Setting

Alison Botham, Director of Children’s Services, Plymouth City Council Jo Turl, Executive Lead for the CCG, with responsibility for Plymouth Alison Hernandez, Police and Crime Commissioner Shaun Sawyer, Chief Constable of Devon and Cornwall Police Siobhan Wallace, Head of Service, Plymouth Youth Offending Team

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mental health in Plymouth

Between 18 November 2019 and 22 November 2019, Ofsted, the Care Quality Commission (CQC), HMI Constabulary and Fire & Rescue Services (HMICFRS) and HMI Probation (HMI Prob) carried out a joint inspection of the multi-agency response to ‘front door’ services, evaluating all forms of abuse, neglect and exploitation, as well as an evaluation of the responses to children’s mental health in Plymouth. 1 This inspection included a ‘deep dive’ focus on the response to children’s mental health. Inspectors also considered the impact of leaders and managers, including the Plymouth and Torbay safeguarding children partnership (formerly the Plymouth safeguarding children’s board).

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mental health in Plymouth

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

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mental health in Plymouth

Partnership working is integral to Plymouth’s approach to improving services for children. Well-established strategic planning helps to focus on improving services to meet the emotional and mental health needs of children. Well-embedded commissioning arrangements mean that services are available to support children’s emotional well-being and mental health. Leaders and managers demonstrate a strong commitment to children’s participation when planning for service improvements.

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mental health in Plymouth

A clear commitment to learning and development from the partnership ensures that the workforce is equipped to understand and meet children’s emotional well-being

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mental health in Plymouth

1 This joint inspection was conducted under section 20 of the Children Act 2004. and mental health needs. The Plymouth trauma-informed practice approach has recently been embraced by leaders and members as a model of good practice. This approach is starting to be visible in practice across the partnership, although it is too soon to evaluate the impact on children.

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mental health in Plymouth

Quality assurance by the Plymouth and Torbay safeguarding children partnership is underdeveloped. This means that the partnership does not have the benefit of a robust analysis of the impact of statutory training and multi-agency audits.

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mental health in Plymouth

The governance arrangements for the youth offending team (YOT) are weak and require urgent attention. The emotional well-being and mental health needs of children accessing the YOT are not yet fully known or understood, and the partnership cannot be confident that they are being met.

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Key Strengths

◼ Senior leadership across the partnership is stable. Attendance and commitment to key strategic boards provide a robust multi-agency overview of children’s mental health needs.

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Key Strengths

◼ The children and young people partnership system design group (CYPPSDG) reports to the health and well-being board and maintains a strong focus on children’s emotional well-being and mental health. An example of this work is the protocol agreed to inform practice to meet effectively the needs of children being discharged from hospital following an admission relating to their mental health.

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Key Strengths

◼ Joint commissioning in Plymouth is reflective of the well-developed partnership arrangements between strategic leaders. The Devon, Plymouth and Torbay joint strategic needs assessment has helped commissioners to understand the health needs of children, including the prevalence of poor emotional well-being and mental health. Pooled budgets enable effective joint decision-making about where resources should be directed in order to meet local needs.

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Key Strengths

◼ A wide and varied range of services from the community and voluntary sector (CVS) work well together to deliver targeted emotional health support for children. The intent is to focus on early intervention and prevent escalation to statutory services. Children and their families use these services when support is required to address their emotional and mental health needs.

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Key Strengths

◼ School-based interventions support Plymouth’s approach to recognising and meeting children’s needs at the earliest opportunity. All schools have a mental health lead. Training for pupils as peer listeners and school-based staff receiving mental health awareness training also supports this preventative approach. ◼ The growth and commitment of the Plymouth trauma-informed practice network to become a Plymouth trauma-informed city has recently been recognised, understood and supported by senior leaders and members of the Plymouth health and well-being board and cabinet. This inspection identified the use of a trauma- informed approach in several services delivering support for children’s mental health. These include the child and adolescent mental health service (CAMHS), the youth offending team (YOT), substance misuse services, police and the CVS. Inspectors noted an increasing use of a common language and practice. The

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Key Strengths

trauma-informed approach is also beginning to influence commissioning intentions, and this is supported by the strong links between the health and well- being board and the safer Plymouth partnership. It is early days for the implementation across all Plymouth’s services for children and therefore too soon to evaluate the impact on children.

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Key Strengths

◼ Partners are aware of the referral pathways to raise concerns for children. The co-location of agencies in the multi-agency safeguarding hub (MASH) generally supports timely and effective decision-making. However, the lack of a consistent presence of health and education decision-makers in the MASH means that some decisions lack appropriate input from these agencies.

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Key Strengths

◼ The co-location of the children looked after health team, CAMHS and the permanence social work team is effective in promoting information-sharing and joint planning to meet children’s emotional well-being and mental health needs.

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Key Strengths

◼ Mental health specialists from CAMHS provide consultation to multi-agency professionals to support children’s emotional well-being and mental health.

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Key Strengths

◼ The community mental health team, CAMHS and local policing teams in Plymouth actively work together to assess intelligence and information to develop local policing plans. Mental health practitioners support tactical policing decisions so that they are developed in the best interests of children experiencing mental ill health.

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Key Strengths

◼ When school nurses are supporting children, they are persistent in ensuring that the needs of children are met.

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Key Strengths

◼ Devon and Cornwall police’s mental health delivery board oversees the response of local police to children experiencing mental ill health. The force encourages innovative practice, and this has resulted in a more child-centred approach through the introduction of a child-centred policing team.

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Key Strengths

◼ An effective liaison and diversion service within police custody suites means that children experiencing poor mental health receive prompt intervention during their time in custody. The police and crime commissioner and Devon CCG have worked collaboratively to expand this service, meaning that children who are not arrested will now receive the same level of service. Outcomes for a small number of children could be improved through more effective information-sharing between Devon and Cornwall police and the YOT.

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Key Strengths

◼ A street triage car delivered through Devon and Cornwall police, an approved mental health practitioner and the ambulance service provide a community-based response for children experiencing mental ill health. This prevents children from presenting to acute services and provides effective support at the earliest opportunity.

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Key Strengths

◼ Good multi-disciplinary work between CAMHS and other health services ensures that children receive well-planned care delivered by the most appropriate service. When children present in mental health crisis at the acute hospitals, the CAMHS outreach team (COT) provides a timely response, and all children are seen within 24 hours. The CAMHS outreach practitioner supports hospital ward staff to commence an assessment as soon as the child is well enough, and this means that appropriate intervention is offered at an appropriate time for the child.

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Key Strengths

◼ School staff promptly refer concerns for children when they are first identified. Schools provide key support for children when emotional or mental health needs are identified and complete comprehensive assessments when alternative education provision is required to meet children’s needs.

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Key Strengths

◼ Senior leaders from all agencies within the partnership recognise the need for their workforce to have the right knowledge and understanding to support the emotional well-being of children experiencing mental ill health and with any additional needs. The local authority provides a varied range of learning and development opportunities that address children’s mental health needs for all the workforce. YOT staff are provided with specific targeted training, for example skills training on risk management (STORM) that focuses on suicide and self- harm. Frontline staff in health providers access relevant training that focuses on safeguarding, child sexual exploitation and the impact of adverse childhood experiences on children’s lives. Hospital staff have all received training on ‘mental health first aid’.

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Key Strengths

◼ Devon and Cornwall police have invested in external training for 36 officers to become trauma-informed ambassadors. These officers have been allocated two additional days of training to disseminate their learning to their peers. The force has also trained enhanced crisis communicators in the control room to engage with callers (including children) who are suicidal, are threatening self-harm or are high-risk missing persons. Inspectors saw evidence of these skills resulting in police intervention and preventing serious harm. ◼ Regular reflective learning panels help Devon and Cornwall police to understand the standards of practice of the workforce. An additional two days per year training supports continual improvement.

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Key Strengths

◼ At the children’s social care ‘front door’, practice is consistently stronger than when a child is already known to children’s social care. Local authority assessments are timely, they mostly consider the impact of past experiences, provide a good analysis and they clearly record the child’s voice.

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Key Strengths

◼ Assessments completed by health practitioners are mostly child-focused, and identify risks and needs.

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Key Strengths

◼ Professionals explore children’s diverse needs that arise from their culture and religion. This enables professionals to work sensitively with children and their families to understand how to best provide support.

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Key Strengths

◼ Children are meaningfully and actively involved in consultation about the development of services and co-production of initiatives in Plymouth. An example of this was earlier this year when the ‘Young Safeguarders’ group took over the safeguarding children’s board meeting. The young people identified their three areas of priority as mental health, suicide and knife crime. Each strategic leader of the board made a pledge to address these issues and improve practice. Strategic leaders told inspectors how powerful it was to hear children’s views directly.

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Key Strengths

◼ The partnership responded swiftly to the findings of this inspection, firstly addressing the needs of a small number of children that were raised by inspectors. The partnership then reflected on its practice and has developed a new multi-agency case resolution protocol to be implemented with immediate effect. This will provide an agreed pathway for raising concerns when outcomes for children are not achieved.

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Case study: effective practice

A looked after young person with a number of adverse childhood experiences has experienced a significant number of episodes of going missing, criminal and sexual exploitation, substance misuse, offending behaviour and disengagement from education. The young person has substantial mental health difficulties, impacting on their safety and emotional well-being. They have previously been provided with a series of unsuitable places to live. More recently, agencies have worked collaboratively to improve things for this young person. A change of placement, and good coordinated support, using a trauma-informed approach, means that professionals now have a stronger understanding of the young person’s needs and how best to work with them. A robust multi-agency approach to supporting the young person’s access to mental health provision and a tailored education package have helped the young person to settle well in their home. The

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Case study: effective practice

young person’s identity has been considered and they have been given the opportunity to decorate their own personal space. Risks have significantly reduced for this young person. Professionals describe the young person as being a positive role model for others. This young person now reports feeling safe and has told staff that they are happy.

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Areas for improvement

◼ The governance arrangements for the youth offending team are weak and require urgent attention. Children allocated within the YOT do not have their needs fully and holistically known or understood at board level, and the partnership cannot be confident those needs are being met. A period of change and transition has meant that the leadership is not providing a coherent or comprehensive oversight of the service. Leaders cannot be assured by the current arrangements that they know the local needs of young people or that they have the right range of services available for them. ◼ Plymouth and Torbay safeguarding children’s partnership strategic board members are not sufficiently sighted on the activity of the quality assurance and learning and development sub-groups. Quality assurance work by the board is underdeveloped. An example of this is the recent completion of two multi-agency case audits (MACAs) specifically focusing on children’s mental health and

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Areas for improvement

emotional well-being. The strategic board members were not aware of these multi-agency audits or the findings and recommendations for delivering further training and improving practice. The findings from the MACAs are strong and could inform the wider strategic planning of services to meet children’s emotional and mental health needs. The arrangements to evaluate the impact of statutory training delivered by the board are not robust enough and do not provide adequate information to measure its effectiveness and impact on practice ◼ The local authority quality assurance framework is also not robust enough. The framework does not provide an analysis of how learning from the wide-ranging quality assurance activities will support continued learning within the workforce. ◼ The front door referral pathways used by the police are complex and are at risk of missing opportunities to share information to support multi-agency decision-

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Areas for improvement

making and planning. The force uses a red, amber, green (RAG) rating system to assess the risk to children through the use of a vulnerability, identification screening tool (VIST). Assessments of risk graded at green are not internally reviewed or shared with partners. The risk assessments graded amber or red are reviewed by the police central safeguarding team, and decisions to share information are made solely on police information. This team does not have access to information held on children’s social care records to influence and enhance their decision-making. This means that important information about children and their families may not be shared even when they are open to other services.

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Areas for improvement

◼ When a VIST is sent through to the Plymouth children’s gateway, police officers and staff in the MASH do not always review them unless further information is requested by children’s social care. Therefore, they are not able to take part in multi-agency discussions with children’s services to support effective decision- making.

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Areas for improvement

◼ The mental health street triage service is based in the police control room and provides essential information and advice to officers who are responding to concerns where mental ill health is an issue. Appropriately skilled and experienced staff volunteer additional shifts to cover this service. In practice, this means that there are gaps in provision, therefore officers will not always have access to the expertise of these members of staff to inform their work with children.

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Areas for improvement

◼ YOT referrals to MASH vary in quality. YOT staff do not always use the correct template, and referrals often lack depth and clarity about the impact of YOT’s concerns, making it difficult for the Plymouth children’s gateway to make informed decisions about levels of risk for children and next steps. Furthermore, assessments completed by YOT do not always provide an analysis of the impact of mental health on a child’s lived experience.

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Areas for improvement

◼ Multi-agency information requests in the MASH do not always include the most relevant agencies involved with the child. For example, the staff in SHARP (young people’s substance misuse service) are not always contacted to share information and participate in decision-making when substance misuse or alcohol are factors for the child.

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Areas for improvement

◼ When children experience neglectful home conditions and parental care, social workers do not always consider historic information to sufficiently analyse the cumulative impact on children’s lives or consider the planning for what needs to happen to effect change.

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Areas for improvement

◼ The partnership has an agreed child sexual exploitation screening tool. However, the tool is not used consistently. When it is used, it is not always being applied in order to evaluate and review the level of risk.

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Areas for improvement

◼ The school nursing service does not have a standardised health assessment tool, which would assist staff in exploring children’s emotional well-being and mental health.

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Areas for improvement

◼ When a child is already known to children’s social care, strategy meetings to assess and analyse new child protection concerns do not always include relevant professionals. When professionals do attend strategy meetings, they do not routinely input the details on their recording systems. This means that other practitioners accessing the child’s record may not be aware of additional risks, decision-making and planning.

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Areas for improvement

◼ For some children already open to children’s social care, multi-agency information-sharing and working together are not effective. Assessments of children’s needs are not routinely undertaken when their circumstances change. Parental disguised compliance is not always given consideration. Key multi- agency meetings are too infrequent, and the quality of child’s written plans is variable. Plans are not always child-focused, responsive to children’s emotional and mental health needs or timebound, with clear actions for families and professionals to understand. This means that it is not always clear what is expected of professionals and families. Furthermore, a poor-quality written plan cannot be effectively reviewed.

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Areas for improvement

◼ School staff do not always promptly share safeguarding information when a child is transitioning from one provision to another. This means that the receiving school does not consistently receive all the information about the child that would enable them to have a relevant package of support available on the child’s arrival.

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Areas for improvement

◼ This inspection identified some inappropriate use of language about children in their written records and insensitive thinking around exploitation and vulnerable children. This concerning practice has not been recognised or sufficiently challenged by frontline managers across the partnership. Consideration needs to be given to the impact on the child if they choose to read their written records later in life.

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Areas for improvement

◼ Staff across the partnership are mostly provided with reflective supervision opportunities. However, the quality is not consistently strong and does not always drive appropriate action. This limits opportunities for practice to improve.

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Areas for improvement

◼ Too many children looked after live in unsuitable accommodation for short periods in their life. The partnership collectively acts to provide support to try and mitigate the impact of this. However, it is not acceptable for children to be cared for in bed and breakfast establishments, hotels or other unregulated placements.

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Case study: area for improvement

This is a young person who is a child in need, with a long history of involvement with agencies in the partnership. They have a complex range of needs, including autism spectrum disorder and attention deficit hyperactivity disorder, and are at risk of child sexual exploitation and going missing. They have been self-harming for a significant period of time, and this behaviour is increasing in frequency and severity. Risk continues to escalate, with several notable significant events in the last six months. Despite these concerns, they continue to be held at the threshold for child in need services.

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Case study: area for improvement

Although a range of appropriate professionals from different agencies are involved, outcomes are not improving for this child. Actions are generally a crisis response and are often taken in isolation from the multi-agency group. Partners are not effectively sharing all relevant information. The child’s assessment has not been updated to take account of changing circumstances and escalating risk, and the plan is not effectively addressing these risks. The child in need review meetings are too infrequent and are not proportionate to the child’s needs. Furthermore, not all agencies attend the child in need review meetings. The professional network does not yet have a full understanding of the impact of the risks identified for this young person.

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Next steps

Plymouth city council should prepare a written statement of proposed action, responding to the findings outlined in this letter. This should be a multi-agency response, involving police, health and the YOT. The response should set out the actions for the partnership and, where appropriate, individual agencies. 2

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Next steps

Alison Botham, DCS should send the written statement of action to ProtectionOfChildren@ofsted.gov.uk by 16 April 2020. 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 Probation

Wendy Williams HMI Constabulary and Fire & Rescue Services Helen Davies Assistant Chief Inspector

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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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