Setting

Nikki Edwards, Executive Director: People, Bracknell Forest Sarah Bellars, Director of Nursing and Executive Lead of the CCG, with responsibility for East Berkshire Anthony Stansfeld, Police and Crime Commissioner Francis Hapgood QPM, Chief Constable of Thames Valley Police Karen Roberts, Manager, Bracknell Forest Youth Offending Team Melanie Smith, Head of Berkshire Local Delivery Unit, National Probation Service Alex Walters, Chair of Bracknell Forest LSCB

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abuse in the family in Bracknell Forest

Between 21 and 25 January 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 abuse and neglect in Bracknell Forest. 1 This inspection included a ‘deep dive’ focus on the response to sexual abuse in the family environment.

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abuse in the family in Bracknell Forest

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 Bracknell Forest.

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abuse in the family in Bracknell Forest

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 Bracknell Forest this is known as 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 evaluated the effectiveness of the multi-agency leadership and management of this work, including the role played by the local safeguarding children board (LSCB).

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abuse in the family in Bracknell Forest

Bracknell Forest benefits from a senior multi-agency leadership team that offers clear oversight and direction within committed and cooperative working relationships. This commitment is evident even when wider structures and boundaries make it more challenging for some partners, particularly health and police colleagues. Leaders in Bracknell Forest ensure that, as a smaller local authority, they have a voice and

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abuse in the family in Bracknell Forest

1 This joint inspection was conducted under section 20 of the Children Act 2004. influence equal to larger authorities and describe this as successfully ‘punching above their weight’.

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abuse in the family in Bracknell Forest

Senior leaders have a good understanding of the experiences of individual children. They undertook their own ‘deep dive’ audit in January 2018 in order to understand the experiences of children at risk of sexual abuse in the family environment and they have actively sought out information about the wider prevalence and effect of this abuse. They understand that sexual abuse in the family environment can often be hidden, and the explicit or subtle ways in which this might be displayed. There is a good understanding of how the effects of abuse on children can materialise in different ways, which is best described within the leadership group as ‘behaviour is the voice’.

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abuse in the family in Bracknell Forest

The considerable strengths found in most single agencies are not yet maximised to best effect in multi-agency practice, and some practice has led to a disproportionate amount of work being placed on children’s social care. The partnership is aware of this, and plans were in place prior to this inspection to review and develop the areas of practice considered within this JTAI. These plans specifically include a review of the front door ‘MASH’ and services for children at risk of sexual abuse in the family environment. There are plans for improvements to front door arrangements, but these are not yet in place. This means that, currently, there is more of a ‘co-location’ of partners rather than fully integrated partnership working. Children are safeguarded appropriately. However, for some children, the lack of full and prompt sharing of information and joint planning in the early stages impacts on the quality of

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abuse in the family in Bracknell Forest

intervention they initially receive. Partners responded positively and immediately to feedback provided during this inspection any issue that could improve their services.

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Multi-agency strengths

 Senior leaders and managers in Bracknell Forest have positive and productive working relationships. There is a shared ambition to ensure that high-quality services are available for children, as well as a determination to continuously improve services, systems and processes. Some partners face challenges in fulfilling their role in Bracknell Forest as a result of their wider responsibilities in the region. However, all agencies are aware of this and have open and frank discussions to overcome any potential barriers and build on their multi- agency strengths.

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Multi-agency strengths

 The positive multi-agency culture includes proactive relationships with the voluntary sector to support all vulnerable children, including those at risk of sexual abuse in the family environment. A wide range of services are available. The partnership approach to commissioned services and the voluntary sector is expansive, inclusive and properly integrated.

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Multi-agency strengths

 There is an impressive multi-agency culture of creativity, reflection and active problem-solving. This strong existing learning culture and approach to improvement should enable the partnership to further build on their existing strengths.

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Multi-agency strengths

 The high degree of self-awareness means that, collectively, the partnership is already well advanced in reviewing and refining areas of practice requiring some development. Leaders have been proactive in developing their understanding of the complex theme of this joint targeted area inspection. This included undertaking a deep dive evaluation of sexual abuse in the family environment in order to understand the prevalence of the issue, and the implications for practice. The resulting detailed action plan is overseen by the local safeguarding children board (LSCB) and is having a positive impact on practice. For example, older children are now seen alone at the enuresis clinic.

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Multi-agency strengths

 The LSCB identifies, monitors, coordinates and evaluates the work of partner agencies. The LSCB effectively galvanises action and interrogates regular updates on areas considered in this inspection. This has included the review of the MASH, development work to support a local private provider for children who display sexually harmful behaviour, the sexual abuse referral centre (SARC) and the monitoring of children waiting for a child and adolescent mental health service (CAMHS) assessment.

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Multi-agency strengths

 Leaders have a good understanding of the current limitations in the MASH, with agencies having separate processes to manage their single-agency work. Advanced plans are underway to test a more integrated approach to the analysis and assessment of risk in order to inform planning for children. In the interim, protective action is still taken as needed to reduce risk for children. The service has developed ways to ensure that children receive a good standard of practice. Timely triage for children’s social care contacts ensures that referrals are efficiently progressed to strategy discussions when needed. Social workers visit children in a timely manner and joint investigation visits are undertaken with the police when there is clear evidence of a crime. Direct work is appropriately used to gather children’s views and feelings during investigations. Concerns about historical child sexual abuse receive a prompt

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Multi-agency strengths

response. The emergency duty service provides an effective service that meets the safeguarding needs of children outside office hours.

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Multi-agency strengths

 A range of services are available to support children when they have experienced harm, including specialist services and family support workers, who deliver short-term interventions to improve children’s outcomes. All children whose experiences were considered as part of the ‘deep dive’ theme were safer as a result of the multi-agency response to child sexual abuse in the family environment. Key professionals understand their wider safeguarding responsibilities and support direct work with children. Good engagement was seen with both children and their families, and individual children benefited from highly specialist placements if this was required.

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Multi-agency strengths

 An accessible and responsive integrated paediatric SARC provision is available. Practitioners at the SARC provide support and training to multi-agency staff. The sexual health service analyses and shares with the police information provided by young people who have presented for treatment. This analysis has identified cohorts of young people who may be at risk of sexual exploitation.

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Multi-agency strengths

 The Young People’s Substance Misuse assessment teams provide specialist training helping schools to identify and support children who are displaying harmful sexual behaviour or who are misusing drugs or alcohol. The youth offending service (YOS) and the police have supported a specialist local provider to develop restorative approaches to care.

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Multi-agency strengths

 The Executive Director: People, with the statutory designated role of director of children’s services (DCS), provides strong, determined leadership and vision. There is a clear and aspirational strategic plan to build further on the already successful services. This has included taking action to ensure that the right structure, resources and people are in place to progress and develop children’s social care. The DCS has a clear understanding of, and insight into, the span of her responsibility, and ensures that this works to the partnership’s advantage. The range of her responsibilities has only recently expanded, but already positive impact can be seen. It is best reflected, for example, in the work undertaken in finding suitable and sustainable accommodation for high- risk perpetrators. This is timely and is a clear attempt to support effective risk management.

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Multi-agency strengths

 The DCS is supported well by a relatively new senior local authority team. Performance and quality assurance are strong, and there has been additional investment to expand the capacity for this work and to develop it further. The DCS is directly involved in activities, including children’s case file audits, to help her understand individual children’s experiences.

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Multi-agency strengths

 The local authority seeks out opportunities for learning and innovation. Its participation in the What Works Centre, looking at evidence-informed practice, is helpfully targeted at developing systems at the front door. The multi-agency family safeguarding model is already showing a positive effect on integrated experiences for children. The recently expanded and highly effective child exploitation team provides a flexible and immediate response that is extremely child-centred. The team understands well how the risks of sexual abuse in the family environment may be displayed through hidden behaviours, including children going missing or other forms of exploitation. The awareness and skills of the exploitation team have ensured that children who have gone missing have subsequently been able to make disclosures about sexual abuse within the family environment. The achieving best evidence-trained specialist social

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Multi-agency strengths

worker is then able to support the child fully through to court if required.

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Multi-agency strengths

 The MASH and duty and assessment 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. There are no delays in contacts being reviewed by a manager, and decision-making is proportionate and child-focused. Recording is focused on the impact of harm on children. The duty team visits children immediately when necessary. Children’s assessments include partner agency input, which ensures that relevant information is considered in order to reduce risk for children and improve their outcomes. Children’s views are sought and listened to. Children’s outcomes improve through effective interventions and direct work, including the input from the family safeguarding team, which provides specialist support to address parental substance and alcohol misuse.

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Multi-agency strengths

 Education is an area of strength, with close cooperative working relationships and strong systems to support and challenge within the partnership. This includes support for when children go missing from education. The local authority policy and guidance on elective home education is thorough and provides effective advice for school leaders.

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Multi-agency strengths

 Named and designated professionals across the health disciplines in Bracknell Forest provide strong leadership. Practitioners are supported well to both identify vulnerabilities and report risk of child sexual abuse in the family environment. There is good availability of training available for frontline health practitioners to help in the identification of child sexual assault. Percentages of appropriately trained health staff are at levels in line with intercollegiate guidance. Practitioners also access a range of supervision, including dedicated safeguarding supervision from supervisors trained to undertake this important role.

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Multi-agency strengths

 The stability and continuity of staff across the health landscape in Bracknell is a strength. Established practitioners have detailed knowledge of children and families, which is important in the building of sustainable relationships with potentially vulnerable young people.

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Multi-agency strengths

 The health strategic safeguarding group meetings are a forum where individual cases, local trends, national issues and updated advice and guidance are discussed. Named and designated professionals’ meetings are also held on a regular basis. The outcomes of such meetings and discussions are then, when appropriate, cascaded down to practitioners to better inform their work with vulnerable children and young people.

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Multi-agency strengths

 Health services provide a well-evaluated instant messaging text service which allows children and young people to anonymously text questions and then receive appropriate signposting and support. Similar support is available for children and young people who receive a Tier 3 CAMHs service provided by Berkshire Healthcare Foundation Trust. The safeguarding team at Frimley Health Foundation Trust has effective oversight of all safeguarding referrals made by the clinicians in the emergency department and midwifery service. These referrals clearly articulate risk for children. Mental health liaison nurses in Frimley Park hospital emergency department carry out holistic and detailed assessments of children. Opportunities are created to ensure that the children are seen alone, which creates a safe space for children and young people to disclose any past trauma, which may include sexual abuse.

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Multi-agency strengths

 There are robust and effective processes in place at Frimley Park Hospital to ensure that unborn babies of vulnerable mothers are kept safe. When women transfer into the area close to their due date and no pre-birth plan is in place, a safeguarding plan for the unborn baby is created. These plans are robust and clearly articulate risks to the mother and baby. Plans are contained in the mother’s notes, and midwives do not discharge new mothers until there has been a multi-agency discussion and analysis of risks.

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Multi-agency strengths

 Children and young people who attend the sexual health service provided by Berkshire Healthcare Foundation Trust are given priority over adults. Reception staff are trained and carry out good observations of children and young people who are in the waiting room.

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Multi-agency strengths

 General practitioners (GPs) receive timely information from the SARC about sexual assault examinations and screening for sexually transmitted infections. This helps to inform their ongoing healthcare planning and enables timely follow-up. Some positive examples of professional curiosity were seen from GPs, including one case which led to a referral being made to the MASH for alleged sexual assault.  Thames Valley Police is clearly committed to strong multi-agency partnership working in its force area. This is evidenced by it having established a Protecting Vulnerable People (PVP) command with focused leadership and a strong complement of appropriately trained level 2 investigators and specialist child abuse investigators. The force has invested in the national vulnerability training for all its workforce.

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Multi-agency strengths

 Berkshire, including Bracknell Forest, is served by a dedicated child abuse investigation unit (CAIU) and each of the six local authority-based MASHs include a permanent police presence as part of its core team. This police MASH capability represents a significant investment by Thames Valley Police to ensure that staff are able to work across all areas of vulnerability. The police have also invested in additional supervisors so that each MASH includes a dedicated police supervisor. This offers flexibility and resilience across the MASH service in the absence of specific individuals.

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Multi-agency strengths

 There are no backlogs in the work of the police team in the MASH and staff respond in a timely way to requests for information made by the local authority and other partner agencies. High-risk cases are prioritised across the area through the Police Berkshire MASH manager and a daily police MASH conference call.

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Multi-agency strengths

 The police MASH daily management meeting ensures flexibility in managing workload between the six Berkshire MASHs and provides opportunities to improve learning and consistency of decision-making. The police out-of-hours staff ensure that acute cases are assessed and allocated when appropriate. MASH supervisors and researchers have received relevant training and have been afforded shadowing and mentoring opportunities in order to develop their understanding of the nature and scale of child abuse and appropriate safeguarding responses.

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Multi-agency strengths

 The YOS makes an assertive and active contribution to safeguarding children. Children and young people benefit from the support and supervision they receive from a stable, well-trained and committed staff team. The team undertakes accurate and balanced assessments of the risk of harm that children pose to others and of any vulnerabilities children have. Assessments lead to targeted interventions, with highly effective joint work with other agencies.

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Multi-agency strengths

 The YOS is well managed and staff value the support they receive from managers. Staff are confident in their work and can challenge partners if needed. There are clear risk-management processes, which are well established and are multi-agency. The inclusion of children’s social care and specialist workers in the team leads to the planning and delivery of interventions that are tailored to each child’s needs, while also providing protection for actual and potential victims. This includes interventions to reduce sexually harmful behaviour . YOS staff are suitably trained to assess and support children who have experienced sexual abuse or who display sexually harmful behaviours. There are specialist gender-specific interventions that allow children to explore their experiences around consent and healthy relationships, and these enable staff to take a tailored approach to interventions.

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Multi-agency strengths

 National probation service (NPS) managers attend key strategic boards and groups and make a positive contribution to public protection. This includes effective use of the control methods to manage risk from adult offenders, including the use of exclusions and licence conditions. The NPS has provided resources that allow information to be shared with social care about offenders. This information is provided quickly and supports social care assessments.

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Multi-agency strengths

 The NPS regional public protection lead in Bracknell Forest is also the national safeguarding lead. This profile and expertise has led to a continued focus and commitment to improving safeguarding practice. High-risk perpetrators of sexual abuse in the family environment have access to specific and intensive offending behaviour programmes such as Horizon and Becoming New Me. The NPS region is just about to implement a follow-up programme designed to consolidate and help maintain changes in behaviour.

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Practice study: highly effective practice

In the case of Jason, within one week of a multi-agency strategy meeting, he was placed on a child protection plan on the grounds of sexual abuse. The initial child protection case conference demonstrated a good understanding of the risk posed to him by an extended family member. All relevant professionals have been engaged in safety planning for Jason and his family.

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Practice study: highly effective practice

Jason has good friendships at school, where he is being supported and is doing well. The school is vigilant about his welfare, and staff have built positive protective relationships with his parents and work very closely with other agencies, particularly Jason’s social worker. Both the school and the social worker undertake helpful direct work with Jason.

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Practice study: highly effective practice

The local authority has a clear and current assessment of risk for Jason, and his social worker has worked particularly hard to engage Jason’s family and build trusting relationships, despite the complex and challenging circumstances.

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Practice study: highly effective practice

The child protection plan is clear and robust and explicitly names the key risk as sexual abuse, ensuring that there is no doubt as to how Jason needs to be protected. Actions are methodically followed up at core group meetings and the child protection plan is appropriately considered at well- attended review case conferences.

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Areas for priority action

 There are no areas for priority action

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Areas for improvement

 Despite the committed and skilled leadership and the considerable strengths found in most single agencies in Bracknell Forest, these strengths are not yet maximised to best effect in multi-agency practice. Multi-agency systems and processes are not always efficient when identifying risks. This places a disproportionate pressure on the local authority to undertake more work. For example, all child concern contacts are forwarded by the police to children’s social care without any triage or assessment of risk. This creates unnecessary volumes of work for the children’s social care MASH to assess and follow up.  There are missed opportunities for the key safeguarding agencies to fully inform the analysis and decision-making for children when risk of harm is being considered at an early stage. There is a lack of consistent attendance and/or participation at both strategy discussions and case conferences. This

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Areas for improvement

means that while strategy discussions take place in a timely way, they are usually held between children’s social care and the police and the focus is on the sole issue of whether a joint or a single investigation is required. The local authority needs to more effectively use the contribution from partners and seek out the unique roles and skills available to ensure richer and fuller discussion and planning that is informed by all available information. Children’s social care has invested in additional senior management capacity for the MASH in order to support transformation work and provide more quality assurance activity.

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Areas for improvement

 A small number of children in Bracknell Forest do not receive a consistently good service and more work needs to be done to improve consistency. Leaders are aware of this and it is a key focus of the enhanced single agency audit and quality assurance processes in children’s social care.

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Areas for improvement

 Although children are generally visited in a timely manner by social workers, and are seen alone, for some children there are not sufficient visits to establish trusting relationships. Not all assessments consider the wider needs of children in the family. Supervision is regularly provided to social workers, but does not consistently drive the progression of work. Caseloads are higher in the duty and assessment team than managers would like, and this is being closely performance managed.

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Areas for improvement

 The limited presence of health representation in the MASH and the multiplicity of record-keeping systems across the health partnership does not always facilitate effective and timely information-sharing. Health information is limited in the early stages and is gathered later in the assessment process. There is more to do across the partnership to better involve and understand the variety of health services and the significant contribution they can make to the lives of children. As well as this, all health partners need to be proactive in promoting their role in effective partnership working. Some children who require a child protection medical experience delays in receiving this and wait to be seen in the accident and emergency department.

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Areas for improvement

 Referrals are not always sufficiently detailed to help the MASH or children’s social care make appropriate decisions about the level of risk. This is compounded by the wide variety of referral forms used. Some partners do not routinely receive the outcome of the referrals they have made, including, for example, the acute hospital trust or GPs. This means that they are not always aware of any ongoing risks or of the status of families that use their service. GPs contribute information to the MASH when requested and in accordance with the timescales required. GPs acknowledge that they could do more to ensure that they follow the outcomes of serious referrals made themselves, rather than waiting for the local authority to feed back.

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Areas for improvement

 In some instances, decision-making is overly influenced by children’s views and police investigations are not taken further as the child did not wish this. Although this shows appropriate consideration of children’s wishes and feelings, in a small number of cases this means any wider potential risk from perpetrators to other children is not fully explored.

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Areas for improvement

 Berkshire Health Foundation Trust needs to improve oversight of the quality of information in referrals provided in order to inform the decision-making process at the MASH. This is particularly important as health practitioners at the MASH do not always see original referrals. CAMHS practitioners do not always review risk assessments in a timely way and alerts are not consistently relevant or up to date in records. Partnership working between GPs, the sexual health service, midwifery teams and New Hope is under-developed. Information is not routinely shared between services, which means that client records may not be complete. The safeguarding information management processes in GP practices in Bracknell is inconsistent. In one practice, there are efficient processes and dedicated staff who enable the lead GP to have a clear picture of all children and families on their list where there are child protection concerns, or where children and families are otherwise vulnerable.

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Areas for improvement

In another practice, those processes are under-developed and there is a risk that information about current risks to individual children may be overlooked.  The school nursing service is not commissioned to provide a ‘drop in’ service for school-age children in Bracknell Forest. This means that children and educational staff are not benefiting from a visible and named school nurse, which limits the opportunity of children and young people to build a rapport with a school nurse practitioner so that they might identify and report risks and vulnerabilities.

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Areas for improvement

 There are several areas in which a better understanding of the working practices of the NPS and children’s social care would quickly improve safeguarding and risk management processes. At present, some processes that are designed to manage serious risks operate in isolation rather than cooperatively. These include information-sharing with the NPS for court and planning for the release of high-risk offenders. It is positive to see the new initiative taken in partnership with housing to develop a specific pathway for vulnerable people and high-risk offenders. However, it remains a challenge to secure suitable accommodation.

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Areas for improvement

 The police MASH staff work across Berkshire. This means that work is often undertaken on Bracknell cases by staff who are not co-located in the Bracknell MASH. The management oversight of the work of police MASH staff is limited and does not take place as part of a formal regime of governance. The police MASH supervisor focuses on whether a crime has been committed and whether the investigation should be single or joint agency. Although response to risk is timely, the widest safeguarding risk to children is not always fully considered, actioned and recorded. Police need to improve the quality of decision-making in order to ensure that crime is identified but that, equally, sources of potential risk to children are identified and activity to remove or mitigate the threat of harm is prioritised. The police do not routinely use the Police National Database as part of their research processes.  The current police practice of passing almost every contact they record to the

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Areas for improvement

local authority without any meaningful review and supervisory evaluation is undermining the effectiveness and efficiency of the MASH. Police do not collect data on child protection case conference attendance by subject, and risk to individuals is not always accurately flagged on information systems.

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Areas for improvement

 Police and NPS co-chair multi-agency public protection arrangements (MAPPA- 2) meetings in Bracknell Forest. The pathways for cases to be raised at this forum do not appear to be well known to safeguarding practitioners who are dealing with level 1 offenders. Therefore, when these offenders are involved in new matters, referrals to MAPPA-2 are not always considered.

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Areas for improvement

 YOS assessments of young people who are subject to out-of-court disposals are mostly of a good quality. However, processes could be refined to better capture the safety and well-being concerns of these children and young people

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Areas for improvement

 Training on safeguarding for NPS staff is readily available and completion is monitored. However, there is currently no specific training in place on child sexual abuse in the family environment. Senior managers recognise this is a gap but have limited influence on training provision. As a result of this, inspection plans have been put in place to provide guidance for staff until training can be provided.

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Practice study: area for improvement

In the case of Lucy, there were significant gaps in the multi-agency information-sharing from the outset. Disclosures made at school by another child in the family were not shared immediately, and the risk indicators of child sexual abuse were not fully recognised.

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Practice study: area for improvement

Full information about known offending behaviour of an adult family member had not been taken into account meant that not all relevant agencies were invited to contribute to the strategy discussion. The level of risk could not, therefore, be appropriately assessed. This error was compounded by the decision-making at the initial child protection case conference, which focused on issues of neglect rather than the risk of sexual abuse. The resulting child in need plan was ineffective and did not appropriately address the degree of risk or the core issue of concern. There is no up-to-date children’s social care assessment for Lucy, and only social care and school attend the child in need meetings. There is limited evidence of a positive impact for Lucy from this intervention.

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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 Bracknell Forest local authority, the clinical commissioning group for East Berkshire, Thames Valley police and the National Probation service. 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 20 June 2019. 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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