Setting

Stuart Gallimore, Director of Children’s Services, East Sussex Giles York, Chief Constable, Sussex Police Katy Bourne, Police and Crime Commissioner, Sussex Sam Allen, Chief Executive, SPFT Adam Doyle, Chief Executive Officer at NHS Eastbourne, Hailsham and Seaford CCG and NHS Hastings and Rother CCG and NHS High Weald Lewes Allison Cannon, Chief Nurse Sussex CCGs, Head of Safeguarding East Sussex CCGs Dr Adrian Bull, Chief Executive of East Sussex Healthcare NHS Trust Reg Hooke, Chair, East Sussex Safeguarding Children Partnership

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mental health in East Sussex

Between 24 February and 28 February 2020, Ofsted, the Care Quality Commission, HMI Constabulary and Fire & Rescue Services and HMI Probation carried out a joint inspection of the multi-agency response to abuse and neglect in East Sussex. 1 In the inspection of the ‘front door’ of services, we evaluated agencies’ responses to all forms of abuse, neglect and exploitation, as well as evaluating responses to children living with mental ill health. This inspection included a ‘deep dive’ focus on the response to children subject to child in need and child protection plans, and children in care, who are living with mental ill health.

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mental health in East Sussex

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 East Sussex.

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mental health in East Sussex

Partnership arrangements in East Sussex are well established and effective. Children’s emotional well-being and mental health are a high priority in strategic planning. Service development directed through the East Sussex local transformation

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mental health in East Sussex

1 This joint inspection was conducted under section 20 of the Children Act 2004. plan is delivering improving services for children and young people with mental health needs.

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mental health in East Sussex

Leaders demonstrate a strong commitment to co-production with children and young people when implementing new or revised services. Leaders have continued to develop existing services to meet a greater range of children’s emotional and well- being needs and have created new services to address emerging or lower levels of need. This work is supported by a highly effective Safeguarding Children Partnership and Health and Wellbeing Board.

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mental health in East Sussex

There is an embedded culture of collaborative learning and development across the partnership in East Sussex. Schools are well supported to play a key role in identifying and supporting the emotional well-being needs of children.

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mental health in East Sussex

The recent move to extend and integrate the Single Point of Advice (SPOA) is helping to address emerging emotional well-being needs of children. An effective multi- agency safeguarding hub (MASH) ensures that, where risk of harm is identified, child-focused responses follow, and children are protected. Many children benefit from interventions to address their complex needs within appropriate timescales. However, some children wait too long when they need a mental health assessment by the child and adolescent mental health services (CAMHS).

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mental health in East Sussex

While the numbers of children receiving emotional well-being or mental health services are monitored, there is more to do to evaluate the quality of the experiences of children within different mental health pathways and to measure the impact of interventions. A Sussex-wide independent review of access to emotional health and well-being support is currently under way and will inform future evaluations and planning.

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mental health in East Sussex

During this JTAI, inspectors found that some areas of multi-agency working could be further strengthened. Most of these areas are already a focus within strategic and operational plans to improve outcomes for children.

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Key strengths

 Professionals make timely and sufficiently detailed referrals about the safety, emotional well-being or mental health of a child or young person through the recently established SPOA triage service. This reduces the number of referrals a child or young person experiences and ensures better access to services to meet their needs. Children are appropriately signposted to other services, including targeted emotional well-being support, if they do not meet the threshold for specialist CAMHS intervention.  Thresholds for services are understood across the partnership. This demonstrates the positive impact of a range of safeguarding children training on frontline practice to recognise and respond to risks from abuse, exploitation and neglect.  Initial decision-making within the SPOA avoids delays in assessing children’s needs. Within the MASH, most police referrals to children’s social care are triaged

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Key strengths

jointly. This helps prioritise children at risk of immediate harm.  When children are identified as being at potential risk of significant harm, multi- agency strategy discussions are mostly timely. There is effective information- sharing from partners and consideration of children’s histories and their emotional and well-being needs.  Assessments of children’s needs are of consistently good quality across a range of agencies within the partnership. They are comprehensive, consider history and demonstrate an in-depth understanding of emotional well-being and mental health needs.  Children and families benefit from an exceptionally stable social care workforce and inspectors heard from young people and parents how much they value the continuity of relationship with their social worker. Social workers use a range of tools to support children’s emotional well-being, including coping strategies for children experiencing anxiety. A cohesive practice model of relationship-based

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Key strengths

approaches continues to underpin high-quality social work with children experiencing poor emotional well-being or mental ill health.  Children open to the youth offending service benefit from prompt access to specialist assessments, including psychological assessments, which analyse the effect of emotional and mental ill health on offending, leading to the timely provision of a range of appropriate services. Wider joint work with a range of partners and the placement of a youth offending worker at a local pupil referral unit is helping to support young people’s desistance from further offending. Leaders of the youth offending service have analysed the prevalence of emotional and mental health needs in the children they supervise in order to better understand the profile of need.  Children who are detained in custody are supported through timely identification of mental health needs by the liaison and diversion service. Assessments are

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Key strengths

completed, and plans put in place, which are shared with relevant agencies to ensure that the correct level of support is provided. Children are referred on for support, for example to Reboot, an early intervention project.  The deep dive analysis of children identified that children benefit from a wide range of services to support their mental health needs within appropriate timescales. Specialist assessments clearly inform multi-agency planning and support appropriate interventions with families. For example, for one child, the substance misuse service facilitated a psychiatric assessment in response to escalation of risk-taking behaviours linked to increased substance misuse. This ensured that there was clear recognition of their underlying mental ill health leading to increased absence from school and offending behaviour.  Overall, children’s plans are effective and bring together a range of services to

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Key strengths

support and address issues for children and adults, including their emotional well- being needs. For children unable to attend school full time, there is tailored education provision which is well matched to children’s assessed needs, resulting in some improvement in engagement and learning.  Professionals work with children to ensure that their mental health needs are prioritised at the child’s pace. Therapeutic interventions are carefully sequenced to ensure that children do not become overwhelmed, outcomes in plans are realistic and there is a sensitive but tenacious approach by workers to keep the child engaged.  Professionals make good use of children’s complex life histories. Good information-sharing across partners ensures that other professionals understand what the child has experienced, and how their responses are affected by their mental ill health. This ensures that children do not have to repeat their, often

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Key strengths

traumatic, personal histories.  There is effective work with brothers and sisters of children with mental ill health, including assessments and plans which recognise and address the emotional impact on children of living with a brother or sister with emotional well-being issues.  There is a cohesive strategy to build the skills and capacity in schools to address children’s emerging emotional well-being at an early stage. School leaders report increasing confidence in being able to plan this early support, facilitated by a dedicated school adviser for mental health and emotional well-being. One of the numerous examples of how this work is coordinated with school staff is the mental health network across schools, which includes 194 school leads and 85 governors.

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Key strengths

 The trailblazer mental health support teams and the newly commissioned emotional well-being support service provided by the school health nurses have ensured that children with these needs can access early support across the whole county.  Sussex Police has a clear approach to dealing with mental health vulnerability and is fully engaged with multi-agency safeguarding partners, supporting partnership initiatives to tackle those presenting risks to children and to formulate plans to support vulnerable children. An assistant chief constable is the force strategic lead for mental health and there is also a force lead who coordinates activity to promote awareness and to improve operational responses for children and young people living with mental ill health.  The force has invested in mental health triage, meaning a police officer and a specialist mental health nurse jointly attend incidents for adults and children.

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Key strengths

Prompt assessments of need reduce the occasions on which section 136 of the Mental Health Act is being used inappropriately. Nurses provide immediate advice, and officers across the force are increasingly knowledgeable and confident in responding to children and young people with mental ill health.  The police workforce is well trained in responding to vulnerable members of the community, including those living with mental ill health. Regular professional development days include input on mental health. Training for officers on capturing the voice of children has resulted in better-quality police referrals to children’s social care. Officers are increasingly aware of risks to children arising from criminal exploitation, and the force co-chairs the strategic multi-agency child exploitation group (MACE) group.  Practitioners in the main health providers in East Sussex are well supported through robust supervision processes and their organisations’ safeguarding

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Key strengths

specialists. There is good coverage of safeguarding training across the providers at all levels, including for staff who are providing direct support to children.  There is a broad universal school health service that offers timely assessment. This provides good opportunities to identify additional health needs. There is active involvement with multi-agency safeguarding practice, and training around emotional well-being and mental health for children of secondary school age.  Children and young people open to the substance misuse service (SMS) benefit from access to cognitive behavioural therapy interventions to support emotional well-being needs, without the need for onward referral. Effective joint work by SMS with partners, for example through an integrated clinic with specialist CAMHS, is supporting a coordinated approach to work with young people who have complex emotional well-being needs. The SMS team delivers training to staff

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Key strengths

in schools, CAMHS and GP practices.  The safeguarding team in East Sussex Healthcare Trust has good oversight of children who attend the emergency department due to mental ill health. Young people deemed at high risk are reviewed at weekly meetings and this ensures that appropriate follow-up has taken place and information is shared with universal health services and primary care.  General Practitioners have good oversight and flagging of children who have attended the emergency department. This alerts clinicians to safeguarding vulnerabilities relating to the child and family and ensures that appropriate follow- up has taken place.  There are well-established, mature arrangements for the joint commissioning of emotional well-being and mental health services for children using a cohesive place-based approach as part of the Sussex-wide Integrated Care System. Senior commissioning posts are jointly funded by the clinical commissioning groups and

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Key strengths

East Sussex County Council.  This continuity in leadership has ensured that successful services have continued to grow. For example, the jointly commissioned and local authority led ‘Swift’ service is providing multidisciplinary consultation, assessments and intensive interventions to address a range of identified needs, such as mental ill health, sexual abuse, sexual risk and domestic abuse. This well-established service continues to develop, with additional commissioning partners enabling it to offer other areas of specialism, such as trauma-informed responses to young people who are at high risk of exploitation. The emotional well-being needs of younger children are well considered, and video interactive guidance is available to adoptive parents and special guardians.  Recent service developments, directed through the well-established East Sussex local transformation plan, are helping to provide better access for children to

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Key strengths

more targeted interventions for emotional well-being and mental health across the continuum of need. The newer primary mental health worker service, the extended SPOA, the mental health support teams for schools, and the newly commissioned emotional well-being services provided by the school health team provide greater capacity in the system to help children and young people to get more timely access to the right level of support. The local plan has made good use of existing sources of data and evidence-based research to help commissioners and partners understand the prevalence and profile of children living with mental ill health.  The East Sussex Health and Wellbeing Board has effective oversight of how strategic priorities and ambition are translating into service delivery and integration. Further planned changes to governance should ensure that a high priority is given to children’s mental health; for example, two new sub-groups

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Key strengths

have been created, which will report to the Health and Wellbeing Board.  Co-production with young people is an integral part of strategic planning, commissioning and priority-setting in East Sussex, with senior leaders engaging with a range of young people’s groups. Recent examples such as ‘Takeover Challenge’ and the ‘Make Your Mark’ ballot in schools have informed strategic priorities. Young people told inspectors that they can influence decisions and are helping to design services to support emotional well-being, so they are less stigmatising for children.  A dynamic voluntary sector works collaboratively to deliver services to vulnerable children with a range of emotional well-being and mental health needs. The partnership has a clear strategic focus on building the capacity of the voluntary sector to deliver services at both a highly localised level, such as Hastings Opportunities Area Project, and across East Sussex. The sector is well

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Key strengths

represented in the East Sussex Safeguarding Children Partnership meetings and workstreams.  The Safeguarding Children Partnership provides robust scrutiny of a wide range of safeguarding arrangements. The partnership’s performance dashboard has a breadth of key indicators across a range of partners and includes indicators about children’s well-being and mental health, such as numbers of referrals to CAMHS. This routine scrutiny informs well-targeted quality assurance work. The Safeguarding Children Partnership also supports the strategic focus on schools and the voluntary sector having the capacity and resilience to provide accessible emotional well-being support to children. This is supported through a comprehensive training offer for partners, which is adapted to respond to demand and emerging themes, such as responding to children who self-harm.  Learning from a recent serious case review, Child T, has been widely

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Key strengths

disseminated across the partnership and has improved frontline practice when working with older children with both long-term health conditions and mental ill health. As well as informing improvements at a local level, the learning is being used by several national organisations.  The MACE has used analysis and profiling to understand the prevalence of mental ill health in young people at risk of exploitation to better understand how this increases children’s vulnerability to exploitation. Responses to children who are at risk of criminal exploitation in East Sussex are developing, including the use of safeguarding approaches to reduce the risks children face from county lines. The partnership is considering, informed by an ongoing research, how to identify an approach to contextual safeguarding which will work within a large county with contrasting communities and profiles of need.  Initiatives, like the recently established open access multi-agency i-Rock hubs,

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Key strengths

have been successful in providing immediate access to a range of services, including emotional well-being support, to young people who may not engage with traditional community mental health services.  There is a range of training and support available for foster carers and residential workers to support children’s mental ill health, including understanding self-harm and the impact of the digital world on emotional well-being. The mindfulness- based stress reduction course improves foster carers’ own sense of well-being and helps to contribute to greater placement stability for children.  Performance management, feedback from children and families, and audit information are all used effectively in children’s services to inform improvements and service developments. A recent example of this, following a review of longer- duration child protection plans, is the development of the Be-safe team to provide

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Key strengths

intensive support to families where there are long-term interventions to address neglect.

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Case study: highly effective practice

Children benefit from well-coordinated multi-agency working that is informed by high-quality assessments of needs completed and shared across relevant agencies in East Sussex.

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Case study: highly effective practice

For one child, an exemplary quality health assessment resulted in prompt action to address undiagnosed and emerging emotional well-being and mental ill health needs. The contribution from a consultant paediatrician ensured a good understanding of the difficulties linked to the child’s attention and hyperactivity disorder. Close liaison between the child’s social worker, ‘Swift’ and CAMHS services led to effective therapeutic work which took place at the child’s pace. This work is informing a highly individualised learning programme which is helping to gradually improve attendance and engagement in education. Combined, these actions are providing the foundations for improved emotional and mental health.

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Areas for improvement

 For some children, there are difficulties establishing the right pathway when their emotional well-being needs are first assessed or when there is a need to respond quickly to deteriorating mental health. Where emotional well-being or mental ill health are the presenting issue, professionals do not always consider the wider needs of children and young people. In a very small number of cases, there is delay for children while professionals agree which service is most appropriate to assess and address the children’s emotional and mental health needs.  The deep dive analysis of children identified that, although risk and children’s mental health needs are recognised, this has not always translated into effective and timely multi-agency interventions for all children. In some cases where children may display chaotic and high-risk behaviours, and frequently go missing, the seriousness of new safeguarding incidents is not sufficiently recognised by

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Areas for improvement

professionals. The risks from professional networks becoming ‘stuck’ or overwhelmed when there is little improvement in children’s emotional well-being, or families are highly avoidant, are not always recognised.  Plans for children, including child in need and child protection plans, are not always clear about who is doing what and by when. Contingencies or alternative actions are not clearly set out, including when there is limited engagement by families. There are not always timely and effective escalations by agencies when risk is not reduced, and there is a lack of progress, including a lack of action in criminal investigations related to children with mental ill health who are at risk of harm and exploitation.  When children are at risk of harm, actions agreed in multi-agency meetings, such as strategy meetings and MACE meetings, do not consistently record who will undertake tasks or timescales; this makes it difficult to hold professionals to

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Areas for improvement

account or ensure timely responses to risks. Not all strategy meetings are timely and a very small number lack information from all the key agencies.  All children who may be at risk of exploitation are discussed in multi-agency child exploitation meetings. There is insufficient time in the meetings to consider each child in depth and this results in a lack of focus on key aspects of planning to tackle exploitation, including mapping and disruption activities. These weaknesses have been recognised by leaders and the scope and format of MACE meetings are currently under review.  For children unable to attend or manage full-time education, referrals by schools for early intervention for attendance or behavioural concerns linked to mental ill health are not always timely. This results in delays for some children receiving a more tailored alternative educational provision.  The current arrangements for assessing the mental health of children and young

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Areas for improvement

people who present at hospital emergency departments in crisis are insufficient due to the limited capacity of the mental health liaison provided to the emergency departments. Some children wait too long to be seen by specialist mental health practitioners and some are admitted to hospital unnecessarily. Leaders have been slow to address this key area of risk; however, plans are now under way to make immediate improvements in the liaison service.  Some children and young people wait too long for an initial assessment by CAMHS, followed by significant waits to access treatment for mental ill health across most pathways and services within CAMHS. Despite attempts to address these delays, and support provided for some children via primary mental health workers, the overall response to address these unmet needs and the level of scrutiny and monitoring by commissioners have not been effective.  Some children in care wait for a significant length of time for their treatment to

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Areas for improvement

begin due to insufficient resources to meet the level of increased demand for the looked after children mental health service (LACMHS). A waiting list of 15 children is actively managed through increased consultations with professionals, including foster carers, and the more recent offer of therapeutic group work. Liaison between looked-after children nurses and LACMHS needs strengthening to ensure that young people’s mental health needs are kept under joint review. Leaders recognise that they need to do more to improve the access to therapeutic support for children in care.  Communication and information-sharing between universal health services and GPs are underdeveloped. Not all practices have a named link health visitor although every health visiting team has a duty system in place as a more consistent support to GPs, and some are unaware of how to contact the school health service. This means that information about children’s emotional and

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Areas for improvement

mental health, and about safeguarding, may not be managed effectively between GPs and universal services, and there is a risk that neither service will have a complete picture of children’s needs or risks.  Assessment documentation in use in the emergency departments at the Conquest and Eastbourne hospitals does not contain a safeguarding assessment tool, and this does not support staff to be professionally curious about children’s presentations. A mental health triage tool designed to support staff in identifying mental health needs is not being used routinely in the Conquest hospital. Furthermore, the child’s voice is not consistently captured in the records, which means that practitioners cannot be assured of a holistic assessment of need, including consideration of the impact on a child, when a parent or carer attends the emergency department.  GPs do not always adopt a ‘think family’ approach to identify the risks to children

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Areas for improvement

when parents, carers or other significant adults are seen. Not all GPs visited are yet fully aware of, or engaged with, the local multi-agency risk assessment conference (MARAC) processes to plan for victims at high risk of domestic abuse. The process for requesting information from health services to inform MASH decisions is underdeveloped. Requests do not give enough detail about concerns for children to support the practitioner in identifying what information is appropriate to share, and subsequent decision-making is not consistently fed back to health services.  When there are cumulative concerns about children, including their mental ill health, these concerns are not always being recognised or informing decision- making. There is not currently a system to consider children about whom there are a high number of repeat contacts to children’s social care. This is compounded by limited recording of the rationale for decisions made by

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Areas for improvement

managers within the SPOA and the MASH.  For children who offend, the out-of-court disposal process does not consistently or effectively identify those who would benefit from assessment and interventions to address offending behaviour, including behaviour linked to mental ill health.  Where children are detained in custody, officers do not always refer these incidents to children’s social care. This means that, despite ongoing awareness- training, some officers do not yet fully understand the vulnerability of children who are in custody.  The use of warning markers and flags for vulnerability and risk on police force systems is inconsistent and does not always support officers in responding to risk. A senior officer is leading a review to identify improvements in this area.  In this inspection, a review of some children’s cases where children were the victims of crime due to abuse or exploitation highlighted that the force has some

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Areas for improvement

areas of weakness in its investigations. Leaders are committed to addressing these areas for improvement, including the need for authoritative management and supervision of such investigations.  Senior leaders have a range of measures to establish changes or trends in the use of services. However, the use of more qualitative information to establish whether young people have greater access to, and choice of services would better demonstrate the impact of these new services. Leaders intend to incorporate this within a wider review of the recently extended SPOA.

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Case study: area for improvement

The partnership needs to do more to reduce delay and avoid drift in planning for children with long-term complex mental health needs.

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Case study: area for improvement

Recently, one child in care has experienced a delay in receiving a specialist assessment, despite long-standing concerns in relation to emotional, behavioural and mental health issues. Delays in completing both specialist assessments and a neuro-developmental assessment have meant a delay in the start of therapeutic work. However, the child has benefited from direct work by their social worker, with whom they have a trusted relationship.

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Case study: area for improvement

Partners missed earlier opportunities to consider this child at MACE and to create a robust response plan to a high number of incidents of being missing from care. This child has missed a significant amount of their education. Although more recent planning and interventions reflect a clearer focus and greater urgency in planning, they have not yet improved the child’s safety and emotional well-being.

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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 the police, children’s social care, the clinical commissioning group, health providers in East Sussex, and the youth offending service. The response should set out the actions for the partnership and, where appropriate, individual agencies. 2

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Next steps

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. The director of children’s services should send the written statement of action to ProtectionOfChildren@ofsted.gov.uk by 23 July 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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