of their safeguarding delivery against statutory regulations and targets, is strong. Effective challenge and monitoring of progress is seen through regular review of organisational performance and capacity in meeting safeguarding children training and supervision targets.

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Key Strengths

 A culture of organisational learning and improvement is evident in health agencies, and there is a strong promotion of lessons learned from serious case reviews and complaints. The named general practitioner (GP) provides effective support and guidance to drive forward continuous improvement in the engagement and contributions of GPs. This is enabling shared understanding of their professional accountabilities for safeguarding children. Focused work with GPs is strengthening identification and reporting of domestic abuse within families, enabling effective joint working with the police and wider partner agencies. Positive progress in strengthening GPs’ engagement in early help supports timely information-sharing about children’s needs and risks to their health and well-being.

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Key Strengths

 The YOS management board members have a sound knowledge of the work of the service. They receive regular good-quality reports on performance that take into account both national and local indicators, and this enables leaders to have a clear understanding of frontline practice. Practitioners and young people attend board meetings in order to further enhance the board’s knowledge. At an operational level, there is effective management oversight of cases. A strength is the arrangements for a monthly joint supervision clinic with children’s services. This provides the opportunity for staff to reflect on the safeguarding aspects of young people under their supervision. A practice and outcomes forum drives improvements in practice standards.

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Key Strengths

 The NPS has seen recent changes to local managers in Islington. However, there is a clear organisational commitment to engaging with the ISCB. Staff told inspectors that there are good working relationships with children’s services, and implementation of practice improvement activity draws on the findings of previous London JTAIs. There are also improvements in the monitoring and identification of links between vulnerable children and adults who pose a risk. Despite some technical problems in accessing NPS systems from the MASH, the identification of a named link helps build mutual understanding of children’s needs across the partnership at the front door.  Highly developed safeguarding children and adult practice is seen in the work of the emergency department at Whittington Hospital (Whittington Health NHS Trust). There is strong governance and oversight from senior leaders of risks to children. Management oversight and support for frontline practitioners is well

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Key Strengths

managed through regular multi-disciplinary reviews and tracking of outcomes for children. Local arrangements for meeting the health needs of children looked after who are at risk of or who have been sexually abused are well developed. This ensures that children who require specialist help to understand and address the impact of abuse and trauma receive timely and appropriate support.

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Key Strengths

 The Whittington Hospital emergency department has a positive learning culture, and, as a result, safeguarding practice is a strength. Thorough safeguarding checks are made, comprehensive assessments are carried out and robust mechanisms are in place to ensure that concerns are responded to appropriately. Information is shared with community health teams, and all safeguarding concerns are discussed at weekly management departmental team meetings in order to provide further oversight and assurance of safeguarding practice. Whittington maternity service ensures that all women are screened for female genital mutilation and that appropriate follow-up action has been carried out. Furthermore, the named midwife network pan-London alert system allows risks regarding expectant women to be shared. This means that measures can be put in place to keep new-born babies safe should pregnant women present at a different hospital to give birth.

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Key Strengths

 There is good partnership working in the CSCT and in the MASH, with particularly strong relationships between police and children’s social care. The CSCT and children in need teams are well established, with confident and competent social work staff and managers, who can recognise issues of child sexual abuse along with other safeguarding issues and respond sensitively. Partners share relevant and timely information when raising concerns about children, and this is responded to in a timely and proportionate manner. Children’s safety is prioritised when the risks of harm from child sexual abuse within the family are clear. The application of thresholds is consistent and appropriate to identified needs, meaning that children receive the right service at the right time. An emergency duty team provides an effective emergency service, meeting safeguarding needs of children out of office hours.

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Key Strengths

 Communication and information-sharing between partners at the front door is strong. Police in the MASH and YOS have access to children’s records, which means that they can check for current or historical children’s social care involvement. This helps to enable quick decision-making and the arrangement is being extended to the NPS. GPs report that there is good multi-agency working for safeguarding children. When children are at risk of significant harm or have additional needs identified, decisions are made quickly, and children benefit from timely interventions.

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Key Strengths

 The creation of the Central North BCU, which incorporates Islington and Camden police boroughs, has seen the Child Abuse Investigation Team referral desk now being housed within the MASH. This has led to timely professional decision- making and face-to-face strategy discussions. Decisions to hold child protection strategy meetings are appropriate and the rationale to progress child protection enquiries is evidenced well, with clear actions to reduce risks to children. For most children where there is concern of sexual abuse, there is a prompt initial response, with joint strategy discussions. Joint visits between police and children’s social care give due consideration to safeguarding children from the person responsible for the abuse.

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Key Strengths

 When children are identified as needing help or protection following a referral to the ‘front door’, they are seen regularly and promptly. Social workers build effective working relationships with children, and gain their trust through frequent visits in accordance with the child’s needs. The model of practice used in Islington is clearly embedded and demonstrates good outcomes for children. Children’s views are sought and listened to and they influence future planning. There is a clear understanding of the child’s experiences, which is well articulated in children’s records. Assessments for most children are of a good standard. They are child-centred and, where deemed appropriate, complemented by specialist assessments of risk of child sexual abuse in the family.

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Key Strengths

 Partners access the ISCB comprehensive multi-agency safeguarding training programme. In addition, they also benefit from enhanced specialist consultation and advice at the front door. The child sexual exploitation/sexually harmful behaviour specialist social worker has a pivotal role in ensuring the needs of vulnerable children are kept at the forefront of planning among members of the partnership. Training relating to gangs has specifically enhanced social workers’ practice in this complex area of social work, while lunch and learn sessions organised by police promote joint learning among partners and provide an opportunity for joint discussions around learning. GP safeguarding training in Islington is a strength, and referrals made by GPs are of a good standard. NPS training priorities include the effective use of home visits. This is particularly important in helping probation assistants to develop the confidence to exercise

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Key Strengths

appropriate professional curiosity when seeing service users at home.  The YOS includes a wide range of specialist staff who can respond to the needs of young people. YOS assessments are generally good and young people open to YOS or the targeted youth service (TYS) have good access to drug and alcohol support through effective integration of Islington Young People’s Drug and Alcohol Service (IYPDAS), YOS and TYS. Decisions on the use of out-of-court disposals are made through a multi-agency panel and are based on information shared from agency records. The low number of young people entering the justice system is an indication that these processes are successfully diverting young people from formal criminal justice outcomes.

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Key Strengths

 CAMHS support to children in schools is strong. Foster carers and children’s social care staff are well supported to offer a holistic approach to children’s mental health and emotional well-being. The specialist sexual exploitation social worker also offers schools a range of services, including one-to-one work with children, presentations at school assemblies and advising teaching staff on strategies with individual children who are exhibiting harmful sexual behaviour. As a result, designated safeguarding leads demonstrate a good grasp of safeguarding issues in relation to children who experience sexual abuse in the family environment, and those children who display harmful sexual behaviours. They consider their training to be effective and to a high standard. They understand risk and are aware of the need to sensitively work with children and provide challenge when they consider that situations need to be escalated.

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Key Strengths

 Schools understand the risks associated with children who exhibit harmful sexual behaviours, ensuring appropriate strategies are in place so that these children are not alone with other children. Key partners also ensure that children are not inappropriately criminalised in relation to harmful sexual behaviour and that their abuse is considered as part of ongoing planning and intervention. Family group conferences are used appropriately to elicit support. Timely viability assessments inform future care planning for children when care proceedings are underway. This has helped children to remain with family members during initial assessment of need. Less effective is the assessment of children as young carers.

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Key Strengths

 When risks of child sexual abuse in the family are clear, social workers have appropriately escalated concerns to care proceedings and taken children into care. Once children become looked after by the local authority, planning is strong, and children benefit from the timely and holistic review of their needs. Social workers make good use of enhanced services and of CAMHS links in the children in care teams to ensure that purposeful direct work helps children make sense of their experiences. There is good attention paid to children’s individual and cultural needs when they need an alternative home.  Children at risk of sexual abuse and harmful sexualised behaviours benefit from a wide range of commissioned support services. Providers have good access to ISCB training and value the opportunity to network with partners at training events. They have extensive knowledge of young people’s lives, and their

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Key Strengths

contribution to decision-making and identifying risk to children is valued.

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Practice study: highly effective practice

A key strength in Islington is the strong multi-agency implementation of a trauma-informed approach and how this translates into practice by building positive relationships with children and listening to their views. For Mathew, aged 12, and his sisters, there was a timely referral, leading to a strategy meeting where all relevant agencies were given the opportunity to inform an assessment of risk of sexual abuse within his family. This meant that the ongoing multi- agency activity to locate the children and make them safe was successfully achieved following assessment of risks of sustained significant harm.

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Practice study: highly effective practice

There was evidence of appropriate professional challenge, both at the strategy meeting and subsequently by senior managers. This excellent multi-agency approach has continued since the abuse came to the attention of services, thus making the children involved safer. Once Mathew and his siblings were placed in foster care, he was very clear he did not want to change schools and was adamant he would rather live somewhere else than change school. The school agreed and were of a similar view that it would be best to keep him safe at school, where he was supported with his learning and his emotional well-being and he felt very secure. It was agreed by the multi-agency team that, although a school place was sought closer to his foster placement, it was in his best interest to stay at his school.

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Practice study: highly effective practice

Mathew is described by his teachers as being very polite to adults and his peers. He is very receptive to the support he receives and now has the ability to stay focused on class work throughout lessons. He is demonstrative towards his siblings, comforting them and checking in to see if they are OK. Mathew is settled and making good progress. He has developed friendships, enjoys play, makes use of the garden and loves playing football in the local park. Multi-agency working at its best has created an environment for Mathew where he is safe and able to thrive.

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Areas for improvement

 There is a need across the partnership for shared multi-agency analysis of information about child sexual abuse in the family environment to enhance senior leaders’ understanding of the prevalence and profile of children at risk of sexual abuse in the family environment. The analysis of the experiences of the children considered in the deep dive indicates that senior leaders need to further understand the quality and impact of interventions for children subject to and at risk of sexual abuse in the family environment. Strategic documentation and plans do not specifically focus on the needs of these children and there is a missed opportunity to explicitly link them to the development of trauma-informed practice.

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Areas for improvement

 Inspectors found an inconsistent identification and understanding of risk to children, particularly where there are multi-faceted elements of abuse within a family. For some children, there is delay in the risks of child sexual abuse being identified. An example of this includes an insufficient response to the breach of a written agreement following disclosure of sexual abuse by one child. For another child, the understanding of risk presented by a father who was a sex offender was insufficiently robust and the plan to reduce supervision of contact and working towards case closure was premature.

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Areas for improvement

 While some children and their families benefit from excellent partnership working leading to appropriate decisions being made to ensure the children’s safety, this is not consistent practice. On occasions, agencies conducted their single-agency roles without consideration of the views and impact on partners, and, consequently, the children and families themselves. A holistic approach to working with some children and their families leads to good recognition of wider risks to siblings. However, this approach was not consistently in evidence across the multi-agency partnership.

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Areas for improvement

 While the police safeguarding dashboard provides managers with performance data to support oversight of operational practice, including the timeliness of investigations, and presentation of cases into court, information in terms of understanding outcomes for children and qualitative measures requires further development. Police officers who manage child-related investigations are committed and dedicated to their work. However, they said that they were under significant pressures, with factors such as capacity and the supply of staff impacting on their ability to provide a consistently good service.  Although appropriate safeguarding procedures and guidance are in place in all NHS Trusts, further work is needed to enable frontline practitioners to confidently and effectively challenge their own and wider agency practice where there are concerns about escalating risk, or outcomes for children are not improving quickly

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Areas for improvement

enough. There are a limited number of appropriately trained safeguarding supervisors in Camden and Islington NHS Trust. This means that frontline staff are not accessing regular support and challenge to enable them to remain vigilant to risks of harm to children. The levels of confidence, knowledge and expertise of child health staff in supporting children and young people who have been exposed to child sexual abuse in the family environment are variable. While some health staff benefit from good access to safeguarding training and updates, some practitioners recognise that their practice could be further enhanced through access to additional specialist training.

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Areas for improvement

 Capacity is challenging in some key areas, such as sexual health, child and adolescent mental health and school nursing services. This is leading to delays in access to support and it risks disengagement of children and their families. Gaps in local provision have been identified, but service re-design and transformation plans have yet to fully impact on the response to increased demand.

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Areas for improvement

 Police vacancies in safeguarding, coupled with a shortfall of qualified detectives, result in some investigations being conducted by staff who are not experienced in working with child sexual abuse and who have not received the specialist child abuse investigation training. Senior leaders know this, and planning is in place to provide further specialist training.

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Areas for improvement

 It is recognised by the senior leadership team of Central North BCU that there is a lack of trained and experienced child protection detectives allocated to investigations. There are examples of delays of up to six months in investigations involving children. Supervisors do not consistently challenge or oversee the progress of investigations or ensure the delivery of identified lines of enquiry. This is leading to drift, delays and missed opportunities to intervene and safeguard some children.

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Areas for improvement

 Key health and education professionals who know the children well are not always invited to participate in initial strategy discussions to consider next steps. This reduces their opportunity to be fully involved in decision-making and planning for children. Although children’s information is routinely given by health partners, information provided is not always analytical, which means that children’s social care on some occasions must interpret complex medical information from a range of providers. When children’s social care distributes strategy meeting minutes to involved professionals, there can be up to a three-week delay. Some partners do not routinely receive updates on children they have referred to the front door, for example sexual health services, school nurses and GPs. This means they are not always aware of the outcome of decisions and any ongoing risks to children using their service.

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Areas for improvement

 Police recording of strategy meeting decisions is not consistently updated to reflect the information shared with the agreed outcomes. Further to this, police case records do not always indicate what investigative or safeguarding activity has taken place and how well it is meeting the individual’s needs, reducing risk and improving outcomes. Officers in the MASH and the safeguarding investigation teams are used to help with other operational commitments. This has an impact on their ability to fulfil their core role and is a contributory factor to the delay seen for children in several investigations.

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Areas for improvement

 When partners disagree with threshold decisions for some children, there is insufficient challenge and escalation, so opportunities are missed to keep children safe. Planning for children does not always include specific actions or timescales, and in the deep dive analysis, the category of sexual abuse for one child was not sufficiently reflected in the child’s plan. For some children, important information to inform ongoing risk was not always recorded in their plans.

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Areas for improvement

 Some children subject to and at risk of child sexual abuse experience delays in assessments for therapeutic support and investigations and delays in having medical examinations. There are often delays in obtaining the services of intermediaries, who are skilled workers used to interview children in ABE interviews, and this has a negative effect on the timeliness of interviews and investigations. Availability of skilled intermediaries to assist with the interviews of younger children and children with learning and physical disabilities is poor. This is impacting on the length of the investigation and could lead to increased attrition rates.

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Areas for improvement

 Midwives providing antenatal care do not regularly offer home visits, which would enable better identification of potential risks. All bookings are carried out in clinics, and home visits are only undertaken where concerns have been identified. This limits the opportunity for them to assess the home and family environment for any emerging safeguarding concerns, especially when there are safeguarding concerns for children.

p.14

Areas for improvement

 Safeguarding practice and record-keeping in IYPDAS are not of a consistently good quality. Assessment of risks and individual review arrangements lack relevant detail. Records do not clearly evidence the impact of work undertaken. This reduces staff identification of emerging safeguarding concerns for children. Senior leaders across the partnership produced an action plan to address gaps in safeguarding practice while the inspection team was on site.

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Areas for improvement

 Oversight of young people who present across the Camden and Islington Young People’s Sexual Health network is poor. This is due to stand-alone assessment documentation and isolated electronic patient record systems in use by three different providers that do not work with one another. Unless a young person has met the threshold for the multi-agency sexual exploitation panel, information is not shared. This means that children may access multiple sites and services without detection of risk or robust mechanisms to identify patterns of concerning attendance. In particular, the Pulse sexual health services are significantly oversubscribed, and except for a dedicated weekly under-18s clinic, senior leaders cannot be assured that all young people requiring sexual health interventions have good and timely access.

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Areas for improvement

 Cross-boundary working between local authority areas is a challenge. Children’s social care and health partners in Islington do not consistently share minutes and plans about children known to health services in neighbouring boroughs. There is also limited evidence that Islington health partners adequately pursue follow-up information, and this means that there is potential for missed opportunities for sharing their safeguarding knowledge on their involvement with children.

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Practice study: area(s) for improvement

Risks to children of sexual abuse in the family environment are not always well understood. David is aged 14 and at significant risk from his father, who is a registered sex offender. Recording in police systems does not reflect all risks, and appropriate planning is not taken when the risk of the father potentially abducting David and his siblings has been identified, despite clear concerns that this is possible. Furthermore, while all professional assessments of David’s father consider his risk to the children as high, agencies have removed controls, such as David’s child protection plan and MAPPA, allowing the father unsupervised access to his children.

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Practice study: area(s) for improvement

The responsible probation officer appropriately identified the offender’s compliance as superficial and that he remains a high risk to children. Despite the good work by probation in recognising the risk posed, the multi-agency plan failed to mitigate the risk to these children. Additional risk factors, including the mum’s mental health and non-compliance, are not considered, despite risk assessments highlighting these as key features in assessing the father’s risk to the children.

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Practice study: area(s) for improvement

While additional licence conditions were appropriate in relation to David’s father, these were not visible in police systems, meaning that, across the partnership, potential breaches of licence, including any contact with children, would not be identified or acted on.

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Next steps

The local authority should prepare a written statement of proposed action responding to the findings outlined in this letter. This should be a multi-agency response involving partners.

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Next steps

The response should set out the actions for the partnership and, where appropriate, individual agencies 2

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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 10 May 2019, 70 working days from pre- publication. 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

Yvette Stanley 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 Davies Assistant Chief Inspector

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HMI Constabulary HMI Probation

2 The Children Act 2004 (Joint Area Reviews) Regulations 2015 www.legislation.gov.uk/uksi/2015/1792/contents/made enable Ofsted’s chief inspector to determine which agency should make the written statement and which other agencies should cooperate in its writing.

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