Setting

Jonathan Williams, Director of Children’s Services, London Borough of Sutton Sarah Blow, Chief Executive of South West London Integrated Care Board Sophie Linden, Deputy Mayor of London for Policing and Crime Sir Mark Rowley, Commissioner of Metropolitan Police Christine Davies, Independent Scrutineer Andy Brittain, A/Chief Superintendent, South BCU (Croydon, Bromley and Sutton Boroughs)

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Dear Sutton Local Safeguarding Partnership

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Joint targeted area inspection of London Borough of Sutton

This letter summarises the findings of the joint targeted area inspection (JTAI) of the multi-agency response to identification of initial need and risk (often referred to as the ‘front door’) in Sutton.

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Joint targeted area inspection of London Borough of Sutton

This inspection took place from 10 to 14 July 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

Children and their families in Sutton benefit from inclusive multi-agency local safeguarding children’s partnership (LSCP) arrangements. Committed leaders have an accurate and realistic understanding of the services they lead, including both the strengths and the challenges, ensuring that most children can access the requisite level of help, support and protection at the right time across front door services. A critical aspect of mitigating the impact of significant changes taking place in health services and in the Metropolitan police service has been the LSCP’s proactive action, together with key partners, to address the significant gaps in resources and staffing capacity at strategic and operational levels. Leaders recognise that, despite their endeavours, this is not sustainable in the longer term. The LSCP is an equitable partnership with full engagement from police, health, social care and education

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Headline findings

representatives and commissioned services. Leaders are not complacent and act quickly to implement joint changes linked to agreed priorities.

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Headline findings

Established governance and independent scrutiny are in place, with effective links across key strategic and operational multi-agency working groups. There is a comprehensive training and development multi-agency plan, but participation by police and health staff is limited, despite creative endeavours to increase accessibility, due to staff capacity pressures. This adversely impacts the quality of multi-agency referrals and supervision. Leaders are outward looking and welcome external scrutiny. They fully accept the findings of this inspection and have acted swiftly to strengthen support for children and staff in areas identified by inspectors for improvement.

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What needs to improve?

 The effectiveness of management oversight and supervision across health and police services.  Management and staff capacity in the police, early help teams and health services.  The timely provision of suitable accommodation for children subject to police protection.  The consistent attendance by health and police professionals at meetings about children.  Communication between health professionals, police, schools and children’s social care following strategy meetings about next steps to help and protect children.  The quality and consistency with which the voices of children and their lived experiences are recorded in referrals and assessments across all agencies.  The consistent identification of the needs and risks of each child in the family by frontline professionals.  Effectiveness, quality assurance and impact of Operation Encompass.  The attendance of health and police professionals at multi-agency training.

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Strengths

 Despite increasing demand pressure and limited staff capacity, LSCP leaders make strenuous efforts to drive improvement for vulnerable children while simultaneously working collectively to reconfigure services in response to significant national and regional policy and practice changes.  Children in need of help and support and those who are at immediate risk of harm receive a prompt, proportionate and, in most cases, effective response across the partnership from the multi-agency Children’s First Contact Service (CFCS) front door.  Daily multi-agency meetings in CFCS consider all referrals joint decisions on the next steps to help and protect children. Twice-weekly multi-agency domestic abuse meetings make appropriate decisions on the level of risk for children in domestic abuse situations. The named midwife for safeguarding chairs a monthly multi-agency vulnerable antenatal forum, effectively identifying mothers and their

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Strengths

unborn babies requiring support and risk assessments. A multi-agency police meeting, ‘Every child, every time,’ effectively reviews work across policing areas where children are impacted.  Effective multi-agency interventions and support reduce harm for most children during the assessment period in early help and statutory services.  Excellent support and help provided by school staff and initiatives taken by school leaders are helping to increase attendance and reduce school exclusions.  Working relationships across the partnership are positive, and staff at all levels know each other and most children well. They are enthusiastic about helping and protecting children and are fittingly proud of children’s achievements.  Practitioners consistently report that they feel supported and valued by accessible line managers and senior leaders.

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Main findings

Sutton LSCP leaders and managers across agencies have a comprehensive understanding of the unique and diverse needs of their vulnerable children, informed by joint strategic needs analysis, performance data and multi-agency audits. Strong governance arrangements are augmented by a culture of professional accountability and respectful challenge. Partners have the components in place to drive continuous improvements across services, supported by elected members, but recognise their limitations due to resource and staff capacity constraints at all levels.

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Main findings

Most agencies in Sutton are undergoing significant change while simultaneously working together to ensure that vulnerable children and their families receive the requisite help, support and protection. Leaders recognise that absorbing the consistent rise in the complexity of work and demand is not sustainable in the longer term without systemic changes. Work is already under way across the partnership to reconfigure the creative delivery of services. This is testament to the LSCP’s determination to help and protect children early.

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Main findings

Leaders are working collaboratively to mitigate challenges in staff and senior leader capacity. For instance, they are working to establish and embed revised place-based healthcare services across larger geographical areas as part of integrated care system (ICS) changes. The local authority has established and funded a multidisciplinary therapeutic hub to support children with emerging emotional and mental health difficulties, to alleviate gaps in mental health provision. The police have conducted a review in schools following the Child Q inquiry to raise awareness and to prevent the adultification of Black children. In addition, the police are increasing the number of neighbourhood police staff to identify and support vulnerable children and families earlier. Children’s social care is reconfiguring the delivery of services with partners, considering the children’s social care review and LSCP priorities. They are creating family hubs, located in GP surgeries and libraries,

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Main findings

to increase families’ access to universal and targeted early support. However, it is too soon to evaluate the impact of these new arrangements. Partners recognise and support the importance of addressing needs early to support children. Skilled and experienced early help team managers and their practitioners provide sensitive, imaginative, child-centred interventions that make a positive difference for families. Effective working relationships between early help targeted support and health professionals, schools, youth services and police to support families at lower levels of need is preventing harm to children escalating. Leaders are exploring how partners can work together to reduce waiting times for children identified as requiring early help, without overburdening already stretched services.

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Main findings

The quality of information provided in referrals, including the voice of children, is variable. In a small number of children’s cases, the needs of brothers and sisters in the same family are not routinely risk assessed or included in referrals and subsequent meetings. The referral processes used in the emergency and maternity departments do not align with the LSCP and pan-London published threshold criteria. While police referrals are timely, the recording of the voice and experiences of children is limited. Leaders recognise that increased management oversight and training are required to improve police and health practitioners’ understanding of referral processes and to ensure children’s experiences are included.

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Main findings

Agencies work diligently together in the multi-agency CFCS front door to obtain parental consent and share information about children. Thresholds of risk, need and harm to children are mostly understood and used by experienced and knowledgeable co-located health, police, education navigators, children’s social care and early help professionals to identify children requiring help and protection. Assiduous efforts are made by police researchers and other agencies to gather pertinent information about children’s experiences. Professionals value the advice, support and timely response provided by health and education navigators. Daily multi-agency meetings, chaired by social care managers, consider all new referrals, including those made out of hours. Levels of risk are prioritised appropriately and the rationale for decisions is recorded clearly. Children at risk of immediate harm are identified swiftly and passed

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Main findings

Risks and strengths for children who require protection from harm are identified and carefully analysed, and decisions are appropriately informed by previous history. Child protection strategy meeting ‘surgeries’ are scheduled for Tuesdays and Thursdays, to accommodate the attendance of the police child abuse investigation team and other agencies. There is delay for a small number of children who wait for multi-agency strategy meetings to be convened. Business support staff record ‘strategy surgery’ meetings but do not routinely circulate a record of the meetings and the agreed actions. A high number of additional strategy meetings are convened on other days but attendance by relevant professionals is not consistent, due to capacity constraints. These meetings are not recorded by business support staff. Multi-agency review strategy meetings following single and joint investigations are not regularly convened to agree the next steps to help and protect children.

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Main findings

The sufficient provision of alternative accommodation for children subject to police protection is a challenge. While the immediate risk is mitigated, and despite the efforts of children’s social care staff, children are too often taken to the police station, frequently for extended periods until more appropriate arrangements can be made. This is escalated to daily senior police leaders’ meetings, due to the impact on children and on police resources. Placement sufficiency is a priority area for children’s services working regionally to increase accommodation for children who cannot live safely at home.

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Main findings

Supporting children at risk of extra-familial harm and those missing from home is a key priority for the LSCP. Risks and interventions are adapted to changing circumstances, with screening tools used to measure increasing or decreasing risk. Police promptly share information with children’s services about children who go missing. Detailed information from return home interviews informs case supervision and planning for children who are frequently missing from home. Police attend strategy meetings, conduct research and provide clear and current information about children and perpetrators. The police child sexual and criminal exploitation teams have dedicated staff to support child victims. They play an effective role as a conduit between families, investigators, the missing team and support services. Contacts and information-sharing are well recorded on a specific police record.

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Main findings

Most child assessments are thorough and child-centred. In stronger assessments, details include the views and observations of all children in the family. Good and timely support and interventions are available in schools and in specialist services. In most children’s cases, practitioners’ effective and authoritative practice adds value and work is purposeful. Social workers know children well and are persistent in their efforts to engage and support children, working together with a range of committed teams across services. Social workers and early help staff spoke positively about working in Sutton. All described their line managers and senior managers as supportive and accessible. Supervision is regular and is enhanced for most newly qualified staff. Opportunities for training are good and are also open to agency staff.

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Main findings

Leaders have identified that additional training is needed for frontline police officers and support staff involved in processing referrals and attending strategy meetings. For example, neighbourhood officers have not had updated safeguarding training and CFCS researchers are not trained in understanding the voice of the child or the impact of domestic abuse. Focused additional training was due to be held for frontline officers and police sergeants in August 2023, to help them understand the importance of including children’s experiences in all referrals.

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Main findings

Operation Encompass is embedded in CFCS, however, when a domestic abuse incident has occurred, only limited information is shared with schools. Leaders acknowledge more work is needed to enhance this basic minimum standard and include, for instance, missing children and children who are exposed to domestic abuse out of the borough.

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Main findings

The frequency and effectiveness of safeguarding supervision are inconsistent across most services. Police frontline supervisors do not provide a consistently good-quality record of management oversight or supervision; this is linked to capacity, training and a lack of professional curiosity. Supervision in children’s services is more frequent but in some instances there is an absence of contingency thinking and planning, particularly in relation to children known to services for extended periods of time and who are the subject of repeat referrals.

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Main findings

There is limited recorded management oversight and supervision of safeguarding practice across most health services, although it is stronger in the adult substance misuse team and in maternity services. There are no audits of safeguarding referrals, case records and the CFCS health navigator’s analysis. Therefore, health managers have limited assurance that health practitioners are analysing risk effectively or understanding safeguarding thresholds, which could result in practitioners missing timely opportunities to safeguard children.

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Main findings

The South West London Integrated Care Board and NHS trusts’ safeguarding leads are equal partners and active contributors to the safeguarding partnership arrangements. Leaders are fully cognisant of the increasing capacity issues across services and the adverse impact on the quality of help, support and protection provided to children. Leaders in health services have highlighted this on their risk registers. Nevertheless, each organisation identifies staff with appropriate safeguarding skills and experience to represent health services on the range of LSCP sub-groups and board meetings.

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Main findings

All health practitioners undertake the mandatory training provided by their organisation, but there is limited evidence of its impact on practice being evaluated. Capacity across health services has affected the availability of staff to participate in multi-agency training events. Consequently, there is variation in the quality of practice in capturing the voice of the child in health services. However, services such as school nursing, and maternity and substance misuse services show evidence in records of appropriate professional curiosity. Child adolescent mental health services work closely with a range of practitioners to discuss any new safeguarding risks or changing needs at the triage and assessment stages.

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Main findings

The named midwife for safeguarding chairs the monthly multi-agency vulnerable antenatal forum. This provides an opportunity for information to be shared early about vulnerable children and their families and for proportionate plans to be made by all agencies. Practitioners from the hospital emergency department appropriately seek advice from the social care emergency duty team. There is a strong and effective multi-agency approach to keeping children safe out of hours. For example, if children attend the emergency department when intoxicated and/or make allegations of abuse, hospital staff work collaboratively with multi-agency partners to make sure that appropriate support is in place before discharging children to home. Epsom and St Helier hospitals have agreed with social care that children with additional vulnerabilities and complex needs will carry a ‘teddy file’. These files provide details about the specific needs of individual children. This enables multi-

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Main findings

agency partners to plan to support and keep children safe when there is a possibility of the child being admitted to hospital.

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Main findings

The school nursing team has a named nurse for each school and a ‘high impact nurse’ who has regular contact with children and young people who are missing from education, as well as those in the youth offending service. This provides additional oversight for potentially out-of-sight school-age children who could be at risk of harm.

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Main findings

School leaders strongly value the LSCP drive for improvement in safeguarding children; it is recognised as everyone’s business. Schools report that ‘every concern is taken seriously’. Consequently, designated safeguarding leaders (DSL) are confident about contacting CFCS for advice. One school DSL reflected the thoughts of many when they said that the education safeguarding services in the borough were ‘the best they have ever been’. Schools strongly value the ‘social worker in schools’ initiative delivered locally. The education safeguarding team provides a raft of relevant training and briefings, for example, in emotionally based school avoidance. They facilitate updates and information-sharing sessions about contextual safeguarding. This supports confidence in understanding the services available to support families. School leaders appreciate the effective partnership work with police school liaison and neighbourhood police teams. This has helped to support pupils

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Main findings

and their families who are victims of crime and racism.

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Main findings

A multi-agency approach at the monthly vulnerable pupils’ panel to tackling identified barriers to school attendance ensures that children’s needs are prioritised and tracked. The success of interventions such as the ‘turnaround project’ is supporting pupils to improve their behaviour. Schools report that the education welfare officers allocated by the local authority to individual schools have made a positive impact. Well-established procedures for reporting children who are missing education to the local authority are eliciting a positive multi-agency response. A small number of children remain on reduced timetables or are out of school for too long, despite the joint efforts of practitioners. Partners are working to reduce temporary and permanent school exclusions, in the context of high demand for alternative provision.

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Next steps

We have determined that children’s social care 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

The LSCP should send the written statement of action to ProtectionOfChildren@ofsted.gov.uk by 8 December 2023. This statement will inform the lines of enquiry at any future joint or single-agency activity by the inspectorates.

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