Safeguarding Children Case File Audit:

Safeguarding Children Case File Audit: Health Visitor and School Nurse records 2012 Jackie Wilkinson & Vicki Spencer Safeguarding Leads LPT Audit Period: January 2012 March 2012 Report Date: June 2012

Contents Page Page Contents... 2 Abbreviations 2 Summary... 3 Background... 4 Aim... 4 Standards... 4 Method... 4 Sample & data source 4 Data collection & analysis 4 Findings... 5 Sample 5 Referrals 5 Post referral 5 Multi agency working 6 The child protection process 8 Comments... 9 Key findings: 9 Areas of good practice: 9 Areas where practice could be improved: 10 Recommendations... 10 References... 11 Appendix 1 Audit tool... 12 Appendix 2 Results table... 19 Appendix 3 Distribution list... 21 Appendix 4 Action Plan... 22 Abbreviations LPT LSCB Leicestershire Partnership NHS Trust Local Safeguarding Children Board S47 Section 47 of the Children Act 1989 LCCHS Leicester City Community Health Service LCRCHS CAF TCS Leicestershire County and Rutland Community Health Service Common Assessment Framework Transforming Community Services Safeguarding Children Case File Audit: Contents 2 of 22

Summary Reason for audit Objectives Case file audit of HV and SN reports on children with safeguarding plans is undertaken on an annual basis, against s11 Children Act 2004 requirements, LSCB procedures and internal policies and protocols as an assurance check on standards. To continually improve the quality of safeguarding practice, through a cycle of audit action planning and review Methodology The audit was conducted on a sample of 49 health visitor and school nurse records, on children with safeguarding plans, located on SystmOne. The children included in the case file audit were randomly selected from the 1,000 children living within Leicester, Leicestershire and Rutland with safeguarding plans. The case files and details of the children s records reviewed have been anonymised to protect identity. Key Findings Section Average compliance Rating 2011 12 Pre referral 86% Good practice Post referral 85% Good practice Multi agency working 92% Excellent practice The child protection process 88% Good practice Improved outcomes for the child 90% Excellent practice Key Actions Management oversight of Safeguarding Supervision Arrangements for HV and SN staff needs to be strengthened. The named nurse team will develop an agreed Policy for Supervision across LPT following TCS and implement this across services. Each staff member will have an allocated supervisor and engagement will be monitored by the Named Nurse Team. Any exceptions will be reported to line managers. Staff will be reminded of the importance of recording ethnicity, language on children s records this will be monitored through the record standards audit. The Trust Lead for Safeguarding will present the Audit findings at both Leicester City and Leicestershire County & Rutland LSCB effectiveness sub groups: a) 45% of case files audited demonstrated a strategy discussion took place with health staff following safeguarding referral this needs to be raised with local authorities as an area for improvement. b) 2 of the case files audited health staff had not been invited to the initial case conference. Areas of good Practice arising from the report and recommendations are communicated with staff. Including the importance of face to face contact with children within health assessment processes to hear the voice of the child Safeguarding Children Case File Audit: Summary 3 of 22

Re audit Date (TBC) TBC Background This audit was conducted in the context of Working Together to Safeguard Children, HMO 2010 which sets out the relevant statutory and non statutory guidance for all organisations. The audit is led by safeguarding leads working across LPT with support from the named professionals and the audit team. Clinical audit is an important assurance process for health organisations to check the quality of the safeguarding records and that internal and multi agency procedures have been followed. Aim To continually improve the quality of safeguarding practice, through a cycle of audit action planning and review. Standards This audit checked compliance with s11 of Children Act 2004 and essential standards registration, Care Quality Commission 2010. Method Sample & data source The audit was conducted on a sample of 49 health visitor and school nurse records regarding children who had been referred under s47 arrangements because of safeguarding concerns. Health visiting and school nursing records are held on the SystmOne electronic patient record. The population consisted of approximately 1,000 children living within Leicester, Leicestershire and Rutland who were identified as being under s47 arrangements (either by were core assessments were taking place or were children with safeguarding plans). The sample of 49 records were selected at random from this population. Data collection & analysis Case notes for the 49 samples were reviewed by the auditors, who are the trust Safeguarding Leads, against the LSCB case file audit tool for health agencies (Appendix 1, p. 12). This audit was originally scheduled as part of the LCCHS (City Community Health Services), but since the merger between LCCHS, LCRCH & LPT in April 2011, was broadened to include the whole of Leicester, Leicestershire and Rutland. The case files and details of the children s records reviewed have been anonymised to protect identity. Safeguarding Children Case File Audit: Background 4 of 22

Findings Sample The sample included 27 school nurse records and 21 health visitor records. 21 children live within Leicester City, 23 Leicestershire County, 4 Rutland supported by each of our 3 local authorities. Referrals 10% of the children in the case file sample had a Common Assessment Framework (CAF) in place prior to safeguarding referral; demonstrating that agencies identified families and children s needs and had tried early family support, before then generating a s47 referral, at a point where concerns of significant harm to a child, see table (1). 80% (n=39) of safeguarding children referrals were generated by public or agencies other than health to social care, health professionals generated 20% safeguarding referrals on the case file audit sample selected, based on concerns of significant harm to a child. Post referral 45% of health professionals contributed to an initial strategy meeting arising from the safeguarding referrals made on these children. Strategy meetings or discussions are initiated by the local authorities responsible for investigation of the referral; the figure of 45% is lower than would be expected, as health services provide universal services to children locally, all involved agencies should be involved in strategy discussions. Once a referral was communicated to health professionals, 67% of these children were then in receipt of continued health support; 27% of these were not applicable as following a health assessment a number of school aged children may be assessed as having no unmet health needs and therefore the school nurses would not be active members of the core group, see Figure 1 and Table 1. Figure 1 Post referral Safeguarding Children Case File Audit: Findings 5 of 22

Case file audit Yes No N/a Blank Did the health professional contribute to any strategy meeting or discussion? Was continued health support provided to the child and family following the safeguarding referral? Table 1 Post referral 45% 41% 12% 2% 67% 4% 27% 2% 67% of children within the sample had a safeguarding plan in place prior to the first case conference. These plans were drawn up through strategy meetings. 25% of children (n=12) did not have safeguarding plan in place prior to first conference, but these meetings were held within 10 working days of a safeguarding referral being made, adhering to LSCB procedures. 55% (n=27) of the case files demonstrated that social care was updated from health professionals on relevant new information on the child. 35% (n=17) there was no new relevant information to communicate to local authority key workers; this provides good assurance of effective communication systems in place between health professionals and key workers, see Figure 2. Multi agency working Figure 2 Multi agency working 67% of the cases had a safeguarding plan in place prior to first case conference, of these, all but one record demonstrated Specific, Measurable, Realistic and Timely (SMART) safeguarding action plans in place. This demonstrates that supervision arrangements and safeguarding training within LPT is effectively supporting practitioners with health action plans. Safeguarding Children Case File Audit: Findings 6 of 22

Yes No N/a Blank Prior to first case conference / Is there a safeguarding plan in place? 67% 25% 6% 2% Does the plan identify the actions needed to improve outcomes for 63% 2% 31% 4% the child / family, are they SMART? (specific, measurable, achievable, realistic and timely) Is there evidence of appropriate information sharing within multiagency 82% 4% 12% 2% meetings? Is there a Child Protection Plan within the record? 71% 8% 16% 4% Was the health professional invited to the Review Case Conference? 59% 6% 33% 2% Are review case conference reports/safeguarding plans evidenced 57% 6% 35% 2% within the record? Table 2 Multi agency working 84% of the case study sample records evidenced dates and outcomes from multi agency meetings held to safeguard the child. In only one case file did the auditors find no evidence of this information sitting within the record, the child had recently transferred into the area with an existing Child Protection Plan from an outside local authority. There is sometimes a delay in the transfer of paper records from outside areas, but the child s safeguarding needs were flagged on our electronic child health records. 82% of records demonstrated appropriate information sharing within multi agency meetings. There were only two cases where this was not evident; one case the practitioner was invited to the initial case conference, the second case the initial case conference had not yet taken place, so information sharing had occurred during strategy discussion only. 55% of records audited had initial child protection case conference records scanned onto the child s records. In 18% of cases this was not applicable, because the initial case conference had not taken place. For 22% of records the initial case conference record was not available; there can a period of delay between case conference and local authority sending out case conference report to staff, and this can be a period of up to two months. However these staff has recorded their attendance and outcomes from the multi agency meeting within the child s SystmOne records to support communication and information sharing, see Graph 3. Figure 3 Case conference report in the records Safeguarding Children Case File Audit: Findings 7 of 22

In 69% (n=34) cases the health professional attended and contributed to the initial case conference. For 24% (n=10) records this was not applicable, either because these cases were audited prior to initial conference, or still subject to strategy discussions or child was in receipt of s17 family support. There were four records which did not evidence health visitor or school nurse attendance. Two case files audited recorded that the health professional was not invited; mother had a disability so the most relevant professional was the adult neurology nurse who attended the conference in place of the school nurse. The other case file evidenced that the conference was cancelled due to improvements within the family. 59% (n=28) of the records audited demonstrated that health professionals were invited to Review Case Conferences, these multi agency meetings were well attended by staff, with case conference reports identified in the case files. 37% (n18) records this was not applicable because the school nurses had identified no unmet health needs so they were not members of core groups or on going multi agency meetings. 82% (n=40) case files audited recorded that children had received a recent health assessment (previous 3 months) within the SystmOne record. The child protection process Figure 4 The child protection process 67% (n=33) of the records audited demonstrated that the practitioner had supported the voice of the child within the safeguarding process. 16% (n=8) this was not applicable because these related to pre birth multi agency work, or to babies. 12% (n=6) of records the child s voice was not supported within the safeguarding process, two records stated the practitioner had no opportunity to see the child, 1 record this related to a baby, one child with disabilities likely to affect their communication. Health care services delivered in a culturally sensitive manner, 76% of the records demonstrated that there was evidence within the record of family needs being recorded or supported within the child s records. The trust is striving to improve this. Safeguarding Children Case File Audit: Findings 8 of 22

59% of the case files audited identified that health professional s demonstrated respectful uncertainty in their work supporting the family. Lord Laming in the inquiry into death of Victoria Climbié identified the need for professionals to remain vigilant and objectively check out new information provided by parents when working with family s, he termed this phrase as remaining respectfully uncertain. It is positive that this was demonstrated so positively within the audit, because it has been a feature of our safeguarding children s training programmes for over 3 years. 34.7 % of cases audited recorded this as not applicable as no new relevant information was disclosed by families which then needed to be checked out with other agencies. Safeguarding supervision was evidenced within 76% (n=37) of the records audited. It was not applicable for 16% (n=8) as these cases had not yet reached timeframes for supervision to take place 10 days post conference. There were 6% (n3) of records where supervision was not evidenced, one case the health visitor was represented at initial conference by a school nurse but then did not seek supervision on the case following this, one because of sickness absence of staff and was unavoidable. There needs to be improvements in management oversight of SN & HV supervision arrangements by named nurses across the trust Comments This case file audit utilised the approved Leicestershire County LSCB audit tool for health to examine all areas of the safeguarding process for children, record standards, with lessons from national serious case reviews for practice around listening to the voice of the child and demonstrating respectful uncertainty when families present practitioners with new information. This audit has positively included children on health visiting and school nursing records across Leicester, Leicestershire and Rutland, which is an appropriate development following the Transforming Community Services (TCS) changes and the new divisional arrangements. This audit was conducted six months after TCS and the merger of city and county community services. It needs to be recognised that the health visitor and school nurse teams are still embedding SystmOne records, as the previous year has seen revisions of safeguarding templates and guidance in relation to records. There are capacity issues across health and local authority agencies in a context of increased Safeguarding / Child Protection activity being experienced both locally and nationally. These include delays in allocating social workers, delays in receiving Child Protection Conference Decisions and Recommendations, cancelled Core Groups. Key findings: There is a need to improve the timeliness of scanning and recording of child protection information on SystmOne There is a need to maintain and continue to improve timeliness and quality of supervision and ensure work to match health visitors, school nurses and other members of the children s workforce to a child protection supervisor is a continuous process. Health Professionals are not routinely being included in Strategy Discussion in relation to Safeguarding Concerns with children the case file audit identified that this was evidenced in only 45% of the sample across the area. This finding needs to be raised at both LSCB effectiveness sub groups. Areas of good practice: 81.6% of records demonstrated appropriate information sharing within multi agency meetings. Safeguarding Children Case File Audit: Comments 9 of 22

83.7% of the case study sample records evidenced dates and outcomes from multi agency meetings held to safeguard the child 79% case files demonstrated that the practitioner had supported the voice of the child within the safeguarding process, appropriately according to the stage of the child s developmental needs and ability to communicate. 90% of records audited demonstrated staff had applied respectful uncertainty in checking out information from families with safeguarding concerns, when this arose.. Examples of good practice in case files : children s needs and improving outcomes SN represented at all multi agency meetings, good assessment and engagement of the child and parents, response with referral to CAMHs to support mental health needs. Example of HV engaging with family in ante natal period, attended safe discharge planning meetings prior to discharge. Mother has learning disabilities, HV documented she supported communication with pictorial aids to support health messages around parenting. Areas where practice could be improved: 24.5% of the records audited demonstrated that ethnicity was not recorded within a child s records, this this should always be recorded to support care assessment and delivery. School Nurses should ensure they have a face to face to contact with the child and not rely solely on parents reporting children s health needs when they move into the area and require a health assessment. Three practitioners had not accessed safeguarding supervision according to the agreed guidance / protocols in place. Management oversight of supervision arrangements and systems need to be strengthened. 2 case files identified health staff had not been invited to initial case conferences by the local authority for the child. Recommendations 1. Management oversight of Safeguarding Supervision Arrangements for HV and SN staff need to be strengthened. The named nurse team will develop an agreed Policy for Supervision across LPT following TCS and implement this across services. Each staff member will have an allocated supervisor and attendance will be monitored by the Named Nurse Team. Any exceptions will be reported to line managers. 2. Staff will be reminded of the importance of recording ethnicity, language on children s records this will be monitored through the record standards audit. 3. The Trust Lead for Safeguarding will present the Audit findings at both LSCB effectiveness subgroups: 45% of case files audited demonstrated a strategy discussion took place with health staff following safeguarding referral this needs to be raised with local authorities as an area for improvement. 2 of the case files audited health staff had not been invited to the initial case conference. Safeguarding Children Case File Audit: Recommendations 10 of 22

4. Areas of good Practice arising from the report and recommendations are communicated with staff. Including the importance of face to face contact with children within health assessment processes to hear the voice of the child References Children Act 1989 & 2004 DcSF (2008) Information sharing pocket guide DcSF ( 2010) Working together to safeguard children; a guide to inter-agency working to safeguard and promote the welfare of children www.education.gov.uk/publications/standard/publicationdetail/page1/dcsf- 00305-2010 Ofsted (2011) The voice of the child: learning lessons from serious case reviews Safeguarding Children Case File Audit: References 11 of 22

Appendix 1 Audit tool CASE FILE audit Health Records 1. All files should be audited on all area s that are relevant to that file, but it is expected that the following will apply: General Information & Identifying Details The Child Protection Process Closure of the case Involvement of the family & line management 2. In addition, there is space to record quality issues on the right hand side. The information contained in these boxes should be used as prompts and any additional information in relation to the quality of safeguarding interventions / recording should also be included. 3. Each box on the audit tool should be completed although if there is no information to be included, auditors should mark this on the form and not leave empty boxes. Additionally, the N/A section on the scored boxes should be used minimally. 4. Each audit will be commissioned and scoped on an individual basis in order to meet identified aims and learning outcomes. Ethnicity Codes: Asian or Asian British Mixed A1 Indian M1 White & Black Caribbean A2 Pakistani M2 White & Black African A3 Bangladeshi M3 White & Asian A4 Other Asian Please Specify) M4 Other Mixed (Please Specify) Black or Black British White B1 Black Caribbean W1 British B2 Black African W2 Irish B3 Other Black W3 Other White Chinese or other Racial Group C1 Chinese C2 Other Ethnic Group G1 Gypsy / Roma T1 Traveller of Irish heritage U1 Unknown Safeguarding Children Case File Audit: References 12 of 22

General Information and Identifying Details Name of auditor: Health Agency: Date of Audit: Looked After Child: yes/no Type of placement: Subject to child protection plan: yes/no Child s Date of Birth: Gender: Ethnicity Code: Child Disability: Yes / No If yes / specify: Safeguarding Children Case File Audit: References 13 of 22

The Safeguarding / Child Protection Process health records; consideration of the following information Yes No N/A Quality Issues What evidence is there of work undertaken with the child and family before the referral in relation to early intervention? Were there any previous concerns raised or referrals made? Pre referral: Was there a current Common Assessment Framework (CAF) prior to referral? Was the assessment framework used? Is the lead professional identified? Is there a multi-agency action plan in the records? Was the safeguarding referral discussed with parents / carers and child if age appropriate? Was the referral discussed with the line manager or named nurse prior to referral? Post- referral: yes no n/a Quality issues Is there evidence of information sharing between the agencies throughout the Child Protection Process? Is there any evidence of any disagreements in relation to decision making through the process? What examples of safeguarding interventions and continued Safeguarding Children Case File Audit: Appendices Audit tool 14 of 22

The Safeguarding / Child Protection Process health records; consideration of the following information Yes No N/A Quality Issues What evidence is there of work undertaken with the child and family before the referral in relation to early intervention? Were there any previous concerns raised or referrals made? Multi Agency Working: yes No n/a Quality Issues: Which agencies are involved in the child s plan (including voluntary sector and adult services) and are these appropriate to the child s needs? Are there any cross authority issues and how have these been dealt with? Is there a safeguarding plan in place? Does the plan identify the actions needed to improve outcomes for the child / family, are they SMART? (specific, measurable, achievable, realistic and timely) Are multi-agency meetings recorded? Did the family attend and contribute to multi- agency meetings? Was a discharge planning meeting held prior to child s transfer from hospital / CAMHS inpatient care to community? If yes, did the health professional contribute to the discharge planning meeting? Is there evidence of appropriate information sharing within multi-agency meetings? Safeguarding Children Case File Audit: Appendices Audit tool 16 of 22

The Safeguarding / Child Protection Process health records; consideration of the following information Yes No N/A Quality Issues What evidence is there of work undertaken with the child and family before the referral in relation to early intervention? Were there any previous concerns raised or referrals made? The Child Protection Process: yes No n/a Quality Issues What is the agency involvement within the child protection process? Are they undertaking actions within the child protection plan and are fully involved within discussions with Social Care? Are any disagreements with decisions made at conferences recorded? Is there a case conference report for Initial Child Protection Case Conference (ICPC) within the child s records? Did the health agency attend and contribute to the initial child protection conference? Is there a Child Protection Plan within the record? Is the health professional a member of the core-group? Are they attending / or sending a report to core-group meetings? Has information been shared with involved professionals? Was the health professional invited to the Review Case Conference? Did the health professional attend / or send a report to the Review Case Conference? Are review case conference reports / safeguarding plans evidenced within the record? Safeguarding Children Case File Audit: Appendices Audit tool 17 of 22

The Safeguarding / Child Protection Process health records; consideration of the following information Yes No N/A Quality Issues What evidence is there of work undertaken with the child and family before the referral in relation to early intervention? Were there any previous concerns raised or referrals made? Improved outcomes for the child yes no n/a Quality Issues Practitioner s should ensure that actions take account of children and young people s views, recognise behaviour as a means of communication, understand and respond to behaviour indictors of abuse, sensitively balance children s and young people s views with safeguarding their welfare Did we ascertain the child s views within the safeguarding process? Were healthcare services delivered in a culturally sensitive manner? (evidenced within the child s record that language, religion & ethnicity are recorded) Did the child or young person receive a health assessment to identify needs? Were/ are the child s or young person s health care needs met? Did safeguarding Supervision take place and was this recorded within the records? Safeguarding Children Case File Audit: Appendices Audit tool 18 of 22

Appendix 2 Results table Pre referral Compliance Was there a current Common Assessment Framework (CAF) prior to referral? 11% Was the assessment framework used? 82% Is the lead professional identified? 100% Is there a multi agency action plan in the records? 68% Was the safeguarding referral discussed with parents / carers and child if age appropriate? 30% Was the referral discussed with the line manager or named nurse prior to referral? 57% Post referral: Compliance Did the health professional contribute to any strategy meeting or discussion? 51% Was the telephone referral to specialist services (formerly children s social care in the child s health record? 100% * Was an intra agency safeguarding referral form sent to specialist children services or CYPS within 24 hours? 100% * Was continued health support provided to the child and family following the safeguarding referral? 92% Were Specialist Children s Services (formally children s social care) updated with any new information from the agency? 84% * In the 3 cases where the referral was made by a member of LPT staff this was appropriate for one child. Multi Agency Working: Compliance Is there a safeguarding plan in place? 86% ** Does the plan identify the actions needed to improve outcomes for the child / family, are they SMART? 91% (specific, measurable, achievable, realistic and timely) Are multi agency meetings recorded? 95% Did the family attend and contribute to multi agency meetings? 83% Was a discharge planning meeting held prior to child s transfer from hospital / CAMHS inpatient care to community? 27% If yes, did the health professional contribute to the discharge planning meeting? 100% *** Is there evidence of appropriate information sharing within multi agency meetings? 93% ** In 32 out of 37 cases. *** In 3 out of 3 cases. The Child Protection Process: Compliance Is there a case conference report for Initial Child Protection Case Conference (ICPC) within the child s records? 68% Did the health agency attend and contribute to the initial child protection conference? 87% Is there a Child Protection Plan within the record? 85% Is the health professional a member of the core group? 89% Are they attending / or sending a report to core group meetings? 89% Has information been shared with involved professionals? 93% Was the health professional invited to the Review Case Conference? 88% Did the health professional attend / or send a report to the Review Case Conference? 87% Are review case conference reports / safeguarding plans evidenced within the record? 88% Safeguarding Children Case File Audit: Appendices Results table 19 of 22

Improved outcomes for the child Compliance Did the practitioner support the child s voice within the safeguarding process? 80% Did we ascertain the child s views within the safeguarding process? 88% Were healthcare services delivered in a culturally sensitive manner? (evidenced within the child s record that language, religion & ethnicity are recorded) 91% Did the child or young person receive a health assessment to identify needs? 98% Were/ are the child s or young person s health care needs met? 91% Did safeguarding Supervision take place and was this recorded within the records? 90% Calculation of compliance: Standards To help differentiate between excellent practice, good practice and practice which requires improvement, the following arbitrarily set standards and colour coding have been used: 90% 100% Excellent practice 80% 89% Good practice 79% and below Practice requiring improvement Grey coloured criteria indicate that the practice being measured is not totally within the remit of LPT. Safeguarding Children Case File Audit: Appendices Results table 20 of 22

Appendix 3 Distribution list Target audience Clinical Audit & Effectiveness sub group members. For review and adoption of the report and action plan. To (for action) name, designation Divisional Clinical Governance Lead To add to CASE agenda and to circulate to members. Cc (for info) name, designation Safeguarding Children Case File Audit: Appendices Distribution list 21 of 22

Appendix 4 Action Plan Objective Management oversight of Safeguarding Supervision Arrangements for HV and SN staff need to be strengthened. Level of Risk L M H L Agreed Action The named nurse team will develop an agreed Policy for Supervision across LPT following TCS and implement this across services. Each staff member will have an allocated supervisor and attendance will be monitored by the Named Nurse Team. Any exceptions will be reported to line managers. Level of Recommendation Individual, Team, Directorate, Organisation FYPC Person responsible Vicki Spencer Action by date July 2012 Resources required Supervision policy Data collection systems established Action Status Amber Improve the recording of ethnicity on children s records L Brief staff on required record standards Embed within future record audit SN/ HV services Children s Services Named Nurses Katie Willetts July 2012 February 2013 Staff briefing The Trust Lead for Safeguarding will present the Audit findings at both Leicester City and Leicestershire County & Rutland LSCB effectiveness sub groups L Discuss the findings and actions arising from the audit, Strategy discussions not consistently including health professionals Non invites to case conferences. Agree actions across agencies. Organisational Jackie Wilkinson August 2012 Agenda item at both City & County LSCB effectiveness meeting Safeguarding Children Case File Audit: Appendices Action Plan 22 of 22