Setting

Joanne Siddle, Director of Children’s Services, Blackburn with Darwen Professor Sarah O’Brien, Chief Nursing Officer at NHS Lancashire, and South Cumbria ICB Andrew Snowden, Lancashire Police and Crime Commissioner Chris Rowley, Chief Constable, Lancashire Constabulary

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Dear Blackburn with Darwen Local Safeguarding Partnership

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Joint targeted area inspection of Blackburn with Darwen

This letter summarises the findings of the joint targeted area inspection (JTAI) of the multi-agency response to identification of initial need and risk in Blackburn with Darwen.

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Joint targeted area inspection of Blackburn with Darwen

This inspection took place from 22 to 26 May 2023. It was conducted by inspectors from Ofsted, the Care Quality Commission (CQC) and His Majesty’s Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS).

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Headline findings

Committed leaders across Blackburn with Darwen (BwD) safeguarding partnership fully support the Pan-Lancashire Children’s Safeguarding Assurance Partnership (CSAP) decision to reconfigure its strategic safeguarding arrangements. They rightly recognise that the current CSAP arrangements do not provide sufficient assurance at a granular level. They are moving to devolved local ‘place-based boards’ across the three local authority areas of Lancashire, Blackpool and BwD by September 2023. CSAP will retain some shared functions.

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Headline findings

Aspirational BwD leaders have taken decisive and effective action to expedite work aligned to the CSAP shared priorities to ensure that vulnerable children and their families can quickly access locally delivered help, support and protection. Recent changes in the BwD senior leadership team have been a catalyst to this transformation, intended to enhance the quality of practice with vulnerable children. These changes have supported the framing of shared objectives and a culture of high expectation, where understanding the child’s experiences is driving improvements. Partnership working is strong. The Lancashire and South Cumbria Integrated Care Board and NHS trusts’ safeguarding leads, the police and children’s social care are equal partners and active contributors in the development and implementation of the revised safeguarding partnership arrangements. Action by BwD senior partners to include local school leaders is a significant improvement.

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Headline findings

While it is too soon to fully evaluate the impact of these changes, credible plans are in place, building on the existing strengths to create an environment where children’s voices are consistently central to safeguarding decisions, both strategically and operationally. Leaders are outward looking and welcome external scrutiny. They fully accept the findings of the inspection. They know their services and the population needs well and have a clear understanding of their strengths and challenges.

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What needs to improve?

◼ Shared and consistent multi-agency processes and records of referrals when professionals identify children in need or at risk of harm. ◼ The quality and consistency with which the voices of children and their lived experiences are recorded in referrals, assessments, plans and multi-agency reviews. ◼ Formal multi-agency triage processes, or meetings to consider referrals that do not meet child protection thresholds in the children’s advisory duty service (CADS). ◼ Communication with and involvement of health professionals, police, schools and children’s social care in meetings and in decisions about next steps to help and protect children. ◼ Contingency planning and effective challenge by health professionals, police, schools and social care for children who are the subject of repeated referrals or child in need or child protection plans. ◼ The effectiveness of management oversight and supervision in health, police and

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What needs to improve?

children’s services. ◼ Accurate partnership performance management systems, routine multi-agency audits and rigorous evaluation and analysis of the impact on children’s experiences across services. ◼ The involvement of children and their families in co-creating services locally.

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Strengths

◼ Children who are at immediate risk of significant harm receive a prompt, proportionate and effective partnership response through CADS. ◼ Children and their families benefit from responsive, well-coordinated universal and multi-agency targeted early help services, including out of hours, which are helping to reduce harm. ◼ Children who go missing from home or are at risk of sexual and criminal exploitation receive effective help and protection from the police-based co-located multidisciplinary Engage team. ◼ Schools provide a range of excellent proactive support for children and families. ◼ The highly effective multidisciplinary weekly ‘transforming lives panel’ ensures that individual children are provided with the right level of help from the most relevant professionals. ◼ Resolute practitioners and accomplished leaders across agencies work well together to understand the experiences of individual children in their families.

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Strengths

Working relationships across the partnership are extremely positive, and staff at all levels know each other well . ◼ Senior leaders are working together well to accelerate the development of a cogent ‘place-based’ children’s safeguarding board, specifically designed to provide high-quality, locally and swiftly delivered child-centred services.

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Main findings

Thresholds of risk, need and harm to children are mostly understood and applied by co-located health, police, children’s social care and early help professionals in CADS. The importance of obtaining parental consent for services is well understood and clearly recorded. Staff with the requisite safeguarding skills and experience represent their respective organisations. Strategic leaders have taken action to ensure that health professionals’ expertise is fully utilised in CADS in response to all referrals about children. Although managers constantly discuss children’s referrals, there are no formally recorded multi-agency triage processes or meetings to consider referrals that do not meet child protection thresholds or to confer when social care managers make decisions to close referrals. This is not challenged or escalated by professionals. Leaders recognise more work is needed to ensure that all partners are

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Main findings

routinely included when social work managers make decisions about the next steps to help and protect children. Furthermore, that they are consulted when decisions are made to step children down from statutory services to early help.

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Main findings

The absence of an agreed or standardised multi-agency referral system means that it is not possible to ensure sufficient audit or management oversight of the quality of referrals. The police consistently provide a police safeguarding referral form to CADS when they identify children requiring help, support or protection. All other referrals to CADS are made verbally by phone. Partner agencies are reliant on the written interpretation of the relayed information by social care staff. Consequently, leaders are unable to evaluate the quality of information provided across the partnership or about children’s experiences. For example, staff in the hospital emergency department make safeguarding referrals verbally to CADS and then record on the hospital system that a referral was made, but details of the concerns are not recorded. This means that the health safeguarding team is unable to monitor thresholds of harm and risk or to audit the quality of referrals. In addition, children’s

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Main findings

case records in CADS indicate that information-gathering with schools is inconsistent. For instance, some social workers send emails to school staff and ask for welfare checks; in other children’s cases, social workers telephone schools. Practice notes are not consistently detailed enough to indicate what information is gathered from schools or how it is sought. Professionals across agencies respond quickly and take effective action to protect children at immediate risk of harm. Strategy meetings are timely and involve relevant professionals, although in urgently convened child protection strategy meetings education professionals are not routinely consulted. Contributions from schools at planned child protection strategy meetings are more consistent. Health visitors or school nurses represent health services at child protection strategy meetings, and CADS health practitioners attend urgently convened strategy meetings. A designated

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Main findings

police staff member takes appropriate responsibility for attending and sharing police information. Interventions are proportionate to risk. Detailed notes are provided by social care business support officers, but minutes are not shared consistently across the partnership.

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Main findings

Child protection investigations are mostly thorough. Stronger investigations and assessments are informed by the child’s history and incorporate previous involvement by most agencies. Risks and strengths are identified and analysed well. Communication with the police, especially in cases of domestic abuse, continues throughout the process. Multi-agency information-sharing and interventions are evident during the assessment period. Direct work using a range of tools helps children to express their views. Sensitive work by persistent social care and family support workers, school professionals and police officers is effective. Most children are seen alone and there is evidence, across teams and services, of persistent child- centred work to engage each child and their parents, for example, joint visits with health visitors and direct work in schools. Multi-agency child in need and early help family planning meetings are held regularly and most are used effectively to review

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Main findings

and update plans. Nevertheless, despite a clear understanding of children’s experiences by practitioners, children’s case records, assessments and plans do not consistently capture the voices of the children.

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Main findings

Several children known to services, sometimes for years, who are living with parental domestic abuse, parental substance misuse or who experience chronic neglect are subject to repeat referrals and children in need and child protection plans. In many of these children’s cases, contingency thinking and planning are absent. Children and parents are often subjected to the same parenting assessments and interventions more than once, without evidence of previous changes having been sustained. This approach is insufficiently challenged or escalated by the professional partnership. It is also exacerbated by frequent changes in social work staff and a ‘start again’ culture. Practitioners working with the same family do not consistently make joint decisions or share pertinent information for these children.

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Main findings

Most children benefit from skilled and committed frontline early help, social care and health practitioners, police officers and school staff working collaboratively to support them and their families and to prevent risk and harm escalating. Police staff understand vulnerability well and complete risk assessments which they use in their role to protect children. Children presenting to East Lancashire Child and Adolescent Service (ELCAS) at risk from domestic abuse or criminal or sexual exploitation are fast-tracked when there are safeguarding concerns, to ensure that their mental health needs are met swiftly. The school nurse team offers a universal service to children who are home educated . Children are appropriately safeguarded from harm out of office hours by the emergency duty team, which collaborates well with the police, health staff and day services.

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Main findings

Well-coordinated universal and multi-agency targeted early help services are helping to reduce harm across all age groups of children. Compassionate practitioners across all agencies work well together to understand the experiences of individual children in the family. Working relationships across the partnership are incredibly positive at all levels. Staff know each other and the children well. They consistently report that approachable and highly visible senior leaders listen to them and provide support. The partnership commissions an array of accessible and effective services to meet children’s and young people’s assessed needs. For example, these services include access to the local football club for some children who are receiving support, or specific support that is making a difference to children who experience parental domestic abuse.

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Main findings

The highly effective multidisciplinary weekly transforming lives panel ensures that individual children are promptly provided with the right level of help from the most relevant professional. Exemplary proactive work by school staff working collaboratively across the partnership, with assistance from skilled family support workers, is making a tangible difference to enhancing the outcomes achieved by children of all ages. Inspectors saw examples of sensitive direct work with children from diverse backgrounds and cultures that provides children with opportunities to tell their stories and to explore any worries they may have. Agencies recognise the impact that poverty and unstable housing have on families and work diligently alongside housing organisations, the Department for Work and Pensions and charities to support families to ensure that children’s basic needs are met.

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Main findings

A Department for Education pilot project provides effective supervision and challenge for designated safeguarding leads (DSLs) in schools. Leaders have determined this has had a positive impact and will continue to provide this support locally. This project has expedited support for children and their families. Leaders have established network meetings for DSLs, which are used effectively to improve school leaders’ safeguarding practice and knowledge about services. Mental health practitioners based in schools identify children with emotional difficulties quickly and support them to access appropriate resources. Well-established and effective systems are in place for schools and within health services to receive Operation Encompass domestic abuse information. Police have extended Operation Encompass to include any concerns for children, when police consider that alerting schools enables additional safeguarding support for children.

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Main findings

Effective and authoritative practice by the co-located multidisciplinary Engage team adds value and leads to better outcomes for vulnerable children at risk of sexual and criminal exploitation and those missing from home. Inspectors observed patient, tenacious and respectful work with children, helping them to build trust with adults. Staff spend time with children to help them understand what is happening to them and to gain a good understanding of their needs. Online abuse is taken very seriously. Links with external agencies are helping to raise awareness, and the recent inclusion of Engage staff in CADS is a strength. Increased digital support to improve effectiveness in mapping high-risk areas and disruption of perpetrators is planned. Leaders acknowledge that performance reporting and evaluation of the impact of the Engage team’s work need to be strengthened.

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Main findings

The frequency, model and effectiveness of safeguarding supervision is inconsistent across most services. In children’s social care, while supervision takes place regularly, the impact is variable. It often lacks analysis about whether requisite changes are being achieved or sustained, limiting its focus to the completion of tasks. Staff supervision in the early help service is stronger. Police staff have good access to their supervisors and specialist units when they need further help or guidance in relation to child protection matters.

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Main findings

The Lancashire and South Cumbria NHS Foundation Trust safeguarding team has effective oversight of the activity completed by the CADS and 0-19 health practitioners for children and young people. This supports a positive understanding of demand, capacity and the standard of the health contribution, but formal safeguarding supervision is not in place for all health staff. There are opportunities in some services for practitioners to request advice and guidance and explore complexities in their practice, but this is not routinely recorded. In addition, there is limited management oversight of adult mental health caseloads when children are linked to adult service users, unless safeguarding risks are already known. Conversely, SPARK adult substance misuse service leaders have a strong understanding of all children linked with adult service users.

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Main findings

Performance management is a key priority for improvement, as BwD leaders recognise that the current CSAP partnership performance management and audit arrangements are underdeveloped. This impedes their ability to track and demonstrate continuous improvement. BwD leaders have taken action to develop a separate local multi-agency quality assurance and audit subgroup. This is augmented by increased governance and scrutiny provided by the independently chaired local authority improvement board. Strategic leaders have a shared understanding of their role, function and purpose and are focused on continuous child-centred improvement. Practitioners across all agencies in BwD benefit from effective safeguarding children training, which is developed and delivered in the respective organisations using a range of mediums. During their initial training, police officers from Lancashire Constabulary receive training in protecting vulnerable people and children. There is

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Main findings

also mandatory interactive e-learning available to all practitioners. Staff report that they are well supported, feel valued and have good access to a wide range of multi- agency training and development opportunities. Nonetheless, engagement with multi-agency safeguarding training by all services is limited. BwD local leaders across the partnership actively advocate the benefits of multi-agency training on practice and have identified the improvements needed to strengthen attendance by frontline staff.

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Next steps

We have determined that BwD Children’s Services is the principal authority and 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 individuals and agencies that this report is addressed to. The response should set out the actions for the partnership and, when appropriate, individual agencies. The local safeguarding partners should oversee implementation of the action plan through their local multi-agency safeguarding arrangements.

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Next steps

Blackburn with Darwen should send the written statement of action to ProtectionOfChildren@ofsted.gov.uk by 23 October 2023. This statement will inform the lines of enquiry at any future joint or single-agency activity by the inspectorates. Yours sincerely

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