Safeguarding: Child Safeguarding Practice Reviews: The Key Takeaways

Posted  25th April 2024

This blog is based on Judicium’s Safeguarding ‘Sofa Session’ from the 25th of April, with our resident expert Sarah Cook. This session focused on reviewing the Child Safeguarding Practice Reviews which are most relevant to schools, an analysis of common themes and learning, and top tips that can be implemented in schools.

Child Safeguarding Practice Reviews

Chapter 5 of Working Together to Safeguard Children (DfE, 2023) tells us that safeguarding practice reviews are required when:
  • abuse or neglect of a child is known or suspected.
  • the child has died or been seriously harmed.

It also explains the purpose of a practice review is to identify improvements which can be made to safeguard and promote the welfare of children. It is clear they are not conducted to hold individuals, organisations, or agencies to account, as there are other processes for that purpose.

Last year, Anne Hudson, Chair of the Child Safeguarding Review Panel, reflected in her introduction to the panel’s Annual Report, “the quality of learning emanating from reviews has undoubtedly improved, but the degree to which this has resulted in discernible changes in practice is less evident.

It is important for all professionals, including schools, to think about how learning from practice reviews can be reflected in their own practice.

What is a Safeguarding Practice Review?

Safeguarding Practice Reviews are published documents available for anyone to read. In addition, the Safeguarding Practice Review Panel publish an annual report looking at themes and findings. This year’s Child Safeguarding Review Panel’s Annual Report was published in January 2024 identified six key practice themes to make a difference.

Poll 1

The Statistics

Of the 133 children of school age and subject to a review for an incident that occurred between April 2022 and March 2023, the majority (64%) were enrolled at a mainstream school at the time of the incident, with a further 18% enrolled either at a special educational needs establishment or in alternative provision.

Overall, 11% of the children were not enrolled at school at the time of the incident with 11 of these reported to be receiving elective home education. Nine children (7%) were recorded as having an unknown education status.

Of those enrolled in a mainstream school, 29% were reported as having regular absences or low attendance and 2% were reported as being temporarily excluded at the time of the incident.

Synopsis - Case of Child A

Child A, 7, lived with his mother and two older sisters. He was struck by a car and killed at 10pm and immediate investigations revealed he was alone and at the time of the incident and no one was at his home address. 

The family had contact with a variety of services in the years prior to Child A’s death. They were known to the police and adult mental health team due to reports of domestic abuse and significant concerns around mum’s mental health. Safeguarding concerns were identified by the children’s school and several reports were made to Social Care by a variety of agencies, including the school, raising concerns about the supervision of the children.

Despite these referrals, joint s47 enquiries weren't undertaken and there was no multi agency approach. The report highlights that although the school shared these concerns, they did not follow these up and challenge the status quo when Children’s Social Care did not act. It is recognised this was a missed opportunity to safeguard Child A and his sisters.

The children in this family (including Child A) were articulate and able to voice their opinions. They related their concerns about their home life a number of times. Notably, Child A’s older sister (aged 13) gave a very detailed account of being at home alone with her siblings. After her brother’s death the eldest sister described often going into school, looking unkempt with frequent headlice, and often needing food in school because they were so hungry. At times they were left for much of the weekend without food, gas, or electricity.

Key Practice Themes

Effective leadership and culture supporting critical thinking and professional challenge:

This key practice theme is not only relevant for social care professionals but also for schools.

In some reviews, schools were identified as key in providing safe spaces for children to talk about their home lives and worries yet reviews also identified schools as not always being included in multi-agency activity where they had valuable information to share or where their relationships with children and families might have facilitated multi-agency engagement.

The need for schools and other education providers to be included in multi-agency safeguarding arrangements was also reflected in the recent Ofsted/Joint Targeted Area Inspection report focusing on early help and children in need. This suggested that local safeguarding partnerships need to ensure greater consistent engagement and strategic consensus with schools and other educational partners, who can be working in isolation to keep children safe.

How can schools do better to support this key practice theme to make a difference?
  • Play an active role in multi- agency plans and challenge other agencies where this does not happen.
  • Be proactive in challenging external professionals.
  • Familiarise yourself with your local authority’s resolution and escalation procedures and be confident to use these.

It is important school leaders think about how they support their frontline DSL staff.  Some reviews identified cases where practitioners would have benefited from more time, resources, and training to gain knowledge, skills, or confidence in relation to different aspects of child protection work, and in working in a multi-agency context.

This could take the form of:
  • Providing more protected time off within the timetable.
  • Accessing more specialist training in particular fields.
  • Providing safeguarding supervision to support with strengthening practice and building confidence.
  • Taking an active role in facilitating parental engagement.
  • Focusing on sharing key information in a timely manner and challenging professionals to ensure you receive the information you need.

Operation Encompass:

Information sharing is a theme which comes up time and again in practice reviews. Operation Encompass is an example of a specific safeguarding partnership working between police and schools. It also links to the six key areas identified by the annual report for improving practice, i.e., Domestic abuse and harm to children. It works across services by enabling schools to offer immediate support to children experiencing domestic abuse.

Poll 2

How can schools better support this key practice theme to make a difference?
  • Sign up to Operation Encompass or domestic abuse notifications and ensure that you are receiving all notifications.
  • Follow up on all notifications.
  • Ensure staff receive training to develop an awareness of the signs and indicators of domestic abuse.
  • Ensure all and any concerns around potential domestic abuse are shared.

An awareness around pupils’ home lives also supports schools to actively engage in key practice theme 3 – the importance of a whole family approach to risk assessment and support. 

Whole family approach to risk assessment and support:

The absence of a whole family approach was evident across Child A’s review with services often focused on one specific family member, most often the mother or one child who was the focus of the review. The vulnerabilities of other family members were not routinely recognised.

While the child should be the focus of child protection activity, some reviews continued to show the voices of children themselves were absent from service records.

It was also noted children with caring responsibilities experience a range of both positive and negative outcomes, and these are directly affected by the level of informal or formal support they receive. It highlights the challenge of identifying 'hidden' young carers.

Schools with their daily contact and close relationships with children and their families are often uniquely situated to be able to understand the vulnerabilities and areas of risk and strength posed by the whole family.

How can schools do better to support this key practice theme to make a difference?

Ensure when working with children their wishes and views are sought and these are shared with external professionals or as part of referrals. For example, you could ask the child, “Tell me what it's like for you on a normal day?”

Suggested questions to ask yourself:
  • How do you ensure the child’s voice and experience is heard within multi-agency meetings such as the team around the family, child in need, core groups?
  • How do you as a practitioner remain curious?
  • How do you record/make a note of non-verbal communication? What language do you use to describe children’s behaviours?

Challenge where necessary if you are concerned the voice of the child(ren) is not being heard.

Giving central consideration to racial, ethnic and cultural identity and impact on the lived experience of children and families:

The report recognised after controlling for demographics and social care history, mixed white and Black Caribbean children were around 30% more likely than white British children to have a child protection plan following referral. Importantly, the same study found that Black and Asian children were less likely than white and mixed ethnicity children to have been on a child in need or child protection plan in the 8 years prior to becoming looked after.

These figures indicate some groups are less likely to access preventative and early help support. The Care Review also described how although children from Black and minoritised ethnic backgrounds were overrepresented on CPPs, they were underrepresented in early help services.

This indicates an ‘invisibility’ of some aspects of the lives and experiences of children from Black and minority communities, suggesting practices are sometimes failing to recognise and respond to the specific needs of some groups of children.

There is also evidence some Black children are ‘adultified.’ This is where practitioners hold children responsible for their actions, overlooking their vulnerability as children by treating them as adults. It is manifested in the language sometimes being used to describe children’s behaviour – emphasising their choices rather than their vulnerability and the potential risks around coercion and exploitation. This can result in practitioners not focusing on children’s underlying needs.

What can schools do better to support this key practice theme to make a difference?

Things to consider could be:
  • Are you ensuring that records are factual, non-emotive and recognise the vulnerability of children?
  • Are you talking to children and families about their faith, beliefs, family traditions, identity and culture?
  • Learning from reviews has highlighted the need to talk to all children and families about their identity and family traditions. Conversations need to go beyond ethnicity or religion.

Suggested question: "If your best friend came to your home, what would they find different and new in your home that doesn’t happen at theirs?"

This professional curiosity has the added benefit of supporting the identification of other underlying concerns including neglect, which continues to be identified and will be the subject of a thematic review in 2024.

Poll 3

Most families of children who died or suffered serious harm were either open to children’s social care at the time of incident (35%) or had previously been known to children’s social care (42%). Overall, 10% of children were on a child protection plan at the time of the incident and a further 23% had previously been on a child protection plan.

NB: This means these are not ‘unknown’ children slipping through the system. These are often children that have been identified as being at risk of harm and who are being worked with.

The annual report identified several critical issues that are detrimentally impacting the work done to safeguard children. The report recognises factors such as the increase in the number of children experiencing mental and emotional health challenges, workforce recruitment and retention, and workforce churn as areas of high concern as is the increase in high level mental health concerns.

Top Tips 

  • Play an active role in multi- agency plans and be pro-active in challenging external professionals.
  • Familiarise yourself with your local authority’s resolution and escalation procedures and be confident to use these.
  • Focus on sharing key information in a timely manner and challenge professionals to ensure that you receive the information that you need.
  • Ensure the child’s voice and experience is heard within multi-agency meetings such as team around the family, child in need, core groups
  • Remain curious
  • Ensure that records are factual, non-emotive and recognise the vulnerability of children.
  • Talk to children and families about their faith, beliefs, family traditions, identity and culture.

    Additional Information

    Take a look at our Safeguarding blog on: Tackling and Responding to Domestic Abuse: What Schools Should Know

    Refuge National Domestic Abuse Helpline

    Operation Encompass

    The Safeguarding Service is  hosting live, virtual training courses this term including a new Online Safety course, Safeguarding for Governors, Safer Recruitment, Live @ 3:45 sessions and much more. To view all upcoming courses, dates and links click HERE. 

    Safeguarding eLearning Courses

    You can follow us on Twitter: @JudiciumSG       @JudiciumEDU


    If you’d like to review Judicium’s forthcoming sofa sessions please click here

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