Setting

Tom McCabe, Chief Executive Officer, Norfolk County Council Sara Tough OBE, Executive Director Children’s Services, Norfolk County Council Tracey Bleakley, Chief Executive Officer, Norfolk and Waverley Integrated Care Board Paul Sanford, Chief Constable, Norfolk Constabulary Sarah Taylor, Norfolk Police and Crime Commissioner Alex Osler, Regional Probation Director, East of England Chris Robson, Independent Scrutineer, Norfolk Safeguarding Children Board

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Dear Norfolk Safeguarding Children Partnership

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Joint targeted area inspection of Norfolk

This letter summarises the findings of the joint targeted area inspection (JTAI) of the multi-agency response to children who are victims of domestic abuse in Norfolk.

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Joint targeted area inspection of Norfolk

This inspection took place from 9 to 13 December 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

This inspection focused on the multi-agency response to unborn children and children aged 0 to 7 years who are victims of domestic abuse. Our evaluation of strategic arrangements in the local area took a broader look and considered the multi-agency response to children of all ages.

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Context

The inspectorates recognise the complexities in providing a multi-agency response to children and families when there is more than one victim and where there may be risks in addition to domestic abuse. Consequently, risk assessment and decision- making have several challenges for partners, not least of which is that the impact on the child is sometimes not immediately apparent.

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Context

A joint inspection of the multi-agency response to children who are victims of domestic abuse will highlight the significant challenges to partnerships in improving practice. We anticipate that these JTAIs will identify learning for all agencies and will contribute to the debate about what ‘good practice’ looks like.

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Headline findings

Strong strategic leadership and collaborative partnership arrangements in Norfolk are helping to ensure that most unborn children and children aged 0 to 7, who are victims of domestic abuse, receive an effective response that safeguards them and meets their needs.

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Headline findings

Domestic abuse is seen as a ‘priority for everyone’ in Norfolk. Overseen by the Norfolk Community Safety Partnership (NCSP), the Domestic Abuse and Serious Violence Group (DASVG) leads on the delivery of the Norfolk domestic abuse strategy, which focuses on tackling the causes of domestic abuse and supporting all victims of domestic abuse. There is an evident synergy between partners and coherent governance arrangements that provide and oversee the multi-agency response to domestic abuse at all levels. This is helping to ensure that preventing, responding to and supporting children who are victims of domestic abuse are suitably prioritised by all partner agencies.

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Headline findings

Relationships between agencies and strategic leaders are mature and allow for constructive mutual challenge and problem-solving. There is good crossover between connected boards, including the NSCP, the Norfolk Safeguarding Adults Board and the Domestic Abuse Local Partnership Board (DALB), to ensure that a whole-systems approach to tackling domestic abuse is provided. The NSCP appropriately maintains a high level of oversight of the impact of domestic abuse for children, and domestic abuse is integrated into all aspects of the NSCP work in safeguarding children.

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Headline findings

The voices and experiences of children and families are central to needs analysis and service development. Strategic leadership and prioritisation have led to the development of a wide range of services to meet the needs of victims of domestic abuse and seek to prevent future harm. The needs of unborn children and children aged 0 to 7 at risk from domestic abuse are generally identified early and mostly responded to well. Support is well coordinated and sensitively delivered at the right level.

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Headline findings

There remains, however, more work to do. The partnership itself has recognised the need for greater emphasis on evaluating service impact and measuring the effectiveness of domestic abuse training across the partnership to ensure that learning is leading to improved practice. There are some weaknesses in multi-agency information-sharing, and not all practitioners are sufficiently focused on obtaining the voice of the child or understanding children as victims in their own right. Multi Agency Risk Assessment Co-ordination (MARAC) processes are not always well utilised or understood. For a small number of children at risk of cumulative harm, the risks to them of repeated incidents of domestic abuse are not grasped soon enough.

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What needs to improve?

◼ Partners’ understanding and engagement in MARAC and the Partnership’s oversight of its operation. ◼ The consistent consideration of the cumulative harm to children aged 0 to 7 from repeated experience of domestic violence. ◼ How well the voices and experiences of individual children who are victims of domestic abuse are listened to, understood and captured by practitioners, across the partnership, and are used to inform children’s plans. ◼ The timeliness and consistency of information-sharing, in a small number of practice areas, related to risk management. This includes digital information- sharing of health records. ◼ The accessibility of domestic abuse training to practitioners, its take-up by those practitioners, and how well they apply learning to practice.

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Strengths

◼ Strong strategic leadership and collaborative partnership working. ◼ The co-design and co-production of services with children. ◼ The commitment to father-inclusive practice. ◼ Multi-agency evaluation of referrals to the Multi-Agency Safeguarding Hub (MASH). ◼ The implementation and monitoring of Operation Encompass and its extension to services supporting children not in school. ◼ Multi-agency practice to support and protect unborn children. ◼ The development of domestic abuse champions across education and health settings and the deployment of specialist domestic abuse workers in children’s social care teams. ◼ The operation of the Domestic Violence Disclosure Scheme (Clare’s Law). ◼ Support by partners for the strategic and operational work of a specialist commissioned domestic abuse service. ◼ The quality and range of support provided by Independent Domestic Violence Advisers (IDVAs). ◼ The provision and quality assurance of safe accommodation for victims of

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Main findings

The partnership’s strong strategic intent and commitment to supporting Norfolk children to ‘flourish’ as a strategic ambition is helping to safeguard children, including unborn children, who are victims of domestic abuse. Leaders have created a strong ethos and culture of openness and shared learning across the partnership. They know themselves and their services well and are committed to a journey of self- improvement and continuous development.

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Main findings

The NCSP is accountable for delivering the statutory duty placed on the local authority to support victims of domestic abuse, including children. The commitment to following a public health approach is firmly established in its strategic ambitions and priorities. The NCSP is well attended and meets regularly. Partner relationships are mature, which enables constructive discussion and challenge and effective joint working. The NCSP exercises strategic oversight of the DASVG, which is accountable for the delivery of strategic priorities and actions around domestic abuse. The impact of domestic abuse for children is integrated into every strand of work being undertaken by the DASVG subgroups. The DASVG is focused on developing the work around children being understood as victims in their own right, and on measuring the impact of domestic abuse training across the partnership to ensure that learning is

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Main findings

impacting on practice. Collectively, these arrangements have ensured that service development in Norfolk is well coordinated, suitably prioritised and responsive to the needs of children.

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Main findings

The work of the DALB, which holds accountability for the delivery of safe accommodation, is diligent and robust. There is a clear multi-agency approach to the provision of accommodation and to the support needs of victims of domestic abuse, including children. This work is informed by robust performance management information and a range of comprehensive needs assessments. It has led to a good range of quality-assured, suitable accommodation being in place to meet need, including sanctuary support to help parents and their children to live safely in their own homes. Children and parents living in safe accommodation are well supported by a range of skilled and experienced support workers and volunteers. Families are helped to achieve their next steps, with careful thought given to their move-on plan.

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Main findings

The NSCP is well established and supported by a range of effective subgroups. Education services are well engaged and there are clear plans to further strengthen representation across the partnership board and subgroups. Domestic abuse is not named as a priority for the partnership as it is clearly integrated throughout all the work being undertaken. Independent scrutiny of the work of the NSCP is well established and provides critical challenge and insight, which supports service improvement. Leaders are open to learning and embrace opportunities to improve practice and the responses provided to children affected by domestic abuse. A recent audit of practice to address domestic abuse undertaken by the NSCP has accurately identified practice strengths alongside key areas where practice needs to improve. Leaders acknowledge the need for enhanced workforce development, improved information-sharing and to achieve better consistency of practice with children as

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Main findings

victims of domestic abuse. This learning is being responded to in a timely way within a comprehensive action plan, which is being tracked and reviewed by both the NSCP and NCSP strategic boards.

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Main findings

Co-design and co-production with children are a strength for the partnership. Children are involved in strategic planning and are helped to produce strategic plans that are specifically written by children, for children to understand. Children have been instrumental in designing specific services to support them as victims of domestic abuse, and leaders regularly hear from children to learn from their experiences to help improve domestic abuse support and services even further. For example, leaders have advocated powerfully about the need for self-help resources and contributed to the production of a mindfulness guide and anxiety handbook. In addition, the partnership commitment to achieving father-inclusive practice is demonstrated throughout frontline practice with a range of innovative programmes designed especially for fathers by fathers.

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Main findings

The intelligent use of partnership data, combined with audit and the voices of children and families, provides an in-depth understanding of the needs of children and families at risk from domestic abuse in Norfolk and the impact of services to support them. The partnership has correctly recognised the need to put even more emphasis on measuring the impact and outcomes of its interventions linked to domestic abuse.

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Main findings

A specialist commissioned service, as a response to domestic abuse, is highly valued across the partnership, both strategically and operationally. Its impact is tangible and far-reaching in providing domestic abuse services and in bringing the voices and experiences of victims and survivors to help shape these. The commissioned service of IDVAs, is available across the county and provides invaluable support to victims, including specialist support for children. Across Norfolk, IDVAs are also based in acute hospitals. They enable prompt support to be given to those experiencing domestic abuse, as well as improving understanding of domestic abuse for practitioners. The strategic placement of these roles, in key settings, have promoted access to the right support and help for children and their families impacted by domestic abuse.

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Main findings

Effective partnership working has also led to a wide range of commissioned, community, voluntary and social enterprise domestic abuse services being in place to support children, adult victims and perpetrators. These services are available across the continuum of need, ranging from universal to specialist programmes. Inspectors met with a group of victims and survivors, who spoke positively about how completing a specialist domestic abuse programme had helped them to understand the powerful impact of domestic abuse on themselves and their children. While commissioned services are well integrated into the governance arrangements across the partnership, some smaller voluntary services feel less integrated and involved.

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Main findings

Services in Norfolk work well together to identify children who may be at risk from domestic abuse. The investment in creating domestic abuse champions within education and most health services is making a positive difference in raising awareness of domestic abuse, which supports the early identification of risk for children and adult victims.

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Main findings

Primary care has effective processes to ensure that children with safeguarding risks are monitored. Practitioners review all emergency department notifications, safeguarding meeting minutes and police notifications, and they update alerts on the patient record.

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Main findings

Midwives and public health practitioners make every contact count for routine enquiries into domestic abuse. The identification of the impact of domestic abuse on unborn children leads to early and effective support. Ambulance practitioners are professionally curious when attending incidents, with either adults or children as the patient, where domestic abuse could be a factor. They proactively seek the voice of the child and make careful observations of the family dynamics and home environment. If there are safeguarding concerns, they quickly refer children to the children’s statutory services via the Children’s Advice and Duty Service. This ‘Think Family’ approach has children in the forefront and helps keep them safe.

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Main findings

Early years providers and schools build open and trusting relationships with young children and their families and engage well in multi-agency planning for vulnerable children. Regular safeguarding audits in early years settings are helping to raise awareness and practice responses to domestic abuse. There are plans to roll out specific training on understanding and responding to domestic abuse to early years settings in 2025.

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Main findings

When unborn children and children aged 0 to 7 affected by domestic abuse are referred to children’s statutory services, most receive a timely and appropriate response. This includes children who require help out of hours. Referrals are taken over the phone by consultant social workers, who work to the principle of ‘never do nothing’. These rich and detailed conversations quickly help to identify the level of need and risk for children and what interventions and support are needed to help safeguard and support children as early as possible. This ethos of collaborative conversations together with early help support is providing an effective response to children experiencing domestic abuse and is helping to improve their lives. While parental consent for referrals is considered at an early stage, consent is not always fully understood by some partners. This can lead to delays for a small number of children receiving help.

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Main findings

When there are immediate safeguarding concerns for unborn children and children aged 0 to 7, referrals are swiftly passed to the MASH for an interagency response. Partner agencies, including probation and the commissioned domestic abuse service, are well represented and engaged in the MASH. Referrals are effectively triaged and responded to by multi-agency practitioners. Social workers research the family’s history and gather pertinent information, which helps them to swiftly build up a picture of the child’s experiences. Next steps are proportionate and based on the careful consideration of strengths and risks. When immediate action is required to keep children safe, this takes place without delay. Referrals about domestic abuse incidents from the police vary in quality and do not consistently include important information about the child and family, for example information about their ethnicity, religion and beliefs. Practitioners understanding of the child’s needs, experiences and

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Main findings

the risks to them is missing this important information, at the earliest point in time, so that workers can provide a suitably informed response.

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Main findings

Following domestic abuse incidents, police use Operation Encompass effectively, to quickly share information with schools. Regular dip sampling of notifications provides assurance that appropriate information is being shared and acted on. Nearly all children receive additional support in school following information received via Operation Encompass. This information-sharing also helpfully extends to services supporting children not in education and children being home educated. There are firm plans to extend this to early years settings in 2025. This development is very welcomed and long-awaited by early years providers.

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Main findings

There are good examples where information-sharing between partners is supporting effectively the partnership identification of risk and response to children who are victims of domestic abuse, but this is not sufficiently consistent. There are barriers across health providers’ ability to share digital records, and to identify and flag concerns. The police do not always respond to requests for information in a timely way so as to assist with probation risk management and the assessment of children and families by children’s services.

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Main findings

Most social work assessments are informed by multi-agency information, which includes extended family members. This helps to identify the needs of and risk to children affected by domestic abuse within the context of their family, including any adult vulnerabilities. While assessments include resident and non-resident fathers whenever possible, not all children of separated parents or blended families are identified and fully considered within practice. The voice of the child is not consistently being sought or well recorded by health, probation and police practitioners. While there are some strong examples of practitioners speaking to children and taking the time to listen to and understand their experiences, this is not the case for all children. Children’s voices are captured consistently well within children’s services records.

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Main findings

Pre-birth practice across the partnership is a strength, with timely referrals and responses ensuring that workers have an opportunity to work alongside families and provide support or address risks before the baby arrives.

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Main findings

When children need help, support and protection, meetings are timely and involve most key practitioners from across the partnership.

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Main findings

Practitioners develop multi-agency safety plans with children and their families at an early stage, which help to mitigate risk. Often, these safety plans draw on the family’s natural network to support children and to sustain the progress made. Social workers sensitively undertake purposeful direct work with children to help them develop and understand their own age-appropriate safety plan. However, these important plans are held on children’s services electronic records and are not consistently shared with all practitioners. When safety plans are shared, there is greater multi-agency oversight and monitoring, which helps to safeguard children.

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Main findings

Once the need for family help is identified, most children and their families receive the level of support that they need and move seamlessly between levels of support, often maintaining relationships with practitioners who know them well. When adult family members are supported by adult services, some of these professionals are not involved in key meetings around the risks for children and are, therefore, unable to contribute to safety planning and support. Similarly, representatives from housing services often do not attend key meetings where their input would be helpful. When practitioners from adult-focused services are included, they can sometimes underestimate the risks posed to children.

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Main findings

Specialist domestic abuse roles in children’s social care teams are highly valued by social workers and contribute to effective and creative plans to help keep children safe and improve their situations. Workers patiently build relationships and use a range of tools (and their own creativity) to access children’s voices and understand their experiences. Disabled children also benefit from sensitive work to identify and reduce the impact of domestic abuse.

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Main findings

The multi-agency scaling of risks for children within key child protection and child-in- need meetings is not consistently understood by all practitioners, and their non- attendance at meetings can have a negative impact on the consistency of their understanding because previous scaling is being used that does not reflect the most recent information about risks or concerns for the child. This can distort the level of risk, as it is not wholly based on the current risks or the seriousness of the situation for the child. Positively, the use of multi-agency chronologies for child protection conferences helps to ensure that there is a shared understanding of all the risks and significant events known to each of the agencies involved. Families have shared with practitioners that they benefit from seeing a visual representation of the concerns.

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Main findings

For a small number of children aged 0 to 7, adults’ needs can sometimes overshadow children being seen as victims of domestic abuse in their own right. The cumulative risks of emotional harm and the impact of repeated domestic abuse are not always understood soon enough, and these children do not get the help they need quickly enough. Additionally, while practitioners can articulate the family’s cultural identity and the impact of domestic abuse on their lives, this is not always captured well. Consequently, it is unclear how well partners understand the role culture has to play in the adult’s experiences of being victim and perpetrator.

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Main findings

Children benefit from accessing special domestic abuse support and services across the continuum of need. This includes support from the children’s services domestic abuse workers, bespoke domestic abuse intervention from the commissioned service, and an extensive range of other commissioned and community and social enterprise domestic abuse services. These services are positively supporting children with their emotional well-being and provide them with strategies to manage their feelings.

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Main findings

Most multi-agency practitioners understand the needs and risks to children. There has been positive joint working between practitioners across the partnership to support the progression of child protection plans, with appropriate licence restrictions put in place and effective oversight by Multi-Agency Public Protection Arrangements (MAPPA). This includes some effective pre-release planning and use of approved premises to bolster the risk management of domestic abuse perpetrators. However, while MAPPA are working well to manage the risk posed by highest harm domestic perpetrators, there is often an insufficient focus on the voice of the child as a victim of domestic abuse.

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Main findings

The Multi Agency Risk Assessment Conference (MARAC) model has been adapted in Norfolk into a process known as Multi-Agency Risk Assessment Co-ordination. This aims to bring agencies together more quickly to coordinate planning for victims. However, these arrangements are not consistently understood by practitioners across the partnership. Some practitioners are not confident that they understand how to make a referral into MARAC or what value MARAC brings. Outcomes of the MARAC are not consistently being shared with relevant practitioners. Leaders accepted the findings of the inspection and planned to undertake prompt action to review the current delivery of the MARAC.

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Main findings

There is a clear process for the Domestic Violence Disclosure Scheme (Clare’s Law), and partners are working well together. All applications are considered by a weekly multi-agency panel using information from all agencies. The police receive referrals from most partner agencies. There is an online portal on the police website (single online home) for victims to raise the ‘Right to ask’ request. This is helping parents to proactively protect their children and make choices that will help to keep them safe.

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Main findings

Children’s social care has introduced a model of multi-agency case supervision known as Team Around the Child Supervision (TACS) meetings. While these provide a space for professionals to share information and explore what might be happening for children, not all multi-agency practitioners feel confident in sharing or escalating concerns about practice, and there isn’t always attendance from non-children’s services professionals. Leaders know that TACS meetings are not always providing the necessary direction to drive positive change for children, and they are working on plans to improve this. Not all practitioners across probation and health are receiving good-quality and regular supervision that supports their practice with children.

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Main findings

There is a comprehensive workforce development and training offer in place, which addresses both multi-agency and individual agency needs. The offer is regularly reviewed and updated by the partnership. However, across agencies, not enough practitioners are currently accessing this training.

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Main findings

Schools and early years providers rightly feel that they make a constructive contribution to strategic direction in Norfolk. They value multi-agency training and how this has increased their understanding of the complexity of domestic abuse and its interconnectedness with neglect. They report positively on the difference this has made to their practice and in turn, the support to children. Most school and early providers are positive about their role in partnership working in supporting children who are victims of domestic abuse.

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Practice study: areas of highly effective practice

For some children, there are areas of highly effective practice across the partnership that help to safeguard children and prevent and reduce the risk of domestic abuse.

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Practice study: areas of highly effective practice

Practice with unborn children at risk of domestic abuse is a strength. Practitioners across the partnership engage parents with sensitivity and persistence and offer bespoke interventions to parents when needed. The safety of pregnant women is given high priority, and there is sensitive work undertaken with brothers and sisters to understand the plans for their new family member. Safety plans are formed early, and appropriate services and support are made available. Extended families are well engaged in safety planning to help keep children safe once they are born. Partner agencies are involved at all stages of the work, with effective and creative joint working that safeguards the unborn child and supports families. Plans made are well constructed, are relevant to need, and they help families to make progress.

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Practice study: areas of highly effective practice

For one young child, risk from domestic abuse and neglect has been very well managed. Relevant health practitioners were involved at every opportunity during the mother’s pregnancy. There was swift assessment and planning to safeguard the child following birth. A comprehensive and evidence-based social work assessment demonstrated good insight into the impact of domestic abuse on the unborn child and identified the risks for the child post birth. The understanding of the family history and thorough analysis of risk led to timely protective action being taken for the child. Safety planning for the child included the family network. This early use of family networking ensured that the parents were well supported to understand the assessment process, child protection plans and court processes. The use of a multi-agency chronology for the child protection conference provided a purposeful and shared understanding of all the risks

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Practice study: areas of highly effective practice

identified for the child by practitioners across the partnership. This helped the parents to understand the nature and seriousness of the situation for their child.

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Practice study: areas for improvement

For a small number of children, the cumulative risk of domestic abuse has not always been well understood by practitioners and plans have not been progressed as quickly as they could have.

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Practice study: areas for improvement

The experiences and practice for one pre-school-aged child reflect the complexities of providing a multi-agency response to children and families where there may be risks in addition to domestic abuse. For example, the child has been known to the partnership since birth and has witnessed repeat domestic abuse incidents within the home. While practitioners across early years, health, children’s services, probation and police identified the risk of domestic abuse and have worked together to progress plans to reduce risk, the risk assessment and actions did not sufficiently reflect the impact of cumulative harm. There was minimal engagement by the extended family network, and practitioners have not consistently utilised domestic abuse tools in order to assist their interventions with the family. The child’s behaviours and presentation were not fully considered in the context of the impact of domestic abuse. The accuracy of multi-agency

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Practice study: areas for improvement

scaling of risk was also impaired by the absence of some practitioners at key meetings and previous scaling being used that did not reflect the most recent information about risks or concerns for the child. Further complicating factors included how well practitioners were able to engage the adults in meaningful work to achieve positive change. The adults’ own health needs and the status of the adults’ relationship had a negative impact on how well practitioners could engage them in the safety plan and interventions to reduce risk.

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Practice study: areas for improvement

Positively, progress is now being made for the child. Partners have recognised the strengths and risks for the child and have advocated for escalation of the continuum of needs.

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Practice study: areas for improvement

Leaders have acknowledged the learning for this child and are taking appropriate action.

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Next steps

We have determined that Norfolk local authority 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. Norfolk local authority should send the written statement of action to ProtectionOfChildren@ofsted.gov.uk by 11 June 2025. 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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