Setting

Danielle Swainston, Director of Children’s Services, Redcar & Cleveland Borough Council John Sampson, Managing Director, Redcar & Cleveland Borough Council Martin Short, Executive lead, North East and North Cumbria Integrated Care Board Matt Storey, Police and Crime Commissioner Mark Webster, Chief Constable, Cleveland Police Bronwen Elphick, Regional Probation Director – North East Edwina Harrison, Independent Scrutineer

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Dear South Tees Safeguarding Children’s Partnership

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Joint targeted area inspection of Redcar and Cleveland.

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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 Redcar and Cleveland.

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This inspection took place from 7 to 11 April 2025. 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 has several challenges for partners, not least 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

The absence of a specific domestic abuse strategy that focuses on children impedes South Tees Safeguarding Children’s Partnership (STSCP) leaders’ joint understanding of the quality of multi-agency practice for all children, including for unborn children and those aged 0 to 7 who are victims of domestic abuse in Redcar & Cleveland.

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Headline findings

Domestic abuse is not a strategic priority for children in the STSCP, which is responsible for two local authority areas. This is because the focus of the recent partnership work has been to address risks to children experiencing harm outside the home and children who experience neglect. This sequential approach limits leaders’ ability to recognise that these are often the same children. It also impacts on the ability of leaders to work together across the partnership to analyse the prevalence of need and risk for unborn babies and young children in their local area in response to increasingly high volumes of domestic abuse referrals.

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Headline findings

While strategic leaders across the partnership work collaboratively to commission effective services, the emphasis, focus and priority is on adult victims of domestic abuse. Priorities for all children who experience domestic abuse are not aligned across the strategic partnerships. Unborn babies and children aged 0 to 7 who are victims of domestic abuse are not fully recognised or afforded sufficient scrutiny in the local authority domestic abuse strategic partnership, the community safety partnership, and the adults safeguarding partnership. Evaluation is not based on a systematic analysis of the impact of frontline work across services. This inhibits joint priorities and planning. Consequently, the STSCP multi-agency leaders do not have a sufficient understanding of the effect of domestic abuse on children’s lived experiences. Strategic links between probation and the safeguarding children’s partnership are underdeveloped. These deficiencies are linked to the lack of a

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Headline findings

children’s domestic abuse strategy. This has also impacted on the effectiveness of the STSCP’s development and delivery of multi-agency domestic abuse training.

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Headline findings

Safeguarding partners accept that they need to review their governance arrangements in the senior strategic lead safeguarding partnership, who are responsible for delegating safeguarding functions to the STSCP executive. The recently appointed director of children’s service, the STSCP chair and integrated care board representative have welcomed the inspection as an important learning opportunity. Leaders across the partnership fully accept that coordinated strategic arrangements need to improve exponentially in order to provide evidence and assurance that the needs of vulnerable children affected by domestic abuse are fully understood.

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Headline findings

Despite these significant strategic deficits, the operational joint practices across teams and services are stronger. Although there is some inconsistency of practice, enthusiastic, experienced practitioners and managers across agencies provide sensitive and child-centred interventions for most children. Parents who are victims of domestic abuse and perpetrators receive respectful and thoughtful services which help them to recognise the harm their children experience. Risks of harm to unborn babies and young children are identified and, in most children’s cases, responded to promptly. Decisions for children who need protection are based on effective timely information shared by relevant agencies. Most staff are clear about their roles and responsibilities. However, there are some areas of practice that are not as effective across the whole partnership.

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What needs to improve?

◼ The STSCP governance arrangements, development and alignment of a specific children’s domestic abuse strategy across the partnership that recognises children as victims of domestic abuse.

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What needs to improve?

◼ Redcar & Cleveland’s understanding and needs assessment of the impact of domestic abuse on unborn and young children’s unique and diverse needs locally. ◼ The inclusion and consideration of children’s experiences in referrals and in multi- agency meetings. ◼ How well practitioners across the partnership are listening to the voices of children and understanding what it means for children to be victims of domestic abuse. ◼ Communication with and involvement of probation services strategically and operationally. ◼ The overreliance of safety plans on non-abusing parents, mostly mothers, in protecting children. ◼ Multi-agency training for all agencies in recognising children as victims of domestic abuse and understanding parental consent. ◼ The consistent completion of work with perpetrators of domestic abuse and engagement with victims prior to decisions being made to end child protection plans.

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Strengths

◼ Prompt communication across the partnership to help and protect children who are victims of domestic abuse. ◼ Committed and caring practitioners across early help, social care, in health settings, schools and police work collaboratively and provide most children with effective help and protection, despite the lack of a dedicated strategic domestic abuse strategy for children. ◼ Leaders’ positive response to the inspection findings and determination to actively make the necessary changes to drive the much-needed development and reform. ◼ A comprehensive, well-established and effective commissioned service for victims of domestic violence, children and perpetrators is offered in Redcar & Cleveland. ◼ Practitioners in the Emergency Operation Centre and ambulance crews demonstrated professional curiosity and diligence in referring children to safeguarding teams in all cases sampled.

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Main findings

Thresholds of risk, need and harm to unborn babies and children aged 0 to 7 who are victims of domestic abuse, although inconsistent, are increasingly recognised by co-located health, education, children’s social care, early help practitioners and police officers in the multi-agency children’s hub (MACH). Probation does not currently participate in the MACH, which limits practitioners’ understanding of probation’s role and impacts on early information-sharing.

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Main findings

Not all agencies consistently recognise children as victims of domestic abuse in referrals to the MACH . Their voice and experiences are not consistently recorded. Police protection notices are sent to the MACH daily, but information about children present during police incidents is often missing. Experienced police staff check records, adding linked children and perpetrators. Daily screening of referrals by experienced police officers and social workers ensures that harm thresholds are promptly evaluated. In a small number of children’s cases that were RAG rated as red because they either met the threshold for significant harm, or needed action to be taken quickly, referrals did not progress to a child protection strategy meeting as the focus was inappropriately on the adult victim.

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Main findings

Health referrals reviewed are mostly detailed and information-sharing from and to other agencies is evident. For some children, there is a lack of professional curiosity about children’s experiences as the focus is on adult victims. This means that a medical developmental approach to presentation in health settings leads to missed opportunities to explore the impact of domestic abuse on children as victims.

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Main findings

Effective and timely information-sharing between health services is facilitated by a shared patient record system used by public health nurses, GPs and community health services. Safeguarding alerts and summaries of hospital attendances and admissions are visible on children’s records. This means that health practitioners can view each other’s records to have a comprehensive and up-to-date picture of a child and family’s circumstances and healthcare. The MACH works well with schools through strong relationships and information- sharing, where the needs of children who are at risk of domestic abuse are recognised and responded to effectively. The education safeguarding officer for schools in the MACH provides a valuable point of contact for schools and early years settings. Staff value the advice and appreciate the timely opportunity to discuss concerns, leading to prompt referrals for children.

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Main findings

Operation Encompass makes a positive contribution to multi-agency safeguarding for children. Referrals on the system are received by schools, early years providers and health services. Positively, a partnership review identified that additional details about the effect of the incident on the child would improve these communications and work is under way to implement this.

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Main findings

Decisions about the next steps to help and protect children are informed by the previous history. Parent victims of domestic abuse and perpetrators are consulted to gain further understanding of their personal situation and to determine the most appropriate intervention for the family. This enables families to be directed to the right agency and support at an early stage and ensures that they are not subject to unnecessary statutory interventions. For some children, cumulative harm is not recognised, leading to re-referrals and missed opportunities to intervene earlier.

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Main findings

Effective early help interventions delivered in locally based early help family hubs offer multi-agency support services that are aligned to children and families’ assessed needs. There are strong links with schools, health visiting, maternity services and housing. Parents, both mothers and fathers, are encouraged and supported to be child focused, with early help practitioners having skills that offer positive strengths-based interventions that are helping to reduce harm to children. This has been enhanced by effective domestic abuse training.

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Main findings

Most unborn babies and children aged 0 to 7 benefit from child protection strategy meetings that identify risks well. The right multi-agency partners are present to share information, and appropriate actions are being made to safeguard children. Complex strategy meetings are not held when offenders traverse multiple children’s lives in different households and cross local authority boundaries. These are missed opportunities to share information, track perpetrators and assess risk to children who are victims of domestic abuse.

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Main findings

Joint police child protection enquiries are mostly thorough. Domestic abuse responses and investigations are the largest demand on the force’s responses and investigation capabilities. The force prioritises the arrest of domestic abuse perpetrators. Police leaders are working to improve the inclusion of children’s experiences in all domestic abuse incidents. The police force control room staff consistently use THRIVE risk assessments to decide the priority of the response to incidents of domestic abuse. This is a tool for police to determine the most appropriate response to a call for service, considering the potential threat, harm and risk, while also focusing on the victim’s needs and vulnerabilities . When responses are delayed, incidents are systematically reassessed. In addition to attending domestic abuse incidents, rapid video response is being developed with a child-centric approach. Video calls are used if there are children in

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Main findings

the household, and officers are required to speak to the children. If this is refused, the call is ended and a response officer is tasked to attend the address.

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Main findings

Assessments of children’s needs are timely and include most partner agencies’ contributions. Skilled social work practitioners, together with most partner agencies, listen to and act on children’s views. Most children are supported to talk about their lives and experiences through age-appropriate and effective direct work using a range of tools. Parents’ views are explored thoroughly as part of the assessments. Social workers know these parents well, as they have taken the time to build trust and break through barriers. This includes efforts to engage perpetrators of abuse and constructively challenge when they minimise their abusive behaviours. For a small number of children known to services over many years, assessments are superficial, leaving children exposed to harm for too long. The assessment used by the local authority does not allow for a holistic overview of children’s or parents’ experiences or their unique situations, including parenting capacity. Children’s unique

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Main findings

identities and cultural backgrounds are not sufficiently well understood or reported in assessments, records and plans. The needs of culturally diverse communities living in Redcar & Cleveland are not understood, which is linked to the outdated needs assessment locally.

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Main findings

Schools and early years settings are actively involved in multi-agency planning to support children affected by domestic abuse. They are committed to ensuring children’s safety and build strong and trusting relationships with children and their families. Schools and early years settings are often the first port of call if a concern arises in the home. They actively help parents to understand risk and encourage them to engage with other agencies for support. Providers demonstrate a strong understanding of children’s wider vulnerabilities. They know children well and give the voice of the child a high priority. Specialist settings catering for pupils with special educational needs work closely and effectively with the local authority to ensure that children’s voices are heard.

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Main findings

Effective work by the ‘Indigo’ midwifery team and the social care pre-birth team to identify vulnerable pregnant women at risk of domestic abuse ensures that information-sharing is prompt across the partnership and interventions are focused on the needs of the unborn children. However, this benefits only a small number of women and their unborn child. For example, women who have children living with them do not benefit from the expertise of the social work pre-birth team. These unborn babies and their brothers and sisters are allocated to social workers in the assessment and locality teams. The pre-birth team only works with first-time mothers or those where children have been removed due to significant harm. The rationale for a two-tier system for assessing unborn babies impacted by domestic violence is unclear and is being reviewed by recently appointed senior social care leaders.

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Main findings

The identification of women and children experiencing domestic abuse is effective in the 0–19 public health nursing service. Practitioners use the domestic violence toolkit, which was developed in response to a serious incident, and routinely ask women the four HARK (Humiliation, Afraid, Rape, Kick) screening questions. Home visits and appointments are managed creatively to see women on their own and give them every opportunity to disclose domestic abuse. The 0–19 public health nursing team routinely receives invitations to strategy meetings, child protection case conferences and other multi-agency meetings.

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Main findings

In primary care, there was significant variability in practice and understanding of children as victims of domestic abuse. For example, in stronger work, the GP regularly contacts the families of known children to check on their well-being and proactively seeks information from partners such as social workers. Practitioners in primary care report less effective direct work with the 0–19 team. There is no named health visitor linked to a GP practice and no regular safeguarding meetings locally that include the 0–19 team.

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Main findings

The lack of strategic join-up between probation and the STSCP permeates down to frontline practice. Probation practice focuses on risk to adults, while the risks to children of being exposed to domestic abuse are not consistently identified. Probation assessments sometimes use inappropriate language when describing the experience of children, such as ‘being caught in the crossfire’ or ‘indirect victims’. In some cases, the risks to children are identified as being lower than for adults, although it is unclear how this could be the case given the impact of domestic abuse on children.

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Main findings

Probation practitioners do, however, consider domestic abuse a child safeguarding issue and make timely safeguarding referrals to the MACH. For instance, in the pre- sentencing stage, risks were identified due to a concealed pregnancy. In stronger cases, comprehensive risk management plans and structured interventions to address domestic abuse behaviour are a strength, with regular home visits and effective communication with children’s services and the police. This includes proactive information-sharing from police to probation, including rearrests for further offending . This practice is underpinned by effective management oversight. Weaker practice issues include failure to identify risks to children, insufficient liaison with other agencies, lack of structured interventions and response to new information or offences.

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Main findings

For adult and child victims, from unborn babies to age seven years, a comprehensive, authoritative service commissioned by the local authority for victims of domestic violence, children and perpetrators is offered in Redcar & Cleveland. The commissioned service allows for independent abuse advisers to be available across the local area in different agency settings, including James Cook University Hospital and GP surgeries. Families are referred for services by agencies including police, health visitors, maternity and social workers.

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Main findings

Families benefit from interventions provided by the commissioned service, which are based on risk assessment and tailored to meet individual children and families’ needs. Preliminary assessment appointments ensure that cultural and ethnicity needs can be incorporated into the provision of services and appropriate safety planning is put in place to reduce risks for children. The service provides high-quality refuge accommodation accompanied by well-being activities and therapeutic intervention for parents and children so that they can recover from abusive behaviour.

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Main findings

Confusion about consent and lack of engagement from families inhibits the progression of some child in need and child protection plans when parents do not consent to aspects of plans. For example, some children step down from child protection plans too soon, prior to essential work being addressed to reduce risks. This occurs when there is a lack of meaningful parental engagement with the commissioned service or perpetrator work is not completed. Most children remain open to statutory teams, but risks to and the impact of domestic abuse on children are not fully recognised and children are not viewed as victims in their own right. Safety planning is often superficial, relying on the female victim to protect herself and the children. Issues about understanding consent is a recurring theme and is linked to the absence of a domestic abuse strategy for children and limited multi- agency training.

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Main findings

‘We Are With You’ (WAWY) drugs and alcohol rehabilitation services are members of the Thrive partnership, which is an integrated domestic abuse, drug and alcohol service consisting of key delivery partners, plus Redcar & Cleveland Borough Council’s vulnerabilities and housing advice and information teams. Co-located WAWY staff work jointly with social workers, conducting home visits, and are part of children’s reviews and core groups. This means that parents with substance misuse issues benefit from simultaneous support in relation to domestic abuse as well as their addiction.

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Main findings

Police arrange and coordinate effectively multi-agency risk assessment conferences (MARAC). Relevant multi-agency attendance at MARAC ensures that the voice of the child and the impact of domestic abuse are understood and that appropriate actions and support for children and their families are agreed. This is not always reflected in the minutes, as actions tend to be adult focused. In all cases involving children, it was positive to see that an action was set for the minutes to be shared with the relevant school. In addition, police-led multi-agency tasking and coordination (MATAC) meetings are used effectively to disrupt perpetrators.

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Main findings

In multi-agency public protection arrangements (MAPPA) meetings about high-risk domestic abuse perpetrators, when children are linked to the victim and/or perpetrator, there is good attendance from relevant agencies, including children’s services. Information-sharing is comprehensive and risks to children are fully considered, but their experiences and voice are not reflected in minutes or in specific actions.

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Main findings

While the multi-agency partnership has a good understanding of applying for information under Clare’s Law, notifications that a disclosure has been made, or a domestic violence prevention order has been authorised, are not shared consistently. This means that practitioners are not always aware of the detailed risks and the impact on children.

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Main findings

Highly effective practitioners in the Emergency Operation Centre and ambulance crews demonstrate professional curiosity and diligence in referring children to safeguarding teams when there are concerns about domestic abuse. All staff, including call handlers, access level 3 safeguarding training leading to child-centred, timely referrals about children in domestic abuse situations, including out of hours.

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Main findings

Leaders have not ensured that there is comprehensive multi-agency training to build up the skills and knowledge of the workforce to ensure that it responds jointly to children who are victims of domestic abuse. Instead, domestic abuse responders and practitioners rely on single-agency or self-arranged training. While this is positive, some training content is not current, resulting in confusion for staff and families. There are examples of innovative work, such as the introduction of virtual reality training to develop awareness of the impact domestic abuse can have on the unborn child. The STSCP recognises the need to prioritise multi-agency training so that it ensures children receive an effective multi-agency response.

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Practice study: highly effective practice

Ambulance practitioners are often the first service to respond to children who are experiencing domestic abuse in their home. Call handlers in the Emergency Operation Centre have received additional training to support them to be professionally curious and attentive to the signs of domestic abuse involving children. The ambulance service has enhanced police and probation alerts on its records, linked to people and addresses, that notify both call handlers and clinical practitioners of known victims and perpetrators of domestic abuse.

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Practice study: highly effective practice

Safeguarding alerts on children’s patient records provide information on children who are subject to child protection plans or those who are in care. This effective multi-agency information-sharing ensures that ambulance practitioners are well informed and prepared when dealing with an emergency call-out.

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Practice study: highly effective practice

For one young child, the risk of domestic abuse was identified early. The practitioner taking the 999 calls carefully listened to the background noise while recording details of the emergency. She noted a verbally abusive and highly agitated adult and a distressed young child. Swift action ensured that an ambulance and police were dispatched to the address. The use of a sensitive and detailed approach by the ambulance crew on scene provided further detailed information about the child’s emotional and physical presentation, the family dynamics and the home environment. For this child, the multi-agency information- gathering and assessment of risk resulted in effective decisions and response from children’s services.

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Practice study: area for improvement

The impact of cumulative harm is not identified soon enough for some children, leading to them experiencing incidents of domestic abuse for too long. This is not always well understood by practitioners and has led to plans not progressing quickly enough. For a small number of children, plans are ended without assessed work being completed, leading to repeat referrals and further interventions.

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Practice study: area for improvement

The lived experiences of school-age children in one family, who had been known to multi-agency partners since pre-birth of the youngest child, were not addressed. Vulnerabilities for parents, in a recurring domestic abuse situation, were viewed as ‘low level’ and highlight the challenges of providing a multi- agency response to work on the areas needed to change to reduce emotional harm to children. The recent audit identifies that the partnerships need to review their approach to assessing the cumulative impact of verbal arguments and incidents.

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Practice study: area for improvement

For these children where parental conflict is entrenched, the professional challenge between agencies to ensure that work is completed and change for these children is sustained is insufficient. Low-level incidents have been repeated without partnership challenge. For example, not meeting the threshold for intervention, police have not considered evidence-led prosecution or video interviewed children as victims and witnesses, allowing harmful parental behaviours to continue. The partnership has struggled to challenge breaches to safety planning and non-completion of essential work for change, leading to repeated patterns and continued emotional harm for the children. The partnership has not fully understood the lived experience of these children and is now taking action to address the safeguarding concerns.

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Next steps

We have determined that Redcar & Cleveland 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

STSCP Chair should send the written statement of action to ProtectionOfChildren@ofsted.gov.uk by 16 September 2025. This statement will inform the lines of enquiry at any future joint or single-agency activity by the inspectorates.

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