Setting

Stephen Kitchman, Director of Children’s Services, London Borough of Bexley Neil Kennett-Brown, Managing Director Greenwich and Bexley, Clinical Commissioning Groups Anjan Ghosh, Director of Public Health, London Borough of Bexley Sophie Linden, Deputy Mayor for Policing and Crime Cressida Dick DBE QPM, Commissioner, Metropolitan Police Severine Aare, Manager, Youth Offending Service Team Manager

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mental health in Bexley

Between 20 and 24 January 2020, Ofsted, the Care Quality Commission (CQC), HMI Constabulary, Fire and Rescue services (HMICFRS) and HMI Probation (HMI Prob) undertook a joint inspection of the multi-agency response to children’s mental health in Bexley. This inspection included a ‘deep dive’ focus on the response to children’s mental health needs.

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mental health in Bexley

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 Bexley.

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mental health in Bexley

The safeguarding partnership in Bexley is highly effective. This strong, mature partnership works well to help and protect children. It demonstrates care and compassion and a vigorous approach to striving to deliver excellent services. The partnership has a comprehensive knowledge of strengths and areas for improvement and is responsive to external challenge. Partners demonstrate effective scrutiny and oversight of frontline practice across all agencies. The development of the learning hub is one example of the determined commitment of partner agencies to the enhancement of multi-agency learning across the partnership. This has contributed to improving the provision of services to children and young people with mental health needs.

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mental health in Bexley

The partnership in Bexley is clearly focused on driving improvements to ensure the appropriate recognition and response to children with mental health needs. Children can access a wide range of services to help support them with their emotional well-being and mental health needs. Partners work well and innovatively together in order to provide different avenues of support for children. Across the majority of services inspected, there is good recognition of children’s mental health and safeguarding needs. Partner agencies spoken to during the inspection reported that they benefit from the support and advice they receive from staff within the multi-agency safeguarding hub (MASH). Thresholds of need are well publicised across the partnership, and partners are clear about the thresholds for referral into children’s social care.

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mental health in Bexley

Partners recognise the importance of addressing needs early in order to support children and families. This is done by a substantive and highly effective early help offer. Within this offer, there is a wide range of universal and early help services, including children’s centres that support families with children up to two years old, and targeted youth support, which are focused on improving children and young people’s emotional health.

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mental health in Bexley

The commissioning and the provision of services for young people with emotional and mental health needs in Bexley are undergoing a process of transition. These plans are well advanced and have been developed alongside and aligned to the Bexley Health and Wellbeing Strategy. The strategy identifies four priorities. Two of these are mental ill health, and children and young people’s services, which both come under the overarching objective of prevention. The real and clear commitment of professionals to early intervention and the avoidance of hospital admission was seen by inspectors. However, although a children and young people’s Joint Strategic Needs Assessment (JSNA) is being developed, there is currently no children’s chapter in place in the JSNA in order to support the strategy or fully inform commissioning decisions. This means that the area is currently challenged by there being limited accurate data to support the identification of need, and also by the means by which

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mental health in Bexley

the effectiveness of services commissioned to meet needs can be evaluated. For example, the current cohort of around 40 young people supported by the children’s substance misuse service is unusually low for an area the size of Bexley, and this indicates that the extent of this problem has not been fully identified.

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mental health in Bexley

The THRIVE operating model has been positive and influential in the development of the service offer for children and young people’s emotional health and well-being. This means that services are appropriately aligned to the government’s long-term plan for area-based new models of care. Within this structure, and following the ‘prevention’ objective, services have been commissioned creatively, with a view to increasing the accessibility of services for children and young people. Examples of this include Headscape, a website designed to help young people access what support they need to address their social, emotional and mental health needs, and Kooth, an online counselling service. The community health and well-being service has a range of targeted interventions focused on improving children’s emotional health. For some children who have been subject to longer-term involvement with agencies and who have complex needs, progress of plans is not sufficiently well monitored to

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mental health in Bexley

ensure that the plans are responsive to changes in children’s needs. Within the deep dive cases, inspectors found examples of drift, a lack of effective response in a timely manner to children’s changing circumstances, and where a lack of effective multi- agency planning has led to decisions being delayed.

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Key Strengths

◼ Senior leadership across the partnership is stable and effective. Priorities are shared and partners’ attendance and commitment to key strategic boards provide a robust multi-agency view of children’s mental health and of how this can be better met. ◼ Leadership across health commissioners and providers is strong. Commissioners and providers are active and influential participants in the safeguarding partnership, and most provide effective safeguarding governance and assurance. This is through the providers’ safeguarding committees and the Clinical Commissioning Group’s (CCG) quarterly Safeguarding Commissioning Standing Committee, which has a clear line of accountability to the CCG’s Quality and Safety Committee.

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Key Strengths

◼ There is evidence in most agencies of a strong commitment to, and understanding of, the importance of listening to and engaging with children about their emotional well-being and mental health. Staff across the services inspected are highly committed and motivated professionals, who demonstrate a good understanding of children living with mental health issues. In all cases seen, children’s mental health needs had been identified, although there was some variability in the quality of response in the tracked cases.

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Key Strengths

◼ There is strong and effective leadership in children’s services and a clear approach to developing child-focused practice to support children’s mental and emotional health. The director of children’s services has a thorough grasp of the strengths and areas for development across the broad range of services provided for children. This means that through the effective engagement with partner agencies at a strategic level, the local authority is progressively exercising a level of system leadership that is enhancing services for children, including those with mental health needs.

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Key Strengths

◼ Strong and highly effective partnerships in the multi-agency safeguarding hub (MASH) serve to protect children from harm. A clear system to screen and track referrals, aligned with rigorous management oversight, ensures that risks are prioritised appropriately. Children’s experiences are central to timely decisions about the steps needed to help and protect them from harm. ◼ Professional communication in the MASH is timely and effective. This leads to multi-agency risks being prioritised for specific children and vulnerable adults. Proportionate checks are undertaken, and consent is appropriately considered, or overridden, to protect children. The extensive collation and consideration of previous history informs risk analysis and appropriately informs decisions about required actions. The co-located police child abuse investigation team (CAIT), together with health, education and social care professionals, is leading to more

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Key Strengths

timely interventions for children in need of help and protection, including the early identification of those with mental ill health. This is augmented through the daily MASH meeting that considers all new police referrals about vulnerable children and their families.

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Key Strengths

◼ The health practitioner in the MASH performs a key role in decision-making processes, effectively supporting the assessment of contacts and referrals. Information from health practitioners is sought and analysed within agreed timescales. Such analysis is detailed and ensures that the health needs of children and young people are considered in subsequent decision-making.

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Key Strengths

◼ In most cases seen, timely multi-agency strategy discussions result in swift and timely actions. Most joint police and single agency child protection enquiries are of a high standard.

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Key Strengths

◼ The exceptional early help family and well-being service ensures that families have access to an array of well-structured multi-disciplinary services. This means that children and families get the right level of help and protection at the right time. This is delivered by caring and highly skilled key workers and is making a positive difference to their day-to-day lives, protecting children from harm and preventing the escalation of concerns. Early help key workers are supported in their work by experienced emotional well-being clinicians. These staff work directly with children who are sad or anxious because of their family’s circumstances. For this reason, vulnerable children are being helped to cope with stressful situations and to regulate their behaviours at home and at school. Regular individual and group supervision provides all staff with an opportunity for professional reflection. This informs and enables clarity of thought to enable them

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Key Strengths

to take the actions required to sustain changes for children.

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Key Strengths

◼ Assessments completed in the referral and assessment teams effectively use the local authority’s model of practice. They are of a good standard and are comprehensive and analytical. Evidence was seen of social workers sensitively evaluating the impact that domestic abuse, poor parental mental health and substance misuse have on parents’ ability to provide safe care for children. The culture of listening to children and acting on their views drives good-quality practice. Multi-agency child in need and child protection plans, written in plain and accessible language, ensure that parents and other professionals know what the concerns are and how these need to be addressed. Such plans clearly reflect the child’s voice and are updated regularly. ◼ A dedicated telephone consultation service for professionals ensures that emerging concerns about individual children are identified and responded to quickly, enabling children to access the right level of support. Partner agencies

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Key Strengths

share and analyse intelligence every day to target children most at risk, for instance children missing from home and care and those who are being drawn into associated areas of criminal and sexual exploitation. Dedicated and persistent work engages many highly vulnerable children and reduces risks of further serious harm on a case-by-case bases. Inspectors saw examples of effective multi-agency mapping of criminally and sexually exploited children within and across other London boroughs, which is successfully disrupting perpetrators.

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Key Strengths

◼ Within the children’s front door and the wider referral and assessment service, managers ensure that there is timely and regular oversight of work with children and young people. This ensures that there is appropriate decision-making guidance and case progression. This is very effective in a large majority of children’s cases.

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Key Strengths

◼ A broad range of services from the community and voluntary sector work well together to deliver targeted emotional health support for children. There is a clear focus on early intervention and on preventing escalation to statutory services. Children and families use these effective services well when support is required to address their emotional and mental health needs.

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Key Strengths

◼ All professionals across the partnership explore well 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 best to provide support.

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Key Strengths

◼ Education-based interventions support Bexley’s approach to recognising and meeting children’s needs at the earliest opportunity. School staff have access to regular and up-to-date mental health training, and apply this effectively to children in their care. They are proactive in ensuring that the risks to children are mitigated and that children’s needs for emotional health support are identified while children are in school. School staff effectively participate in multi-agency meetings in relation to children and are able to advocate effectively on their behalf because they know them well. Schools respond creatively to children’s individual circumstances to enable them to access the curriculum when their mental health needs might otherwise impede their learning.

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Key Strengths

◼ Bexley’s emergency duty team (EDT) responds well to crises and emergencies out of hours. This ensures that safe arrangements are in place and that protective action is taken to safeguard children when required. The service is staffed by experienced and committed social workers. Highly effective and swift communication with day services and good-quality recording ensures that all teams are fully informed of risks to children, including their mental health needs. ◼ Good partnership working within health and multi-agency partners reflects a culture of openness. This enables clear escalation processes between agencies to be effective for children with mental health concerns. Disagreements between partners about the level of service that children receive are effectively resolved in a timely manner.

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Key Strengths

◼ The named safeguarding general practitioner (GP) provides proactive support to Bexley GPs, with clear safeguarding systems in place. These enable the clear identification of children who are the subject of child protection or child in need plans and those for whom there are mental health concerns. This facilitates effective partner agency information-sharing.

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Key Strengths

◼ All schools in Bexley benefit from the work of a named school nurse. This means that education staff are able to seek advice and guidance if they are concerned about the social, emotional and mental health needs of children and young people in their settings. School nurses are well supported by child and adolescent mental health services (CAMHS) practitioners, who give timely feedback when children are signposted to the service, and practitioners are accessible for further guidance and support if children’s needs escalate.

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Key Strengths

◼ The introduction of the adolescent intensive support team and crisis response team within CAMHs has led to a significant reduction in Tier 4 paediatric admissions as a result of mental health concerns. This service, which operates between the hours of 8am to 10pm, seven days a week, provides intensive support during periods of crisis or following a presentation at emergency departments. The service is effective in supporting young people to remain safely at home.

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Key Strengths

◼ There is a strong culture of audit activities carried out by health leaders, and these are used to direct improvement activity. Inspectors saw audits for participation in strategy discussions and the effectiveness of capturing the voice of children in healthcare records. These audits provided a clear picture of performance in these areas and resulted in recommendations for practice improvement.

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Key Strengths

◼ A new initiative for Bexley, introduced in December 2019, between the police and the National Health Service has enabled the crisis team nurses to have access to a police car. This means that they are able to accompany police officers to incidents between 5pm and 4am when professional mental health support is needed. This is reported by partners to be reducing the need for those in crisis to go to a police station.

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Key Strengths

◼ Central funding has assisted the Metropolitan Police Service to devise and deliver mental health training to frontline officers across London. This is enabling them to understand the impact of childhood trauma and identify those who may be vulnerable and in need of support. ◼ The Metropolitan Police Service has appointed a lead responsible officer for mental health at superintendent level. This role is complemented by a central mental health team that assists in providing advice and organisational guidance in relation to mental health. A mental health toolkit provides clear operational guidance for police officers and staff when they are dealing with someone who has mental ill health.

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Key Strengths

◼ There is a dedicated mental health police team in Bexley, co-located with staff who are dealing with exploited and missing children. This enhances collaborative working and information-sharing. Staff within this team are trained as serenity integrated mentoring (SIM) officers. They work with mental health trusts to identify high-intensity service users, provide care and create response plans. This leads to effective interventions and pathways.

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Key Strengths

◼ The police are represented at a number of pan-London groups involved in working together to provide a collaborative response to those affected by mental health, for example the Cavendish Square group. This enhances partnership working in order to understand and respond to the mental health needs of children.

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Key Strengths

◼ The youth offending service (YOS) has an active management board with good partner representation, including health. There is commitment to holding the service to account as well as supporting it to develop and innovate. Performance management processes provide information on practice audits, as well as quantitative information being provided to the board. This enables the board to effectively challenge when performance is not at the desired level.

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Key Strengths

◼ The recent review of the youth justice plan analyses current performance and sets out the priorities for the next year well. This identifies local priorities for the youth offending services, such as work to meet the mental health needs of children, as well as linking to the Youth Justice Board national targets.

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Key Strengths

◼ The YOS has access to a rich suite of data and uses this to shape the service well. Information has been used to identify a number of children open to the YOS who were experiencing low-level mental health, poor coping strategies and low self-esteem. This has led to the nurse post being re-evaluated, and the new postholder will be taking on these cases and providing interventions for these children.

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Key Strengths

◼ There are clear processes in place in the YOS to gather the views of young people to help gain an understanding of the impact of the service. Members of the management board meet with young people on a one-to-one basis to enhance their understanding of young people’s experiences.

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Key Strengths

◼ Children within the YOS receive assessments undertaken by skilled staff. These are timely and informed by a range of information that gives a holistic view of need. Staff understand the links between adverse childhood experiences, emotional well-being and mental health and offending behaviour. This means that children receive effective support with their emotional and health needs, prior to interventions to address their offending behaviour. ◼ There is strong and effective leadership in children’s social care, as well as a clear commitment to developing child-focused practice to support vulnerable children, including those with emotional and mental health needs. There is a range of training and development opportunities for social workers to enhance and develop their practice, including attachment-based training and developmental trauma. ◼ Social workers make positive efforts to engage with children and ensure that their

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Key Strengths

views are integrated into plans. Manageable caseloads mean that they have time to get to know the children they work with well, and social workers demonstrate how children’s views have influenced case planning. ◼ The local authority has a clear line of sight on workforce recruitment and retention. It is appropriately focused, with a clear action plan for increasing the number of permanent social workers and reducing the reliance on agency staff. This is particularly important for children with emotional and mental health needs, to enable them to build a trusting relationship with a particular adult, who can help them to build relationships with wider networks of professionals. ◼ Looked after children’s review health assessments have a clear focus on children’s emotional and mental health as well as on their physical health needs. Risk and protective factors are identified, and the voice of the child is evident. Strengths

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Key Strengths

and difficulties questionnaires are used well to identify areas of emotional vulnerability and to plan a response to meet this need. ◼ There is a dedicated, multi-agency looked after children CAMHS team that responds effectively to the mental health needs of children and young people who are in care or who have been adopted. The manager of this service is a senior social worker who has been seconded from the local authority. This multi- disciplinary service providing assessments and interventions is aware of the full social care and familial history of the child. This gives a good overview of previous trauma and adversity that may have a long-term effect on their mental health and well-being.

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Key Strengths

◼ There is a good electronic offer to support children and young people who may feel anxious or worried about attending CAMHS and clinic-based settings. This provision is enabling young people to access some support without face-to-face attendance at clinic-based or other formal settings. ◼ The partnership has positively responded to findings identified during this inspection. Arrangements were made to ensure that the MASH immediately responded to the fact that checks were not being made with the YOS prior to MASH meetings. Such checks now take place.

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Case study: highly effective practice

When all agencies work together in a coordinated, consistent and purposeful way, positive outcomes are possible, as inspectors saw for one young person. A careful well-coordinated approach means that this young person is currently in a safe and secure environment, is beginning to address their mental health needs and is starting to flourish. She is attending classes, showing a real interest in her education and is integrating well with friends. Her teachers describe her as a very caring pupil who likes taking responsibility, and she has a fantastic rapport with staff and their friends. Due to this effective joint- working, the self-harming and daily desire to end their life is reducing. While there is still progress to be made, this clearly demonstrates that when agencies work together effectively, the outcomes are very positive for young people, especially when they have mental health needs.

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Areas for improvement

◼ Response to concerns about children who go missing, or who are at risk of sexual exploitation and criminal exploitation, is not yet consistently strong for all children. Multi-agency activity to track and cross-reference children at a number of panels could lead to inconsistent responses and too much duplication. This could inhibit the formulation and agreement of a single multi-agency plan that identifies all of the needs for each child and how these will be met and reviewed. The partnership was already aware of the need to rationalise panels, and proposals are well advanced.

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Areas for improvement

◼ While all children who were reviewed as part of this inspection have had a service in place to support them with their emotional well-being and mental health, there has been a delay in some receiving a service that is consistent with their level of need. In the deep dive cases tracked in this inspection, children’s mental health needs had been well identified, but this has been done with varying degrees of understanding of the complexity of issues that some children face.

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Areas for improvement

◼ While consistently evident in all cases, management oversight was, for a minority of children with complex needs, not robust enough to avoid delay in effective care plans being devised. This was particularly evident in cases where risks escalated or needs increased.

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Areas for improvement

◼ For some children already open to children’s social care, multi-agency information and working together are not consistently effective when children are subject to longer-term children social care intervention. ◼ Multi-agency partners to ensure that outcomes from a referral to the MASH are consistently recorded on children’s records.

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Areas for improvement

◼ The outcome of referrals and assessments are not always being received and recorded on the electronic patient record system used by school nurses. This limits the ability of frontline practitioners to appropriately respond to children and young people’s safeguarding risks and vulnerabilities associated with mental ill health.

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Areas for improvement

◼ As part of the health contribution to education, health and care plan assessments, relevant information about children from school nursing should be considered as appropriate to inform plans. Final plans should be routinely shared with the school nursing team.

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Areas for improvement

◼ The police are not represented on the health and well-being board. This means that there is no formal mechanism by which important information held by the police in relation to children’s emotional and mental health can be considered by the board. This has subsequently been addressed by the partnership.

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Areas for improvement

◼ Other than the children being referred by the YOS, there is a low number of children accessing substance misuse services. There is a lack of accurate data to help the partnership to understand the extent of children and young people’s substance misuse in Bexley.

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Areas for improvement

◼ The management systems in use in Queen Elizabeth and Darent Valley hospitals are not robust enough to identify deficits in safeguarding practice in the emergency departments. This is despite every child’s record of attendance being scrutinised in both hospitals by an additional layer of oversight. Safeguarding triage tools or prompts lists that are designed to support the identification of risks to children (there are different tools in place in each hospital) are not effective or consistently used. Professional curiosity was limited and specific risks to individual children or the voice of the child were not fully documented in records used by both trusts. Neither is there enough exploration of the risks that certain adults may pose to dependant and associated children. In Darent Valley, inspectors identified shortfalls in safeguarding practice in a minority of cases where children’s circumstances warranted a referral to the MASH, but no such referrals

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Areas for improvement

were made. In such cases, there was an evident lack of effective consideration of potential risk factors to children.

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Areas for improvement

◼ There is insufficient understanding across the partnership of the adverse effect that substance misuse may have on the mental health of children and young people. In health settings, there is a lack of consistent professional curiosity to identify whether the use of substances was in an attempt to self-medicate or in response to trauma or adversity. ◼ There is a lack of consistent understanding of the impact of parental substance misuse across the partnership, and particularly in relation to the use of cannabis. The impact of such misuse and its relevance for parents’ well-being, as well as that of their children, was not consistently sufficiently considered.

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Areas for improvement

◼ There is a lack of training available for police officers holding crucial roles in the MASH. Some staff have roles in the MASH with no previous child protection experience. They are effectively having to learn on the job, as opposed to the organisation providing them with the learning and skills they need to undertake these roles.

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Areas for improvement

◼ There is no fully proactive approach to preventing the unnecessary criminalisation of children in care. Information about these children is known, and there is scope to do more work with providers of placements and education settings to manage these children in a more restorative approach and potentially reduce placement or education breakdown, which can lead to offending behaviour.

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Areas for improvement

◼ The YOS is part of the London children in custody protocol, and this reviews all cases of children held overnight in police custody. While the numbers are low, the YOS has identified that some young people are occasionally held overnight unnecessarily. It is recognised that further work is needed with both EDT and police custody to reduce the risk of this occurring.

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Areas for improvement

◼ Emergency department staff report that they are not aware of the range of services available in the community and recognise that they need this information to be part of the THRIVE approach.

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Areas for improvement

◼ There is ineffective use of alerts on electronic patient records systems. Inspectors found examples of children who were subject to child protection plans, but there is a lack of clear electronic ‘flags’. This means that practitioners may not be immediately aware of children’s vulnerabilities and needs unless they physically read through the child’s records.

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Areas for improvement

◼ A performance dashboard gives police managers a good sense of mental health activity levels across the south east London basic command unit. However, the dashboard is limited in terms of its usage; it does not provide borough-specific data and information for practitioners to fully understand the quality of outcomes for children.

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Case study: area for improvement

For one child, there was a lack of coordinated partnership planning and information-sharing, and this led to an ineffective partnership response to their risk. There were repeat referrals, assessments and plans for the same concerns. These were not effectively responded to, and this meant that the escalating risks were not recognised or addressed. There was a lack of professional curiosity, and all of these circumstances mean that this child is not accessing education and their situation has not improved. They continue to show high levels of stress and anxiety.

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Next steps

The director of children services should produce a written statement of proposed action responding to the findings outlined in this letter. This should be a multi- agency response, involving all partners. The response should set out the actions for the partnership and, where appropriate, individual agencies. 1

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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 18 June 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

1 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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