Setting

Ann James, Director of Children’s Services, Gloucestershire Dame Gill Morgan, Chair at NHS Gloucestershire ICB Mary Hutton, Chief Executive Officer at NHS Gloucestershire ICB Dr Marion Andrews-Evans, Chief Nursing Officer at NHS Gloucestershire ICB Rod Hansen, Chief Constable, Gloucestershire Police Chris Nelson, Police and Crime Commissioner Gloucestershire Mark Power, Independent Scrutineer

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Dear Gloucestershire Local Safeguarding Partnership

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Joint targeted area inspection of Gloucestershire

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 Gloucestershire.

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Joint targeted area inspection of Gloucestershire

This inspection took place from 12 to 16 June 2023. It was carried out 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

Most children living in Gloucestershire who are initially identified to be in need of help and protection receive a swift and appropriate multi-agency response from the ‘front door’. Senior leaders’ strategic partnership is strong, and this mature relationship is supported by effective governance in the Gloucestershire Safeguarding Children’s Partnership (GSCP). Senior leaders on the executive board have appropriate oversight and knowledge of the effectiveness of multi-agency safeguarding arrangements. Their commitment to a continuous learning culture results in proactive intervention to improve services for children.

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What needs to improve?

◼ The consideration of children’s wishes and feelings as initial need and risks are identified, so that children’s voices are used to help inform decisions across all partner agencies. ◼ The efficiency of partner recording systems to better support multi-agency information-sharing about children’s needs. ◼ The consistent application and timeliness of Operation Encompass notifications to schools when children have experienced domestic abuse in the family home. ◼ The consistent use of the police vulnerability identification screening tools (VISTs).

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Strengths

◼ The independent scrutiny arrangements in Gloucestershire provide effective challenge and accountability to the GSCP. ◼ A daily multi-agency vulnerability meeting held in the front door promotes effective partnership working. Information on the current impact of risks to children is appropriately shared and next steps identified. ◼ There is strong partnership working between the police and schools. Police proactively provide training and attend assemblies to talk to children in schools about keeping safe in relation to specific topics, such as online safety and knife crime.

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Main findings

When children are identified as needing help and protection in Gloucestershire, the majority of children receive an appropriate and swift multi-agency response from the front door. Most contacts and multi-agency referral forms (MARFs) completed by partner agencies identify children’s needs and appropriately consider the impact of children’s current circumstances on their lived experiences. Referrals from the South West Ambulance Service are particularly strong. This detailed information about children’s circumstances helps to support multi-agency safeguarding decision- making, based on holistic family information.

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Main findings

Pregnant women in Gloucestershire are assessed using the pre-birth multi-agency protocol. This means that additional vulnerabilities can be identified, and further referrals for support made appropriately to the front door. Women who book late or conceal their pregnancy are appropriately referred into the multi-agency safeguarding hub (MASH). They are triaged in a timely way, which helps to protect the unborn baby. In addition, health visitors make effective and timely referrals into the MASH when children’s additional needs are identified. This ensures that information on those children they are concerned about is shared with partner agencies, which supports a multi-agency response.

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Main findings

While the quality and information about children in the majority of MARFs is strong, the electronic process for submitting and receiving acknowledgements and feedback from the front door is challenging for some services. Some practitioners, for example staff in the emergency department (ED), midwives and health visitors, report that the portal does not always work and, as a result, acknowledgements of MARFs submitted are not timely. When this happens, staff are required to follow up the referral to ensure that it has been received and appropriately responded to. Partners mostly obtain appropriate consent from parents and families before sending requests for help and support to the front door. The majority of partners understand Gloucestershire’s levels of intervention guidance and the early help graduated pathway. The response to most children’s contacts in the front door is effective and proportionate. Families’ views are obtained, and this enables them to make informed

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Main findings

choices about services and support. Consent is routinely considered, and if it is dispensed with, the rationale for this is recorded in children’s records.

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Main findings

When partners consider that children need early help support, the early help triage response in the MASH is timely and effective. Families are contacted to discuss the support required and, when appropriate, they are signposted to community support services or stepped across to early help for intervention from a family support worker. Some children and families can wait for up to 10 weeks before allocation to a children’s centre family support worker for completion of an early help assessment. While families are supported in the interim by a duty early help worker, there remains a delay for some children in receiving the right help quickly enough. Senior leaders have identified this, and recommissioning plans for this provision are in place.

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Main findings

Once children are allocated to a family support worker, children’s early help assessments are comprehensive and child-focused. They include the views of children, their worries and daily life experiences. Parents’ views and their own childhood history are collated and used effectively in the analysis about risks and needs, to inform planning. Safety plans are clearly written and easy for families, children and professionals to understand.

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Main findings

Good partnership working between the police and schools and early intervention are helping to prevent the need for some children to be referred to the front door. Police proactively provide training and attend school assemblies to talk to children about specific areas such as online safety and knife crime. Schools value this, and report that it is effective in de-escalating issues that may otherwise increase risks to children.

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Main findings

When risks to children increase, referrals are appropriately escalated for MASH checks. MASH checks are requested from relevant agencies and information is generally received back within the agreed time frame. Social workers report strong partner relationships and good communication. If they need additional clarification or information, they can approach their MASH partners, and co-location enables this to happen quickly.

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Main findings

Decision-making about the most appropriate next steps to safeguard children is informed by a range of relevant multi-agency information. The MASH health practitioners receive requests for information for all contacts into the MASH at different priority levels. They have full access to information about children from community health services and read-only access to the acute hospital system for ED attendances, admissions and outpatient appointments.

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Main findings

When MASH health practitioners are unable to directly access information about children and families, such as in maternity and sexual health services, alternative arrangements are in place for professionals to share information. This information and analysis help to inform multi-agency decision-making about next steps. Police staff in the MASH have access to children’s social care records; this provides an efficient means of establishing if a child is open to social care and helps speed up the referral process.

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Main findings

Children’s voices, wishes and feelings are not always consistently considered when needs are identified. This reduces professionals’ ability to use children’s views in decision-making on next steps. A very small number of children living in large sibling groups receive insufficient focus on their individual needs. There can also be reduced understanding of the impact of a child’s additional needs, which contributes to a failure to capture the voice of the child. Senior leaders know there is more to do to capture the voices of children effectively. While there are strong examples of this in health services and schools and in early help records, this is inconsistent across the partnership.

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Main findings

Electronic systems used by partners to share information about children’s needs and risks to children are inefficient. This can lead to challenges in sharing information about children effectively, resulting in a weaker understanding of the child’s voice and their lived experience. A Children and Young People’s Wellbeing Coalition, composed of strategic representatives, is in place to coordinate the transformation plans of local partners, to improve outcomes for all children and young people. Integral to this plan is for partners to develop a shared digital platform that will support information-sharing about children’s needs. This will provide partners with a single view of the key information about the child and their family, from a range of single-agency systems.

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Main findings

Despite this shared transformation ambition, there are current challenges for partners in being able to share information about children efficiently. The front door response arrangements rely on four different operating systems. This means that information about children’s needs is not easily transferable, so it can sometimes be problematic to locate. The hospital trust has several different digital systems that do not link to each other. In addition, when police submit a VIST to the front door, this information remains in the MASH inbox until read by MASH police staff. Not all VISTs submitted on the digital mobile app used by frontline officers are being uploaded to the main Gloucestershire police information management system. This means that when a police officer interacts with children in the future, the officer will have to access a number of different systems to understand all the available information. This has the

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Main findings

potential to affect decision-making if any of these systems are overlooked.

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Main findings

The daily vulnerability meeting held in the MASH is a partnership strength. The meeting is well attended by partners, who share relevant information about risks to children and their needs, following submission of police VISTs. The impact of decision-making about children and who is best to work with them and their family is well considered. Next steps and actions may include early help intervention. Decisions are appropriate, in line with the level of risk and needs identified for children in the meeting. Meetings are chaired by MASH police staff, who demonstrate effectively relevant questioning, professional curiosity and pertinent actions.

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Main findings

When children are considered to be at risk of or subject to significant harm, these risks are appropriately considered at multi-agency strategy discussions. Strategy discussions are timely and well attended by partners. Discussions in strategy meetings focus on risks to children, including unborn babies, and actions from strategy discussions are appropriate. The resulting child protection investigations are focused directly on the actions identified in the strategy discussions, and this helps ensure that they are appropriately progressed.

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Main findings

Emergency duty team (EDT) staff can access children’s records in early help and social care. This enables them to see all relevant information about children’s current circumstances and risks, so they are well informed if they receive a request for intervention. When children are at risk of significant harm, EDT workers convene urgent strategy discussions with health and police partners, so that protective plans can be put in place to ensure children’s safety until further intervention can be initiated by the MASH.

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Main findings

The child exploitation, missing and mental health team, based at police headquarters, is co-located with the multi-agency child sexual exploitation team. This helps to ensure that there is a coordinated multi-agency response when children are identified to be at risk of or experiencing harm from exploitation, including children who are reported to be missing from home or care. Partners have a close working relationship, and this supports effective information-sharing to better understand exploitation risks to children. Through a multi-agency child exploitation meeting, partners share intelligence and information effectively about local hot spots, perpetrators and persons of concern. This enables professionals to identify emerging themes to develop targeted disruption activity. In addition, the coordination of actions to inform children’s current risk assessments and trigger plans is supported by daily multi-agency

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Main findings

Dedicated teams in the police and the youth support service focus on missing children, and these professionals know the children well. When children are reported to be missing from home or care, return home interviews are completed by the youth support team. These are offered within appropriate timescales and outcomes shared consistently with the police, albeit in summary form. The youth support team creates, manages and updates children’s plans from information obtained from these interviews. These plans help to inform the actions and enquiries that the police use as a priority to trace a missing child quickly when they go missing. They are known as trigger plans. This intelligence-led response provides a better chance of tracing missing children earlier, thus reducing the potential risk of harm.

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Main findings

There is a lack of robust process to ensure that police VISTs are submitted when they should be. Police logs indicate that some VISTs have been submitted. However, this may not occur until days or weeks after the related incident.

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Main findings

When children are initially reported missing to the police, they can be placed in a concern for safety category by the force control room before being recorded as missing. This means that if they are found while still in the concern for safety category, it does not automatically result in the creation of a VIST, as it would if they were recorded as missing. This has the potential to affect decision-making, due to a lack of understanding of all the risks to children. This can also mean that, for some children, a return home interview is not requested and as a result trigger plans are not updated.

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Main findings

When children’s needs warrant further children’s social care intervention following MASH checks, children’s assessments are detailed and thorough, with most including relevant information from partners. Children are seen promptly at the allocation of assessment, on the same day when this is required. Children are visited at home and, when appropriate, in school. Children’s needs and risks are identified in assessments and outcomes. Children’s plans lead to children receiving the right help and intervention.

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Main findings

The majority of professionals across the partnership are able to access regular supervision with their line managers. However, health practitioners across all services receive an inconsistent safeguarding supervision offer. Some health staff benefit from restorative and reflective supervision on a one-to-one basis and reflective practice group sessions. Not all staff are aware of such sessions, and while they can access advice and guidance from the safeguarding team, this is reliant on them requesting such support and is not embedded as part of day-to-day practice.

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Main findings

The GSCP executive board is supported by the management group, which has representation from the chairs of appropriate and relevant subgroups, including the MASH subgroup. The management group meets before and after executive board meetings, which helps to ensure that information about multi-agency services to support children flows effectively across the partnership.

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Main findings

The GSCP business unit has sufficient investment and resources that are appropriately shared across the partnership. Data is used effectively to monitor performance at the front door and partners have recently agreed additional investment for a full-time partnership data analyst post. Senior leaders consider data to be essential, and the vision for this post is to enable different agencies to better understand the needs of children who are receiving support from a number of services. While not yet demonstrating impact, this investment shows a clear strategic commitment to safeguarding children.

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Main findings

The GSCP has responded well to capacity challenges within the health safeguarding leadership teams. The safeguarding partnership has supported the development of business cases to increase health resources in both the Integrated Care Board and provider organisations, to better meet their multi-agency obligations. This work is currently ongoing, as there is still more to do, particularly to increase the capacity in the acute trust’s safeguarding team.

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Main findings

Performance information, including scorecards on activity in the front door and MASH, helps support leaders and managers to have oversight of frontline practice. A significant joint scoping exercise and multi-agency audit activity, with a focus on strategy discussions, was completed following local and national learning reviews. The results have led to a revised strategy discussion guidance document and changes to partner resources that have increased their capacity. As a result, the timeliness and quality of multi-agency strategy discussions about risks to children have improved.

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Main findings

The independent scrutiny arrangements for the GSCP help senior leaders across the partnership to keep a focus on continuous learning, both locally and nationally. This effective challenge from the independent scrutineer, alongside an appropriate escalation policy that is well used, helps partners keep a focus on current safeguarding priorities for children. The multi-agency training offer, provided by the safeguarding partnership, is comprehensive. Training is well attended and highly valued by staff across all agencies. Schools, in particular, report that multi-agency safeguarding training is of high quality. Schools can receive bespoke training in specific contexts when identified. For example, designated safeguarding leads have the opportunity to visit the MASH to learn how to complete MARFs accurately and this enables them to better understand the referral processes to the front door.

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Main findings

There has not been sufficient oversight from the partnership of the effectiveness of Operation Encompass notifications for schools when children have experienced domestic abuse in the home. These notifications to schools can only take place once police submit a VIST. Some VISTs are delayed and a few not submitted at all. It is positive that all schools are fully engaged in Operation Encompass; however, some report delays in receiving timely notifications. This impacts on the school’s ability to provide the appropriate support and responses to children’s vulnerabilities following domestic abuse incidents.

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Next steps

We have determined that Gloucestershire County Council 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

Gloucestershire County Council should send the written statement of action to ProtectionOfChildren@ofsted.gov.uk by 10 November 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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