Setting

Ian Dodds, Director of Children’s Services, Richmond upon Thames Elaine Clancy, Executive Lead, Integrated Care Board Sophie Lindon, Deputy Mayor of London for Policing and Crime Sir Mark Rowley, Commissioner, Metropolitan Police Ian Cameron, Chair, Kingston and Richmond Safeguarding Children’s Partnership (KRSCP) Amanda Boodhoo, Independent Scrutineer, KRSCP

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Dear Richmond upon Thames Local Safeguarding Partnership

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Joint targeted area inspection of Richmond upon Thames

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 Richmond upon Thames.

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Joint targeted area inspection of Richmond upon Thames

This inspection took place from 15 to 19 July 2024. 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

The local safeguarding partnership functions under a joint arrangement with a neighbouring authority. Senior leaders from police, children’s social care and the integrated care board share the statutory responsibility for safeguarding and promoting the welfare of children in both local areas, via a strategic leadership group. There is currently inconsistent engagement across the three statutory partners in the local safeguarding arrangements, with limited attendance at strategic meetings by police representatives. Relationships between children’s social care and health are well established and mature. The strategic lead for the police is relatively new to the partnership but is its current chair. There is still a need to ensure the police are consistently engaged with the Kingston and Richmond Safeguarding Children’s Partnership (KRSCP) and the key priorities and statutory duties, and that there is appropriate support and challenge from health and children’s social care

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Headline findings

As a partnership, KRSCP knows its strengths and areas for improvement well. Leaders use a wide range of measures to monitor practice and evaluate its impact for children and families. The KRSCP subgroups are effective in their planning and their scrutiny of performance data. A recently established education subgroup is successfully promoting the function of education providers as an influential and equal partner. The independent scrutineer acts as a critical friend to the partnership, using a variety of information, including performance data and observations of practice. The partnership is responsive to this challenge and their recommendations for improvement. The partnership recognises there is more work to be done to develop the independent scrutineer role further to include the voice of children and young people in Richmond upon Thames.

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Headline findings

Partner agencies work well together at an operational level, and the majority of children receive a timely and appropriate response through the ‘front door’ single point of access (SPA). There are a variety of multi-agency safeguarding meetings that are well attended by a range of partner agencies, with relevant information- sharing and effective multi-agency planning. Thresholds are generally well understood, such that most children receive the right support at the right time, in response to their identified needs and risks. In a small number of children’s cases, referrals to the SPA from health services and police do not contain enough information to enable professionals in the SPA to make timely and proportionate decisions to safeguard children.

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What needs to improve?

◼ The quality of partners’ referrals to the SPA, specifically, the use of professional curiosity and the details given about children’s family circumstances and their lived experiences. ◼ The timeliness of formal strategy meetings outside of normal working hours, for children who may be at risk of significant harm. ◼ The delivery of Operation Encompass, to ensure police are consistently informing schools when children have experienced domestic abuse. ◼ The consistency of partnership engagement and participation at formal strategic leadership meetings, to ensure police attendance is consistent, and that there is robust support and challenge from children’s social care and health to promote all statutory partners fulfilling their statutory duties. ◼ The attendance of police officers and staff at multi-agency safeguarding training. ◼ The oversight of safeguarding in the Kingston Hospital Foundation Trust

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What needs to improve?

emergency department to ensure that safeguarding procedures are consistently followed. ◼ The consistency of feedback to all partners following contacts to SPA, and in the recording by all partners of referral outcomes and strategy meeting outcomes. ◼ The quality of police debriefing of children who have been missing from home, to ensure visits are carried out in person rather than on the phone.

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Strengths

◼ Early help partnership working is making a positive difference for many children and their families. ◼ The education welfare service works proactively with children and families to offer input and support at an early stage in children’s school attendance. This includes early intervention with parents who are considering elective home education for their children. ◼ Most children referred to the SPA receive a prompt and effective response in line with their presenting needs and risks. ◼ There are robust and regular quality assurance audits at both single agency and multi-agency level. This helps leaders and managers understand the experience of children and families and enables them to put appropriate action plans in place. ◼ There is good oversight and monitoring of concerns for unborn babies, through the monthly psychosocial maternity concerns meeting. ◼ Managers in the SPA collate themes from referrals and regularly meet partners to

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Strengths

discuss both threshold issues and quality of referral information. As a result, there has been a notable improvement in the number of referrals that are written directly to the child and that include the child’s voice. ◼ The initial response and risk assessment of children with mental health needs by the children’s emergency child and adolescent mental health service (CAMHS) in the emergency department.

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Main findings

Children and families receive a prompt response to new contacts to the front door SPA. Managers screen contacts accurately to prioritise them and allocate them according to the level of presenting risk and need. Social workers and contact information officers undertake appropriate agency checks and contact families when they need to. Levels of need are mostly understood by partners and the quality of information in contacts, such as family members’ details and children’s unique circumstances, has been gradually improving since the last inspection. This means that the screening process in the SPA is robust in analysing information about children and deciding what action needs to be taken next. When necessary, immediate steps are taken to ensure children are appropriately safeguarded.

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Main findings

Police officers and health navigators are co-located in the SPA and contribute to the gathering of children’s information via the multi-agency assessment hub (MASH) process. The capacity of the health professional in the SPA is stretched at times due to staff vacancies. There is a vacancy in the health navigator role, impacting on their ability to offer oversight and the provision of health information. Police officers and police staff in the MASH research police systems to clarify information and the majority of police referrals contain a detailed criminal history. This helps to build a detailed picture of potential and actual risks to children and ensure appropriate next steps in safeguarding actions. School staff establish strong relationships with children and their families. They are quick to identify concerns about children’s well-being and safety and are proactive in ensuring that support is provided as quickly as possible, including sending timely

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Main findings

contacts to the SPA when necessary. An education safeguarding officer in the SPA can provide additional education information to contribute to a full picture of children’s needs.

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Main findings

Some partners, for example community health services, capture the child’s voice and lived experience well in their records and in their contacts to the SPA. However, this is not consistently embedded across the whole partnership. Some frontline police officers do not fully understand the importance of capturing the child’s voice, resulting in a focus on an account of the incident rather than on the impact and the experience of the child. In most contacts, the initial response by officers is appropriate, based on the presenting risk and needs of the child. However, when officers attend incidents involving domestic abuse, responses are often primarily adult-focused, with children in some incidents not being seen or spoken to. The early information-sharing partnership between schools and police, Operation Encompass, is not well embedded in police processes. Because of this, schools are not routinely informed when children have witnessed domestic abuse incidents. As a result,

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Main findings

schools are often unaware of such incidents and cannot offer appropriate emotional support to children.

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Main findings

Contacts from the local hospital emergency department are of variable quality. Hospital staff do not always gather a holistic picture of the child, including who they live with and their family circumstances. Monitoring of safeguarding practice is underdeveloped in the emergency department. Leaders do not have full clarity around the level of safeguarding activity or a system in place to manage this practice. For a very small number of children who present at hospital, safeguarding processes are not followed, resulting in children returning home with parents without a full medical assessment or a multi-agency exploration of safeguarding concerns.

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Main findings

Partners work together to ensure that assessments are comprehensive and timely. Children are at the centre of assessments. Social workers see and speak to children alone and undertake purposeful direct work with them to understand their experiences, wishes and feelings. Workers listen to families, including extended families where they are part of the support network. Their views influence the steps that workers take and the help they offer.

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Main findings

Workers in the SPA do not consistently inform partner agencies of the outcome of contacts made to the SPA. In addition, there is variability in how outcomes and minutes from strategy meetings are stored on children’s records in different partner agencies’ systems. This leaves some partners unsure of the outcome and the action taken and whether the risk to the child has been addressed. Early help partnership working is mostly strong. There is good communication and support from schools, who commit resources such as mentoring and work well with children’s networks. Children’s centres provide a valuable resource for families, with access to a wide range of support. Children’s centre staff take an active role in team around the child meetings, to ensure that their support is relevant to the family’s needs and is well coordinated. Regular meetings are held which include families and are well attended by professionals, which enables early help plans to be updated in

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Main findings

response to any changes in children’s circumstances.

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Main findings

When children’s risks escalate, there is a prompt and appropriate response in most cases. Most strategy meetings are held within appropriate timescales. The majority of strategy meetings are attended by relevant professionals, with good sharing of relevant information. For children who progress to child protection enquiries, there is appropriate consideration of joint visits from police and social workers when necessary. Child protection medicals are routinely considered in all strategy meetings and provided for those who need it, in line with their health needs. For a small number of children, the need for immediate strategy meetings, including at evenings and weekends if necessary, is not always recognised by social care and police officers. Individual immediate steps are taken by police and social workers to safeguard children; however, the lack of a formal strategy discussion sometimes leads to a lack of detailed information-sharing and formal joint planning for a small

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Main findings

For most children, early help, initial child in need and initial child protection plans support well-coordinated interventions from a range of services, including community and voluntary organisations. Community health practitioners are tenacious in their approach to contacting families, and they have good oversight of the children they are supporting. Schools work proactively with partners such as speech and language services. The education welfare service plays a key role in collaborating with schools to improve poor attendance, including challenging schools and families when necessary. This work has significantly improved some children’s attendance at school.

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Main findings

Children’s risk of exploitation is recognised and understood by partners in most cases. A daily risk briefing takes place between the police and social care, sharing information when children have been arrested or involved in serious youth violence incidents. This enables swift intervention and support to be put in place. Children who are missing from home or from care receive a persistent and relational response from children’s social care. The Philomena Protocol is in place with children’s homes in Richmond. The police appropriately challenge partners to ensure they are completing their required actions to locate children prior to formally reporting a child as missing. Social workers build relationships with children to understand their experiences and the risks they face, and they use these relationships to help children accept support. However, in the majority of missing children’s incidents, police

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Main findings

complete their subsequent welfare checks with children over the phone rather than in person. This limits the quality of the interview with the child and the information gathered to help understand why children have been missing. The use of police ‘trigger plans’, intended to assist officers to locate missing children, is not consistent, due to many of these plans being out of date and difficult to find on police systems. Consequently, police officers may not have the full information to assist them in finding missing children quickly.

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Main findings

When children attend the emergency department with suicidal ideation, they receive a swift response from the children’s emergency CAMHS team or the adult psychiatry team who carry out detailed holistic assessments, exploring fully the child’s lived experience and any factors which may have triggered their presentation in crisis. Risk management plans are created to help protect these children and to reduce their immediate risks. Children who have enduring mental health needs wait for varying lengths of time to access support for their mental health or emotional well- being. This includes access to Tier 2 therapeutic support provided by the local authority, as well as CAMHS assessment and support. Leaders recognise that more needs to be done to reduce waiting times for children, as some wait too long for the right support. CAMHS staff have recently implemented a system where they telephone families who are waiting, to establish whether the child’s mental and

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Main findings

emotional health needs are increasing and their needs should be reassessed. This system is not yet embedded across all pathways to ensure that all children waiting for therapeutic support are reviewed.

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Main findings

Leaders and managers appropriately support practitioners and assess the quality of their work, with challenge as required. Most practitioners receive regular formal supervision as well as access to informal management direction when needed. Group supervision is available, such as Thinkspace, a multi-professional forum to look at complex cases and help professionals find solutions for children and young people.

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Main findings

Robust and regular quality assurance audits are undertaken at both single-agency and multi-agency level. A number of multi-agency management meetings are held to discuss the quality of practice and threshold decisions and identify learning as part of a continual improvement process. Managers in the SPA proactively build strong working relationships with partners, attending team meetings and holding coffee morning workshops to share emerging themes. Effective operational working relationships enable managers and practitioners to work through most challenges and professional differences without the need for formal escalation procedures. This means many issues can be resolved quickly without any delay or impact on the work with children and families.

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Main findings

The strategic leadership group of the safeguarding partnership sets clear priorities, and they are informed by the work of effective and regular subgroups. The learning and development subgroup provides the partnership with a comprehensive training package. The case review subgroup collates thematic learning from significant incidents, using seven-minute briefings which are widely disseminated. There are also regular opportunities across the partnership for informal learning. While there is good take-up of multi-agency safeguarding training from most partners, police attendance at training is poor. Some officers told inspectors that they do not have a good understanding of how to speak to children or how to gather children’s views. This has not been sufficiently challenged or resolved by the strategic leadership group.

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Main findings

The role and remit of the education subgroup has been reviewed and updated in recent months to widen the participation of partner agencies. The safeguarding partnership education coordinator has been proactive in developing an initiative to inform children and their families about the risks of substance misuse. Termly electively home educated (EHE) meetings, involving an appropriate range of agencies including social care, schools’ admissions and other services, ensure themes and opportunities for joint working are regularly discussed. The forum has established a task and finish group to address educational neglect and the issues facing children who are missing from education. A safeguarding audit tool is widely used by schools. As well as supporting schools in reviewing the effectiveness of safeguarding provision, the local authority uses the outcomes of these audits to review and tailor provision to the needs of schools.

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Main findings

Strategic leaders in Richmond have developed close working relationships. They have regular conversations about presenting themes that affect children and families in the local authority area. There is inconsistency in the attendance of statutory partners at both the multi-agency safeguarding strategic leadership meetings and MASH strategic and operational meetings, most notably by the police. Although leaders reported that they have regular informal engagement outside of these meetings, the lack of formal attendance at meetings means that some strategic decisions are not well documented in meeting records. The strategic escalation process is rarely used, even when some matters, such as the gaps in the fulfilment of Operation Encompass, would benefit from this. This has meant that some areas for improvement have not been tackled effectively at the strategic level.

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Next steps

We have determined that London Borough of Richmond upon Thames 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. London Borough of Richmond upon Thames should send the written statement of action to ProtectionOfChildren@ofsted.gov.uk by 13 December 2024. This statement will inform the lines of enquiry at any future joint or single-agency activity by the inspectorates.

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