Dorset County Council Safeguarding Inspection Outcome

Report on the Outcome of the Integrated Inspection of Safeguarding and Looked After Children s Services in Dorset County Council Date of Inspection 12 th September to 23 rd September 2011 Date of final Report 28 th October 2011 Commissioning PCT NHS Dorset CQC Inspector name Jan Clark Provider Services Included: CQC Region CQC Regional Director Dorset Healthcare University NHS Foundation Trust (DHUFT) NHS Dorset general and dental practitioners Dorset County Hospital NHS Foundation Trust (DCHFT) South West Ian Biggs This report relates to the recent integrated inspection of safeguarding and services for looked after children which took place in the above Authority recently It provides more detailed evidence and feedback on the findings from the Care Quality Commission s (CQC) component of the inspection, and links these to the outcomes requirements as set out in the Essential Standards for Quality and Safety. Thank you for your contribution to the inspection and for accommodating the requests for interviews and focus groups with your staff and those of partner agencies at relatively short notice. The team provided feedback to your local Director of Children s Services at the end of fieldwork and the joint inspection report to the authority is now published on the Ofsted website and can be accessed via this link: The joint inspection report. Dorset County Council Safeguarding Inspection Outcome Overall effectiveness of the safeguarding services Capacity for improvement The contribution of health agencies to keeping children and young people safe Looked After children Inspection Outcome Overall effectiveness of services for looked after children and young people Capacity for improvement of the council and its partners Being Healthy Aggregated inspection finding Good Good Good Aggregated inspection finding Good Good Adequate Report on Safeguarding and Care of Looked After Children Dorset Page 1 of 18

This report includes findings from the overall inspection report, and provides greater detail about what we found, mapped where relevant to the Essential Standards, in order that your organisation can consider and act upon the specific issues raised. A copy of this report is being sent to your commissioning PCT, and CQC Regional Director. This report is also being copied to the Strategic Health Authority/Monitor as appropriate and CQC s head of national Inspections, who has overall responsibility for this inspection programme. The Inspection Process This inspection was conducted alongside the Ofsted-led programme of children s services inspections. These focus on safeguarding and the care of looked after children within a specific local authority. The two-week inspection process comprises a range of methods for gathering information document reviews, interviews, focus groups (including where possible with children and young people) and visits in order to develop a corroborated set of evidence which contributes to the overall framework for the integrated inspection. CQC contributes to the inspection team and assesses the contribution of health services to safeguarding and the care of Looked after children relating to that authority. Our findings from the inspection contribute to the joint report published by Ofsted and also enrich the information we use to assess providers against the Essential Standards of Quality and Safety. This report sets out specifically the evidence we obtained in relation to these standards and extracts from the published report are included and identified. CQC used a range of documentary evidence in advance of and during this inspection, and interviewed individuals and focus groups of selected staff and, where possible, children and young people, their parents and carers in order to provide a robust basis for the findings and recommendations. This document sets out the findings in relation to the organisations listed above, but includes some areas which apply to one or more other NHS bodies where pertinent. Report on Safeguarding and Care of Looked After Children Dorset Page 2 of 18

Context: Dorset is a two-tier local authority situated in the south west of England, comprising Dorset County Council and six district and borough councils. Dorset as a whole ranks amongst the least deprived areas of England, but this masks significant pockets of deprivation. The total population in Dorset is estimated to be 404,000 and rising mostly due to inward migration. Dorset s birth rate is significantly lower than the national average and has fallen steadily over the last 15 years. However, there are recent signs that this trend is reversing in some areas of the county. Of this population the number of children and young people aged 0-19 is 89,400 (22.2%) which is less than the national average of 23.8%. The proportion of children and young people in Dorset who are entitled to free school meals at 9.8% is significantly below the national average of 16.5%. Within the context of delivery of children s services it is of relevance to note that the proportion of people of retirement age in Dorset at 29.5%, significantly higher than England and Wales averages of 19.5%. Children and young people from minority ethnic groups account for 7.3% of pupils in primary schools and 6.6% of pupils in secondary schools which is significantly below the national average of 24.5% and 20.6% respectively. Children and young people from Gypsy, Roma and Traveller heritage make up the largest group with an increase of children and young people from Eastern European countries. In 2011 the percentage of pupils who speak English as an additional language is 1.9%. There are 66 languages spoken in Dorset schools which include Polish, Bengali, Chinese and Tagalog (Filipino). Children and Young People s Partnership arrangements were set up in 2005-06 with Dorset s Children s Trust established in 2009. Despite the removal of statutory requirements the Dorset Children s Trust Board remain committed to continuing the arrangements for collaborative working and the preparation and publication of a Children and Young People s Plan (CYPP). The Children s Trust has recently redesigned itself to become a smaller executive partnership board focusing strongly on commissioning. Its membership is made up of key partner agencies from statutory, community and voluntary organisations. The Local Safeguarding Children Board has an independent chair and brings together representatives from all the main organisations working with children, young people, families and carers in Dorset. Within Dorset, primary care services to children, young people, their families and carers living in the community are commissioned by NHS Dorset as part of a cluster arrangement with NHS Bournemouth and Poole, which from April 2011 operates across Bournemouth, Poole and Dorset. Acute hospital services are provided by Dorset County Hospital NHS Foundation Trust (DCHFT), and Poole Hospital NHS Foundation Trust. Services provided by Poole Hospital NHS Foundation Trust were not included as part of this inspection. Specialist Child and Adolescent Mental Health Services and services for children who are learning disabled are provided by Dorset Healthcare University Foundation Trust and Dorset County Hospital NHS Foundation Trust, which operates a respite care unit. Health visiting, school nursing services and minor injuries units in 8 locations are provided by Dorset Healthcare University NHS Foundation Trust, through its Dorset Community Health Services directorate. Report on Safeguarding and Care of Looked After Children Dorset Page 3 of 18

At the time of the inspection there were 294 children and young people looked after by Dorset County Council comprised of 62 children under the age of five, 202 children of school age (5-16) and 30 aged 17 years. The council and its partners currently support 148 care leavers. General leadership and management 1 There is strong partnership working between the PCT, health providers, public health and social care at strategic and operational levels, delivering good quality safeguarding services. NHS Dorset and Dorset Healthcare University NHS Foundation Trust (DHUFT) are part of the Children s Trust overseeing the delivery of shared priorities for children and young people. The Trust and the Children s Safeguarding Board (DSCB) provide strong leadership overseeing a range of sustained improvements to services based on a localised model of service delivery. There is a shared commitment to the development of joint commissioning through the jointly appointed head of strategic planning, commissioning and performance. Staff in community and acute services have easy access to and a clear understanding of safeguarding policies and thresholds and are making positive contributions to safeguarding children and young people. 2 Health outcomes for children in care and care leavers are adequate overall. Governance of the health provision for children in care has recently been strengthened. Management arrangements for children in care are now separate from the safeguarding management arrangements which has resulted in clearer lines of accountability and a dedicated management focus under the Trust s Head of Children & Families. This is a positive development, but an effective performance management framework is not yet in place and this is the key area for development. The new strategic manager has a clear strategic and operational vision and a four point plan for service improvement is being implemented with some early achievements evident, although it is too soon for full impact of these arrangements to be evidenced. Until recently, health had not had a strategic connection with the corporate parenting board. This has been addressed with the Trust s head of children & family services imminently becoming a member of the board. Report on Safeguarding and Care of Looked After Children Dorset Page 4 of 18

Outcome 1 Involving Users 3 Input from young people in the development and quality assurance of health services is evident, with potential for increasing this further. Young people are routinely participating in the interviewing and recruitment of key health staff at strategic and operational levels and have made significant contribution to planning for the new sexual assault referral centre. The Young Inspectors project has made a positive impact on the provision of sexual health services and is being extended. Most notable is how young people are participating in the very innovative interactive website developments on a range of topic and service areas. These include the Portland project, aimed at helping young people gain insight into the possible consequences of risky behaviour through an interactive scenario based website; Keep Love Sweet giving information and advice on sexual health and Where s your Head At? helping young people to better understand their emotional wellbeing and mental health needs. These projects are impressive. Dorset Healthcare University Foundation Trust also has an active carer and service user group focusing on services for children and adults delivered by the trust. 4 Health support to care leavers is under developed and there is scope for greater involvement of young people in their health assessments, and in the development of the Being Healthy agenda for children in care. Health assessments are not currently shared with individual young people, their GPs or foster carers. While young people and foster carers are contributing to assessment, re-assessment and planning, this is not sufficient. Health passports and information packs for care leavers are in the process of being developed but not yet available. Young people are to be involved in this initiative. Health support to care leavers is not systematically offered and the majority of care leavers leave the care system without a comprehensive summary of their health records. Dialectic behavioural therapy (DBT) for self harmers is being offered to care leavers with two cycles completed to date and plans to involve residential workers in subsequent programmes. 5 A Health Awareness Day in April 2011 was attended by a small number of looked after children. Topics covered included how exercise is fun, how our bodies work, barriers to good health, food awareness session, including a healthy lunch made by the children, internet safety and how to access health services. Children and young people in care who attended the event gave positive feedback on the range of topics covered and their usefulness. 6 Although the number of teenage pregnancies in the children in care population is very low, health support specifically targeted to this group is undeveloped. Support services for teenage mothers are available through generic programmes. However looked after teenage mothers and care leavers who met with inspectors said that they found these services to be unwelcoming and isolating and feel that existing groups do not meet their specific needs. They are trying hard to parent their babies but feel they lack support in creating better relationships and family life in the future. Only one young person reported a positive relationship with her health visitor. Report on Safeguarding and Care of Looked After Children Dorset Page 5 of 18

Outcome 2 Consent 7 Within both the acute and mental health providers, there are appropriate policies and procedures in place that ensure consent is taken prior to any treatment of children and young people and staff are mindful of the issue. Consent is gained from parents and carers and is appropriately documented. 8 Consent to undertake health assessments is obtained by the children in care health team in accordance with the Department of Health s Guidance. Outcome 4 Care and welfare of people who use services 9 The emotional health and wellbeing services for children and young people are accessible and have been reshaped to put the child at the centre of services, with consistency of Tier 3 key worker maintained as different levels and intensity of service support a child s changing level of need. Tier 2 services have been expanded providing a greater level of prevention and early intervention. Transitions into adult services are working effectively. Planning for transition is initiated at an early stage, is personalised and involves the young person. There has been inconsistency and difference in access to the specialist psychology service for cared for children between the East and West of Dorset. This has been recognised by the partnership resulting in an increase in capacity and expansion of the service across the county to ensure that NICE guidance will be met in West Dorset as it already is in the East. 10 The crisis and intensive home treatment team, early intervention for psychosis team and day services operate effectively to prevent in-patient admissions whenever possible. For the few young people who do require inpatient services, provision is being expanded across Dorset, Bournemouth and Poole from four to eight places. A new adolescent unit with high dependency facilities is due to open in March 2012. There has been good involvement of young people which has influenced the development of the unit. Where young people are admitted to in-patient facilities locally, or for high dependency, safety or other reasons are placed out of county, the local emotional health and wellbeing service continues to provide a high level of engagement. An example of this is that each placement has an identified clinical lead who attends clinical reviews to ensure the placement is meeting assessed need. When such placements are made there is also close management oversight and the young person is returned to the home locality at the earliest and most appropriate time. Report on Safeguarding and Care of Looked After Children Dorset Page 6 of 18

11 The LAC nurses are committed and work hard to ensure the health needs of LAC with whom they are engaged, are identified and addressed. For example, through their persistence they have had some success in engaging some individual young people who have previously been reluctant or have refused to engage with health services. While there is evidence of some good health outcomes for individual looked after children, with improvements in immunisation provision, dental health and addressing obesity problems, there are no specific targeted sexual health or public health programmes delivered to children and young people in care and this is a key deficit. Positively, records have check lists evidencing discussion taking place between the LAC nurses and the child s social worker prior to the LAC review. While overseeing the provision of health assessments and reviews for the whole LAC cohort, their main focus of work is on children with complex needs. The team is gender balanced and from complimentary health backgrounds which enables young people to have a choice of worker or for allocation of worker which best reflects the child s needs. They are well known and well regarded across health and social care and young people who met with inspectors reported positively on the support they receive from the children in care nurses. 12 Initial health assessments (IHAs) are completed by GPs with input from health visitors as required. The quality of assessments seen is variable and GPs do not get feedback or guidance on the quality of the assessments they undertake. GPs spoken to said they would welcome this. Completed IHAs are not consistently returned to the children in care nurses in a timely way, resulting in potentially delaying the provision of health services to address the identified needs of children and young people. The plans are predominantly task focused and expected health outcomes are not routinely identified. Where objectives are set out, these are not SMART. Examples included monitor alcohol intake and encourage cessation of smoking, without giving specific actions practitioners should undertake to achieve these goals. 13 While growing attention is paid within schools and other professional forums to addressing e-safety with children and young people, this topic is not routinely addressed within the annual health reviews. The use of strengths and difficulties questionnaires (SDQs) is inconsistent and these are not routinely used to track a looked after child or young person s development from year to year. Where they are used, the child or young person, where competent to do so, is not encouraged to complete their own SDQ or enabled to use them to reflect on their own personal growth and development. Report on Safeguarding and Care of Looked After Children Dorset Page 7 of 18

14 There is a good range of sexual health services and support to teenage mothers in targeted areas. Numbers are comparable with neighbouring authorities and there has been significant success in reducing second pregnancies, by 60% in one area. There is also a young mums-to-be course run by NACRO aimed at 14-19 yr olds to develop parenting skills, encourage re-engagement with education and promote cessation of smoking. The result has been to reduce the not in education, employment or training (NEET) population for teenage pregnancy to its lowest to date for 16 to 19 year olds from 158 in Aug 2010 to 114 in Jan 2011 and there is positive improvement in sustained cessation of smoking. At the end of 2009, there was a reduction of 9.5% in the rate of teenage conceptions in the county to 28.1 per 1,000 15-17 year olds. Data on teenage parenthood indicates that the numbers of 16-19 women who are pregnant or parents has reduced from 288 in July 2010 to 224 in July 2011. School nurses work closely with the schools inclusion officer identifying health issues affecting children in care between health reviews. School nurses play a positive role in giving contraceptive advice and signposting young people to other sexual health services, emergency contraception and pregnancy testing. 15 Midwifery services are integrated across community and hospital which facilitates continuity and good quality provision. There is a good awareness of minority communities and different cultural needs and staff work well with other services to ensure smooth transitions into community support. Palliative and end of life care for children is being developed and existing services accommodate the needs and wishes of families sensitively and flexibly. A contract is being developed with the county s two hospices to ensure equitable provision countywide and this is viewed by health commissioners as a very positive development. Report on Safeguarding and Care of Looked After Children Dorset Page 8 of 18

16 Substance misuse services are good quality and taking an increased focus on prevention and raising awareness about the risks of hidden harm to children and young people where adults in the family are misusing drugs or alcohol. Referrals to services have significantly increased as a result of this work. The children in care nurses operate a basic database containing identified health needs for children in care. This is not routinely monitored so there is no routinely collated health profile for children in care. Current figures show 12 children in care have identified substance misuse issues, a notable increase when compared to data from recent years. There are some very innovative preventative services being developed under the Risky Business Dorset banner with a strong input from carers and young people and which are multiagency in delivery. Examples include; The Portland Project, where sexual health clinics, Bikeability, art & graffiti and cookery classes (particularly popular with 16 and 17 year old young men) are all being delivered at an existing church based drop-in centre well used by local young people. Not only have directly attributable positive outcomes been identified for individuals but since these preventative services were introduced, anti-social behaviour on Portland has dropped by 14%. Other examples are Healthwise and street pastors in Weymouth. Street pastors involves SHADOWS (Substance Misuse service) in close co-operation with the Police, and aims to engage young people. Disturbances and anti-social behaviour at weekends has decreased. The Healthy Schools programme demonstrates sustained engagement from most schools with outcome measures identified and monitored. Outcome 6 Co-operating with others 17 There is a strong partnership approach across all service development with health playing a full role in the children s safeguarding board (DSCB), serious case review processes and action plan delivery. Health staff routinely participate in child protection procedures and are regarded as key partners. Staff understand their roles and responsibilities in producing reports for conferences and are well supported by managers and lead professionals to undertake these. 18 The health needs of children placed outside Dorset are identified and met effectively. The LAC nurses liaise with their health colleagues in the placement area to ensure the child s health needs are identified and met, if the child cannot easily be seen in Dorset. Where the required service is not available locally to the child, NHS Dorset will commission services privately. Health s support to the adoption panel is effective and no issues have been raised. There is training and support for foster carers on specific health topics and some good examples of this were seen in individual cases. Children in care nurses have identified the improvement of multi-agency support to foster carers as one of the expected benefits of co-location with social care. Three nurses are based in the youth offending team (YOT) and are qualified to assess mental health or drug and alcohol issues. A specialist psychologist is also attached to YOT six sessions a week, making access to these health services for children in care timely, well coordinated and effective. Report on Safeguarding and Care of Looked After Children Dorset Page 9 of 18

19 Health pathways are clear for children with disabilities and complex needs and no interface problems are reported. Multiple appointments for children with disabilities or complex needs are avoided whenever possible and practitioners from different disciplines co-ordinate activity so that multiple procedures can be undertaken under a single anaesthetic. Practitioners cited dentists as delivering highly sensitive and flexible services to vulnerable children. Medical grab sheets setting out the specific and personal health needs for children known to access acute medical services frequently are held on the paediatric ward. Individual health passports for children and young people with disabilities or complex needs are used effectively through the provision of the Yellow Book system. Educational visits to Minor Injury Units (MIUs) are routinely arranged for children and young people with Autistic spectrum disorders to help children understand and deal with these environments. A health transitions group meets regularly and there are regular meetings between social care, disability and CAMHS teams to discuss common issues and improve co-operative working. Health staff are routinely invited to children in care reviews. Outcome 7 Safeguarding 20 The pan-dorset safeguarding arrangements led by the Assistant Director for Safeguarding NHS Poole, Bournemouth and Dorset and including the designated safeguarding nurse are well designed. They bring children and adult safeguarding together under a single infrastructure with scope for increased capacity as required and are bedding in well. Staff across all health services are aware of the safeguarding leads and there is good connectivity with primary care which is the team s main focus. The team are providing effective leadership, support and direction to the safeguarding named doctors and safeguarding support staff (named nurses) across services. 21 Clinical and non-clinical staff are alert to the potential risk indicators they should look for in their routine contact with children and families using a range of checklists and registration forms to ensure that risks are identified and referrals to social care made promptly. These risk assessment checks have been improved and expanded as a result of lessons learnt from SCRs nationally and locally. If initial referrals are not accepted by children s social care the lead professionals are aware of how to escalate safeguarding concerns through the formal processes where they disagree with this decision. Adult health services also have a good awareness of their children safeguarding responsibilities. Staff in these services undertake regular safeguarding training. The identification of safeguarding concerns and risks of hidden harm are routinely monitored by managers, through supervision, documentation triggers and performance management processes. Report on Safeguarding and Care of Looked After Children Dorset Page 10 of 18

22 Staff are aware of the work and decisions of the DSCB, child death overview panel (CDOP) and lessons arising from serious case reviews (SCRs) and participate in the formation of and delivery of action plans as required. The regular synopses on lessons learnt from SCRs are particularly valuable to staff across services including primary care as they are concise and readable making it easy for services to apply lessons. Staff are able to evidence how the lessons learned and identified in the synopsis is informing their practice. CDOP reviews and other work is undertaken effectively and with sensitivity towards the needs of those involved and affected by the processes. 23 Named doctors and nurses comprising the community support staff for safeguarding across provider services are accessible, provide training, are reported as giving helpful advice and guidance and are well connected with strategic and operational multi-agency arrangements and lead contacts. They support staff through child protection and common assessment framework (CAF) processes according to staff experience and confidence and this is valued. Community safeguarding support staff also support staff very effectively through child protection and CAF processes, improving staff experience and confidence. Staff report this level of support to be valuable. However no protocols are in place to ensure consistency of practice or effective monitoring. For example, there are some inconsistencies in how aware the community safeguarding support staff are of safeguarding referrals made from their specific service areas. In some service areas community safeguarding support staff are routinely sent copies of referrals while this is not the case in Dorset Community Health Services. 24 Currently there are different electronic recording systems in place between the countywide minor injuries units (MIUs) and the Dorset County Hospital (DCHFT). This presents ineffective information sharing in cases where there may be identified safeguarding concerns. For example if a child or young person presents at one or more of the MIUs and later presents at DCHFT (or vice versa) there is no way to identify this at the point of presentation and the issue could only be identified through the routine post-presentation notification to GP, health visitor or school nurse. The MIUs locally developed Somerset and Dorset Information system (SADI) does not link to the NHS national system and this reduces the capacity to identify risks and vulnerabilities relating to visitors to the county. This is of significance in an area with a seasonal high tourist population. Local plans developed to resolve this issue were aligned to the national procurement strategy, the halting of which has delayed progress locally. Regular meetings between the emergency department (ED), and paediatrics (including safeguarding), established to promote cohesive working, effective communication and sharing good practice have been in abeyance, this is now widened to include MIU s. The issue of communication between MIUs and the Acute Trust is being considered by this group Report on Safeguarding and Care of Looked After Children Dorset Page 11 of 18

25 GPs and dentists are becoming increasingly engaged in safeguarding arrangements. Each practice has a named GP trained to level 3, who takes the lead with the practice manager in ensuring training is undertaken by all staff and that the practice actively contributes to safeguarding. Practices are well connected to the NHS pan - Dorset safeguarding team and seek advice and guidance appropriately. Good use is made of their patient record databases to flag identified risks and vulnerable children and their siblings. GPs spoken to where able to identify looked after children in their practice and were well connected with the children in care nurses. GPs have a good awareness of MARAC, are undertaking MARAC training and are making referrals. 26 Arrangements for children and young people to receive a forensic examination following an allegation of sexual abuse are adequate. Currently there is no specifically designated sexual abuse referral centre (SARC) within Dorset meaning that currently any examination takes place within a hospital or Police setting. However there are plans to open a SARC to serve each of the three council areas in Bournemouth, Dorset and Poole in January 2012. These are expected to provide follow-up support. In the meantime robust partnership arrangements between the Police, forensic officers and paediatricians ensure there is always out of hours cover. All paediatricians carrying out examinations are appropriately trained and have access to appropriate equipment. 27 Good arrangements are in place to follow up appointments missed by children and young people. The revised and strengthened protocols ensure that community safeguarding support staff (named nurses) are alerted as well as the social care safeguarding team when a child or young person on a child protection plan, or a looked after child, misses a health appointment. Practitioners across services have a good awareness of this expectation. The children s management group receives a monthly missed appointments report so effective governance arrangements are operating. Outcome 11 Safety, availability and suitability of equipment 28 Through a single point of entry to the emergency departments at Dorset County Hospital (DCHFT), children and young people are triaged and directed to a separate children s waiting area in the minor injuries unit or fasttracked through to the majors area. The children s area is observable by reception staff and there is a nurse practitioner on duty until 8pm each day. There are suitable play areas. Young people s experiences in the children s emergency department have been surveyed and are contributing to improvement plans development. Staff are aware of the needs of disabled children and those with complex needs and are able to provide quiet areas for vulnerable children or young people who may benefit from this provision. Report on Safeguarding and Care of Looked After Children Dorset Page 12 of 18

29 Children s safeguarding is given prominence on the patient records system at DCHFT and there is effective flagging of children on child protection plans or families where there is known to be social care engagement. A robust system is in place to ensure liaison with health visitor and school nurses by the ED staff, this includes a patient card check by the lead children nurses who direct ED and community liaison. 30 Security arrangements across the emergency departments and maternity services are satisfactory. Babies are tagged and door alarms are in place. No security issues have been reported to date. 31 No issues are reported with the procurement of equipment for ED or the MIUs and the provision of equipment for children with disabilities. Therapists are able to provide training and support to school and children s centre staff in operating and maintaining specific pieces of equipment for children. Outcome 12 Staffing recruitment 32 Health staff in provider services are CRB checked at enhanced levels on recruitment in line with minimum national requirements. Basic awareness in children s safeguarding is included in all induction for new staff. Outcome 13 Staffing numbers 33 A recent review of the health visitor service has been undertaken to address the significant challenge of ensuring sufficient capacity within the service with Dorset currently the lowest of the region (20%) against target. Improvements have been made through the implementation of a clear management structure and a broader recruitment and positive skill mixing approach, developing the role of nursery nurses to undertake additional tasks. While these fresh approaches are welcomed by many staff and there is enthusiasm for the development opportunities for nursery nurses, anxieties also exist across community services. Strain on junior staff and loss of caseload memory as health visitors are moved to different locations were cited as causing concerns across the partnership. Inspectors did not see any evidence of risk to children but there is potential for risks to be missed. The current service plan while it is delivering improvements in some aspects of service, is not fully aligned to the government target requiring an increase of 25 WTE by 2015. Report on Safeguarding and Care of Looked After Children Dorset Page 13 of 18

Outcome 14 Staffing support 34 Health staff have access to good quality safeguarding training at the appropriate levels. Training is updated regularly and supervision arrangements across services are in place led by the safeguarding community support team. There is a need to ensure that the uptake of support and reflection at an appropriate forum, either in individual or in a group, is better accessed for non clinical staff. Safeguarding is also not a standing agenda item across all services clinical and non-clinical team meetings. 35 Safeguarding community support staff (named nurses) report good access to training and professional development. They are well supported in undertaking further training and development through the trust and have good access to the designated nurse s expertise. 36 A training and development plan for the children in care nurses to develop a core skill base to deliver targeted public health programmes in conjunction with other services is in development. Outcome 16 Audit and monitoring 37 While there are good health outcomes for some cared for children with improvements in dental health, squint correction and obesity being specific examples, overall effective performance management of health s delivery on Being Healthy is under developed and outcomes inconsistently delivered. A suite of local performance indicators and measurable objectives to monitor improvements in the service has not yet been developed. Reporting arrangements have not been sufficiently frequent to ensure effective governance. Data on health outcomes for looked after children, young people and care leavers has not been collated or analysed and there is no overarching profile of needs that can be used to inform service development and commissioning. No routine audit of children in care health records has been undertaken. There are plans to introduce routine record audits based on existing successful tools used in school nursing and health visitor service but this is yet to be implemented. Report on Safeguarding and Care of Looked After Children Dorset Page 14 of 18

38 Until recently there were separate health databases for children in care operating in the East and West of the county making it difficult to develop a comprehensive monitoring framework for health activity and achieve an overall, current health picture of children in care. These have recently been merged into a single database. The March 2011 children in care annual report did identify a number of areas for development and made recommendations to improve health provision but these were not sufficiently specific or measurable. The head of children s services has recognised the areas for development and is at the early stages of developing a performance management framework to include a children in care service specification with measurable performance indicators to measure outcomes as well as activity. The children in care nurses recently became co-located with adoption & fostering and the 16+ team giving them access to the social care record system. Health and social care are now jointly addressing information sharing which has historically been a difficult area and are working together to develop a new integrated IT system which will link with GPs. 39 There are inconsistencies in how aware the safeguarding community support staff are of the safeguarding referrals made from their services. In some services, lead nurses are routinely sent copies of referrals while this is not the case in community hospital services. No closing the loop protocol or flowchart is in place to ensure consistency of practice and effective monitoring and frontline staff and managers are not able to describe a consistent approach. 40 The approach to the undertaking of section 11 audits across health services is robust and resultant action plans are delivering improvements. Health respond positively to external scrutiny and action plans arising from Strategic Health Authority reviews are in place. Outcome 20 Notification of other incidents 41 The PCT, acute and mental health trusts have satisfactory arrangements in place to ensure that appropriate and timely notifications are made in relation to the required alerts into the various agencies NRLS, NPSA and CQC. 42 Health staff have a clear understanding of the whistle blowing policy and report that they are confident that they would be well supported if using it. Report on Safeguarding and Care of Looked After Children Dorset Page 15 of 18

Outcome 21 Records 43 The completion of initial health checks is undertaken by GPs with input from health visitors as required. Subsequent health checks are undertaken or coordinated by the children in care nurses or, if the child is under five, by a health visitor. The assessments and reviews follow statutory guidance but are of variable quality. Completed initial health assessments are not consistently returned to the children in care nurses in a timely manner and this can result in delay to identified health needs being addressed. All but one seen by inspectors were judged to be adequate overall with a positive focus on the child s emotional wellbeing and personal likes and dislikes with assessments giving a real sense of the individual child. The head of children s services is planning to change the documentation to deliver a greater focus on outcomes and models under consideration are BAAF or the local CAF model. Report on Safeguarding and Care of Looked After Children Dorset Page 16 of 18

Recommendations Immediately Dorset County Hospital NHS Trust to ensure that all staff have access to safeguarding supervision and opportunities for reflective practice and that safeguarding is a standing agenda item across all services clinical and team meetings. NHS Dorset and Dorset Healthcare University NHS Foundation Trust to ensure that young people who are in care are enabled to participate as fully as possible in the assessment, review and delivery of their health needs and in all aspects of service development and quality assurance. Within 3 months (from report) Dorset Police, Dorset County Council and NHS Dorset to review procedures and timeliness for the sharing of notifications relating to incidents of domestic violence. (Ofsted September 2011) NHS Dorset and Dorset Healthcare University NHS Foundation Trust to ensure effective data collection and performance management of health safeguarding referrals. (Ofsted September 2011) Dorset Healthcare University NHS Foundation Trust to ensure plans for health visiting services are aligned to deliver national targets to ensure sufficient service capacity. (Ofsted September 2011) Dorset Healthcare University NHS Foundation Trust to ensure delivery of a public health programme targeted at children and young people in care, including those who are pregnant or young parents (Ofsted September 2011) Within 6 months Dorset County Council, NHS Dorset, and NHS providers of accident, emergency and urgent care services to ensure a rigorous system is in place that safely stores and provides up to date information regarding children and young people with a child protection plan and allows for secure and timely transfer of information between health providers. (Ofsted September 2011) NHS Dorset and Dorset HealthCare University NHS Foundation Trust to ensure that a comprehensive performance management framework is in place which effectively monitors and provides an overall picture of the health of children in care so that targeted service delivery can be improved. (Ofsted September 2011) Report on Safeguarding and Care of Looked After Children Dorset Page 17 of 18

Next steps An action plan is required from the commissioning PCT within 20 working days of receipt of this report. Please submit the action plan to your SHA copied to CQC through childrens-services-inspection@cqc.org.uk and it will be followed up through the regional team. Report on Safeguarding and Care of Looked After Children Dorset Page 18 of 18