Saturday, 30 March 2013

Disappointing news from Ofsted

When I heard that there was a vacancy for the head of social care inspection at Ofsted, I saw this as being an opportunity for the introduction of new talent and new ideas about how to conduct inspections into child safeguarding. 

However, I have learned, via a Freedom of Information Act request, that the post will now be covered by the regional director for London, as an addition to her other duties. I am told by the head of HR at Ofsted that: 

“We have taken the decision not to recruit to the former post of National Director, Social Care due to an internal re-organisation.  Debbie Jones is joining Ofsted in September as the Regional Director for London.  In addition to her RD role, given her vast experience and expertise in social care, she has agreed to be the Ofsted national lead for Social Care.” 

I think this is deeply worrying. It feels as if social care inspection is being drawn ever more tightly into a single inspection regime which, not surprisingly, is largely determined by Ofsted’s primary responsibility, the inspection of schools.

I have always been an advocate of a separate inspectorate for children’s social care. I think that the expertise required to inspect child protection is quite different from the expertise required to inspect schools. I would also like to see an independent inspectorate become a repository of knowledge about child safeguarding and protection, especially through carrying out more thematic inspections and research. Indeed I think it might also be a suitable body to carry out inquiries when things have gone very wrong, much as the Air Accident Investigation Branch does for civil aviation. 

And I think it should be led by somebody who has skills and talents both in child protection and more generally in organisational safety.

Sunday, 24 March 2013

Working Together – some improvement, but could do better!

At long last the new version of Working Together – nattily titled Working Together to Safeguard Children: A guide to inter-agency working to safeguard and promote the welfare of children – has been published. 

For those not familiar with the British scene, I should explain that in England Working Together is the main document of guidance on child protection practice issued by the Government. Scotland, Wales and Northern Ireland each have their own separate documents.

The first version of Working Together appeared in the late 1980s and every subsequent version, until the present one, has been longer, reaching a mammoth 393 pages by 2010.

From the point of view length the 2013 edition is definitely a lot better – only 97 pages. A lot of the verbiage of previous editions has been radically excised.

And there are some good bits to the guidance that must be warmly welcomed, but there is still a lot which to my mind is poor quality and some of which is just plain silly. I’ll deal with each of these in turn. 

The good bits – what I liked 

There are good clear statements (not always presented in the most logical order) about the need for a child-centred approach, such as:

“…for services to be effective they should be based on a clear understanding of the needs and views of children.” (paragraph 8, page 8)

“… the child’s needs are paramount, and the needs and wishes of each child, be they a baby or infant, or an older child, should be put first, so that every child receives the support they need before a problem escalates….” (paragraph 6, p 7)

“Children want to be respected, their views to be heard, to have stable relationships with professionals built on trust and for consistent support provided for their individual needs. This should guide the behaviour of professionals. Anyone working with children should see and speak to the child; listen to what they say; take their views seriously; and work with them collaboratively when deciding how to support their needs.” (paragraph 15, page 9) 

“Failings in safeguarding systems are too often the result of losing sight of the needs and views of the children within them, or placing the interests of adults ahead of the needs of children.” (paragraph 13, p 9)

I can certainly sign up to that and I hope that everyone will recognise how important it is to articulate clearly, and to follow, the child-centred principle. 

There was also a recognition in the document that continuous improvement is a responsibility of all those involved in safeguarding children. The document says:

“… there should be a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children, identifying opportunities to draw on what works and promote good practice….” (paragraph 9, p 66)

Sadly the document contains no suggestions about how this might be achieved.

Another important positive - the need for a just reporting culture - is also acknowledged. The document says:

“... professionals must be involved fully in reviews and invited to contribute their perspectives without fear of being blamed for actions they took in good faith….” (paragraph 9. P 66)

I was especially pleased to see this paragraph, because I suggested something like it in my response to the consultation on the document. I only wish it could have been writ larger! There is little that is more important than establishing a just, reporting culture in child-protection. 

Poor Quality – what could have been better 

I felt that throughout the document there was a need for a keener focus. To my mind it still fights shy of focusing on abuse and neglect – the definitions of which are relegated to a glossary – and the document does not offer any guidance or direction on the issue of recognising abuse and neglect, nor on the related issue of thresholds.

In case I am misunderstood here I should make it clear that I don’t think the document – or practice for that matter - should ignore children’s other needs; far from it. It should, however, make it clear that the gears shift when a child is being abused or neglected (or is otherwise at risk of significant harm) and that different rules apply.

Then there is the issue of language. I suppose that I shouldn’t be surprised that it still reads like a government document; it is one! But given the importance of the subject matter I do wish more attention had been given to readability and user-friendliness. A document designed to be easy to use shouldn’t be beyond the reach of the group that wrote this – but at the moment it seems it still is.

That brings me to the vexed issue of diagrams. The flow diagrams contained in the guidance (pages 27, 29, 32, 35, 83 and 84) are to my mind amateurish and hard work to read. I am not against using diagrams like this per se but I think that they need to be more carefully crafted and should adopt the standard conventions for flow diagrams, especially to distinguish between activities and decisions. 

There seems to be more on information sharing in this document than there was in the consultation draft. And most of it refers back to the dire guidance Information Sharing: Guidance for practitioners and managers issued by government in 2008. 

I say this information-sharing guidance was dire because, long as it is, it really doesn’t help, relying, as it does, on asking professionals to weigh the ‘public interest’ in sharing information without consent.

My own view is that the guidance would have better enjoined practitioners to follow that part of the Data Protection Act 1998 that directs that information can be shared without consent  when it ‘ … is necessary to protect the individual’s “vital interests”’. [1] To my mind that makes it clear that information can be shared without consent to protect a child from abuse or neglect, or injury or death. 

Just Plain Silly – needs a serious rethink 

One of the saddest omissions from the new Working Together, I felt, was the absence of a robust direction to adopt a systems approach in undertaking Serious Case Reviews and other forms of corporate learning. The relevant paragraph couldn’t be much weaker: 

“LSCBs may use any learning model which is consistent with the principles in this guidance, including the systems methodology recommended by Professor Munro.” (paragraph 11, p. 67) 

Eileen Munro did not recommend the adoption of what she calls the ‘systems approach’ [2] because it is interesting, fashionable, clever or fun. She recommended it because it is essential to learning constructively from error. As she says: “Human error is taken as the starting point not the conclusion and the investigation tries to understand why the mistake was made, by studying interacting factors in the practitioners, the resources available, and the organisational context”. [3]

If SCRs are not doing that then I think there is very little hope for them. But the Government clearly feels it should be optional! One suspects that there is a lobby somewhere trying to kick Munro’s report [4] into the long grass.

More generally I was also saddened to see that the ‘learning and improvement’ section of Working Together concentrated on the Serious Case Review and did not make much mention of other forms of corporate and professional learning.

Serious Case Reviews, I believe, have become a bit of a fetish, with the vain hope that somehow they will result in huge strides towards greater safety. But they are expensive, slow and cumbersome and the learning from them is difficult to share and absorb. A report from the Care and Social Services Inspectorate Wales got it about right a few years ago saying that: "...huge amounts of time and resources (are) spent in conducting these reviews ... with little clear evidence to show how they are leading to improvements in systems and practice ...." The report concludes: "Time and again serious case reviews identify the same issues as contributing to not protecting children, yet still the problems keep recurring." [5]

I would have liked to have seen the new Working Together grasp this nettle and to have called upon agencies to develop specific approaches to workplace learning. Of course that would be as part of a continuous improvement culture, but specifically I believe that practitioners require the tools, and the time, to learn daily, not sporadically, about how to improve services. Systems such as Kaizen (in which workers contribute suggestions for improvement) or frequent de-briefing following significant pieces of work would be a start. More safety focused supervision sessions, including peer-group supervision, might also form part of such an approach.

And making practitioners aware of the insights of a human factors approach to error and safety should have been a part of the document. In aviation they made human factors training mandatory.

The government has signalled its belief that child safeguarding should embrace a continuous improvement ideology. Practitioners are enjoined to practice more safely. But Government has not provided any real guidance about how these outcomes could be achieved.

Also very firmly in the ‘silly’ box is the way in which the new Working Together deals with assessment.

In the first place, I think that throughout the document there is too much focus on assessment and too little focus on services that meet children’s needs. It seems so easy for policy makers and civil servants to focus on assessment. Assessment costs less than services and doesn’t require so much thought and hard work.

So focusing on assessment is apparently an easy option. But, in doing so, we have to look at services through a distorting mirror. Doctors, nurses, early years providers, teachers and social workers do not spend most of their working days assessing children. Most of the time they are focused on providing children and their families with complex services, of which assessment is only a minor part.

In recent years a myth seems to have grown-up that more assessment is what we need. The Common Assessment Framework [6] and the Framework for Assessment of Children in Need [7] have been pedalled as comprehensive tools for reducing risk, but so far as I know there is no empirical evidence to suggest that such frameworks, with their tick boxes and checklists, actually work to make children safer or to enhance their welfare.

And, of course, there are downsides to such frameworks. They can be distracting, or even misleading, and they can use up scarce resources that would be better put to the delivery of a service. And sometimes they can delay the provision of the help and care that a child or family desperately needs.

Munro recognises this in her report [4]. That is why she recommended getting away from the straightjacket of conducting both ‘initial’ and ‘core’ assessments every time a child was referred to children’s social care. She recognised that such an approach was inflexible and bureaucratic and actually got in the way of providing services to protect a child.

So it is surprising that in the post-Munro era we find government guidance still so wedded to assessment. Reading the first chapter of Working Together one could be forgiven for thinking that the whole of this guidance is about assessment, especially since the promise of the second part of the chapter’s title (“Assessing need and providing help”) is not delivered.

Frankly I have now come to the view that the whole of Chapter 1 should be torn up and started again. To me the issue is not ‘assessment’ but how a professional or other practitioner, in the course of delivering a service to a child or family, should respond if they come to believe that a child is at risk of significant harm. I know that my view may not be popular in some parts of the children’s services establishment. However, I believe that it is wholly wrong to pretend that child protection concerns invariably arise from performing assessments, when in reality they arise in a variety of different, and sometimes surprising, ways.

Last year, when I responded to the consultation on Working Together [8], I seem to remember wondering who had ever suggested trying to combine guidance on child safeguarding with guidance on assessment. It was, of course, none other than Lord Laming in his report on the death of Victoria ClimbiĆ© [9]. In this, as in some other things, he was wrong. Of course social workers, medics, police officers and others have to ‘assess’ a situation in which it is believed that a child has been abused or neglected, and social workers have to assess the welfare of a child, but assessment frameworks are only tools that may, or may not, help depending on the circumstances. They should not become central to safeguarding; and discussion of assessment frameworks should not be central to child safeguarding guidance.

If making assessment so prominent in this guidance was silly then proposing the development of ‘local assessment frameworks’ was very silly. I have struggled to think of a worse idea.

Eileen Munro has convinced us all, including the government, that convoluted guidance on child protection is a bad idea. So why produce guidance that risks reintroducing the very worst features of the system which Munro declaims as unsafe, but at local level so that not only is guidance convoluted, but it differs randomly depending on postcode? Maybe I’ve just misunderstood what local frameworks on assessment will be, or maybe I’m just a pessimist, but I need some convincing that when the time comes the worst elements of local government bureaucracy won’t get hold of this one and produce voluminous manuals full of totally idiosyncratic gobbledegook. Very silly indeed.

[1] See the Information Commissioner’s Office website at: 
[2] See Munro, E. “A systems approach to investigating child abuse deaths” British Journal of Social Work, 35 (4) pp 531-546, 2005

Monday, 18 March 2013


It was interesting to read in the Denver Post this week about the furore in Colorado surrounding the fragmented child protection system in the state.

In Colorado individual counties run child protection services, resulting in what has been described as a two-tiered system lacking accountability, accessibility and consistency.

A first step to reform has been proposed. This is for a single hotline for the whole state to centralise child abuse reports and responses. Campaigners want a central call centre to receive and allocate referrals believing this will result in more consistent decision-making.

The Denver Post’s headline asks: “If state officials can't enact this simple but important reform, is there any hope for more significant changes that must be made?”

I would like to see a similar headline here in Britain.

What we need, particularly in our major urban areas, but elsewhere as well, is greater co-ordination of services and a single, simple interface for use both by members of the public and professionals.

That would be an important first step to making more flexible use of scarce resources. If our officials can’t get on with it …!!! 

Tuesday, 12 March 2013

The Neglect of neglect

It’s salutary to see reports of research by Dr. Ruth Gardner (University of East Anglia and NSPCC) involving analysis of Serious Case Reviews [1] conducted between 2005 and 2011.

She found that in the cases where a child had been made subject to a child protection plan [2], 101 out of 175 cases (58%) involved neglect. This confirms how serious the consequences of neglect can be.

It is very worrying that Ruth Gardner has to remind us that neglect is just as grave as physical or sexual abused. Apparently a survey of social workers conducted last year revealed many felt cases of neglect are the most likely to be awarded low priority.

We all need to be clear that neglect can, and does, kill children. Not so long ago in Birmingham, England, seven-year old Khyra Ishaq was starved to death [3]. In another horrifying case, this time in 2004, five children were found in appalling conditions and near death in another English city, Sheffield [4]

The long-term impact on children who survive neglect – in the absence of other forms of maltreatment - can be very damaging. Studies [5] by researchers such as Teicher (2000), Shonkoff and Phillips (2000) and Perry (2009) show how ‘global’ neglect [6] can have a devastating impact on the developing brains of small children, resulting in a reduced number of neural pathways being available for the child to learn. In turn this has a long-term debilitating impact on educational and social functioning.

An excellent summary of the effects of neglect and other forms of maltreatment can be found on the Child Welfare Information Gateway website [7]

So why is neglect sometimes seen as low priority by professionals trying to protect children?

I know I’ve said some of this before, but it’s worth saying it again. I think that it is not so much that professionals do not recognise and understand neglect, but they find it difficult to respond to.

Neglect is often an incremental phenomenon. Often there is no single clear event or crisis, but there is an ongoing, progressive deterioration in the child’s circumstances and conditions. That can make knowing when to intervene difficult and sometimes social workers become ‘acclimatised’ because changes in the family’s circumstances are small, frequent, cumulative and difficult to detect.

The second problem is one of resources. Turning around a situation of neglect can require a long-term commitment of resources to a family. Sometimes it is hard for professionals to admit that these efforts have been in vain, so there is often an argument for just trying one more thing.

Thirdly some neglectful parents can inspire great sympathy and compassion. They may not be failing because they do not love their children or because they do not aspire to be good parents. They may be trying their best and still failing. Often deficits in their own histories explain their inability to give their children the care they need. So it can be painful for professionals to think in terms of removing children.

Professionals have to wrestle with these difficulties and, of course, they will not always get it right. What is completely unacceptable, however, is for agencies to downgrade neglect, just because it is difficult.


[1] Serious Case Reviews are conducted in England in circumstances where a child known to safeguarding services or other welfare agencies dies or suffers another serious negative outcome.

[2] Previous referred to as ‘being on the Child Protection Register’


Teicher, M.D. (2000). “Wounds that time won’t heal: The neurobiology of child abuse.”
Cerebrum: The Dana Forum on brain science, 2(4), 50-67

Shonkoff, J. P., & Phillips, D. A. (2000).
From neurons to neighborhoods: The science of early childhood development.
Washington, D.C.: National Academy Press.

Perry, B. D. “Examining Child Maltreatment Through a Neurodevelopmental Lens: Clinical Applications of the Neurosequential Model of Therapeutics”
Journal of Loss and Trauma, 14:240–255, 2009

[6] Global neglect means neglect combined in multiple ways – e.g. different types of physical and emotional neglect, such as leaving alone, not responding to the child’s needs, not feeding etc.

[7] Child Welfare Information Gateway website:

Sunday, 10 March 2013

The Risks of Macho Management

I was struck by something I read recently written by Blair McPherson, a former senior social work manager with a large local authority and a much-published writer on social care management. Blair wrote in the Community Care social work blog:

“The more the public sector behaves like the private sector, with an emphasis on competition, keeping costs (wages) down and cutting overheads (management posts), the greater the pressure to achieve overambitious performance targets. And the greater the risk of bullying, fiddling figures, cutting corners, exploiting staff and intimidating whistleblowers.”

He is right. There is a deplorable tendency in the public sector for managers to think they have to be ‘tough’. The recent article by Amelia Hill in the Guardian recounts the stories of health and social care practitioners who have blown the whistle when they observed service users being abused or neglected by other members of staff. Often these employees have been bullied by managers as a reward for their public-spiritedness.

Or, less dramatic perhaps but equally worrying, a recent survey reveals that senior managers are perceived to be out of touch with practice and fail to consult when changes are introduced – see

A consequence of macho management, which Blair McPherson doesn’t mention, is that it is likely to increase the risk of safety breaches and accidents. If senior managers are out of touch with the frontline, and if people who raise concerns about bad practice are punished for doing so, organisations are simply flying blind, with those leading them unaware of the risks that are being incurred.

Fear and the blame culture are the enemies of safety. In order to create a ‘reporting culture’ in which people feel empowered to report near misses and mistakes, and to draw attention to bad practice and shortfalls in services, people need to feel that they will be safe in doing so. They need to know that they will be treated fairly and justly. It is the responsibility of management to make sure that happens.

Wednesday, 6 March 2013

Adoption - wise advice from the Lords

The House of Lords Select Committee on Adoption Legislation has offered sound advice on the Government’s adoption reforms.

Chaired by the retired family court judge, Lady Butler-Sloss, the Committee warns Education Secretary Michael Gove that his reforms to speed-up adoption risk failure unless adequate resources are made available to local authorities, and child and adolescent mental health services, to provide post-adoption support.

For far too long there has been a failure to understand in government that many children who come into the care system have continuing needs resulting from their early experiences. Both separation and disruption, on the one hand, and experiences of poor care, neglect and abuse can result in problems extending into adolescence and beyond. Stability is one factor in recovery, but children and young people in stable situations may still continue to experience long-term consequences of abuse and neglect that often require specialist treatment and resources.

So Lady Butler-Sloss and her colleagues are right to point out that continuing support for families is essential to meet the complex needs of some adopted children. And the committee’s analysis should be a spur to government to review and increase the funding to provide these services adequately. Not doing so is not a cheap option. The costs of adoption breakdown are high, not to mention the long-term costs to society of children who grow-up with serious unaddressed emotional and behavioural problems.

This committee has also done important work in identifying shortfalls in knowledge about the adoption process. They point out that it is not known how many children re-enter the care system after adoption breakdown (although some guesstimates put this as high as 30%) and that there is no reliable data collection to monitor this.

Tuesday, 5 March 2013

All change at Ofsted

If ever lateral thinking was required, then choosing a successor to John Goldup, the Ofsted head of social care inspection, is a case in point. But I see that they have appointed another local government insider - 

Ofsted’s inspections of child protection arrangements need to be completely refocused. They need to look at outcomes, not processes, and discover how well services are meeting the needs of children and young people; not how well they are conforming to regulations. They also need to focus on improvement rather than simply making judgements. The present regime fails one in three areas without any clear idea of what they are doing wrong.

Sunday, 3 March 2013

Institutionalised child abuse

Carolyne Willow, former national co-ordinator of the Children' Rights Alliance England, is absolutely right to describe the practice of routinely strip searching children in custody as “institutionalised child abuse".

It is amazing that it seems so hard to stamp out this type of practice, especially when, as the Guardian article reveals, most of the searches do not result in finding any contraband.