Safeguarding children: A review of arrangements in the NHS for ...

SummaryThis report provides the initial findings fromour review of the arrangements in the NHS forsafeguarding children. We have carried out the reviewat the request of the Secretary of State for Health,following the conclusion of the legal case relatingto the death of Baby P, now known as Baby Peter.To provide a national overview, our review consistedof an online questionnaire issued to all NHS trustsin England (excluding NHS Direct). In total, wecontacted 392 organisations, comprising 153primary care trusts (PCTs), 169 acute trusts, 59mental health trusts and 11 ambulance trusts. Trustswere asked to tell us about their arrangements forsafeguarding, for the most part, as at 31 December2008. Our findings are summarised below, witha number of recommendations for further action.Who leads the work of NHS trusts on thesafeguarding of children? How well are theysupported?• The vast majority of designated and namedsafeguarding clinicians and professionals weresubstantive post-holders, who were establishedand senior – having been in post for more thana year and no more than two steps down fromboard level in their organisation.• There was a clear difference between doctors andnurses in terms of the protected time they haveavailable for safeguarding duties. Designatedand named doctors had around one day a week,whereas designated and named nurses had aroundthree to four days.• Around 30% of named and designated doctorsdid not have a clear contract or service-levelagreement for their safeguarding work, and aroundhalf did not have a defined and approved set ofcompetencies for safeguarding included in theirjob description.• Just 27% of PCTs said that “all” practices hada nominated lead, 8.5% said “none” had a lead,24% said “most” and 41% “some”. Guidancefrom the Royal College of General Practitionersand the National Society for the Preventionof Cruelty to Children states that all practicesshould have a safeguarding lead and deputy. 1How well trained in safeguarding are NHS staff?• Many trusts either did not have, or possiblyfound it difficult to identify, a dedicated budgetfor training in safeguarding. Just 37% said theyhad a dedicated budget.• The average proportion of eligible staff withup-to-date training at level one, intended for allthose working in healthcare, was worryingly lowat just 54%.• The proportion of eligible staff, across a numberof groups, who were not up to date on trainingat level 2, which is for those staff who haveregular contact with parents, children and youngpeople, also concerns us, particularly since thisissue was highlighted in earlier reviews. For thislatest review, we found that:– In acute trusts, on average 42% of surgeons,anaesthetists and theatre nurses who wereeligible for training at level 2 were up to date.Care Quality Commission review: Safeguarding children 3

• – In acute trusts, on average 65% of paediatricinpatient, day case or outpatient staff working inacute and community services were up to date.• – In PCTs, on average just 35% of those GPs whowere eligible for level 2 training were up to date.What policies do trusts have in place forsafeguarding and child protection? What systemsare in place to help staff protect children?• More than a tenth of trusts did not appear tocomply with the statutory requirement to carryout Criminal Records Bureau checks for all staffemployed since 2002.• There appear to be gaps in the processes coveredby child protection policies. We are particularlyconcerned with the large proportion of trusts thatdo not have a process for following up childrenwho miss outpatient appointments (32% of acutetrusts, 49% of PCTs). This was highlighted as animportant factor in safeguarding in the recentreport Why Children Die. 2• While access to information on families at riskappeared to be good, we have some concernsthat in a minority of trusts, clinical staff may nothave had 24-hour access to a child protectionclinician, and about 12% of trusts did not havea reporting system to flag child protection orsafeguarding concerns.What do senior managers and trusts’ boardsdo to monitor safeguarding arrangements andassure themselves that these arrangementsare working?• Significantly more designated nurses (78%) mettheir board lead at least once every two months,than designated doctors (47%).• Boards monitor compliance with their safeguardingresponsibilities, but the frequency varied.Discussion mainly occurred annually or whenthey were notified about serious untowardincidents or serious case reviews.• As commissioners, PCTs should ensure that allof their contracts and service specifications withNHS and independent providers explicitly includesafeguarding arrangements. Sixty-one per centof PCTs said that this was the case for “all” or“most” of their contracts and service specificationsand 39% said this was the case for just “some”or “none”.How effective is the collaboration betweenorganisations?• While trusts appeared to be fairly well representedat meetings of their local safeguarding childrenboards, we are concerned that provider trustsmay not be fully engaged.• Ninety-five per cent of trusts said that they hadprotocols for sharing information on children andtheir families, both within their organisation andwith other key organisations.• Thirty-six per cent of applicable acute trustssaid they did not have a policy for joint workingbetween maternity services and social services.4Care Quality Commission review: Safeguarding children

What do trusts do when they review individualcases?• Sixty-seven per cent of reviews of individualcases were completed and signed off within oneto three months. Nineteen per cent took morethan four months, suggesting, in these instances,a breach of the target set out in national guidancefor the local safeguarding children board tocomplete the composite serious case reviewreport within four months.• In some instances, it appears that PCTs did notcoordinate the contributions of local healthcareorganisations to the overarching serious casereview. And in 17% of the cases described byPCTs, the PCT had not reported the serious casereview to their strategic health authority.• In general, action plans and recommendationsarising from serious case reviews were providedto responsible service managers. However, notall trusts thought that designated professionalsalways fulfilled their responsibility to review andevaluate the practice of health professionals andproviders involved in a serious case review.What have NHS trusts told us about compliancewith national standards for safeguarding?Separately to this review, NHS trusts have madetheir declarations for 2008/2009 on their compliancewith national core standards, including the childprotection standard (C2). We are cross-checkingthese, using information from this review and fromother sources, and will publish a final assessment inOctober 2009. For 2008/2009, we received 539declarations from 392 NHS trusts – PCTs were askedto make two declarations, one for their commissioningfunctions and a second for any services they provide.We found that 93.9% of declarations reportedcompliance with standard C2, a fall of 3.1%compared to 2007/2008.Recommendations• In light of this report, NHS trusts’ boardsshould urgently review their arrangementsfor safeguarding children – in particular thelevels of up-to-date safeguarding trainingamong their staff. Their reviews should becompleted within six months of this report’spublication. Progress will be checked as partof the joint programme of inspections wewill be carrying out with Ofsted.• Organisations that commission healthcareshould make certain, through their servicespecifications and contracts, that thesafeguarding arrangements of their providers,including GP practices, are effective. This isparticularly important during a period oflocal change, with children’s trusts beingstrengthened and PCTs’ commissioningand community provider functions beingseparated.• NHS trusts’ boards should pay close attentionto our guidance on the requirementsfor registration, including those aboutsafeguarding. We issued the draft guidanceon 1 June 2009 for a 12-week consultationperiod.• We urge the Department of Health andthe Department for Children, Schools andFamilies to use the next Children’s ServicesMapping exercise to repeat key elementsof the data collection carried out for thisreview, to provide a further update onprogress, and to continue to offer localorganisations useful information with whichto benchmark their services.Care Quality Commission review: Safeguarding children 5

IntroductionBackgroundThe Healthcare Commission, a predecessor of theCare Quality Commission, began this review inDecember 2008, at the direct request of the Secretaryof State for Health, following the conclusion of thelegal case relating to the death of Baby P, nowknown as Baby Peter. The Commission was asked tocarry out a “review of the arrangements relevantNHS organisations have in place to ensure they aremeeting obligations with regard to safeguardingchildren”. The review was specifically asked to lookat “board assurance around child protection systems,including governance arrangements; around trainingand staffing; and around arrangements for healthorganisations to work in partnership with others tosafeguard children”. In parallel with this request,the Chief Executive of the NHS wrote to all NHSorganisations in England asking them to review theirarrangements for child protection and to ensure thattheir professional staff were receiving appropriatechild protection training within their professionaldevelopment.In 2007, there were 11 million children aged under19 in England. 3 In 2007/08:• There were more than 1.7 million admissions tohospital of children aged 14 and under (includingbabies born in hospital). 4• There were around three million attendances inA&E of children up to 16, and 4.5 millionoutpatient appointments.• More than half a million children were admittedto hospital as emergency patients and a similarnumber went into hospital for surgery. 5• Around one in 10 consultations in GP practiceswere for children aged 14 and under. 6• Over 100,000 children and young people agedup to 18 years received some form of care fromchild and adolescent mental health services. 7• NHS trusts employed around 97,000 staff(whole-time equivalent) who were directlyinvolved in providing care or therapy or in thepromotion of health. 7There were 59,500 children “looked after” as at31 March 2008. In 2007/08, there were 538,500referrals to social services departments. Of these,24% were repeat referrals within 12 months of aprevious referral. Of the 34,000 children who becamethe subject of a child protection plan in 2007/08, 45%of cases were due to neglect, 15% due to physicalabuse and 25% due to emotional abuse. In responseto our questionnaire, primary care trusts told us thatmore than 32,700 children and young people were thesubject of a child protection plan as at 31 December2008.This reportThe findings of our review are summarised in thisreport, which is organised into sections designed toanswer some key questions about safeguarding inthe NHS. It gives a national picture, and describessome of the variation we have found betweenorganisations – or between different types oforganisation. We hope to present further, moredetailed work based on this review in due course.6Care Quality Commission review: Safeguarding children

The reviewDuring February and March 2009, all 392 NHS trusts(with the exception of NHS Direct) and PCTs wereasked to complete a questionnaire about theirarrangements for safeguarding children. For themost part, the questionnaire asked trusts to reporton their position as at 31 December 2008. Thequestionnaire was divided into three domains:1. Capacity, capability and systems, covering:a. Staffingb. Workload and capacityc. Training2. Governance and accountability, covering:a. Structures and processesb. Human resource issuesc. Policies and proceduresd. Reporting and communicationse. Local safeguarding children boards andpartnership workingf. Serious case reviews and individualmanagement reviewsg. Auditing practice and information sharing3. Specialist elements of service, covering:a. PCTs and their commissioning responsibilitiesb. Mental health servicesc. Maternity servicesThe main reason for carrying out such a detailedsurvey of safeguarding in the NHS was due to a lackof information routinely available that we could useto answer the Secretary of State’s request or thatallowed local practitioners and boards to measuretheir work against their peers. Following this report,we will provide the NHS with the detailed resultsof the questionnaire so that those working in localorganisations can check their arrangements forsafeguarding against those of similar organisations,and against best practice.The questionnaire was largely based on therequirements set out in Working Together toSafeguard Children – a guide to inter-agency workingto safeguard and promote the welfare of children, 8along with other statutory and national guidance.The Care Quality Commissionand children’s safeguardingOn 1 April 2009, we took over responsibility for thisreview, and more broadly, for the regulation ofhealth and adult social care in England.This review is part of a set of activities designed tomonitor and improve arrangements for safeguarding,including our annual assessment of NHS trusts –the ‘annual health check’. This assessment includesprovision for risk-based inspections against nationalstandards for child protection and safeguarding.From 2010, all NHS and independent organisationsproviding healthcare must register with us. Subjectto consultation, we expect that the requirements forregistration will include having appropriate systemsand guidance in place to comply with statutory andnational guidance on safeguarding.We will be joining our colleagues in Ofsted, thechildren’s inspectorate, on a programme of inspectionsof children’s services, which will take place over thenext three years, starting during the summer of2009. These visits will focus on children and youngpeople who are safeguarded and/or looked after.The information we have gathered from our nationalreview of safeguarding will directly inform theseinspections. Further details are available fromwww.ofsted.gov.uk/Ofsted-home/Forms-andguidance/Browse-all-by/Care-and-local-services/Local-services/How-we-inspect.Care Quality Commission review: Safeguarding children 7

Safeguarding and registrationrequirementsOur draft Guidance about compliance with theHealth and Social Care Act 2008 (RegistrationRequirements) Regulations 2009 was publishedfor consultation on 1 June 2009. It states thatproviders should minimise the risk of abuseoccurring by:• Ensuring that staff understand the signs ofabuse and raise concern when those signs arenoticed in a person using the service.• Having effective means of receiving feedbackfrom people who use services.• Taking action to ensure that any abuseidentified is stopped by:• – Having clear procedures, and followingthem, for the management of alleged abuse.• – Removing the alleged abuser from the care,treatment and support of the person.• – Reporting the alleged abuse to theappropriate authority.• – Reviewing the person’s plan of care toensure that they are properly supportedfollowing the alleged abuse incident.The guidance also proposes that people who useservices receive care, treatment and support fromall staff (including volunteers and ancillary staff)who:In general:• Are committed to maximising people’s choice,control and social inclusion and upholdingtheir rights as an important way of reducingthe potential for abuse.• Recognise their personal responsibility insafeguarding people who use services.In relation to safeguarding:• Know how to identify and investigate abusebecause there are clear procedures about thisthat are followed in practice, monitored andreviewed.• Are aware of and understand what abuse is,the differences between supporting childrenand adults who are at risk of abuse, what therisk factors for abuse are, and what they mustdo if a person is being abused, suspected ofbeing abused, is at risk of abuse or has beenabused.• Follow the referral process and timescales asdescribed in local and national multi-agencyprocedures when responding to suspectedabuse, including ‘No Secrets’ and ‘WorkingTogether to Safeguard Children’.• Understand the roles of other organisationsthat may be involved in responding tosuspected abuse, as appropriate to their role.• Contribute to whatever actions are needed tosafeguard and protect the welfare of childrenand take part in regularly reviewing theoutcomes of children against specific plans.• Are confident to report any suspicions withoutfear that they will suffer as a result.• Are aware of their rights under the PublicInterest Disclosure Act (1988).8Care Quality Commission review: Safeguarding children

1 Who leads the work of NHS organisations onsafeguarding children? How well are they supported?What should be in place?NHS trusts’ boards have a legal duty relating tosafeguarding and promoting the welfare of childrenand young people – their responsibilities are clearlyset out in the Children Acts 1989 and 2004 andin the Government’s statutory guidance. Trusts’safeguarding leadership teams must include anominated director at board level, with clinicalsupport and supervision provided by ‘designated’,for primary care trust (PCT) commissioners, and‘named’, for provider organisations, clinicians andprofessionals. These posts are a legal requirement.‘Named’ staff must have specific expertise inchildren’s health and development and in treatingchildren who have been abused or neglected. 8 Theirwork includes:• Providing supervision and support to other staffin child protection issues.• Offering advice on local arrangements within theprovider organisation for safeguarding children.• Playing an important role in promoting, influencingand developing relevant training for staff.• Providing input from skilled professionals to childsafeguarding processes, in line with the proceduresof local safeguarding children boards, and toserious case reviews. 8As commissioners of healthcare, PCTs must appointa designated doctor and a designated nurse to workwith the nominated director and senior management.These designated professionals must be accountableto the board lead for safeguarding and are requiredto take a strategic, expert lead on all clinical aspectsof safeguarding children throughout the PCT’s localarea. Designated professionals may be practisingpaediatricians or nurses, and so may be employedby a local provider trust or by the provider arm ofthe PCT. Where this is the case, the safeguardingresponsibilities of the designated roles need to bemade clear, ideally through service-level agreementsor contracts. These should set out the requirementsof the roles, how they will be managed and madeaccountable and how much time is needed toperform them. 9Designated professionals are a vital source ofsupervision and advice on matters relating tosafeguarding children for other professionals, the PCT,the local authority’s children’s services departmentand the local safeguarding children board. PCTs havea duty to ensure that there is sufficient resource andsupport for these professionals, in proportion with thenumber of people in the area and to the complexity ofarrangements locally for the provision of healthcare. 8All NHS trusts, NHS foundation trusts, and PCTs thatprovide services for children must identify a nameddoctor and a named nurse and/or named midwife forsafeguarding children. For NHS Direct, ambulancetrusts and independent providers of healthcare,this post should be filled by a named professional.Named clinicians and professionals fulfil the keyrole within their own organisation in promotinggood practice in relation to safeguarding children.Care Quality Commission review: Safeguarding children 9

Our findingsStability of leadership rolesWe asked trusts to tell us whether their named ordesignated posts were filled, as at 31 December2008, and if so, to indicate whether this was on asubstantive (permanent) basis or temporarily by alocum. We found that the vast majority of designatedand named posts, in all types of trust, were filled ona substantive basis. Most trusts also told us that thepost-holders in their named and designated roles hadbeen in place for more than one year. Taken together,these findings suggest that leadership on safeguardingis relatively stable. Named doctors working in PCTshad the lowest proportion of substantive post-holders(80%). They also had the lowest proportion of postholderswho had been in place for more than a year(68%). This requires further exploration, but mayrelate to the structural changes within PCTs as theyseparate their commissioning and providing rolesinto separate ‘arms’.Seniority and professionTypically, post-holders are consultants (doctors) orat Agenda for Change grade 8a or above (nursesand midwives). The exception to this was namedprofessionals working in ambulance trusts, whowere mostly at Agenda for Change grade 7. Veryfew named or designated safeguarding staff weremore than 2 steps down from board level in theirorganisation’s hierarchy. Typically, designated doctorswere paediatricians by profession, while designatednurses tended to be health visitors. Thirty-nine percent of PCTs said that their named doctors wereGPs, and 32% paediatricians. Seventy per centof acute trusts said that their named doctors werepaediatricians. Eighty-one per cent said that theirnamed nurses were either registered children’s nursesor health visitors. In ambulance trusts, paramedicswere the largest single group of named professionals.Protected time for safeguarding dutiesWe also asked trusts about the amount of protectedtime that designated and named staff are allocatedfor their safeguarding duties. Substantially moreTable 1: Protected time for safeguarding duties for designated and named staffType of trust Role Average number of days a weekprotected time for safeguarding dutiesPrimary care trust Designated doctor 1.2Designated nurse 3.8Named doctor 0.9Named nurse 4.5Acute trust Named doctor 0.8Named nurse 3.4Named midwife 1.8Ambulance trust Named professional 2.2Mental health trust Named doctor 0.5Named nurse 3.410 Care Quality Commission review: Safeguarding children

protected time is available for those filling nurse,midwife and professional roles than for those indoctor roles (see table 1). While there may beentirely valid reasons for this difference, trustsshould consider whether the time available formedical leadership on safeguarding is adequate.Clarity of role and responsibilitiesWe have found that a minority of named anddesignated staff carried out their role without aclear contract or service-level agreement. This isparticularly notable for those filling designatedand named doctor posts. A substantial proportionof named and designated staff did not have a setof competencies defined, approved and includedin their job descriptions (see table 2), despitethis being a requirement of national guidance.Competencies provide clarity on the responsibilitiesof the designated and named roles and the skillsrequired to perform them.Table 2: Clarity of contract or service-level agreement and defined set of competencies in placeType of trust Role Trusts with a clear Competencies of the rolecontract or service-level defined, approved and includedagreement for the role in their job descriptionPrimary care trust Designated doctor 69% 50%Designated nurse 90% 66%Named doctor 67% 45%Named nurse 89% 65%Acute trust Named doctor 72% 47%Named nurse 82% 72%Named midwife 80% 61%Ambulance trust Named professional 73% 100%Mental health trust Named doctor 71% 63%Named nurse 77% 85%Care Quality Commission review: Safeguarding children11

Table 3: Performance management of designated and named staffPerformance manager for safeguarding duties (% trusts)Type of trust Role Board lead for Designated Usual line Othersafeguarding doctor/nurse managerPrimary care trust Designated doctor 51% n/a 40% 9%Designated nurse 66% n/a 31% 2.6%Named doctor 19% 31% 36% 13%Named nurse 2% 62% 35% 1%Acute trust Named doctor 33% 18% 46% 4%Named nurse 44% 8% 47% 2%Named midwife 23% 3% 68% 5%Ambulance trust Named professional 60% 0% 20% 20%Mental health trust Named doctor 52% 2% 41% 5%Note: Figures are roundedNamed nurse 61% 4% 32% 4%We asked trusts to tell us who manages theperformance of designated and named staff inrelation to their safeguarding duties (see table 3).Other responsibilitiesIn more than 90% of PCTs and acute trusts, thesafeguarding children role was separated from adultsafeguarding, although some of our more recentengagement with staff suggests that roles mayincreasingly be combined. There was more overlap inmental health trusts, with 31% covering both childrenand adults. All named professionals in ambulancetrusts covered both areas. In around half of PCTs,staff filling children’s safeguarding roles also providedan expert resource for looked-after children.There is no formal guidance on whether thesestatutory responsibilities in relation to children’s andadults’ safeguarding should be covered by more thanone person, even if the roles are part-time, as longas the board can demonstrate that its systems andprocesses are effective, compliant and demonstrateimproved outcomes. Separating the roles of adultprotection lead and child protection lead allows staffto cover each other’s work, and provide peer supportand supervision in what can be extremely challengingwork. However, combining the adult and childsafeguarding roles into one, potentially more senioror board-level role, may provide a more systematicapproach to monitoring, resourcing and strategicplanning.We asked PCTs how many staff with safeguardingresponsibilities were line managed by each designatednurse. On average, this was 4.5 whole time equivalent(wte) staff, though responses ranged from 0 to 36.Designated nurses usually carry responsibility forinvestigating incidents and ensuring that appropriatesupervision arrangements are in place across thecommissioned services, so it is important that thisrole is provided with sufficient support to respondquickly when needed.12 Care Quality Commission review: Safeguarding children

Leadership on safeguarding in general practiceGPs are at the heart of an effective child protectionsystem. Their ‘gate-keeping’ role means that theyshould have details about all contact between a childand health services, including health visiting and A&Eservices. GPs should be prepared to raise alerts andtake the initiative in identifying trends and causes forconcern in the way that families have contact withhealth services. It is important that GPs and all staffworking within a practice, including administrative andreception staff, are familiar with the principles of childprotection and with their own role in safeguardingchildren. Each practice should have a nominatedlead and deputy lead to promote this work. 1However, when we asked PCTs what proportion oftheir GP practices had a nominated safeguardinglead, the results were:• ’All’ – 27%• ‘Most’ – 24%• ‘Some’ – 41%• ‘None’ – 8.5%Where there are a number of ‘small’ or ‘singlehanded’GP practices, a ‘cluster’ arrangement canwork effectively, providing each member with peersupport, training and supervision of safeguardingroles and responsibilities.Health visitors – number and caseloadAs part of the review, we asked PCTs to tell us howmany health visitors, as wte staff, they employed on31 December 2008, and to tell us the ‘establishment’or budgeted figure for health visitors at their trust.In total, PCTs reported that they employed just over7,800 wte health visitors. The overall vacancy rate,(the gap between the number of ‘employed’ staffand the ‘establishment’ figure as a percentage ofthe ‘establishment’ figure) was just over 8%.The range of vacancy rates was –30% (for a PCT withan ‘employed’ figure exceeding their ‘establishment’)to 45%. These figures differ from those shown bythe most recent annual NHS workforce census andvacancy survey, though this reflects timing andmethodological differences and should not necessarilybe read as a contradiction. The NHS workforcecensus for September 2008 shows 8,764 wte healthvisitors employed by the NHS – not just PCTs. Thevacancy survey shows a rate for March 2008 of 0.3%,but this defines a vacancy as a post that is fundedand which has been unfilled for at least three months.Our vacancy rate has been calculated from theestablishment and employed figures supplied byPCTs, and makes no allowance for length of vacancy.Using these figures and population data availablefrom National Statistics, we were able to calculatecaseload figures for each PCT. Nationally, there were389 children aged up to and including four years foreach wte health visitor. This is short of the figure of400 suggested in Lord Laming’s most recent report,also the maximum proposed by Unite/CPHVA – thehealth visitors’ trade union and professional body,but well in excess of the ‘normal’ caseload of 250proposed by Unite/CPHVA. Based on the figuressupplied for this review, 62 PCTs have caseloadsin excess of 400, including 29 with caseloads inexcess of 500. Care should be taken in interpretingthese figures, as the issue of caseload is complexand local factors, including those relating to levelsof deprivation, skill-mix within teams, the numberof vulnerable children locally and other servicesprovided locally, need to be taken into accountto determine ideal caseloads. PCTs should use thisopportunity to compare their caseloads with thoseof their peers, taking account of these factors.Care Quality Commission review: Safeguarding children13

2 How well trained in safeguarding are NHS staff?What should be in place?Trusts are responsible for ensuring that all their staffare competent and confident in carrying out theirresponsibilities for safeguarding and promotingchildren’s welfare, as stated in Working Togetherto Safeguard Children. 8 These include being able torecognise when a child may require safeguarding, andknowing what to do in response to concerns aboutthe welfare of a child. Appropriate and comprehensivetraining is therefore essential if staff are to beeffective in safeguarding, and if trusts are to haveconfidence in the safeguarding skills of their staff.The minimum requirements for training for all staff areset out in the intercollegiate guidance SafeguardingChildren and Young People: Roles and Competenciesfor Health Care Staff. 9 This guidance outlines thatdifferent groups of staff will have different trainingneeds to fulfil their duties, depending on their degreeof contact with children and young people and theirlevel of responsibility. Staff should receive updates orrefresher training at regular intervals following theirinitial training – every three years is recommended.They should also receive, at least once a year,written briefings of any changes in legislation andpractice from named or designated professionals.Trusts should hold comprehensive staff trainingrecords to assure themselves that all their staff havebeen appropriately trained in safeguarding children.Staff and managers must be able to work effectivelywith others, both within and outside their owntrust. This is most effectively achieved through staffundertaking a combination of training that is designedspecifically for one organisation (single-agency) andthat which works across organisations (inter-agency).Working Together to Safeguard Children states thatemployers have a responsibility to identify adequateresources and support for inter-agency training bycontributing to its planning, resourcing, delivery andevaluation of training. Inter-agency training is ahighly effective way of promoting a common andshared understanding of the respective roles andresponsibilities of different professionals, andcontributes to effective working relationships. 8Working Together to Safeguard Children also statesthat protecting children from harm requires staff tomake sound professional judgements. It is demandingwork that can be stressful and distressing and allthose involved should have access to advice andsupport from, for example, peers, managers ornamed and designated professionals. 8 It is importantthat staff working with children and families areeffectively supervised to support them and topromote good standards of practice in safeguardingchildren. In line with Working Together, supervisionshould include reflecting on, scrutinising andevaluating the work carried out, assessing thestrengths and weaknesses of the member of staffand providing coaching, development and support.14 Care Quality Commission review: Safeguarding children

Our findingsStrategy and budgetNinety-two per cent of trusts said that they hada specific child protection (safeguarding) trainingstrategy in place. Sixty per cent had last updatedtheir strategy during 2008, and 22% during 2007.Seventy-five per cent of trusts said there was apartial link between their training strategy and awider local safeguarding children board trainingstrategy, and 15% said there was a combineddocument linking the two.Only 37% of trusts said that they had a dedicatedbudget for safeguarding. This figure is troublinglylow. Employers have a responsibility to identifyadequate resources and support for training. Withoutan identifiable, dedicated budget, it is difficult to seehow the delivery of this training can be guaranteed.The average training budget for safeguarding was£19,613. Comparatively few trusts were able tocalculate this figure as a percentage of their overalltraining budget. For those who could, the averagetraining budget for safeguarding represented 8%of the overall training budget.Delivery of training and supervisionWe asked trusts to describe how safeguardingtraining is delivered for their staff. Ninety-sevenper cent of trusts delivered safeguarding trainingin-house, 66% delivered training jointly with otherhealth organisations and 88% delivered trainingjointly with other local safeguarding children boardpartners, including education and social services.It is important that named and designated staffreceive appropriate and current training, and havean opportunity to meet with others in the same roleto share good practice. We asked trusts how manydays of training, relevant specifically to their childsafeguarding duties, each group of staff attendedin the year to 31 December 2008. The averageswere as follows:• Designated doctor: 5 days• Designated nurse: 7 days• Named doctor: 3 days• Named nurse: 8 days• Named midwife (acute trusts): 4 days• Named professional (ambulance trusts): 2 daysSupervision for safeguarding activity is required at alllevels within a trust, and should be available for allstaff who potentially come into contact with children.It should be a separate function from individual linemanagement and performance monitoring, andsupervision meetings should facilitate reflectivediscussion, practical advice, support and thedevelopment of practice. We asked each organisationwhether they had an agreed policy, strategy ormandate for delivering supervision in relation tosafeguarding for the following groups:• All staff who work with children – 61%• Some staff groups who work with children – 79%• Designated professionals (PCT only) – 74%• Named professionals – 76%We asked trusts how often meetings were heldbetween local designated and named staff to discusscases, training and planning. In 89% of trusts, thesehappened at least quarterly, and at least monthlyin 57%. Just 6% of organisations say they haveno formal meetings.Level 1 trainingSafeguarding training at level 1 is, according tonational guidance, 9 intended for all staff workingin healthcare settings. The aim of level 1 training isto ensure that all staff understand what constituteschild abuse and to know what to do when they areconcerned that a child is being abused. On average,54% of the staff considered by trusts to be eligiblefor level 1 safeguarding training were up to date onCare Quality Commission review: Safeguarding children 15

31 December 2008. The data shows relatively littlevariation between types of organisation, thoughthe figure drops to 45% for ambulance trusts.Training for locum and agency staffWe asked trusts whether all their locum and agencymembers of staff were trained in safeguardingchildren. Six per cent said that all were trained andthat this was checked and recorded. Twenty-nineper cent said that all were trained and that this wasarranged by the staff member’s agency, and 57%said that some locum and agency staff were trained,if they were employed for a specific period. Thislatter result requires some further exploration ata local level, as it is not clear what roles and howlong they cover. Boards should be clear about whatsystems are in place to ensure that locum staff areappropriately trained.Level 2 trainingLevel 2 training is required for all clinical and nonclinicalstaff who have infrequent contact withparents, children and young people, such as thestaff groups listed in table 4. This training ensuresthat members of staff are able to recognise childabuse and document their concerns, know who toinform and fully understand the next steps in thechild protection process. 9 We asked trusts to tellus how long their level 2 training lasted. This variedgreatly – in 46% of organisations it lasted half a dayor less, and in 47% it lasted one full day or more,which suggests that the content may be considerablydifferent between trusts. We also asked trusts to tellus, as at 31 December 2008, how many of theirstaff in key groups eligible for level 2 training wereup to date (see table 4).These figures are extremely concerning, particularlythose for surgical teams, therapists and those (suchas GPs and pharmacists) working in primary care.All of these groups may come into contact withchildren and young people requiring safeguarding(and/or their families) and should be properly trainedto recognise signs of abuse and know what to do ifabuse is suspected. A higher level of training, at leastat level 3, would be suitable for many of these groups.Level 3 trainingLevel 3 training is for staff working predominantlywith children, young people and parents andincludes guidance on how to assess and reduce riskand harm. It also trains staff in how to take part in,and contribute to, formal processes and proceduresaround child protection and safeguarding. We askedorganisations whether they routinely kept records ofall staff requiring and receiving training at level 3.Seventy-three per cent said “yes”, but 27% said“no”, which is of considerable concern.As well as asking PCTs to identify the proportion ofeligible GPs who are up to date with level 2 training,we asked a more general question to test whethertraining (at all levels) was centrally recorded, andwhether PCTs could identify the proportion of GPsthat were up to date. All PCTs said that they recordedthis training centrally.We asked acute trusts providing maternity servicesto tell us whether all staff working in these serviceshad received training in handling domestic abusedisclosures – 71% of acute trusts said that “all” or“most” staff had received this training. Three percent said “none” of their staff had received it. Theremainder said that “some” staff had been trained.There is a proven link between households wheredomestic abuse is occurring and the need for childprotection. If abuse is disclosed, it is importantthat maternity staff know how to inform relevantauthorities to ensure that the appropriateassessment happens.16 Care Quality Commission review: Safeguarding children

Table 4: Average percentage of eligible staff up to date on level 2 safeguarding trainingGroup Acute Ambulance Mental Primaryhealth care trustPaediatric inpatient, day case or outpatient 65% n/a n/a n/astaff – acute and community servicesSurgeons, anaesthetists and theatre nurses 42% n/a n/a n/awho treat childrenClinical staff working in emergency or urgent 58% 59% n/a 55%care – e.g. A&E, ambulatory care units, walk-in(7 of 11 ambulancetrusts consideredcentres, ambulances and minor injury unitsthis question tobe n/a, made noreturn or said theyhad no eligiblestaff in this group)Clinical psychologists 75% n/a 53% 48%Obstetric and gynaecological staff 55% n/a n/a n/aTherapy staff (including occupational therapists, 58% n/a 61% 56%speech and language, physiotherapists) whowork with children in acute or community careStaff in sexual health services 54% n/a n/a 53%Dental practitioners and dental care professionals 42% n/a n/a 43%Optometrists – community services 52% n/a n/a n/aPharmacists – hospital and community services 35% n/a 5% 39%(49 of 59 mentalhealth trustsconsideredquestion to ben/a or said theyhad no eligiblestaff in thisgroup)GPs (includes both contractors and salaried GPs) n/a n/a n/a 35%Staff working in adult mental health services n/a n/a 51% 40%e.g. those providing general adult andcommunity, forensic, psychotherapy, alcohol andsubstance misuse, and learning disability servicesCare Quality Commission review: Safeguarding children17

3 What policies do NHS trusts have in place forsafeguarding and child protection? What systemsare in place to help staff protect children?What should be in place?All trusts must have clear policies for safeguardingand promoting the welfare of children and theseshould be in accordance with national guidance andlocally agreed inter-agency procedures. For example,all NHS organisations must have a safeguardingchildren work plan as well as a child protectionpolicy that is joined-up with those of other localorganisations and the local safeguarding childrenboard. 8All staff should be made aware of their organisation’spolicies and procedures on safeguarding children 10and it is good practice to have copies of thesepolicies continually available in locations wheremembers of staff may come into contact withchildren. This includes in wards, clinical assessmentand treatment areas, community clinics and children’scentres, maternity units, mobile community staffbases and on GP premises. Copies of the localsafeguarding children board’s policies and proceduresshould also be made accessible and easily availablefor all members of staff who may encounter childrenduring the course of their work. 10There are key elements that should always becovered in the child protection policy and we askedorganisations whether these were explicitly included.These are:• A process for following up referrals to children’ssocial care.• A process for dealing with children or youngpeople who are at risk from domestic abuse.• A process for ensuring that all patients areroutinely asked about dependents such aschildren, or about any caring responsibilities.• A process for following up children who missoutpatient appointments.• A process for ensuring that families with childrenin the resident population who are not registeredwith a GP are offered registration.• A process for ensuring that if there have beenconcerns about the safety and welfare of childrenor young people, they are not discharged untilthe consultant paediatrician, under whose carethey are, is assured that there is an agreed planin place that will safeguard the children’s welfare.• A process for handling suspected fabricated orinduced illness.• A process for resolving cases where healthprofessionals have a difference of opinion.• A process or protocol that outlines when A&Estaff should check whether a child is the subjectof a child protection plan.Staff lacking awareness of, or failing to follow, one ormore of these specific processes is a recurring factorin many serious case reviews and was highlighted inOfsted’s report Learning Lessons, Taking Action. 11Trusts should also ensure that they have carriedout equalities impact assessments on their childprotection policies.18 Care Quality Commission review: Safeguarding children

Our findingsWork plans and strategiesWe asked trusts to tell us at what level of authoritytheir safeguarding work plan or strategy was approved.Forty-four per cent said that it was approved atboard level, 38% at a sub-committee of the boardand 10% at executive team level. Eight per centsaid they did not have a work plan or strategy forchild protection, which should, for the organisationsconcerned, be extremely worrying and should beaddressed as a matter or urgency. Of those truststhat had a work plan or strategy, 58% said thatthey reviewed progress against this at least twicea year, and 26% said they reviewed it once a year.Seventy-one per cent of trusts said that their workplan or strategy was developed with input andsupport from the local safeguarding children boardand other key partners.Routine Criminal Records Bureau checksand ‘safe recruitment’All health bodies are legally required to conducta Criminal Records Bureau (CRB) check on allstaff appointed since 2002, when the scheme waslaunched. Many trusts also check staff routinelyevery three years, although this is not a statutoryrequirement. Eighty-seven per cent of trusts saidthat they met the statutory requirement on 31December 2008, including some (24% of allorganisations) that had ensured that all staff, includingthose in post before 2002, had been CRB checked.Thirteen per cent said that not all staff, includingsome in post since 2002, had been checked. Thisshortfall should be addressed as soon as possible.We also asked trusts how many of their personnelinvolved in employing staff had ‘safe recruitment’training. Eight per cent said “all”, 30% said “most”,52% said “some” and 11% said “none”. Saferecruitment training was introduced as a learningpackage sponsored by the Department for Children,Schools and Families, and was aimed primarily atschool head teachers and governors. It has beenwidened to apply to all organisations employingpeople who work with children and young people.It requires that there is at least one person on eachinterview panel who is aware of the safer recruitmentprinciples and that these are implemented whenselecting and appointing an individual. The NHSis also required to comply with NHS Employersguidance on employment checks. 12Incorporation of safeguarding responsibilitiesin job descriptions for clinical staffA clear line of accountability should exist within anorganisation, and responsibilities for safeguardingand promoting the welfare of children should beencompassed within job descriptions. 10 Thirteen percent of organisations confirmed that safeguardingresponsibility was covered explicitly in all jobdescriptions for clinical staff and 41% said that thiswas done as job descriptions were updated. Fortysixper cent of organisations said that safeguardingresponsibility was not covered in job descriptionsfor clinical staff.Policies and proceduresEighty-seven per cent of organisations said thatthey had a child protection policy approved by theirboard in the preceding three years, with around halfof organisations saying that this had been approvedwithin the last 12 months. The remainder had a draftor updated policy awaiting approval, or had a policyat the planning stage.Availability of the child protection policy inclinical areasIt is not enough simply to have an approved childprotection policy on file – it should be available tostaff working in clinical areas. We asked trusts aboutthe availability of their policy in several key clinicalareas:• In wards, clinical assessment and treatment areas– 55% of organisations said that the policy wasavailable both online and in hard copy, 40% saidit was available online.Care Quality Commission review: Safeguarding children19

• In community clinic and children’s centres – 45%of organisations said that the policy was availableboth online and in hard copy, 36% said it wasavailable online.• In maternity units – 56% of acute trusts said thatthe policy was available both online and in hardcopy, 34% said it was available online.• In mobile community staff bases – 37% said thatthe policy was available both online and in hardcopy, 36% said it was available online.• In GP premises – 45% of primary care trusts saidthat the policy was available both online and inhard copy, 41% said it was available online.What is included in the policies?As described in our overview to this section, thereare a number of processes that should be coveredby an organisation’s child protection policy, or setof policies. We asked trusts to tell us whether theirpolicies covered these processes, as applicable totheir work, and also to tell us whether they hadcarried out equalities impact assessments on theirpolicies (see table 5).Ofsted’s Learning Lessons report, which evaluatedserious case reviews between 1 April 2007 and31 March 2008, highlighted that drug and alcoholmisuse and domestic violence featured in many seriouscase reviews, and that agencies failed to adequatelyassess the risks posed by drug and alcohol misuse,particularly to very young babies. Agencies alsofailed to understand, accept and assess the impactof domestic violence on children and there wasinsufficient assessment of the impact of the learningdifficulties of adults on their capacity as parents andon their own mental health. Our findings on questionsrelated to these issues vary. While most trusts includedin their policies processes for identifying and acting onrisks relating to domestic violence, other than mentalhealthcare providers, most organisations did not havea process for ensuring that all patients are routinelyasked about dependents or caring responsibilities.The 2008 publication from the Confidential Enquiryinto Maternal and Child Health, Why Children Die,found that a failure to follow up children who did notattend their appointments was associated in somecases with missed opportunities to prevent laterdeath. The report recommended that health services,including primary care and child and adolescentmental health services, should proactively follow uppatients who did not attend their appointments. Inthe light of this recommendation, the relatively lowproportion of trusts that have a specific process forthis follow-up included in their child protection policiesis a matter of concern. The substantial proportion oftrusts that told us their child protection polices didnot include any process for offering non-registeredfamilies GP registration is also a matter of concern.Access to up-to-date information andprofessional expertiseWe asked acute trusts how their A&E staff get accessto a register of those with a child protection plan.Ninety-two per cent said that their staff had online ortelephone access 24 hours a day, seven days a week,and 3% said they had online or telephone access, butfor less than 24 hours a day, seven days a week. Fiveper cent only had a hard copy of the register availablein the department, which was updated regularly.We also asked trusts whether their maternity andhealth visiting staff have 24-hour access toinformation on families at risk. In acute trusts, 98%had access – either automatically or on request –and in PCTs, 97% had access. We also asked alltrusts how many of their clinical staff had 24-houron-call access to a child protection clinician. Eightyfourper cent said that all clinicians had access,and 8% said “most” or “some” had access. We areconcerned that 8% of organisations said that noneof their clinical staff had 24-hour on-call access toa child protection clinician. We next asked trustswhether they had a reporting system to flag childprotection/safeguarding concerns. Eighty-eight percent said they had such a system, but worryingly12% said they did not.20 Care Quality Commission review: Safeguarding children

Table 5: Key processes included in child protection policiesThe trust’s child protection policy Acute Ambulance Mental Primary(or set of polices) includes: health care trustA process for following up referrals to children’s 83% 100% 93% 92%social careA process for the identification of children/ 92% 100% 83% 93%young people who are at risk from domesticabuse, and for recognising/acting on concernsA process for following up children who miss 68% n/a 49% 51%outpatient appointmentsA process for ensuring that local families with 55% n/a 10% 66%children who are not registered with a GP areoffered registrationA process for ensuring that children or young 89% n/a 25% 35%people for whom there have been concerns(75% consideredquestion toabout their safety or welfare are not dischargedbe n/a)until their consultant paediatrician is assuredthat there is an agreed plan in place that willsafeguard the children’s welfareA process for handling suspected fabricated 82% 40% 68% 92%or induced illness(40% consideredquestion tobe n/a)A process for resolving cases where health 74% 50% 85% 79%professionals have a difference of opinion(50% consideredquestion tobe n/a)(76% consideredquestion tobe n/a)A process for ensuring that all patients are 37% 50% 88% 35%routinely asked about dependents such aschildren, or about any caring responsibilities(40% consideredquestion tobe n/a)A process or protocol that outlines when 86% n/a n/a n/aA&E staff should check whether a child issubject to a child protection planThe organisation has carried out an equalities 58% 50% 81% 53%impact assessment on your child protection policy(50% consideredquestion tobe n/a)(56% consideredquestion tobe n/a)Note: 10 out of 11 ambulance trusts provided responses to the questionnaire. Percentage values forambulance trusts in this table are based on the 10 that responded.Care Quality Commission review: Safeguarding children 21

GPs and dentists should have access to a copy ofthe local safeguarding children board’s procedures.Ninety-nine per cent of PCTs said that this wasthe case for GPs, 86% for dentists.Policies specific to mental health trustsMental health trusts face a particular challenge inassessing the impact on dependent children of thetreatment they provide for adults. Sixty-six per centof mental health trusts said they had a policy forcarrying out such assessments, 34% said they didnot. This is concerning. All mental health trusts,including those that do not treat children, shouldhave a clearly defined method for carrying out theseassessments. According to Ofsted’s Learning Lessonsreport, mental health problems often feature in seriouscase reviews. The report concluded that parents’or carers’ mental health problems are not alwaysappropriately considered as part of a risk assessmentfor children. Of those that had a policy, 55% hadaudited it since 1 January 2008. Thirteen per centhad audited their policy prior to 2008, and 36%had not audited their policy. Eighty-one per centof mental health trusts said they had joint protocolsin place for mental health and children’s services.Policies specific to maternity services(acute trusts)We asked acute trusts that provide maternityservices whether a ‘safe discharge’ policy was jointlyadopted by acute/community teams (includinghealth visiting). Sixty-nine per cent said “yes”,and 31% said “no”.22 Care Quality Commission review: Safeguarding children

4 What do senior managers and trusts’ boards doto monitor safeguarding arrangements and assurethemselves that these arrangements are working?What should be in place?Statutory guidance on making arrangements tosafeguard and promote the welfare of childrenunder section 11 of the Children Act 2004 statesthat organisations must identify a named person atsenior management level or equivalent to championthe importance of safeguarding and promoting thewelfare of children throughout the organisation. 10Intercollegiate guidance on the roles andresponsibilities of designated (primary care trusts)and named (providers) nurses and doctors statesthat the named professional in child protection willsupport and advise the trust’s board on safeguardingmatters. 9 Together, the designated/named staff andthe board representative have a duty to monitorsafeguarding throughout the organisation and, fordesignated staff, across the catchment area of theprimary care trust (PCT). These individuals needto work together to ensure that the board is fullyinformed about safeguarding practice andperformance within the organisation.PCTs are responsible for ensuring that the healthcontribution to safeguarding and promoting thewelfare of children is carried out effectively acrossthe whole local health economy, through itscommissioning arrangements. Service specificationsand contracts drawn up by PCT commissioners shouldinclude clear service standards for safeguardingand promoting the welfare of children. 8 Nationalcontracts drawn up by the Department of Healthfor commissioners to use include a section onsafeguarding, and these contracts should alsoinclude details of how performance is monitored.By monitoring the service standards of NHSfoundation trusts and contracted service providers,commissioning PCTs can assure themselves thatproviders are meeting the required safeguardingstandards.The National Service Framework for Children,Young People and Maternity Services 13 states thatall agencies should have robust information systemsthat enable them to monitor practice and themanagement of work with children and familiesto ensure that their welfare is being effectivelysafeguarded and promoted. Trusts should alsohave a programme of internal audit and review thatenables them to continuously improve the protectionof children and young people from harm or neglect.Policies, procedures and practice should be refinedor changed in the light of these audits and reviews.Our findingsMechanisms for safeguarding informationto reach board levelWe asked trusts to tell us who their nominatedboard lead for safeguarding is. In 64% of trusts itwas the nurse director, in 9% the medical director,in 8% the operations director and in 2% the chiefexecutive. Seventeen per cent selected “other”,indicating that their board lead’s role did not fallinto any of these categories. Eighty-two per cent oforganisations said that their nominated board leadhad formal training in child protection/safeguarding,14% said their lead had no training, and theremainder had no record of any training.Care Quality Commission review: Safeguarding children 23

It is essential that staff at all levels understand theirroles and responsibilities regarding safeguardingand promoting the welfare of children and thatthey are appropriately trained to carry these outeffectively. To ensure that the board lead is awareof safeguarding, they ought to have at least level 1training in safeguarding.We asked PCTs how often their designated cliniciansmet board-level leads (see table 6). It is striking thatmeetings between designated doctors and boardrepresentatives are much less frequent than thosebetween designated nurses and board representatives,but this may simply reflect the differences in protectedtime allocated for safeguarding duties for these roles.Thirty per cent of trusts told us that their boardhad received no presentations from a designated ornamed child protection/safeguarding professional in2008. These trusts should consider whether in theabsence of such presentations they are getting anadequate picture of safeguarding in their organisation.Thirty-one per cent had received one presentationand 29% had received two or more. Nine per centof the responses we received were unclear.Ninety-one per cent of organisations said that during2008, they had discussed safeguarding or childprotection at least once, as a minuted agenda item,at their executive team or full board. Seventy percent of organisations said that regular reportingand performance monitoring to their governancecommittee on safeguarding happened at leaston a quarterly basis. Twenty-two per cent saidthat this happened annually.The main ways that boards assure themselves aboutcompliance with their safeguarding responsibilitiesappear to be routine annual reporting and beingnotified of serious untoward incidents. Ten per centof organisations said they used monthly routinereports, and 28% quarterly routine reports.CommissioningPCTs must be accountable for both their ownprocesses for safeguarding children and those used byagencies that they commission services from. Servicespecifications drawn up by PCT commissioners shouldinclude clear service standards for safeguarding andpromoting the welfare of children. 8 We thereforeasked PCTs how many of their organisations’ contractsand service specifications with NHS and independentproviders explicitly include safeguarding arrangements.Table 6: Frequency of meetings between designated staff and board-level representativesHow frequently does How frequently does How frequently does youryour designated nurse your designated doctor designated nurse or doctormeet your primary meet your primary meet with board-levelcare trust’s board care trust’s board representatives of majorrepresentative? representative? local NHS organisations?Weekly 4% 1% 1%Fortnightly 9% 3% 1%Monthly 41% 12% 14%Bi-monthly 24% 31% 32%Less frequently 22% 53% 52%24 Care Quality Commission review: Safeguarding children

Table 7: Discussion at board level, or by delegated decision-making group, of incidents andreviews relating to safeguardingDiscussed? Serious untoward Individual management Serious case reviewsincidentsreviewsYes, on occurrence 41% 65% 68%Yes, at each meeting 46% 18% 19%Yes, on a quarterly basis 11% 7% 7%Yes, on an annual basis 1% 2% 2%No 1% 7% 4%Thirty per cent said “all”, 31% said “most”, 37%said “some” and 2% said “none”. We also askedPCTs whether all health organisations, including theindependent health sector that they commissionservices from, have links with a specific localsafeguarding children board. Sixty-six per centsaid “yes”, and 34% said “no”.Board-level monitoring of incidents and reviewsWe asked trusts to tell us how often their board ordelegated decision-making group routinely monitorserious untoward incidents, individual managementreviews and serious case reviews (see table 7).AuditFinally, if trusts are to ensure that their policies andprocesses are working well, regular audit is essential.We asked trusts to tell us whether they had carriedout an audit of specific safeguarding issues in 2008(see table 8).It is important that trusts review how their policiesare implemented as part of an ongoing focus onimproving outcomes. Given the recent emphasis onsafeguarding arrangements, we would expect thatboards will now have a programme for review ofthese key issues that is coordinated with their localsafeguarding children board and partner organisations.Table 8: Audit of policies relating to safeguarding in 2008Issue Yes NoPolicy relating to safeguarding 57% 43%Documentation 77% 23%Serious case review processes 22% 78%Reporting systems (flagging child protection concerns) 49% 51%Supervision arrangements 38% 62%Information sharing 39% 61%Care Quality Commission review: Safeguarding children25

5 How effective is the collaboration betweenorganisations?What should be in place?Safeguarding children requires comprehensivepartnership working between the relevant statutoryand non-statutory organisations and other localagencies. To enable partnership working, each localauthority is required under the Children Act 2004 toestablish a local safeguarding children board (LSCB). 14This is the key mechanism for agreeing how relevantlocal organisations cooperate to safeguard childrenand ensure that this is done effectively. LSCBsdevelop local policies and procedures, participatein the planning of services for local children,communicate the need to safeguard children andensure that procedures are in place to ensure acoordinated response to unexpected child deaths. 8However, the LSCB is not accountable for theoperational work of individual agencies and WorkingTogether to Safeguard Children 8 states that tofunction effectively, LSCBs must be supportedby their member organisations with adequateand reliable resources. Strategic health authorities,primary care trusts (PCTs), NHS trusts and NHSfoundation trusts are all required to be members oftheir local LSCBs. Board partners should contributetowards expenditure incurred by their LSCB. Thecore contributions should be provided by theresponsible local authority, the PCT and the police.All relevant organisations should attend LSCB andsub-group meetings to ensure successful partnershipworking within an area. Working Together toSafeguard Children 8 requires organisations to ensureconsistency and continuity in the member of staff whoattends the meeting on its behalf. Representativesmust have a strategic role in relation to childrenwithin their own organisation, be able to speakwith authority for their organisation and be able tocommit their organisation on matters of policy andpractice. Representatives must have the confidenceand authority to hold their organisation to accountover safeguarding matters. LSCBs must also haveaccess to experts from each sector, such as namedand designated professionals, whenever necessary.To collaborate effectively on safeguarding childrenand young people, local agencies must shareinformation correctly and efficiently. Organisationsmust have agreed systems, standards and protocolsfor sharing information about a child and theirfamily within each agency and between agencies. 10A new system, ContactPoint, has been developedas a key element of the Government’s Every ChildMatters programme to support more effectiveprevention and early intervention. It began in responseto a key recommendation of Lord Laming’s Inquiryinto the death of Victoria Climbié. ContactPoint isintended to be a tool to support better communicationamong practitioners working with children andyoung people across education, health and socialcare services in the statutory and voluntary sectors.It should provide a quick way for those practitionersto find out who else is working with the same childor young person and to ensure their best interestsare promoted.26 Care Quality Commission review: Safeguarding children

Our findingsInvolvement with local safeguarding childrenboardsTypically, PCTs have formal links with just one LSCB,as they both share the local authority’s boundaries.Provider organisations have a wider geographicreach, and so tend to have links with a greaternumber of LSCBs.On average, PCTs provide 22% of the budget fortheir LSCB, while acute and mental healthcareproviders contribute around 2%.We asked trusts what the job title of their mainrepresentative on their LSCB is. The largest singlegroup, at 41%, was “nurse director”, Followed by“other” with 29%. Other titles were given, but insingle figure percentages, including those staff indesignated and named roles. We also asked truststo tell us how often, and by whom, they wererepresented at meetings of their LSCB (or LSCBs).Table 9 shows the average attendance rate at LSCBmeetings for each key group. The final line providesthe average proportion of meetings at which anymembers of staff were in attendance.Fifty-eight per cent of trusts said that they wererepresented at five or more sub-groups of the LSCB.Fifty-two per cent of trusts said that no LSCB subgroupswere chaired by a health representative fromtheir organisation, though for PCTs this figure wasjust 14%. This raises some questions about thecapacity of provider organisations to influence theirLSCBs. They are represented, but the question ofhow active they are as partners should be examinedfurther. Twenty-six per cent of trusts said that theirchief executive or board lead never meets with thechair of the LSCB to review progress and identifyissues for development. Thirty-three per cent saidthat such meetings happened “occasionally”. Otherresponses to this question were “quarterly” (30%)and “annually” (10%). Again, PCTs appear to bemore engaged, with 57% saying that such meetingshappened annually or quarterly and 14% sayingthat they never happen.Table 9: Attendance by key safeguarding staff at local safeguarding children board meetings(average percentage of meetings attended)Attendee Primary care Acute trust Ambulance Mental Alltrust trust health trustLead LSCB member 78% 67% 60% 68% 72%Designated doctor 68% n/a n/a n/a –Designated nurse 82% n/a n/a n/a –Named doctor 29% 32% n/a 26% 30%Named nurse 30% 45% n/a 41% 39%Named midwife n/a 14% n/a n/a –Named professional n/a n/a 44% n/a –Any 93% 79% 60% 80% 84%Care Quality Commission review: Safeguarding children27

We asked trusts how much they contribute to LSCBtraining. Sixty per cent of organisations said thatthey design and provide a substantial part, or all,of the health element of the training. Seventeenper cent said that the health element was designedby others but that they provided funds andparticipated in the training. Nineteen per cent saidthat the training was designed and funded by otherorganisations but their staff attend. Five per centtold us that either there was no LSCB-wide schemeor that they were not involved in such a scheme.These overall figures mask a clear split betweenPCTs and provider organisations. Ninety per cent ofPCTs said that they design and provide a substantialpart, or all, of the health element of the training.For acute trusts and mental health trusts this wasaround 41%–43%. This probably reflects the localleadership role of PCTs in relation to safeguarding,and their role as the main health body providingfunding for LSCBs.Working between organisationsSeventy-one per cent of organisations said that theyhad participated in multi-agency audit of safeguardingprocedures in 2008. Ninety-five per cent said thatthey had a protocol for information sharing with keyexternal organisations.Sixty-four per cent of applicable acute trusts saidthey had a policy for joint working between maternityservices and social services, and 36% said they didnot. Of those that had a policy, just 17% had auditedthis policy during 2008. Ninety-two per cent of acutetrusts providing maternity services said that theyhad an effective system of multi-agency pre-birthassessment for families where concerns have beenraised.28 Care Quality Commission review: Safeguarding children

6 What do NHS trusts do when they reviewindividual cases?What should be in place?When a child dies or sustains a potentially lifethreateninginjury, and abuse or neglect is knownor suspected to be a factor in the death or injury,local safeguarding children boards must undertakea serious case review (SCR). The key purpose of SCRsis to find out what can be learned from the caseabout the way local professionals and organisationswork together to safeguard children. 8 As part of anSCR, the LSCB commissions an overview report andeach relevant service should complete a separatemanagement review or an individual managementreview (IMR). SCRs and IMRs should look openlyand critically at the practice of individuals andorganisations and explicitly identify any lessons,how they will be acted on, and what is expectedto change as a result. SCRs explore the involvementof the various organisations and professionals withthe child and family and the primary aim of thesereviews is to improve working between agencies sothat they can safeguard children more effectively.Working Together to Safeguard Children 8 requiresthat SCRs should be completed quickly to ensurethat lessons are learned effectively and as soon aspossible. Individual organisations should secure caserecords promptly and work quickly to establish atimetable of their involvement with the child andfamily. Reviews should be completed within fourmonths and should not be delayed as a matter ofcourse, because of outstanding criminal proceedingsor decisions on whether to prosecute or not.The statutory guidance outlines the key roles tobe played in conducting and coordinating SCRs. 8Designated professionals must review and evaluatethe practice of all health staff and providers thatwere involved within their primary care trust’s (PCT)area, and potentially, advise the named professionalsand managers who are compiling the individualreports for the review. Designated and namedprofessionals must also ensure that, when the reviewhas been completed, there is a way for staff to feedback and be debriefed to ensure that the rightlessons are learned throughout the organisation.Our findingsWe asked trusts to tell us about the two most recentIMRs they had undertaken. Some had carried out justone or no IMRs, and the average number of IMRsboth signed off and begun during 2008, was one.Figures below are based on pooled responses for allIMRs described.Serious case reviews and individualmanagement reviews in practiceIn 36% of incidents, trusts were notified by otherhealth bodies. The next highest were notificationsfrom social care (30%) followed by notificationsgenerated from within the organisation (26%)and then from other bodies (8%). None of thenotifications came from education. Thirty-one percent of notifications were immediately following theincident, 29% were within a day and 14% within aweek. Twenty-six per cent of incidents came through“normal reporting channels”.Care Quality Commission review: Safeguarding children 29

Table 10: Did the primary care trust coordinate the health component of the serious casereview (percentage of individual management reviews where this was the case)Type Yes NoPrimary care trust 77% 23%Acute trust 58% 42%Mental health trust 42% 58%Ambulance trust 21% 79%Sixty-seven per cent of reviews were completed andsigned off within one to three months. Nineteen percent took more than four months, which suggeststhat they were in breach of the target set out innational guidance for the LSCB to complete thecomposite SCR report within four months. For 72%of the reviews carried out, trusts said that there hadbeen changes as a result, and 22% said it was “tooearly to say”.When a serious case review takes place, it is theresponsibility of the PCT to coordinate the healthcomponent of the review. For the two most recentIMRs undertaken by organisations, we askedwhether the PCT did, in fact, coordinate the healthcomponent of the SCR. All types of organisation wereasked to respond to this question (see table 10).We asked PCTs the question “did your organisationnotify the strategic health authority about the SCR?”In 17% of instances, PCTs did not notify theirstrategic health authority of the SCR underway.Policies and procedures for individualmanagement reviewsEighty-three per cent of trusts said they had anagreed framework for IMRs. For acute trusts thisfalls to 78%, and for ambulance trusts to 45%.PCTs are at 88% and mental health trusts are at92%. Ninety-one per cent of trusts said they hada clear internal escalation and management process,including timescales, following a serious untowardincident SCR notification.In 78% of trusts, the person responsible for carryingout their IMRs was the named nurse, named doctor,risk manager, or any of these. In 74% of trusts, theperson responsible for implementing the action plansarising from IMRs is the designated doctor or nurse,or the board lead for safeguarding. A number ofprovider organisations (10% of the total) identifieda “designated professional” as the person responsiblefor implementing action plans arising from IMRs,which should be investigated further.We asked whether responsible service managersare provided with a copy of the action plan andrecommendations arising from SCRs. Trusts toldus that this was “always” the case in 72% oforganisations, and “usually” the case in 21%. Threeper cent said that these were provided “on request”and 2% answered “No, rarely”, and 2% did notrespond to the question.Thirty-seven per cent of organisations said that allstaff in their organisation involved in carrying outIMRs had been trained in IMRs. Sixty-two per centsaid that not all staff had been trained, and 1%provided no response to the question.30 Care Quality Commission review: Safeguarding children

We also asked whether designated professionalsreview and evaluate practice and learning from allhealth professionals and providers involved withSCRs. Eighty per cent of PCTs said that this was“always” the case, 16% “usually” and 2% “onrequest”, and 1% responded “no, rarely”. ProviderNHS trusts were also given the option of respondingto this question. Table 11 compares their responseswith those provided by PCTs.Table 11: Do designated professionals review and evaluate practice and learning from all health professionals and providers involved with SCRs? Response: Primary care Acute trust Mental health Ambulancetrust trust trustAlways 80% 68% 48% 60%Usually 16% 21% 19% 20%On request 2% 7% 17% 0%No, rarely 1% 4% 17% 20%Care Quality Commission review: Safeguarding children31

7 What have trusts told us about compliancewith national standards for safeguarding?What should be in place?NHS trusts’ boards are ultimately accountablefor their organisation’s performance in relation tosafeguarding. They must demonstrate leadership andbe informed about and take responsibility for theactions of their staff who provide services to children,young people and their families. 10In May 2009, trusts made their fourth annualdeclaration against the national core standards.These 24 standards include a standard explicitlyconcerned with child protection (C2), which requiresthat healthcare organisations protect children byfollowing national child protection guidance withintheir own activities and in their dealings with otherorganisations. Boards must assure themselvesthat they are meeting this core standard. Declaredcompliance for 2008/09 was lower than for anyprevious year since the core standards assessmentwas launched (see table 12).This fall may reflect a greater focus in 2008/09 onchecking compliance with the standard, and whatconstitutes good practice, prompted by both thecase of Baby Peter, and the requirement to returndata for this review. Table 13 shows the declarationsfor 2008/09 by type of organisation. For 2008/09,primary care trusts were asked to make twodeclarations, one for their commissioning functionsand a second for any services they provide.Table 12: Declared compliance with core standard C2 2005/06 – 2008/09Year 2005/06 2006/07 2007/08 2008/09% declaring compliance 94.4% 95.6% 96.9% 93.9%32 Care Quality Commission review: Safeguarding children

Table 13: Declarations against core standard C2 for 2008/09Type (and number of trusts)% declaring complianceAcute (155) 91.7%Ambulance (10) 90.9%Community trust (1) 100%Mental health (57) 96.6%Other (1) 100%Primary care trust and mental health provider (3) 75%Primary care trust – as commissioner (139) 93.9%Primary care trust – as provider (132) 95.7%Primary care trust/care trust – as commissioner (4) 100%Primary care trust/care trust – as provider (4) 100%The final assessment against this standard will bepublished in October 2009, following a process ofcross-checking and, potentially, follow-up visitsto trusts.Care Quality Commission review: Safeguarding children33

8 Next steps and recommendationsNext stepsFollowing publication of this report, we will provideNHS organisations with detailed local information,to enable them to review their current arrangementsfor safeguarding, and benchmark these against thearrangements of other trusts.Data gathered for this review is being used to crosscheckthe declarations made by NHS organisationsagainst core standards relating to child safeguardingand protection. This data may also be used to targetorganisations for follow-up visits. The final assessmentagainst core standards for 2008/09 will be publishedin October 2009.We will also use the information gathered in thiswork to inform the final guidance we will be issuingon the requirements of the new registration system,which will be in place from 2010.We are also working with colleagues in Ofsted, thechildren’s inspectorate, on a three-year programmeof inspections of children’s services includingsafeguarding and the care of looked-after children.Data gathered for this review will inform this work.Recommendations• In the light of this report, NHS trusts’ boardsshould urgently review their arrangements forsafeguarding children – in particular the levelsof up-to-date safeguarding training among theirstaff. Their reviews should be completed withinsix months of this report’s publication. Progresswill be checked as part of the joint programme ofinspections we will be carrying out with Ofsted.• Organisations that commission healthcare shouldmake certain, through their service specificationsand contracts, that the safeguarding arrangementsof their providers, including GP practices, areeffective. This is particularly important duringa period of local change, with children’s trustsbeing strengthened and PCTs’ commissioning andcommunity provider functions being separated.• NHS trusts’ boards should pay close attention toour guidance on the requirements for registration,including those about safeguarding. We issuedthe draft guidance on 1 June 2009, for aconsultation period of 12 weeks.• We urge the Department of Health and theDepartment for Children, Schools and Families touse the next Children’s Services Mapping exerciseto repeat key elements of the data collectioncarried out for this review, to provide a furtherupdate on progress, and to continue to offerlocal organisations useful information with whichto benchmark their services.34 Care Quality Commission review: Safeguarding children

References1. Royal College of General Practitioners (RCGP)and the National Society for the Prevention ofCruelty to Children, Safeguarding Children andYoung People in General Practice: A Toolkit,2007.2. Confidential Enquiry into Maternal and ChildHealth, Why Children Die, 2008.3. Office for National Statistics, 2007 Mid-yearpopulation estimates, 2007.4. Hospital Episode Statistics 2007/08 (HealthcareCommission analysis, includes provisional datafor Q4 2007/08).5. Healthcare Commission, State of Healthcare2008, 2008.6. The Information Centre, Qresearch report ontrends in consultation rates in General Practices1995–2008, 2008.7. Durham University, Children’s Services Mapping,2008/09.8. HM Government, Working Together to SafeguardChildren: A guide to inter-agency working tosafeguard and promote the welfare of children,2006.9. Royal College of Paediatrics and Child Health,Safeguarding Children and Young People: Rolesand Competencies for Healthcare Staff, 2006.10. HM Government, Statutory guidance on makingarrangements to safeguard and promote thewelfare of children under section 11 of theChildren Act 2004, 2007.11. Ofsted, Learning Lessons, Taking Action, 2008.12. www.nhsemployers.org/RecruitmentAndRetention/Employment-checks/Employment-Check-Standards/Pages/Employment-Check-Standards.aspx13. Department of Health, National ServiceFramework for Children, Young People andMaternity Services, 2004.14. Under Section 13 of the Children Act 2004.Care Quality Commission review: Safeguarding children35

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© Care Quality Commission 2009.Published July 2009.This publication may be reproduced in whole or inpart in any format or medium for non-commercialpurposes, provided that it is reproduced accuratelyand not used in a derogatory manner or in amisleading context. The source should beacknowledged, by showing the publication titleand © Care Quality Commission 2009.ISBN: 978-1-84562-234-3

Where we areThe Care Quality Commission’s head office is atFinsbury Tower103–105 Bunhill RowLondon EC1Y 8TGHow to contact usPhone: 03000 616161Email: enquiries@cqc.org.ukPlease contact us if you would like a summaryof this publication in other formats or languages.This publication is printed on paper made froma minimum of 75% recycled fibre.CQC-027-2000-CWP-072009