Setting

Julie Kelly, Corporate Director of Children’s Services, Hillingdon Tony Zaman, Chief Executive, Hillingdon Rob Hurd, Chief Executive Officer, NHS North West London Integrated Care Board Kaya Comer-Schwartz, Deputy Mayor for Policing and Crime Sir Mark Rowley QPM, Commissioner of the Metropolitan Police Service Jill Horsfall, Borough Commander, Metropolitan Police Service Mary Pilgrim, Regional Probation Director Alan Caton, Independent Scrutineer

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Dear Hillingdon Local Safeguarding Partnership

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Joint targeted area inspection of Hillingdon

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 Hillingdon.

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Joint targeted area inspection of Hillingdon

This inspection took place from 16 to 20 June 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 pose 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

Leaders across agencies have recognised that their collective strategic cooperation, governance and oversight of domestic abuse has not been effective enough. The absence of a strategic needs analysis of domestic abuse and the support to victims was insufficient. In response, since June 2024, partner agencies, working together through the Safer Hillingdon Partnership (SHP), are formulating a clearer delivery plan, to prioritise tackling domestic abuse. They also recognise that there is more work to be done to ensure the delivery plan has impact for children and families who are victims of domestic abuse.

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Headline findings

The absence of a clear needs analysis has had a negative impact on the partnership’s understanding of the needs of all children, including those aged 0 to 7 years and unborn children, who also suffer from the impact of domestic abuse. Inevitably this also has a negative impact on the effectiveness of service delivery.

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Headline findings

Operational practice across agencies in identifying risks of domestic abuse for unborn children and children aged 0 to 7 who are victims of domestic abuse is inconsistent and often adult focused. Once risk is identified, children generally receive stronger services, which does then recognise them as victims in their own right. Despite the underdeveloped strategic response, practitioners in most agencies, in particular the local authority, have a strong awareness of the risks posed by domestic abuse. Consequently, although practice does remain variable overall, there are some areas of particularly effective practice, for example work with children with special educational needs and/or disabilities (SEND).

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What needs to improve?

◼ How effectively the multi-agency public protection arrangements (MAPPA) and multi-agency risk assessment conference (MARAC) processes are being used to protect children and adults from domestic abuse and how well these processes are integrated with, and used to inform, wider work to support and protect children and families. ◼ Strategic and operational links between probation and the partnership, in particular with regard to strengthening the effectiveness of disruption activity. ◼ The effectiveness of multi-agency joint working, in strategic and operational contexts, to tackle domestic abuse. In particular, how well an accurate needs assessment is used to drive the commissioning of services and to assess impact. ◼ The effectiveness of the scrutiny arrangements of the partnership. ◼ The timeliness of child protection processes and the consistency, quality and pace of information-sharing across the partnership.

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Strengths

◼ The members of the partnership know themselves well and understand that they need to strengthen the response to victims of domestic abuse in Hillingdon. ◼ The partnership leaders’ response to the inspection findings and their commitment to implement changes to better support victims of domestic abuse. ◼ The partnership has recently put in place well-considered and robust governance arrangements aimed at providing a framework to support a more effective approach to tackling domestic abuse. ◼ Once risk is identified, experienced and caring practitioners across early help, social care, in healthcare settings, schools, probation and police work together collaboratively and well, to offer generally effective help and protection. ◼ The Hillingdon Domestic Abuse and Advocacy Service (HDAAS) offers high-quality support which strengthens the support and protection of victims of domestic abuse.

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Main findings

Strategic partners in Hillingdon are aware that they need a significantly strengthened focus on domestic abuse, particularly in terms of a shared approach to data collection, the response to victims/survivors, and more specialist support for children. The scrutineer of the Hillingdon safeguarding children partnership has also picked this up as an area in need of much greater priority.

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Main findings

In response to the recognition that the multi-agency safeguarding arrangements were not tackling domestic abuse effectively, the SHP has become more galvanised. Since June 2024, the partnership has contributed to the strategic needs assessment to prioritise goals for the next three years, with domestic abuse being one of the key issues identified. There is now a domestic abuse strategy and an outline delivery plan in place; however, this remains underdeveloped. It is only in the last six months that an operational group has been established, the Hillingdon Domestic Abuse Operational Group (HDAOG), but it is too soon to see impact for children and adult victims of domestic abuse.

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Main findings

The Domestic Abuse Steering Executive (DASE), which reports to the SHP, is aimed at providing strategic oversight and direction, and is attended by all statutory partners with the intention of ensuring that appropriate operational arrangements are in place. Despite governance arrangements being in place, the impact of strategic oversight to drive forward effective services to support children and adults who are the victims of domestic abuse has been too slow. The HDAOG operational group is not yet established enough to be effective; it lacks urgency or focus about how to progress plans and use the resources that partner agencies are willing to provide. There is no obvious clear line that runs from a needs assessment through shared partnership priorities, to the commissioning of services and then to the assessment and review of their impact.

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Main findings

Strategic links between the Probation Service and the partnership are limited, despite the potential significance of recent developments within probation which may have a negative impact on child safeguarding, for example early prison releases, the probation reset and the new Impact Initiative. The partnership is not always aware and at times has had a false sense of security about what the Probation Service can offer to mitigate risks for children who are victims of domestic abuse. This deficit has now been recognised, and a newly appointed probation practitioner is soon to start in the Stronger Families Hub (SFH). This is also aimed at increasing practitioners’ understanding of the role of probation. However, there are wider strategic links to be considered to support the more effective integration of probation into the work of the partnership.

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Main findings

Practitioners from across agencies have a generally strong awareness of how factors linked to the culture, ethnicity and religion of children and adults intersect with their vulnerability and resilience in connection to domestic abuse. This high level of cultural competence also means that, while practitioners typically respect and place value on these key aspects of identity, they also apply a consistent threshold about the level of risk and how children’s needs for safety can be secured. Practitioners, and the children and families they work with, benefit from typically good access to interpreters.

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Main findings

Although the strategic oversight of services for children who are victims of domestic abuse remains underdeveloped, strategic leaders from partner agencies have a mature approach to working together and there is strong commitment from both them and political leaders to improving this situation and doing better for adult victims and in recognising children as victims in their own right.

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Main findings

Practitioners working in the SFH understand and apply thresholds appropriately when responding to children’s needs. However, the quality and range of information shared with the SFH about a small number of children and perpetrators of domestic abuse by referring agencies is variable, with some potentially valuable information not provided. This means that additional time is spent gathering critical information to inform decisions and can result in delays in responding to some children who are victims of domestic abuse. This includes when someone is known to probation or other police force areas.

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Main findings

All contacts and referrals requesting support for children receive management oversight in the SFH. The SFH operates 24/7 throughout the year and hosts a range of multi-agency partners in one place, for example police, health, housing and children’s social care. Most multi-agency safeguarding checks are completed within expected timescales and decisions on next steps are mostly appropriate; however, not all records demonstrate sufficient professional curiosity about risks of domestic abuse. Practitioners from the range of agencies within the SFH consider themselves equal partners, routinely taking part in child protection strategy meetings and challenging decisions when necessary.

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Main findings

Family hubs located within local communities provide a calm and welcoming environment for children and their families, who can access a comprehensive range of multi-agency early and targeted help support services, advice and guidance.

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Main findings

Children and their families who speak English as an additional language, or who speak little English typically benefit from early help key workers who understand the same language. Managers within the family hubs have a list of staff who can provide support as interpreters in a range of languages, and staff demographics reflect the diversity of the local community. This helps families to build trust and positive relationships with workers, which is particularly critical when victims of domestic abuse tell their key worker about the abuse they have experienced.

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Main findings

When frontline police officers identify children at risk, they are expected to submit a ‘vulnerable person to notice report’ to the multi-agency safeguarding hub (MASH) in the SFH. Often these are processed promptly but when there are peaks in the numbers submitted, there can be delays. At these times, reports which contain details of children at the highest risk cannot be clearly identified and prioritised, with the impact of delaying the sharing of risk assessments for children.

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Main findings

Frontline police officers do not always capture children’s voice and experiences. Training is not always translating into police officers’ recording of the child’s lived experiences in a consistent way in ‘vulnerable person to notice reports’.

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Main findings

Police identify vulnerable children using flags on the police national computer to show when children are on child protection plans. A recent positive development is that parents of these children now also have markers to identity them as connected to children at risk. This information can be used to inform decisions to ensure that victims and children are protected.

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Main findings

Multi-agency safety net meetings held at Hillingdon Hospital’s emergency department provide a platform to review all safeguarding referrals made to the SFH. They bring together key partners and are a forum that enables discussion of children whose situations are complex. These meetings are also able to further promote early intervention and challenge care planning when needed. While positive, their effectiveness is limited because social workers do not always attend, which can mean that important information about an unborn or newborn child is not shared with the responsible midwife. Another example in respect of information-sharing is when minutes of child protection and MARAC meetings are not promptly circulated so risks in relation to domestic abuse in care plans are not clearly known quickly enough.

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Main findings

The specialist midwifery ‘Topaz’ team engages with all pregnant women at risk of domestic abuse. They offer vulnerable women tailored packages of support according to their specific needs through engagement with independent domestic violence advisers (IDVAs) and social care workers. Using professional curiosity, timely interventions and a 24-hour on-call duty team, pregnant women who are the victims of domestic abuse across Hillingdon get the support they need.

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Main findings

Across agencies, professional curiosity is not always applied in recognising previous and current patterns of abuse, particularly when there are concerns about unborn and very young babies. The particular needs of unborn and very young babies can be lost within the more generic child and family assessment template. Older children’s views are not always recorded or used in a meaningful way to inform plans, making plans too adult focused and not properly understanding the child’s experience as a victim.

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Main findings

Children who experience domestic abuse outside office hours receive a swift and effective response from the SFH, which operates a 24-hour service. There are positive and effective working relationships between practitioners in the local authority, police, particularly the Metropolitan Police Service Contact Centre, health and education, which means children receive a well-coordinated multi-agency response.

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Main findings

For most children who need them, there are appropriate child protection strategy meetings and conferences, with strong multi-agency partner input and attendance. However, although they are held when appropriate and are generally well attended, there are some small but not insignificant delays in undertaking some child protection enquiries, strategy meetings and initial conferences, and there is limited partner challenge to these delays. Delays, however brief, in sharing information are prolonging the length of time that a small number of children spend in situations of unassessed risk. Despite delays, early safety planning by police, IDVAs or other involved practitioners was generally in place.

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Main findings

Child and family assessments are inclusive of partner agency input. They are well written and evaluative of children’s current risks and needs and are updated regularly. Multi-agency input recognises the risks for children as victims of domestic abuse and social workers explore parents’ views about the potential impact and harm that this can create.

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Main findings

Children with child in need or child protection plans benefit from regular social work visits. Children are seen on their own, at home and within school and children’s centre settings. Work to support families and prevent domestic abuse is sensitively organised to avoid overwhelming families with too many services visiting and to ensure that victims of domestic abuse work with the person they feel most comfortable with.

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Main findings

Practitioners across agencies have a good understanding of the impact of domestic abuse for children. This supports them to have some sensitive and difficult conversations with parents when concerns are shared about their children.

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Main findings

There is positive attendance by staff from partner agencies at multi-agency meetings which helps professionals share information about risks to children to inform next steps. Children’s family history is appropriately shared, including previous incidents of domestic abuse that may have occurred in other local authority areas.

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Main findings

Minutes of some child protection conference meetings and MARAC meetings are not always shared across the partnership, with the impact that key decisions and actions to keep child and adult victims safe are not always accessible or known.

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Main findings

Plans are generally well informed by domestic abuse risk assessment tools. Multi- agency meetings are mostly timely and are well attended by partner agencies and parents. For some children there is limited progress to plans, due to the lack of availability of programmes, such as perpetrator or Freedom programmes, particularly for parents who are working.

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Main findings

The Probation Service makes initial enquiries with police and children’s social care to obtain relevant information at the start of supervision periods to ensure they know about any potential risks for children. This supports a better risk management plan.

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Main findings

Schools and early years settings are instrumental in understanding and identifying risks and concerns when children are victims of domestic abuse. Designated safeguarding leads have promoted this through helpful training and support for staff. For many children who are suffering, or at risk of suffering harm through domestic abuse, their school is a safe space. Schools are often actively involved in multi- agency planning to support children affected by domestic abuse and generally know children and their wider vulnerabilities well. Early years providers, schools and specialist settings give the voice of the child a high priority, especially those with SEND. This plays an important part in helping children to be safer and to achieve better outcomes than they may otherwise have done.

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Main findings

The benefits of ‘Operation Encompass’ are being realised for some children, but not for all who could potentially benefit. Police and the local authority education staff still have more to do to make this process consistently effective by ensuring timely sharing of more relevant information. It is positive that during the inspection leaders extended the direction to officers for ‘Operation Encompass’ to include children who are related to any of the involved adults, not just those present when they respond to calls.

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Main findings

Across health, all practitioners, including those working in adult services, are active participants in safeguarding children who are victims of domestic abuse, supported by their own trust-wide safeguarding teams. Practitioners often use innovative methods to capture the child’s voice, especially for children with SEND needs, and are strong advocates for children and adult victims of domestic abuse, escalating concerns to other agencies when necessary.

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Main findings

Child and adolescent mental health services (CAMHS), including core CAMHS and the under-fives team, are acutely aware of safeguarding concerns, and they routinely contribute to safeguarding processes. They also expedite assessments for children with complex neurodevelopmental needs when this is appropriate. As well as timely access to their own service, CAMHS practitioners signpost families to multi-agency support services for domestic abuse and make referrals to social care via the SFH. The under-fives CAMHS team also identifies needs in informal settings, such as ‘stay and play’ groups at children’s centres.

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Main findings

The IDVA in Hillingdon Hospital plays a highly respected and valued role, because they provide prompt and effective support to women experiencing domestic abuse. Practitioners across services are well informed about the IDVA’s role and referrals are routinely made in a timely manner. The IDVA’s flexibility in supporting families is a key strength, contributing to improved safety planning and victim support.

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Main findings

Hillingdon mental health and substance misuse clinicians, from the Addiction, Recovery, Community Hillingdon service, liaise with staff from partner agencies when parents decide they want to re-engage with their children as they enter into recovery. This helps to ensure that those children’s safety remains paramount and that any contact made is in children’s best interests.

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Main findings

While the breadth and depth of services are not yet sufficient to meet need, and the matching of these services to a clear need profile is work yet to do, there are a range of services and support that are making a difference for children and victims of domestic abuse in Hillingdon. This support ranges from refuge accommodation to targeted youth support, counselling and therapies. Providers themselves recognise that additional resources would be beneficial across all services due to the increase in demand for help needed by children and victims of domestic abuse in Hillingdon.

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Main findings

The partnership makes good use of the Mayor’s Office for Policing and Crime (MOPAC) funding to support safer accommodation through pan-London commissioning of refuge accommodation. The safer accommodation duty is London wide; however, Hillingdon, as a partnership, contributes through the community safety network, attending meetings, and takes the opportunity to apply for additional funding to support the establishment of other services in the community. Wider, strong support networks with other London boroughs support reciprocal arrangements for housing and move-on accommodation. Local arrangements through Hillingdon’s own housing stock are well supported by the council’s HDAA service IDVAs who support priority housing where there is domestic abuse.

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Main findings

The police have allocated dedicated resources to managing perpetrators of domestic abuse. Officers can task a dedicated arrest team to prioritise the arrest of domestic abuse perpetrators. Police leaders recognise that there are sometimes missed opportunities to use partner information to help disrupt domestic abuse perpetrators and prevent avoidable harm.

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Main findings

The Probation Service makes good use of restrictive and control-based interventions in managing perpetrators of domestic abuse. Otherwise, there are limited options for perpetrators to attend programmes, and some services have a long waiting list.

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Main findings

Probation practitioners do not always display professional curiosity to explore changes in the relationships or circumstances of perpetrators of domestic abuse. They do not always make timely contact with children’s social care or engage in multi-agency meetings when they become aware that children linked to the person on probation are open to children’s services and are therefore unable to share or act on important information in respect of the safety of children and adult victims of domestic abuse.

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Main findings

MARAC processes in Hillingdon are not working as efficiently or effectively as they could. There is strategic governance but little evidence of quality assurance that ensures that the right families are referred, the right outcomes are delivered, and that the quality of practice meets the standards they expect.

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Main findings

There is limited safety planning in place for some children, despite being heard at MARAC, and actions agreed at MARAC are not included or followed up in other relevant plans for children, such as child in need or child protection plans, to help to reduce risk. Multi-agency information is not always incorporated in safety planning.

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Main findings

The partnership response to victims of domestic abuse is more effective when agencies have IDVAs working with children and families. The Hillingdon Domestic Abuse and Advisory Service is an effective service for victims of domestic abuse and links in well with MARAC to support stronger safety planning for victims of domestic abuse.

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Main findings

Police have recently commissioned a new project aimed at intervening in domestic abuse situations to reduce the number of child and adult victims by disrupting and challenging perpetrators. All partner agencies can access this new project through the MARAC. This provides intervention options for high-risk perpetrators and is a helpful addition to the range of services in the borough.

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Main findings

Police gather evidence effectively in many investigations, but this is not consistent. Some investigations lacked thoroughness, with missed opportunities to consider evidence-led prosecutions against suspects. There is currently no formal monitoring or systematic enforcement process to ensure that prompt action is taken when protective orders are breached. For example, the police do not have an information- sharing process to notify partners that a domestic violence protection order (DVPO) has been obtained. This means safety plans are not always informed and opportunities for partners to see and tell police of breaches are missed.

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Main findings

In addition, there is no formal process for sharing information with partner agencies when they have made a Domestic Violence Disclosure Scheme (Clare’s Law) disclosure or imposing/changing bail conditions. This means that important opportunities to intervene can be missed.

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Main findings

There is no effective oversight of multi-agency public protection arrangements (MAPPA) from the local partnership. While MAPPA quality assurance and scrutiny sits with the pan-London Strategic Management Board, partner agencies in Hillingdon have not adequately assured themselves that the right cases are being managed via MAPPA or that the process is protecting victims and children effectively from domestic abuse.

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Main findings

Staff from across agencies are mostly positive about the range of multi-agency training about domestic abuse that is available in Hillingdon. This includes training provided by the Hillingdon Safeguarding Children Partnership and the West London Alliance. The training provided has made a difference, supporting practitioners in identifying and helping children who have experienced domestic abuse.

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Practice study: highly effective practice

Many children in Hillingdon benefit from the relationship-based practice of practitioners from across local agencies, who work effectively to create opportunities for improved relationships with parents and carers, so that children’s needs are better met. Inspectors saw tenacious work to engage families despite challenging circumstances. This positive work is helping to support better outcomes for the victims and survivors of domestic abuse. Thoughtful consideration of diverse cultural backgrounds is also helping to support trusting relationships being formed with families. Children are kept at the centre of practice, with SEND needs considered in light of domestic abuse concerns. Such relationship-based practice works best when agencies work together. For example, health practitioners, working alongside education and social care colleagues with children with SEND needs, are using a range of innovative and creative approaches to gain the voices of children. This work then

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Practice study: highly effective practice

supports the engagement of all practitioners with those children.

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Practice study: highly effective practice

Inspectors saw an example of visual tools being used very effectively to understand one child’s experience of domestic abuse.

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Practice study: highly effective practice

For another child, the school nursing offer has been flexible enough to engage a parent creatively, despite previous difficulties, and for a home visit and health assessment to be completed. This led to an additional health support offer which has made a very positive difference to the child’s health outcomes.

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Practice study: highly effective practice

For another family, staff from the child’s school and health practitioners have agreed a consistent narrative to use with the parent and child, and this is helping to secure ongoing engagement. The child feels safe enough with professionals they now know well and trust to share how life is at home. Termly meetings held with multi-agency partners are creating good opportunities for information- sharing and planning the responses to the changing and emerging needs of the child. This child is now benefiting from greater access to education because of the cohesive support offered.

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Practice study: areas for improvement

When children face multiple risks, including domestic abuse, it is necessary for agencies to identify and plan for each risk and for robust, timely information- sharing.

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Practice study: areas for improvement

Young children with complex needs in one family were at risk, in different ways, from a range of adults connected to their family. The children suffered neglect and the impact of parental substance misuse, compounded by the extensive risks, created added layers of complexity and risks. Managing the risks that the adults posed involved a range of probation, police, and drug and alcohol service workers.

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Practice study: areas for improvement

Without key risk information being shared, the safety planning for the children was not able to mitigate risk effectively. The Probation Service, as a key partner, was not told when a new domestic incident occurred, hence did not have the opportunity to review the risks or to identify any potential breach of licence conditions.

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Practice study: areas for improvement

The information about the levels of contact that children had with adults who posed wider risks was unknown, and although risks were felt to be mitigated, the potential for ongoing contact and harm remained. The Probation Service, as a key partner, was not kept informed about new incidents of concern and was therefore not able to review risks.

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Practice study: areas for improvement

When children’s social care was no longer involved with the family, no agency took the lead in sharing information, updating partner agencies about the ongoing level of risk or coordinating a re-referral to children’s social care. This failure to share relevant information and updates, in the absence of children’s social care, limited the agencies’ ability to understand the child’s situation and the extent and level of risk, and consequently their collective ability to keep the child safe.

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Practice study: areas for improvement

The partnership has ensured that risks to these children have been identified and mitigated through the implementation of a comprehensive action plan which is now in place.

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Next steps

We have determined that the chair of the Hillingdon Safeguarding 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

The chair of the HSCP should send the written statement of action to ProtectionOfChildren@ofsted.gov.uk by Friday 21 November 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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