Setting

Claire Winter, Executive Director – Children, Families and Education, Somerset Council Jonathan Higman, Chief Executive, NHS Somerset ICB Clare Moody, Avon and Somerset Police and Crime Commissioner Sarah Crew, Chief Constable, Avon and Somerset Constabulary Samantha Fahey, Youth Offending Service Manager Dr Mark Peel, Independent Scrutineer

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Dear Somerset Local Safeguarding Partnership

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Joint targeted area inspection of Somerset

This letter summarises the findings of the joint targeted area inspection (JTAI) of the multi-agency response to serious youth violence in Somerset.

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Joint targeted area inspection of Somerset

This inspection took place from 20 to 24 May 2024. It was carried out by inspectors from Ofsted, the Care Quality Commission (CQC), His Majesty’s Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS) and His Majesty’s Inspectorate of Probation (HMIP).

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Context

The findings in the report evaluate the effectiveness of the multi-agency response to children aged 10 and over who are at risk of or affected by serious youth violence and/or criminal exploitation. Even where the report does not specifically refer to this group of children, all findings relate to this scope.

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Context

The inspectorates recognise the complexities for agencies in intervening to address serious youth violence when risk and harm occur outside of the family home. As a consequence, risk assessment and decision-making have a number of complexities and challenges. A multi-agency inspection of this area of practice is more likely to highlight some of the significant challenges to partnerships in improving practice. We anticipate that each of the joint targeted area inspections (JTAIs) of this area of practice that are being carried out will identify learning for all agencies and will contribute to the debate about what ‘good practice’ looks like in relation to the multi- agency response to serious youth violence. In a significant proportion of cases seen by inspectors, children had also experienced other forms of abuse, which reflects the complexity of the needs and risks for children.

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Headline findings

Ineffective partnership working between agencies has led to a failure to identify, understand and respond to the extent of serious youth violence and the criminal exploitation of children in Somerset. As a result, children are being left at risk of significant harm. Strategic leaders do not have a local problem profile or analysis of need and rely too heavily on crime data in isolation. This has led to the false assumption that tackling serious youth violence does not need to be a priority in Somerset. Governance arrangements are too complex, and leaders do not know whether the services they have commissioned are the right ones.

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Headline findings

In addition, serious weaknesses in multi-agency safeguarding practice, professional curiosity and information-sharing mean that for many children with increased vulnerability to serious youth violence, the risks are not identified at the earliest opportunity. Safeguarding referrals are not always made to the local authority by health practitioners in emergency departments, despite children presenting with serious injuries, and when they are, they are delayed. Avon and Somerset Constabulary routinely capture information and intelligence relating to serious youth violence and the criminal exploitation of children, but too often they do not share this information with the local authority or other relevant partners, and when they do so it is not timely, leaving children at risk of harm when this may have been avoided.

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Headline findings

Partner agencies do broadly understand that children are more susceptible to serious youth violence if they are not in school, have special educational needs and/or disabilities (SEND), have suffered childhood trauma or have witnessed violence. However, the response to these vulnerabilities is often poor. The rate of exclusions from school in Somerset is very high. Many vulnerable children, including those with SEND and education, health and care plans, miss too much school. Children wait too long for autism assessments. In general, staff across the partnership are insufficiently trained in recognising and responding to trauma and the links to both serious youth violence and exploitation.

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Headline findings

Despite the absence of a clear, strategic approach to addressing serious youth violence and the factors that leave children vulnerable to criminal exploitation, some local neighbourhoods have responded proactively to their concerns for children. These pockets of good practice are proving successful in diverting some children away from violence. Those who know the children well, such as teachers, police community support officers (PCSOs), mentors and family intervention workers combine to share and act on their collective concerns. However, holding multiple meetings without clear ownership of the plan to reduce risk to children undermines some of this good practice by encouraging repetition without focus. As a result, children are left at risk of significant harm.

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Areas for priority action

 How well the Safer Somerset Partnership (SSP) understands the extent of serious youth violence and criminal exploitation in Somerset to enable an informed strategic response and more effective frontline practice.

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Areas for priority action

 The sharing of information and the recognition of risk by partner agencies, to protect children at risk of serious youth violence at the earliest opportunity. In particular, the quality, effectiveness and governance of safeguarding practice by lead safeguarding partners in the Somerset NHS ICB, Somerset Council Public Health Directorate and Avon and Somerset Constabulary in Somerset.

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What needs to improve?

 How effectively the Somerset Safeguarding Children Partnership (SSCP) and the SSP prioritise and fulfil their serious violence duty.

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What needs to improve?

 How effectively partner agencies challenge and support schools to tackle the very high exclusion rates, to enable children to remain in school and to reduce the increased vulnerability to serious youth violence and criminal exploitation associated with being out of school.

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What needs to improve?

 The professional curiosity of practitioners across the partnership, with specific regard to the links between children’s additional vulnerabilities and the risk of serious youth violence and criminal exploitation.

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What needs to improve?

 The quality, extent and impact of training provided by the safeguarding children partnership about the risks associated with serious youth violence.

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What needs to improve?

 How well shared information and intelligence is used to map and understand networks of adults that exploit children.

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What needs to improve?

 The strategic needs analysis of threats and problem profiles and an associated action plan that is specific to Somerset.

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What needs to improve?

 The evaluation of the impact of preventative services.  Processes for working with children at high risk of serious youth violence and criminal exploitation, including children known to the youth offending service.

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What needs to improve?

 The quality and effectiveness of police investigations into serious youth violence and criminal exploitation.

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What needs to improve?

 The effective use of exploitation screening tools to inform assessment and planning for children and families.

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Strengths

 Child-centred and positive relationships between children and early intervention workers, including family intervention specialists.

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Strengths

 The involvement of children in identifying their priorities for reducing risk, both individually and collectively.

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Strengths

 The level of knowledge and understanding in the emergency duty service of serious youth violence and county lines.

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Strengths

 Local neighbourhood responses, including some schools and the charity sector, to increases in the carrying of weapons by children and the support given to them by statutory partners.

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Main findings

The Avon and Somerset Violence Reduction Partnership (referred to as the VRP) has not made a positive impact for the children of Somerset despite some violence reduction initiatives being in place for several years. Mainly, this is due to an overarching strategy that does not identify the specific risks to children in Somerset. The SSP, in effect, delegates its duty to share information and target interventions to tackle serious youth violence to the VRP, which, since its move from being a violence reduction unit in 2023, now covers adults as well as children and four other local authorities. Somerset has low levels of deprivation, ranking as the 109th most deprived local authority in England. About 1.2% of its areas are among the most deprived 20% in England. The schools census in January 2022 identified that 6% of school age children were from ethnic minority groups, below the national average (27%). This information alone suggests that the profile of risk in Somerset may be

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Main findings

different from larger urban areas covered by Avon and Somerset Constabulary, but in the absence of a local needs assessment that informs strategic planning, the SSP does not ‘know what it doesn’t know’ about the context and extent of risks to children. Consequently, the interventions that have been put in place largely replicate those tried in neighbouring authorities and have not been evaluated to test their effectiveness.

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Main findings

The lack of challenge and oversight by the SSP is not an isolated problem. The SSCP, with its remit to bring together the statutory safeguarding bodies, and act as a catalyst for change, lacks drive and curiosity in this complex area of practice. Consequently, the SSCP does not fully understand the level of risk to children. All three of these bodies, the VRP, SSP and the SSCP, rely too heavily on crime rates linked to serious violence, which are comparatively low in Somerset, and therefore provide an incomplete picture of contemporary risk. For example, staff from all the partner agencies covered by this inspection hold additional, detailed information about risks to children that is not routinely shared or gathered together.

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Main findings

Strategic leaders acknowledge that governance and accountability require greater clarity and impact in Somerset. Positively, the partner agencies accepted these findings during the inspection and began to plan a more streamlined approach. However, the commitment of all partners to deliver these changes remains untested at this point in time.

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Main findings

Given that the safeguarding partnership does not fully understand the extent of serious youth violence and exploitation in Somerset, professionals are not provided with a clear training offer that equips them to identify and address factors linked to children’s vulnerability to harm. Training takes place, but is inconsistent and lacks coordination, does not reach all professionals in key positions, and its impact is not fully evaluated. Schools, including the virtual school, receive insufficient training about serious youth violence and child exploitation and are often left to seek out their own training. Staff in the youth justice service (YJS) are knowledgeable about serious youth violence and county lines and they understand the changing profiles of children in relation to these issues. However, their ability to make positive change for children is limited due to the weaker understanding in other agencies.

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Main findings

In responding to serious youth violence and exploitation in schools, the absence of a well-coordinated partnership approach to identifying and responding to these issues means that schools have often set up their own systems or been left to research initiatives and strategies for themselves. Some of this work is very effective and responds to local needs, including the mobilisation of family intervention workers, PCSOs, early years specialists and mental health advice to support children who are at risk of exclusion.

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Main findings

While such initiatives are positive, there are some negative consequences of this individualised approach to serious youth violence. Identified concerns, including when children have been permanently excluded from previous schools, are rarely considered when they move to new educational settings. Children in Somerset are among the most likely to be excluded from education across England. Schools too often focus on behaviour and not enough on understanding underlying risks or children’s vulnerability to serious youth violence or criminal exploitation. An authority-wide, trauma-informed approach is not well established. This means that when the profile of risk to children has changed over time, school policies and systems have not changed with it.

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Main findings

The trauma experienced by children involved with, or who are victims of, serious youth violence is rarely addressed well enough, or soon enough, by evidence-based tailored programmes of support. More generally, a gap in the early identification of health needs contributes to increased vulnerabilities for children at risk of serious youth violence. Assessments for autism can take nearly two years, and intervention is delayed. Similar delays occur when serious incidents are not evaluated by responding police officers and victim support through the Lighthouse (Avon and Somerset’s victim support unit) is not triggered. Conversely, children receive a timely response once referred to child and adolescent mental health services (CAMHS). The majority of children are assessed and seen for treatment within six weeks.

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Main findings

Although not strategically joined up or linked to an evidence-based understanding of need, several services have been commissioned through the local authority and the VRP to help children understand the risks associated with knife crime, county lines and gang activity. Professionals report a positive impact, but this has not been fully evaluated. For example, Teachable Moments, a programme to prevent the exclusion from school of those children who are at greater risk of carrying weapons, using drugs or having poor emotional health, engages children well. Specialist family intervention workers offer relationship-based support to reduce the incidence of children going missing and antisocial behaviour. Early intervention and detached youth workers are deployed in areas deemed to be high risk. Sports mentors, the Turnaround Project and a secondary school have all identified local risks and responded well when tangible risks have increased for children.

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Main findings

The success of these interventions relies too heavily on the skill, dedication and tenacity of individuals. For some children, child-centred approaches include matching the right person to the child and maintaining that relationship through crucial transitions, providing an anchor for the child and the family. Although not always translating into a strong understanding of risk, this focus on the child is consistent across PCSOs, town wardens, social workers, youth justice workers and CAMHS practitioners. Local community organisations, and those involved in One Team meetings (where housing, schools, health and local councillors come together to explore risks in their community), for example, have an awareness of county lines and exploitation concerns and link young people into activities in their local areas that divert them away from harm effectively.

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Main findings

The YJS and police officers work in partnership to avoid criminalising children unnecessarily and have established processes in place to promote diversion away from the criminal justice system. However, Avon and Somerset Constabulary often fails to see children as vulnerable when they are also suspects in a crime.

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Main findings

When there is a clear and immediate risk to children, professionals usually take appropriate action and identify the risks associated with serious youth violence and children’s additional vulnerabilities. Child protection strategy discussions and investigations are swiftly initiated in the multi-agency safeguarding hub (MASH), with appropriate management decisions supporting an effective response.

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Main findings

When serious incidents take place outside of office hours, the local authority emergency duty team demonstrates a strong understanding of serious youth violence and county lines, they deploy good local knowledge of risk and make good use of their established links to the out-of-hours family intervention service and neighbourhood police officers. However, incidents involving serious youth violence or child criminal exploitation are often not investigated effectively by the police. Despite multiple intelligence reports being submitted to the police by partner agencies highlighting risk to children in relation to criminal activity, a lack of collective ownership and clear planning means that disruptions are not considered and safeguarding not explored.

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Main findings

Thresholds for intervention in relation to the risks associated with serious youth violence and criminal exploitation are inconsistently understood and applied by partner agencies, characterised by a lack of analysis of risk factors and their impact on both individual children and their wider family networks. This includes poor use of information about family history and analysis of wider risk factors or previous links to exploitation. Referrals to the MASH often contain gaps in pertinent information and an evaluation of risk factors is not always included. In the emergency departments at both major hospitals, there is poor oversight of safeguarding practice. Poor record- keeping, including the recording of the voice of the child, an absence of safeguarding alerts or flags, and very limited professional curiosity when children attend following incidents of violence or assaults by groups, reduces the opportunity for children to

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Main findings

receive a timely multi-agency response to their needs and risks. Safeguarding referrals to the local authority are often not made or have no audit trail across some parts of the Somerset NHS Foundation Trust, the Somerset-wide integrated sexual health service and the South Western Ambulance Service NHS Foundation Trust. This includes situations in which children have explicitly said that they do not feel safe.

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Main findings

Avon and Somerset Constabulary has a system for capturing information and intelligence it receives from professionals in Somerset, in addition to intelligence it holds from its own investigations. Although the force makes intelligence accessible to all police officers, there is a widespread lack of certainty or confidence among officers about what they are able to share with partner agencies. Consequently, the force has intelligence that it does not share which could help partner agencies to safeguard children. In some instances, this leaves children and other professionals at risk.

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Main findings

Officers from the vulnerability hub of the Lighthouse Safeguarding Unit (LSU) are co- located in the MASH, but they do not always share pertinent information with partners. Combined with no representation from the YJS this undermines the fullness and quality of decision-making. Although there is a fortnightly child exploitation meeting between officers working on Operation Remedy (Avon and Somerset Constabulary’s response to county lines) and the local authority, it is still in its infancy and intelligence-sharing about county lines is inconsistent.

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Main findings

Children and their families do not always benefit from plans that take full account of the specific risks associated with serious youth violence or exploitation. The use of screening tools by partner agencies, other than the specialist criminal exploitation team in the local authority, is highly variable in quality and effectiveness. Often, this leads to delays in mobilising the right intervention and associated disruption of perpetrators. When screening tools are completed, under the guidance of specialist workers, they are a helpful and insightful tool, and they are reviewed as risks change, but too often, this process does not start soon enough, leading to drift and delay.

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Main findings

Too often, children are left at risk because of the absence of a streamlined, coordinated and well-understood process for formal information-sharing and planning. The same children are often discussed at multiple meetings without sufficiently clear oversight and ownership. Safety planning involves children and their families, and social workers are skilled at involving children in the plan, but information and intelligence-sharing are not used effectively enough to map where, and by whom, children are being put at risk. When these discussions do take place, they are not recorded clearly on children’s records across partner agencies. This limits the agencies’ ability to fully understand the extent of criminal influence over children, including those who are high-risk offenders. Mapping itself lacks sophistication.

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Main findings

When social workers and managers have sufficient information, they typically understand risk and concerns relating to serious youth violence and responses are timely and appropriate. Most of the time, social workers and youth justice practitioners have good supervision, the children’s circumstances are thoroughly reviewed, they are helped to think through their approach and clear actions are set, which are then updated regularly. However, assessments and plans are not always dynamic or adapted to changing risks and needs. For some children, networks are not well coordinated, and child-in-need meetings, including those where the risks are from outside of the home, do not involve all relevant professionals, are irregular, and do not coordinate plans to ensure that risks to children are reducing. The YJS is in the process of strengthening management capacity and revising risk management processes for clearer accountability. Additional resources have been

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Main findings

allocated to meet the increased demand for out-of-court disposal work, and efforts are being made to separate prevention work with children from out-of-court work to better understand and address escalating risks for those children at the edge of the criminal justice system. Data challenges from a new database are also being tackled to improve the understanding of serious youth violence and criminal exploitation for children receiving a service from the YJS.

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Main findings

The quality assurance of practice through routine auditing has a multi-agency dimension that is well established in Somerset. The strengths and areas for improvement highlighted by auditing are consistent with the findings of this inspection. Unfortunately, this learning is not collated, shared and used effectively to support strategic and structural change that improves the effectiveness with which agencies are tackling the risk to children from serious youth violence. Many areas of practice, such as cumbersome procedures, delays in screening for risk and poor information-sharing, have been known for a significant period without substantive change being achieved.

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Practice study: effective practice

For one child, who has multiple agencies working with them to reduce the risks associated with serious youth violence and criminal exploitation, each agency has taken the standpoint of amplifying the child’s voice as the starting point for finding practical and effective solutions. This holistic and children’s rights-based approach has maintained a school place and paved the way for a pathway into further education and career opportunities away from situations that have previously resulted in violence. In turn, partner agencies both within and outside of Somerset have devised safety plans that trigger an early and sympathetic response when the child goes missing, and have avoided criminalisation through effective use of out-of-court disposals. When the child attends the emergency department, a high intensity user template contains their views on how medical staff can best support them and how to best gather evidence if there is a link to

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Practice study: effective practice

criminal exploitation. The adults around this child know them well, understand that their behaviour is linked to early life trauma and respond accordingly. For this child, this child-focused, well-informed and coordinated response is making a positive difference.

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Practice study: area for improvement

For one child, a failure to identify their emotional and special educational needs early enough led to their vulnerabilities being masked for many years and increased their vulnerability to serious youth violence and exploitation. This led directly to the child not being able to communicate exactly what was happening to them as they were exploited by criminal networks. Although individual agencies such as the school and the police held vital information about known associates and changes in the child’s behaviour that indicated they were being exploited, this was not shared. The absence of a clear process to gather professionals and the family together to coordinate a joint response resulted in an exclusion from school and the police treating them as a suspect rather than a victim of exploitation. Consequently, wider networks and the grooming of other children were not identified and went unchallenged.

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Next steps

We have determined that the chair of Somerset Safeguarding Children Partnership 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

Claire Winter, Chair of Somerset Safeguarding Children Partnership on behalf of Somerset Council (as a designated safeguarding partner), should send the written statement of action to ProtectionOfChildren@ofsted.gov.uk by 25 October 2024. This statement will inform the lines of enquiry at any future joint or single-agency activity by the inspectorates.

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