The Protection of

Children in England:
A Progress Report

The Protection of Children in England: A Progress Report

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 Return to an Address of the Honorable the House of Commons
dated 12 March 2009
for the

The Protection of
Children in England:
A Progress Report

The Lord Laming

Ordered by the House of Commons to be printed on

12 March 2009

HC 330 LONDON: THE STATIONERY OFFICE £19.15

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ISBN: 9780102958928
 1

Contents

Introduction 2
Chapter 1 – Progress 9
Chapter 2 – Leadership and accountability 14
Chapter 3 – Support for children 22
Chapter 4 – Interagency working 36
Chapter 5 – Children’s workforce 43
Chapter 6 – Improvement and challenge 61
Chapter 7 – Organisation and finance 73
Chapter 8 – Legal 78
Chapter 9 – Complete List of Recommendations 83
Appendix 1: Letter to Lord Laming from the Secretary of State 93
for Children, Schools and Families
Appendix 2: Glossary of abbreviations 96
Appendix 3: List of Lord Laming’s Secretariat and Advisers 98

The front cover picture was drawn by Caitlin, aged 8 years.

The back cover picture was drawn by Megan, aged 12 years.
2

INTRODUCTION

“Children become the victims or the beneficiaries of adult

actions.”

Hugh Cunningham1
‘Please keep me safe’. This simple but profoundly important hope is
the very minimum upon which every child and young person should
be able to depend. Sadly, sometimes even our imaginations fail to
help us understand the dependency of young children or the
vulnerability of adolescents, regardless of their displays of bravado.
Most adults recognise that children and young people need security,
stability, love and encouragement. As the Chief Rabbi Sir Jonathan
Sacks put it, “Children grow to fill the space we create for them, and
if it’s big, they grow tall”.2 The years of childhood pass all too quickly
and become the foundation upon which the rest of life depends.
Policies, legislation, structures and procedures are, of course, of
immense importance, but they serve only as the means of securing
better life opportunities for each young person. It is the robust and
consistent implementation of these policies and procedures which
keeps children and young people safe. For example, organisational
boundaries and concerns about sharing information must never be
allowed to put in jeopardy the safety of a child or young person.
Whilst children and young people’s safety is a matter for us all, a
heavy responsibility has rightly been placed on the key statutory
services to ensure it happens.
But it serves no one, least of all children, if the scale of the task is
under estimated. For example, Department for Children, Schools and
Families (DCSF) information shows that on 31 March 2008, 37,000
children3 were the subjects of care orders (of 60,000 children looked

1 Cunningham, Hugh, The Invention of Childhood (BBC Books, 2006)

2 The Chief Rabbi, Sir Jonathan Sacks, on ‘Thought for the Day’, BBC Radio 4, 12 December
2008. Quoted with the permission of The Chief Rabbi
3 DCSF SSDA903 data collection 31 March 2008 (available online at
www.dcsf.gov.uk/rsgateway/DB/SFR/s000810/index.shtml)
 INTRODUCTION 3

after by local authorities4) and 29,000 children5 were the subject of

child protection plans. Home Office data shows that in 2007/08, 55
children6 were killed by their parents or by someone known to the
child.
It would be unreasonable to expect that the sudden and unpredictable
outburst by an adult towards a child can be prevented. But that is
entirely different from the failure to protect a child or young person
already identified as being in danger of deliberate harm. The death of
a child in these circumstances is a reproach to us all.
Following the case of ‘Baby P’, the Secretary of State for Children,
Schools and Families, the Rt Hon Ed Balls MP, acted decisively. On 17
November 2008 he commissioned me to provide an urgent report on
the progress being made across the country to implement effective
arrangements for safeguarding children. His letter is reproduced at
Appendix 1. The kernel of the task was to evaluate the good practice
that has been developed since the publication of the report of the
Independent Statutory Inquiry following the death of Victoria Climbié,
to identify the barriers that are now preventing good practice
becoming standard practice, and recommend actions to be taken to
make systematic improvements in safeguarding children across the
country.
The Government deserves credit for the legislation and guidance that
has been put in place to safeguard children and promote the welfare
of children over the last five years. Every Child Matters7 clearly has the
support of professionals, across all of the services, who work with
children and young people. The interagency guidance Working
Together to Safeguard Children8 provides a sound framework for
professionals to protect children and promote their welfare. New
models for early intervention developed nationally and delivered
locally through extended schools and Sure Start Children’s Centres
have established a solid foundation on which to build more
imaginative and flexible responses to the needs of children and
4 DCSF CPR3 data collection 31 March 2008
(available online at www.dcsf.gov.uk/rsgateway/DB/SFR/s000811/index.shtml)
5 DCSF CPR3 data collection 31 March 2008
(available online at www.dcsf.gov.uk/rsgateway/DB/SFR/s000811/index.shtml)
6 Homicides, Firearm Offences and Intimate Violence 2007/08 (Supplementary Volume 2 to Crime
in England and Wales 2007/08), David Povey (ed.), Kathryn Coleman, Peter Kaiza and Stephen
Roe (Home Office, available online at www.homeoffice.gov.uk/rds/pdfs09/hosb0209.pdf)
Additional offences where suspect is unknown not recorded here
7 HM Government, Every Child Matters: Change for Children (2004)
8 HM Government, Working Together to Safeguard Children: A guide to inter-agency working to
safeguard and promote the welfare of children (2006)
4 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

families. However, whilst the improvements in the services for children

and families, in general, are welcome it is clear that the need to
protect children and young people from significant harm and neglect
is ever more challenging. There now needs to be a step change in the
arrangements to protect children from harm. It is essential that action
is now taken so that as far as humanly possible children at risk of
harm are properly protected.
One of the main challenges is to ensure that leaders of local services
effectively to translate policy, legislation and guidance into day-to-day
practice on the frontline of every service. As the Society of Local
Authority Chief Executives and Senior Managers (SOLACE) advised me
in their evidence to this report:
“Chief Executives are the best paid most senior members of staff in
councils. Notwithstanding the statutory role of other staff, now
including Directors of Children’s Services, Chief Executives should
accept their role in setting and securing high standards and hiring
and where necessary firing expert staff.”
The personal accountability of the most senior managers in all of the
public services now needs to be fully understood.
Leaders of local services must recognise the importance of early
intervention and ensure that their departments support children as
soon as they are recognised as being ‘in need’, averting escalation to
the point at which families are in crisis.
Frontline staff in each of the key services have a demanding task.
Their work requires not only knowledge and skill but also
determination, courage, and an ability to cope with sometimes intense
conflict. This must be recognised in their training, case-loads,
supervision and conditions of service, and their managers must
recognise that anxiety undermines good practice. Staff supervision
and the assurance of good practice must become elementary
requirements in each service. More should be done to ensure the
well-being and confidence of the staff who undertake such an
important task on behalf of us all.
To support staff in this vitally important task of protecting children,
central government and local agencies must immediately take the
following action:
First and foremost, the Secretaries of State for Health, Justice, the
Home Office and Children, Schools and Families must collaborate in
the setting of explicit strategic priorities for the protection of children
 INTRODUCTION 5

and young people for each of the key frontline services and ensure
sufficient resources are in place to deliver these priorities. There is little
hope for the full integration and joined-up working of local and
regional services if the same approach is not fully realised in central
government. Now is the time to address this imbalance.
Secondly, the Government must immediately inject greater energy
and drive into the implementation of change and support local
improvement by establishing a powerful National Safeguarding
Delivery Unit to report directly to Cabinet through the Families,
Children and Young People Sub-Committee, and to report annually
to Parliament. This multi-disciplinary unit must be led by someone
with great authority, specialist knowledge and obvious ambition for
improving outcomes for children and young people and for the quality
of services they receive, especially for children in danger of deliberate
abuse or neglect. This flexible and agile team must be able to draw on
staff with direct frontline experience from across police, health and
children’s services along with staff from central government who can
act quickly to offer their expertise to improve outcomes for children.
The unit would not have to be a permanent presence, but it is needed
for a short time to bring coherence, drive and energy to the
implementation of change through government departments and
local services whose work is to protect children. Initially, the unit’s
main task will be to drive the implementation of the recommendations
of this report, working with the Cabinet Sub-Committee on Families,
Children and Young People to set and publish challenging timescales
for each recommendation. More detail on the unit is given in
Chapter 6.
Thirdly, the Secretary of State for Children, Schools and Families must
immediately address the inadequacy of the training and supply of
frontline social workers. The message of this report is clear: without
the necessary specialist knowledge and skills social workers must not
be allowed to practise in child protection. A high priority must be
given to establishing a new postgraduate programme to be completed
by all children’s social workers as soon as is practicable. A programme
of management training should be put in place and steps taken to
ensure there is strong and determined leadership in every local
authority. No time should be lost in demanding best practice for some
of the most vulnerable children in our society. Issues of low morale
and esteem within the service must be rectified. In this context,
I welcome the decision by ministers to establish the Social Care Task
6 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

Force led by Moira Gibb, the well-respected Chief Executive of the

London Borough of Camden.
Fourthly, the Secretary of State for Health must immediately address
the wariness of staff throughout the health services to engage with
child protection work. GPs, community nurses and paediatricians must
be helped to develop a wider range of skills and become very much
more confident in this important area of their work. Of greater
challenge still is the need to address the status, training and
responsibilities carried by health visitors. Evidence to this progress
report makes clear that there are a number of challenges to be
addressed in this service. The work of health visitors requires
immediate action to increase the numbers, confidence and
competence of staff.
Fifthly, the Home Secretary must urgently address the adequacy of
the resources devoted to police child protection teams, the specialist
training of these staff, the vacancy rates, the status of this work and
the quality of service provided.
Sixthly, the Secretary of State for Justice should take immediate action
to shorten the time taken in court processes relating to the care of
children. In 2008/09 the average time taken for a case to come to
court was 45 weeks,9 an unacceptably long time to leave a child in
limbo at this formative stage in his or her life. When the state is
seeking to make a care order, there should be no budgetary
impediment to this. The increase in court fees for care order
applications by local authorities was unhelpful, and was made worse
by the transfer of the money into the general funding of local
government. The Ministry of Justice should make arrangements for
these fees to be reconsidered.
The remainder of this document, and its recommendations, are aimed
at making sure that good practice becomes standard practice in every
service. This includes recommendations on improving the inspection of
safeguarding services and the quality of Serious Case Reviews as well
as recommendations on improving the help and support children
receive when they are at risk of harm. The utility of the policy and

9 Family Court, County and High Courts 2008/09 provisional data, Ministry of Justice, England
and Wales. Notes:
(1) Family Court data is from Family Case Tracker and FamilyMan. County Court and High
Court data is from FamilyMan
(2) Figures are for April to September 2008
(3) Care and supervision orders are included and are counted by child for Family Court figures
and by order for County Court and High Court
 INTRODUCTION 7

legislation has been pressed on me by contributors throughout this

report. In such circumstances it is hard to resist the urge to respond by
saying to each of the key services, if that is so “NOW JUST DO IT!”
With greater ambition and determination I am sure it can be done.
Now is the time to prove that the well-being of every child and young
person really does matter, not least because the UN Convention on
the Rights of the Child (Article 6) states, “Parties recognise that every
child has the right to life. Parties shall ensure to the maximum extent
possible the survival and development of the child”.10 It has been put
to me that it is inevitable that some adults, for whatever reason, will
deliberately harm children. That may well be so. Nevertheless, it
cannot be beyond our wit to put in place ways of identifying early
those children at risk of deliberate harm, and to put in place the
means of securing their safety and proper development.
In general, families are best placed to care for children and promote
their welfare. Fortunately the vast majority of parents seek the best for
their children and, entirely rightly, the state supports them in this
important task. However, parenthood incorporates not only rights but
also responsibilities: it is a lifetime commitment. Particular mention
should be made of the part to be played by fathers, not least as good
role models.
Because this report has been conducted against a tight timescale I
wish to record my thanks to the many organisations that responded
so quickly and all of those that have become involved in other ways.
In the course of the report I received over 100 written submissions
from key stakeholders and over 200 letters from a range of individuals
including professionals across the children’s workforce. The report
team visited six local areas and met with key staff from local
authorities, education, health and the police. The team hosted a series
of seminars to gather the views of national stakeholders, local leaders
and frontline staff. I and other members in the team met national
stakeholders, trade unions, officials of government departments, and
some Members of Parliament. I am also most grateful to 11 Million
and to Dr Roger Morgan for consulting young people and passing on
to me their views and experiences of services for children and young
people. It is the evidence, information and opinions gathered from all
of these sources that underpin this report.

10 Available online at www.unhchr.ch/html/menu3/b/k2crc.htm

8 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

I could not have undertaken this report without the strong support of
a team of skilled, enthusiastic and very committed colleagues. Their
names are recorded in Appendix 3. A glossary of abbreviations used
throughout the report is at Appendix 2.

The Lord Laming

March 2009
CHAPTER 1 9

Progress

“Be gentle with the young.”

Juvenal11
1.1 Children are our future. We depend on them growing up to become
fulfilled citizens well able to contribute successfully to family life and
to the wider society. It is of fundamental importance that the life and
future development of each child is given equal importance. Every
child needs to be nurtured and protected from harm. A great deal of
progress has been made towards achieving this and the Government
deserves credit for its policy of Every Child Matters. Yet recent events
have shown that very much more needs to be done to ensure that the
services are as effective as possible at working together to achieve
positive outcomes for children.

Progress so far
1.2 This country has a long history of commitment to the protection of
children and supporting their welfare. Many of those who contributed
to this report have vast personal experience in grappling with these
matters and there have been significant milestones along the way.
At the level of frontline delivery, there is an impressive degree of
individual commitment and enthusiasm for Every Child Matters and
for the vision of what a ‘good’ childhood should be. Throughout
children’s services, police and health, there are many individuals who
are making it their life’s work to protect children and improve their
well-being despite the fact that often this is a challenging task that
can entail facing real conflict.
1.3 The last five years have been a particularly intense time of change.
Every Child Matters came about as a direct result of a failure of the
services to safeguard children with the death of Victoria Climbié and it
still has overwhelming support across children’s services and beyond.
Central government and local agencies are now at the halfway point

11 Juvenal (early AD), Roman poet

10 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

in this ten-year programme of change. The first five years have seen
sound progress in legislative and structural terms. The introduction of
a Cabinet Sub-Committee on Families, Children and Young People
chaired by the Secretary of State for Children, Schools and Families
and supported by a cross-government delivery board for the Public
Service Agreement to improve children and young people’s safety12
are important and welcome developments. The Child Safety Reference
Group utilises the experience of over 20 stakeholders to influence the
safeguarding agenda. At local level, a great deal has been done to
create new universal services for the under 5s, and ensure that
support is in place for children and young people through early
intervention and greater joint working through schools.
1.4 However, despite this encouraging start, there are real challenges still
to address in safeguarding and child protection if children are to have
services they can rely on when their own lives are in crisis.

The challenges that remain

1.5 Working Together to Safeguard Children13 sets out sound practices for
children’s social workers and for other professionals which, if well
understood and used intelligently and effectively will give children and
young people better quality lives and, on occasion, save lives.
However, the evidence is mixed on how well understood these
processes are, and too often the findings of Serious Case Reviews
demonstrate that simple steps from this guidance could have saved
lives.14 There are training and workforce issues to be resolved, and
data systems that need to be improved to support professionals better,
but ultimately the safety of a child depends on staff having the time,
knowledge and skill to understand the child or young person and their
family circumstances.
1.6 Despite considerable progress in interagency working, often driven by
Local Safeguarding Children Boards and multi-agency teams who
strive to help children and young people, there remain significant
problems in the day-to-day reality of working across organisational
boundaries and cultures, sharing information to protect children and
a lack of feedback when professionals raise concerns about a child.
Joint working between children’s social workers, youth workers,

12 PSA Delivery Agreement 13: Improve children and young people’s safety (HM Government,
April 2008)
13 HM Government, Working Together to Safeguard Children: A guide to interagency working to
safeguard and promote the welfare of children (2006)
14 Ofsted, Learning lessons, taking action: Ofsted’s evaluations of serious case reviews 1 April 2007
to 31 March 2008 (December 2008)
 Progress 11

schools, early years, police and health too often depends on the
commitment of individual staff and sometimes this happens despite,
rather than because of, the organisational arrangements. This must be
addressed by senior management in every service.
1.7 Undermining many attempts to protect children and young people
and improve their well-being effectively is the low quality of training
and support given to often over-stretched frontline staff across social
care, health and police. Social work case-loads are often very high and
more than 60 per cent of health visitor case-loads are above
recommended levels.15 The pressure of high case-loads is exacerbated
by the fact that many social workers believe their training fails to
prepare them for working with families in crisis. Within police forces
the profile of child protection is variable with some forces (but by no
means all) having reduced resources for child protection continually
over the last three years and many contributors expressing concerns
that vacancy rates are too high. There is a lack of high-quality
specialist training on child protection across these services that
undermines the good intentions of staff to do the best they can for
the children they work with.
1.8 The issues outlined above have not had the priority they deserve over
the last five years. In part, this may be due to the lack of effective
challenge and support for improvement of safeguarding and child
protection services across agencies. The inspection process has not
been as effective in scrutinising practice in safeguarding as it has been
in education, and the changes to the inspection framework
announced recently are very much needed. The development function
that the Commission for Social Care Inspection provided for children’s
social care has been lost and not effectively replaced or expanded to
support safeguarding and child protection services across agencies
(see Chapter 6).

Understanding the scale and complexity of need

1.9 Childhood and family life today is a complex matter and it is small
wonder that there are still persistent misconceptions about child abuse
and neglect. Safeguarding is not only about very young children or
indeed issues of class, but it extends across society and through the

15 Unite/Community Practitioners’ and Health Visitors’ Association Omnibus Survey, 2008

12 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

teenage years. In 2007/08, 55 children were killed by someone known

to the child (see graph below).16
Fig 1: Child homicides where the suspect was known to the victim
90 85

80
70
70 78
62
60 55
52
49
50 54 46 44
51 41
48
40 35
43
40
30 34 35
30
20 25

10

0
9

8
/9

/0

/0

/0

/0

/0

/0

/0

/0

/0
98

99

00

01

02

03

04

05

06

07
19

19

20

20

20

20

20

20

20

20
Son or daughter Total acquainted

Source: Police Crime Statistics, England and Wales.

Notes:
(1) As at November 2008; figures are subject to revision as cases are dealt with by the
police and by the courts or as further information becomes available
(2) Child homicides including baby battering, neglect, excessive punishment
(3) Offences are shown according to the year in which the incident took place or the year
in which any court decision was made
(4) If a child is killed by their adoptive parents they would be included in the son or
daughter category but if the child is killed by their foster parents they would be
included in the total acquainted category
(5) There are additional homicides where the suspect is unknown

1.10 Of the 11 million children in England17 a total of 60,000 children were

looked after by a local authority:18 37,000 were the subject of a care
order (either full or interim)19 and 29,000 were the subject of a Child
Protection Plan.20 In 2005, the last time national data was collected, a

16 Homicides, Firearm Offences and Intimate Violence 2007/08 (Supplementary Volume 2 to Crime
in England and Wales 2007/08), David Povey (ed.), Kathryn Coleman, Peter Kaiza and Stephen
Roe (Home Office, available online at www.homeoffice.gov.uk/rds/pdfs09/hosb0209.pdf)
Additional offences where suspect is unknown not recorded here
17 Office for National Statistics (ONS) population estimates mid 2007, children aged under 18 years
18 Children in Need Census, February 2005
19 DCSF SSDA903 data collection, 31 March 2008 (available online at www.dcsf.gov.uk/rsgateway/
DB/SFR/s000810/index.shtml)
20 DCSF CPR3 data collection, 31 March 2008 (available online at www.dcsf.gov.uk/rsgateway/DB/
SFR/s000811/index.shtml)
 Progress 13

total of 235,000 children21 were described as being ‘in need’ and

therefore requiring Section 17 support from the local authority.

11 million children in England. Of these …22

●● 200,000 children live in households where there is a known
high risk case of domestic abuse and violence23
●● 235,000 are ‘children in need’ and in receipt of support from a
local authority
●● 60,000 are looked after by a local authority
●● 37,000 are the subject of a care order
●● 29,000 are the subject of a Child Protection Plan
●● 1,300 are privately fostered24
●● 300 are in secure children’s homes25

1.11 The scale of need amongst children and young people, and the social,
emotional and financial consequences of not improving their well-
being and keeping them safe at an early stage in their lives, dictate
that resolving the challenges laid out above should be one of the
highest priorities for central and local government and the other
key services. To effect a step change in services and to transform
outcomes for children and young people the priority given to
safeguarding must be achieved through strong and effective
leadership, early intervention, adequate resources, and quality
performance management, inspection and support.

21 Children in Need Census, February 2005

22 There is overlap between these categories: for example, a child who is living in a household with
domestic violence may also be subject to a child protection plan
23 Co-ordinated Action Against Domestic Abuse based on their work to date on Multi-Agency Risk
Assessment Conferences
24 DCSF private fostering return, 31 March 2008 (available on line at www.dcsf.gov.uk/rsgateway/
DB/SFR/s000803/index.shtml)
25 DCSF SA1 Survey, England, 31 March 2008 (available on line at www.dcsf.gov.uk/rsgateway/DB/
SFR/s000802/index.shtml)
14 CHAPTER 2

Leadership and accountability

“Children are our most valuable natural resource.” ­

Herbert Hoover26

National leadership
2.1 Effective leadership sets the direction of an organisation, its culture
and value system, and ultimately drives the quality and effectiveness
of the services provided. It is essential that there is a sustained
commitment to child protection and promoting the welfare of children
at every level of government and in every one of the local services.
The Cabinet Sub-Committee on Families, Children and Young People,
chaired by the Secretary of State for Children, Schools and Families,
carries ultimate responsibility for shaping a national safeguarding
system that protects the safety and promotes welfare of children and
young people in England. Building on progress already made, the
Sub-Committee will need to continue to work to increase the
momentum on delivering quality services at a local level and to raise
the profile of children as a distinct group at all levels of government.
The National Safeguarding Delivery Unit, which is explained further in
Chapter 6 of this report, has a major contribution to make in this task.
2.2 Children are not ‘little adults’ and need particular support both as
children, and for the particular condition or situation they find
themselves in at any given moment in time. Within central
government, the Department of Health, Ministry of Justice and Home
Office, as departments with key safeguarding responsibilities, must
recognise children as individuals with their own needs and ensure that
their delivery strategies and services are appropriate and well quipped
for the task.

26 Herbert Hoover (1874–1964), US President

 Leadership and accountability 15

Recommendations
The Home Secretary and the Secretaries of State for Children,
Schools and Families, Health, and Justice must collaborate in the
setting of explicit strategic priorities for the protection of children
and young people and reflect these in the priorities of frontline
services.
The Cabinet Sub-Committee on Families, Children and Young
People should ensure that all government departments that
impact on the safety of children take action to create a
comprehensive approach to children through national strategies,
the organisation of their central services, and the models they
promote for the delivery of local services. This work should focus
initially on changes to improve the child-focus of services delivered
by the Department of Health, Ministry of Justice and Home Office.

Managing performance
2.3 Central government departments, particularly the Department for
Children, Schools and Families (DCSF), the Department of Health, the
Home Office, and the Ministry of Justice, need to collaborate to create
an effective system of performance management that drives
improvement in the quality of services designed to safeguard and
promote the welfare of children and enable them to ensure they are
meeting their responsibilities for keeping children safe. There is an
urgent need to develop effective indicators for safeguarding children
and young people that will drive positive improvements and secure
better outcomes for them. The performance indicators currently in
use for the safeguarding of children are inadequate for this task.
Discussion with local authorities suggested that this was because of
concerns that current indicators focus on processes and timescales,
are not helpful in creating shared safeguarding priorities amongst
statutory partners, are unclear in their impact upon positive outcomes
for children and young people, and do not drive improved services.
As a result, the take-up of these National Indicators (NIs) by local areas
as part of their Local Area Agreements (LAAs) is low, with less than
10 per cent of local authorities choosing to adopt targets on most
child protection indicators. A relatively small number of local
authorities have opted to use the indicators as local targets.
2.4 It is undoubtedly not easy to find good measures of outcomes for
safeguarding and child protection. However, it is important to
16 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

continue to find ways of understanding the impact of work to keep

children safe from harm. The Government’s statutory DCSF targets
should be reviewed to include safeguarding and child protection
targets. The NI set also requires revision to ensure that the indicators
available for inclusion in a LAA better describe improved outcomes
and services for children and young people. These indicators must be
specifically agreed by the Department of Health and the Home Office
to ensure they are reflected in the performance management
frameworks of Strategic Health Authorities (SHAs), Primary Care Trusts
(PCTs) and Police Authorities. The complexity of managing
performance across partner services should not be allowed to be a
barrier to improving the safety of children and young people in
England.
2.5 Central government departments need to communicate with
increased clarity to local services their expectations around
safeguarding and child protection. In particular, the Department of
Health and the Home Office have more to do in ensuring that SHAs,
PCTs and Police Authorities fully understand their responsibilities and
statutory duties to provide appropriate and effective local services for
children in need. Furthermore, all partners in Children’s Trusts will
need support from central government to develop a local performance
framework and minimum data sets in order that their performance
can be assessed against the identified needs of local children and
young people.

Recommendations
The Government should introduce new statutory targets for
safeguarding and child protection alongside the existing statutory
attainment and early years targets as quickly as possible. The
National Indicator Set should be revised with new national
indicators for safeguarding and child protection developed for
inclusion in Local Area Agreements for the next Comprehensive
Spending Review.
The Department of Health must clarify and strengthen the
responsibilities of Strategic Health Authorities for the performance
management of Primary Care Trusts on safeguarding and child
protection. Formalised and explicit performance indicators should
be introduced for Primary Care Trusts.
 Leadership and accountability 17

Regional leadership – Government Offices

2.6 Children and Learners Teams in Government Offices support the
implementation of The Children’s Plan27 and the Every Child Matters
programme, the negotiation of LAAs and the translation of national
children’s policy into local delivery. Children and Learner Teams also
have a role in supporting improvement within their region, overseeing
the implementation of Serious Case Review Recommendations and
challenging the performance of local authorities. The majority of
contributors to this progress report recognised the input that they
received from Government Offices. However, some also felt that
Government Office teams were not always able to provide the level of
support or expertise that local areas often need, particularly on
complex child protection issues. There is a stronger role for
Government Offices to play in raising the profile and increasing the
momentum on child protection work. There must be a particular focus
on their role in challenging performance and sharing learning and
expertise at a regional level. In undertaking this work, Government
Offices should ensure that they are joining up sufficiently with all of
the other contributors in the region with an interest in the children’s
safeguarding agenda. Government Office Directors for Children and
Learners will wish to ensure that they have the required expertise in
child protection within their teams to carry out this role effectively.

Local political leadership

2.7 All local authorities must by now have a designated councillor to act
as Lead Member for Children’s Services, with responsibility for
promoting the safety and welfare of children across all agencies in
their area. The sustained commitment from both the Council Leader
and the Lead Member for Children’s Services is essential if the profile
and importance of safeguarding and promoting the welfare of
children is to be understood throughout the authority and the
Children’s Trust. However, it appears that the degree of focus of
Council Leaders and Lead Members on safeguarding children from
harm is variable. At best there are examples of Lead Members who
actively hold Children’s Trust partners to account and who deliberately
seek to understand the range of service provision in their area.
However, such good practice is not yet well established in every local
authority.

27 HM Government (DCSF), The Children's Plan: building brighter futures (December 2007)
18 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

2.8 In order to be most effective, Lead Members must have access to an

appropriate level of up-to-date detail of safeguarding practice for their
authority, including an understanding of the profile of children and
young people in their area, the level of need, and the quality and
effectiveness of the services that protect children from harm. They
should receive regular reports from the Director for Children’s Services
(DCS) on service delivery and local outcomes for children and young
people, and maintain regular contact with the senior managers of
other safeguarding partners. They should provide regular scrutiny of
key management information, including assessment and inspection
reports, and assure themselves that appropriate quality assurance
systems are in place. To support Lead Members in this complex and
challenging role, regular training will be required to develop and
maintain their knowledge base and enable them, where necessary, to
better scrutinise and challenge service delivery to children and young
people. The DCSF has recently completed a consultation on the roles
of the DCS and Lead Member for Children’s Services following the
initiatives set out in the DCSF’s Children’s Plan, with a focus on
prevention. The results of this will be published shortly and will be
invaluable in shaping their responsibilities more effectively.

Local professional leadership and accountability

2.9 In recent months there has been a great deal of attention on the role
of the DCS in safeguarding children, sometimes at the expense of
recognising the importance of the role of the local authority Chief
Executive. This was underlined by the Society of Local Authority Chief
Executives and Senior Managers (SOLACE) in their written evidence to
this report, which stated:
“Decision making about the rights of parents and the needs of
children, we submit, is the most onerous of local government
responsibilities.”
2.10 The time is long past when the most junior employee should carry the
heaviest burden of accountability. The performance and effectiveness
of the most senior managers in each of these services should be
assessed against the quality of the outcomes for the most vulnerable
children and young people.
2.11 Beyond the local authority, the Children Act 2004 placed a duty to
cooperate on each of the key services. It is therefore important that
senior managers in partner agencies such as Chief Executives of
PCTs and senior police officers work to ensure priority is given to
safeguarding children and provide equal commitment, including
 Leadership and accountability 19

resources, to local safeguarding partnerships. At senior level there

should be a culture of mutual challenge, improvement and openness.
Local areas may want to publish an annual report on their
safeguarding practice as a way to raise the profile of safeguarding
children within both agencies and the local community.
2.12 Attention by senior managers to the quality of services delivered at the
front door of each agency, where referrals are received and the risk of
harm assessed, is vitally important. Managers must lead by example by
taking a personal and visible interest in frontline delivery. They must
assure themselves that the assessment of risk of harm to each child
and young person is being undertaken effectively and that the referral
and assessment processes in Working Together to Safeguard Children
are being followed intelligently and effectively. Senior managers
should be confident that decision making, communication and
information sharing within and between each of the local services is
effective in keeping children safe even when those services are under
pressure. In turn, they should support and value first-line managers
ensuring that management oversight of decision making is rigorous
and that the lines of communication between senior managers and
frontline child protection staff are as short and effective as possible.

Recommendation
Directors of Children’s Services, Chief Executives of Primary Care
Trusts, Police Area Commanders and other senior service
managers must regularly review all points of referral where
concerns about a child’s safety are received to ensure they are
sound in terms of the quality of risk assessments, decision making,
onward referrals and multi-agency working.

Directors of Children’s Services

2.13 Directors of Children’s Services (DCSs) are locally at the centre of
safeguarding children, although their remit is far wider, with responsibility
for education, children’s social care, early years provision and other
services to support children and families. There is no doubt that bringing
these services together under one local authority department has
provided a more integrated approach to support children. But it must be
recognised that balancing the many different demands of the role
requires significant levels of determination and leadership skills. The
responsibility of the role should not be underestimated, nor should the
dedication that DCSs show daily in ensuring that children in need receive
20 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

appropriate services, and, when necessary, adequate protection. The

creation of Children’s Services Departments has meant that a large
proportion of DCSs do not have first-hand experience of frontline
social work. It is therefore essential that someone within the senior
management team is able to scrutinise cases properly and challenge
practice from a position of skill and expertise. However, the DCS should
also develop sufficient personal knowledge and understanding of
safeguarding and child protection. The development programme for
DCSs that the Secretary of State for Children, Schools and Families has
recently commissioned from the National College for School Leadership
should provide useful extra support in dealing with the complexity of
their safeguarding responsibilities.
2.14 Every DCS needs a skilled and well-motivated team to support them,
but service delivery is equally dependent on the skills and dedication
of frontline staff. DCSs, therefore, need to pay particular attention to
the capacity of their frontline workforce. Chapter 4 provides more
detail on concerns about the morale of frontline social workers that is
resulting in recruitment and retention problems in many areas and
ultimately is risking the safety of children. No national workforce
strategy will resolve these issues without the robust, decisive and
effective leadership of a DCS committed to creating a supportive
culture for children’s services. It is important to recognise the stressful
and emotional content of social work and to create an environment
that enables social workers to share their feelings and anxieties
without being labelled as inadequate. There is a need for DCSs to put
measures in place to help staff deal with the emotional stress of child
protection work. Such support needs to be reinforced by a system of
good line management that is creative, empowering and sensitive to
the individual needs of frontline staff, yet confident enough to set and
secure high standards of delivery.

Recommendations
All Directors of Children’s Services who do not have direct
experience or background in safeguarding and child protection
must appoint a senior manager within their team with the
necessary skills and experience.
The Department for Children, Schools and Families should
organise regular training on safeguarding and child protection and
on effective leadership for all senior political leaders and managers
across frontline services.
 leadership and accountability 21

Children’s Trusts
2.15 Children’s Trusts Boards (rather than the local authority alone) will
shortly be required by legislation to undertake a needs analysis,
including safeguarding, to inform the development of new Children
and Young People’s Plans (CYPPs) that come into effect from April
2011. However, it is not clear that the quality of the analyses
underpinning current CYPPs is of a consistently high level nationally to
drive the resourcing of services to meet the needs of all children.
Further work should now be done, at local, regional and national levels,
to improve the quality of data on levels of need amongst children and
young people, and local authorities should formally reconsider the
adequacy of their budgetary commitment. This should include ensuring
that management information fully reflect the needs of all those for
whom a local authority has responsibilities, up to 18 for most children
and 25 for care leavers. A more determined commitment to universal
preventative services will facilitate the identification of children in need.
Robust information systems need to be in place locally to improve this
information. The needs analysis for the CYPP should draw on the data
of all partner agencies, and include information about the impact on
children and young people of domestic violence, adult alcohol and
drug dependency, and adult mental health difficulties.

Recommendation
Every Children’s Trust should ensure that the needs assessment
that informs their Children and Young People’s Plan regularly
reviews the needs of all children and young people in their area,
paying particular attention to the general need of children and
those in need of protection. The National Safeguarding Delivery
Unit should support Children’s Trusts with this work. Government
Offices should specifically monitor and challenge Children’s Trusts
on the quality of this analysis.
22 CHAPTER 3

Support for children

“When I approach a child, he inspires in me two sentiments:

tenderness for what he is, and respect for what he may become.”

Louis Pasteur28

Focus on the child

3.1 Every Child Matters is intended to organise services and resources
around children to ensure their safety and proper development, and
improve their well-being. However, there are significant levels of
concern that current practice, and in particular the pressure of high
case-loads for children’s social workers and health visitors, has meant
that staff often do not have the time needed to maintain effective
contact with children, young people and their families in order to
achieve positive outcomes. In these circumstances professionals can
find it very difficult to take the time to assess the family environment
through the eyes of a child or young person. The failure to see the
situation from their perspective and to talk to them was highlighted in
Ofsted’s first annual report of evaluations of Serious Case Reviews.29
Staff across frontline services need appropriate support and training to
ensure that as far as possible they put themselves in the place of the
child or young person and consider first and foremost how the
situation must feel for them. They need to be able to notice signs of
distress in children of all ages, but particularly amongst very young
children who are not able to voice concerns and for whom
bedwetting, head-banging and other signs may well be a cry for help.

28 Louis Pasteur (1822–95), French chemist and microbiologist

29 Ofsted, Learning lessons, taking action: Ofsted's evaluations of serious case reviews 1 April 2007
to 31 March 2008 (December 2008)
 Support for children 23

“It seems like they have to do all this form filling, their bosses’ bosses
make them do it, but it makes them forget about us.”
 Boy, 16
“She does things by text book, she doesn’t know me as a person.”
 Girl, 1630

Demanding excellence for children

3.2 At the autumn DCSF regional conferences on child deaths and Serious
Case Reviews, the University of East Anglia presented early findings
from their work on the overview report of Serious Case Reviews
initiated during the period 2005–07. They identified that professionals
have a “tendency towards justification and reassurance that all was
well, rather than more objective consideration and investigation of
what had occurred”, and that sympathy for parents can lead to the
expectations being set too low.31 Every professional coming into
contact with a child in whatever context should be clear that it is not
acceptable to do nothing when a child may be in need of help. It is
important that the social work relationship, in particular, is not
misunderstood as being a relationship for the benefit of the parents or
for the relationship itself, rather than a focused intervention to protect
the child and promote their welfare.

Early intervention
3.3 Early intervention is vital – not only in ensuring that fewer and fewer
children grow up in abusive or neglectful homes, but also to help as
many children as possible reach their full potential. The Government’s
investment in prevention and early intervention, especially through
children’s centres and extended schools, has been widely welcomed.
The Audit Commission has estimated that, if effective early
intervention had been provided for just one in ten of those young
people sentenced to custody each year, public services alone could
have saved over £100 million annually.32

30 Quotations taken from findings of research with children undertaken by 11 Million in January
2009 specifically for this report
31 Extract from the presentation of early findings from the overview of Serious Case Reviews
during 2005–07, at the recent DCSF regional seminars on child deaths and Serious Case
Reviews (University of East Anglia, 2008)
32 HM Treasury, Policy review of children and young people: A discussion paper (January 2007)
24 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

A recent report co-authored by MPs Graham Allen and Iain

Duncan Smith highlights the need for early intervention, noting
that “child poverty and income are only part of the picture.
Building human capabilities is at least as important and rewarding.
Capable, competent human beings will almost always find their
way in life, find work and raise happy families.” The report also
highlights the importance of the first years of a child’s life and
how they lay the foundation for that child’s growth and
development; the authors believe that “medical evidence points
overwhelmingly in favour of a shift to Early Intervention.
It highlights the essential importance of years 0–3 in human
development, and the vital influence on years 0–3 of their primary
caregivers. That in turn makes it essential to prepare children of
0–18 for their future role as parents. Skills that for generations
were passed on, almost unconsciously, now have to be taught:
if they are not, we will all reap the consequences.”
Graham Allen MP and Rt Hon Iain Duncan Smith MP,
Early Intervention: Good Parents, Great Kids, Better Citizens
(Centre for Social Justice/Smith Institute, 2008)

3.4 However, there are differing understandings (particularly amongst

professionals in universal services) about what early intervention
actually is – from pre-natal assessment to support for children before
they require a child protection plan. Early intervention certainly should
not be seen as something that applies only to babies and toddlers.
Teenagers who are starting to disengage from school or show signs of
anti-social behaviour can also benefit from preventative and early help
and support. Schools, youth workers and other professionals should
be aware of the signs and know how best to respond.
3.5 Schools and early years settings play a key role in early identification,
intervention and support for children at risk of significant harm or
who have additional needs. In the findings of the DCSF biennial
overview report of Serious Case Reviews from 2003–05,33 it was found
that 68 per cent of the children aged 4 and over who subsequently
died or experienced significant harm had been showing signs of poor
school attendance. The commitment in the recent 21st Century

33 Brandon, Marion, Pippa Belderson, Catherine Warren, David Howe, Ruth Gardner, Jane
Dodsworth, Jane Black, Analysing Child Deaths and Serious Injury though Abuse – What can we
Learn? A Biennial Analysis of Serious Case Reviews 2003-05, HM Government (2008)
 Support for children 25

Schools strategy34 to create a clear national framework for early

intervention is timely. Schools and early years settings need to be
encouraged to prioritise safeguarding children within their school
improvement plans. The inspection and improvement regime for
schools needs to ensure that schools are proactively involved in
safeguarding children, for example by offering multi-agency services
on-site, making sure that their staff understand the referral
arrangements in their area, and by continuing involvement in
supporting children by attending child protection conferences and
sharing information where appropriate. This is crucial in keeping
children safe and often in keeping them in education.

Recommendation
Ofsted should revise the inspection and improvement regime for
schools giving greater prominence to how well schools are
fulfilling their responsibilities for child protection.

Front door – safe and welcoming

3.6 A key factor in identifying children and young people who need help
is ensuring services are designed to encourage contact from members
of the public, parents and children and young people as well as by
other agencies. If safeguarding children is everybody’s responsibility,
then everybody should know how, and who, to contact if they are
concerned about a child or young person. All service providers must
look critically at how they receive referrals, the point known as their
‘front door’. In local authorities where callers are directed to call
centres that handle a wide range of local authority business, the local
authority must ensure that any call relating to the protection of a child
or young person is quickly transferred to a trained person with
immediate access to an experienced social worker allocated to work
with that team for more complex or high-risk referrals.

34 HM Government (DCSF), 21st Century Schools: A World-Class Education for Every Child
(December 2008)
26 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

Case study A
A common approach to managing referral and
assessment
One local authority has been successful in developing an effective
and responsive referral system for children and young people. It
has been a priority to organise good responses to information
about vulnerable children and they have now achieved the basic
aim of ‘never doing nothing’. The stories at the ‘front door’ are
now managed well and there are consistent responses to what
are often chaotic and complex referrals. Central to this way of
working are some basic questions:
●● What is the nature of the information?
●● Who is giving the information?
●● How are referrals progressed and who is accountable?
– and three basic principles:
●● Precision – making sure there is a transparent process (consistently
applied) for establishing the cause for concern/referral
●● Visibility of action in order that every professional in the team
knows what is happening and can track progress of the referral
●● Accountability – making sure that there is a supervisor
constantly assessing the decisions being made and the action
being taken
This new approach which enables both managers and
practitioners to view the whole system as it responds to the
identified needs of children and their families is resulting in
important and positive results which include:
●● increased professional confidence and competence in
managing and responding to complex referrals
●● consistent and transparent management of referrals across a
large county area
●● reduced uncertainty amongst referring professionals who
always get a response to their referral
 Support for children 27

●● releasing resources both for more preventative work (pre-front

door) and for direct work with children and families about
whom there are serious concerns
Most importantly, these new practices have ensured that ‘doing
nothing’ is no longer an option. The increased precision and focus
which is applied to managing referral information is creating a
confidence amongst local professionals that children are safer and
resources are targeted where the risk of harm to children and
young people is assessed as being the greatest. It is now hoped
that this approach can be expanded across the Yorkshire and the
Humber region.

Recommendation
The Department for Children, Schools and Families should revise
Working Together to Safeguard Children to set out clear expectations
at all points where concerns about a child’s safety are received,
ensuring intake/duty teams have sufficient training and expertise to
take referrals and that staff have immediate, on-site support available
from an experienced social worker. Local authorities should take
appropriate action to implement these changes.

Accident and Emergency

3.7 In many of the cases where a child has experienced significant harm
or died as a result of abuse, the child has at some point been taken
to the Accident and Emergency department of a hospital. Working
Together to Safeguard Children is helpful in setting out the
expectation that “staff in accident and emergency, ambulatory care
units, walk-in centres and minor injury units, should be able to
recognise abuse and be familiar with local procedures for making
enquiries to find out whether a child is subject to a child protection
plan”. It also recognises the risk that parents may deliberately use
different sources of help to conceal repeated injuries to a child or
siblings. However, not all Accident and Emergency departments follow
this guidance effectively or are yet fully involved in local arrangements
for child protection or have easy, up-to-date access to the names of
children subject to a child protection plan and the knowledge of
whether a child has recently presented at another Accident and
Emergency department. All staff in Accident and Emergency
28 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

departments should be trained to recognise abuse and neglect, with

someone available at all times who has up-to-date information on
children subject to a child protection plan and what further action
should be taken to protect that child. Staff should not work on the
assumption that this is the child’s first presentation at Accident and
Emergency or rely on the parent or carer’s assertion that that is the
case unless they know this to be true.
3.8 Where medical staff suspect that the injury is non-accidental they
must ensure that children’s social care services and the child’s general
practitioner (GP) are notified as soon as possible. Having asked for the
parent’s permission, they should arrange for a more thorough medical
examination of the child in these cases, to identify any additional
injuries or concerns. Full notes should be taken and information shared
with the social worker. Medical professionals should notify children’s
social care services and the child’s GP of any refusal. No child should be
discharged from hospital where medical staff have remaining concerns
about that child’s safety or welfare. Any concerns they have should be
fully explored as set out in Recommendation 19 (see page 86).

Recommendation
The Department of Health and the Department for Children,
Schools and Families must strengthen current guidance and put in
place the systems and training so that staff in Accident and
Emergency departments are able to tell if a child has recently
presented at any Accident and Emergency department and if a
child is the subject of a Child Protection Plan. If there is any cause
for concern, staff must act accordingly, contacting other
professionals, conducting further medical examinations of the
child as appropriate and necessary, and ensuring no child is
discharged whilst concerns for their safety or well-being remain.

Assessment processes
3.9 Fundamental to establishing the extent of a child’s need is a child-
centred, sensitive and comprehensive assessment. Assessment should
involve gathering a full understanding of what is happening to a child in
the context of their family circumstances and the wider community,
using a variety of sources of information. It must, therefore, be a joint or
parallel assessment with all professionals concerned for the child’s safety
and welfare. Time needs to be spent making sense of this information
involving the family where appropriate. Assessment processes should
 Support for children 29

build up an increasingly clear understanding of a child’s situation over

time, building up a picture of continuous neglect or cumulative
concerns about abuse where this exists. This should minimise the risk of
repeated initial assessments not taking account of what has gone
before. Whilst these principles are well embedded in some services,
evidence to this report suggests there is further work to be done to
ensure sound assessment processes are in place in every service.

Recommendation
Children’s Trusts must ensure that all assessments of need for
children and their families include evidence from all the
professionals involved in their lives, take account of case histories
and significant events (including previous assessments) and above
all must include direct contact with the child.

A continuum of support for children

3.10 Local authorities have a general duty to safeguard and promote the
welfare of children in need in their area.35 This is because, for the vast
majority of children, the best place for them to be brought up is with
their families. Local authorities are required to provide a range and
quantity of services appropriate to the needs of children who are ‘in
need’ because they are unlikely to achieve or maintain a reasonable
standard of health or development, or whose development is likely to
be impaired without support, or who are disabled. This is deliberately
a wide definition to ensure every child receives the support needed to
stay with his or her family and to secure their proper development.
But where the local authority has reasonable cause to believe that a
child is suffering or is likely to suffer significant harm the authority
must ensure that enquiries are undertaken to make an informed
decision about how the safety and welfare of that child is best
protected, and take appropriate action to do so.
3.11 In recent years the term ‘threshold’ has been increasingly used amongst
professionals in children’s services and their partner agencies. Thresholds
are an attempt to limit access to services either because of finance or
staffing constraints. Thresholds have no statutory basis and are not part
of the Framework for the Assessment of Children in Need and their
Families.36 Despite this, concerns have been raised from across the full

35 Under Section 17 of the Children Act 1989

36 Department of Health, April 2000
30 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

range of services contributing to this report that thresholds, which act as

gateways to restrict services for children, are inconsistent, and are too
high. As a result local authorities are missing opportunities to intervene
and support families at an earlier stage and avoid situations progressing
on a downward spiral. This undermines the very purpose of Section 17
of the Children’s Act 1989, which is to provide early support to children
and families and prevent the escalation of risk which can lead to a child
being harmed. Local authorities that adopt very high threshold criteria
run the risk of legal challenge. Children who fall just short of needing a
child protection plan are placed at particular risk of suffering harm when
services are not provided for them. Local authorities must address this
issue urgently and ensure they are providing the range and level of
services and support that children in need require. Where this is done
well, both statutory and voluntary partners are involved in service
planning to ensure that they understand the services that are available to
children when making referrals.
3.12 In providing services under the Children Act 1989 it is important that
local authorities do not take a compartmentalised view of the
legislative framework for meeting the needs of children. If a child is
identified as being ‘in need’, their circumstances should be monitored
to ensure they do not change for the worse placing them at risk of
significant harm. There should be constant monitoring of the progress
of children in need by all agencies involved with the family. Where
children are supported at home, the child protection plan must clearly
identify the objectives to be achieved, with timescales, that signal
either the withdrawal of support to the family or, if the objectives are
not achieved, indicate the point when further action must be taken.
This is particularly important in cases of child neglect where often
there is no single event that ‘triggers’ matters escalating to an
application for a court order. In such cases parents may, or may not,
be cooperating and the extent of the risk of harm to the child may
increase over time. Realistic timescales need to be applied for these
cases to ensure a child is not subjected to long-term neglect. Signs of
non-compliance by parents, or indeed threat or manipulation, must
form part of the decision to protect a child.

Recommendation
Local authorities must ensure that ‘Children in Need’, as defined
by Section 17 of the Children Act 1989, have early access to
effective specialist services and support to meet their needs.
 Support for children 31

3.13 Social workers should be confident in using the full range of legal
options, as appropriate, to safeguard a child’s welfare. This includes
child assessment orders, care and supervision orders, emergency
protection orders and voluntary agreement by parents for their child
to be accommodated by the local authority. They must use these
options appropriately and decisively. For example, local authorities
must consider how appropriate it is to accommodate children with the
voluntary agreement of their parents, 37 which can be revoked at any
time, when there are concerns for a child’s safety. They should be
ready to act decisively if it becomes necessary to apply for a care order.

Evidence-based programmes
3.14 Vulnerable children and families have a right to expect that the
services they are provided with are based on evidence that they have
been shown to work in meeting their needs. There have been a
number of examples of evidence-based programmes that practitioners
and service leaders have found particularly supportive in their
contributions to this report. Family Nurse Partnerships, that provide
intensive support for the most vulnerable first time parents, have
proven benefits with evaluations stretching over 25 years in the US
and seem to have been well received here. The announcement of the
expansion of this service in the recent Children’s Health Strategy
Healthy lives, brighter futures38 is welcome. Family Intervention
Programmes have introduced new ways to support parents at times
when their relationships come under strain, and give more support to
children when family relationships break down. Parenting programmes
already being used widely include Webster Stratton, Strengthening
Families, and Triple P, all of which have been shown to be particularly
effective for younger children. Three other programmes – Functional
Family Therapy, Multi-systemic Therapy and Multidimensional
Treatment Foster Care – are currently being piloted in some local
authorities in England and have the potential to deliver positive
outcomes. DCSF, the National Safeguarding Delivery Unit and existing
organisations who work to share good practice in safeguarding
children all have a role to play in sharing the learning from evidence-
based programmes and encouraging their availability.

37 Under Section 20 of the Children Act 1989

38 HM Government (DCSF and Department of Health), Healthy lives, brighter futures – The strategy
for children and young people’s health (2009)
32 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

Reflective practice
3.15 The role of social work staff and managers is particularly critical in
ensuring enabling action to protect children. There is concern that the
tradition of deliberate, reflective social work practice is being put in
danger because of an overemphasis on process and targets, resulting
in a loss of confidence amongst social workers. It is vitally important
that social work is carried out in a supportive learning environment
that actively encourages the continuous development of professional
judgement and skills. Regular, high-quality, organised supervision is
critical, as are routine opportunities for peer-learning and discussion.
Currently, not enough time is dedicated to this and individuals are
carrying too much personal responsibility, with no outlet for the
sometimes severe emotional and psychological stresses that staff
involved in child protection often face. Supervision should be open
and supportive, focusing on the quality of decisions, good risk
analysis, and improving outcomes for children rather than meeting
targets.

Recommendations
The Social Work Task Force should establish guidelines on
guaranteed supervision time for social workers that may vary
depending on experience.
The Department for Children, Schools and Families should revise
Working Together to Safeguard Children to set out the elements
of high quality supervision focused on case planning, constructive
challenge and professional development.

Data systems
3.16 There are definite advantages to electronic record keeping in place of
the previous often inaccessible paper files. Technology offers the
potential for professionals to share information more effectively, to
make information more accessible, and to use systems to manage the
workflow of children’s services. The new ContactPoint system will
have particular advantages in reducing the possibility of children for
whom there are concerns going unnoticed.
3.17 Practitioners and managers are committed to the principle of an
electronic system and have no desire to return to paper-based case
management. However, the current state of the technology –
particularly the local IT systems that support the use of the Integrated
 Support for children 33

Children’s System (ICS) – is hampering progress. Professional practice

and judgement, as said by many who contributed evidence to this
report, are being compromised by an over-complicated, lengthy and
tick-box assessment and recording system. The direct interaction and
engagement with children and their families, which is at the core of
social work, is said to be at risk as the needs of a work management
tool overtake those of evidence-based assessment, sound analysis and
professional judgement about risk of harm.
3.18 There is no single national IT system that delivers the ICS
requirements. Some areas have access to systems that support
practice, but there is wide variation from area to area in the time staff
spend inputting information into the ICS. Local authorities that
ensured practice strongly informed the implementation process appear
to have been successful in reducing time spent by social workers in
front of screens. Those local authorities with strong leadership and a
confident workforce ensure social workers remain primarily focused
upon contact with children and families. However, there remain
fundamental limitations to local systems that impact daily on the
working lives of many social workers and, as a result, affect the quality
of their work with children and their families. Some of the concerns
shared by contributors to this report are detailed below. Local
authorities are having to find ways to work around their systems –
often introducing parallel systems for capturing qualitative data –
with the result that the benefits of the system are being undermined.
Too much time and money is being spent at local level trying to
correct the failings of individual systems and stronger national
leadership of ICS is needed.

Examples of concerns about ICS raised in evidence

●● The systems do not support reflective thinking and risk analysis
●● Some of the systems in use require some data to be re-entered
for each child in a family
●● Some of the systems in use do not allow qualitative
assessments and case notes to be captured
●● Most systems do not produce chronologies that can be used in
court, although the specification published in June 2008
requires this
●● It is hard to use the outputs to engage with children and families
34 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

Case study B
Integrated Children’s System
One local authority has implemented an ICS which is supporting
improvement in the overall management and delivery of children’s
services. It is acknowledged that there are still improvements to be
made, but it is also clear that this would indeed be the case where
any system is being developed to support children and their
families. Critical to their local success in implementation is:
●● a clear and open relationship from the start with the developer/
provider of the system
●● a local dedicated IT team who understand the needs of the
children’s service and who can broker this with the developers
of the system
●● senior leadership involvement in the commissioning and
ongoing development of the system
●● a commitment throughout the service to focusing on practice
and not exclusively timescales. The quality of assessments and
decision making is reinforced at all times
●● recognition that the multi-disciplinary relationships around the
system must be in place and be effective for the system to
work. Where this is the case, good information sharing
amongst professionals will be replicated in the system
●● clarity amongst staff that ICS is not a replacement for professional
judgement but rather a tool to enable and support case-load
planning and management and multi-disciplinary working
 Support for children 35

Recommendations
The Department for Children, Schools and Families should
undertake a feasibility study with a view to rolling out a single
national Integrated Children’s System better able to address the
concerns identified in this report, or find alternative ways to assert
stronger leadership over the local systems and their providers. This
study should be completed within six months of this report.
Whether or not a national system is introduced, the Department
for Children, Schools and Families should take steps to improve
the utility of the Integrated Children’s System, in consultation with
social workers and their managers, to be effective in supporting
them in their role and their contact with children and families,
partners, services and courts, and to ensure appropriate transfer
of essential information across organisational boundaries.

3.19 Irrespective of the methods used for recording and managing

casework, local leaders must ensure that children and young people’s
information is managed and recorded effectively to reduce their risk
of harm. Clearly systems are only as good as the information put into
them, and the priority should be to ensure that staff are able to
dedicate maximum efforts to face-to-face contact with children
and families.
36 CHAPTER 4

Interagency working

“Relationships are crucial; it’s not about structures, it’s about

making it work out there for children.”

Social worker

4.1 It is clear that most staff in social work, youth work, education, police,
health and other frontline services are committed to the principle of
interagency working, and recognise that children can only be
protected effectively when all agencies pool information, expertise
and resources so that a full picture of the child’s life is better
understood. Cooperative working is increasingly becoming the normal
way of working. However, good examples of joint working too often
rely on the goodwill of individuals. Colleagues in education, early
years, health and police are vital partners in protecting children and
they need to be willing and proactive in discharging their statutory
duty to cooperate on child safeguarding.
“Some agencies still think they are helping out social care rather than
thinking that safeguarding is everybody’s responsibility.” Local
Safeguarding Children Board (LSCB) Chair, Loughborough University
2009 LSCB Survey 39
4.2 The Government’s Working Together to Safeguard Children set out
sound principles and procedures for collaborative working, but to
protect children these need to be intelligently and effectively applied
in every local service. All professionals working with a child should
explicitly understand their responsibilities in order to achieve positive
outcomes, keep children safe, and complement the support that other
professionals may be providing. They should all know when a child is
subject to a child protection plan and act accordingly.

39 Interim findings to be published in spring 2009: Loughborough University research led by

Professor Alan France and Emily Munro
 Interagency working 37

Recommendations
The Department for Children, Schools and Families must
strengthen Working Together to Safeguard Children, and
Children’s Trusts must take appropriate action to ensure:
●● all referrals to children’s services from other professionals lead
to an initial assessment, including direct involvement with the
child or young person and their family, and the direct
engagement with, and feedback to, the referring professional;
●● core group meetings, reviews and casework decisions include
all the professionals involved with the child, particularly police,
health, youth services and education colleagues. Records must
be kept which must include the written views of those who
cannot make such meetings; and
●● formal procedures are in place for managing a conflict of
opinions between professionals from different services over the
safety of a child.

4.3 Yet it is evident that the challenges of working across organisational

boundaries continue to pose barriers in practice, and that cooperative
efforts are often the first to suffer when services and individuals are
under pressure. Examples of poor practice highlighted to this report
include child protection conferences where not all the services
involved in a child’s life are present or able to give a view; or where
one professional disagrees with a decision and their view is not
explored in more detail; and repeated examples of professionals not
receiving feedback on referrals. As a result of each of these failures,
children or young people at risk of neglect or abuse will be exposed
to greater danger. The referring professional may also be left with
ongoing anxiety and concern about the child or young person. This
needs to be addressed if all local services are to be effective in keeping
children and young people safe.
38 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

Recommendations
All police, probation, adult mental health and adult drug and
alcohol services should have well understood referral processes
which prioritise the protection and well-being of children. These
should include automatic referral where domestic violence or drug
or alcohol abuse may put a child at risk of abuse or neglect.
The National Safeguarding Delivery Unit should urgently develop
guidance on referral and assessment systems for children affected
by domestic violence, adult mental health problems, and drugs
and alcohol misuse using current best practice. This should be
shared with local authorities, health and police with an
expectation that the assessment of risk and level of support given
to such children will improve quickly and significantly in every
Children’s Trust.
The Department for Children, Schools and Families should
establish statutory representation on Local Safeguarding Children
Boards from schools, adult mental health and adult drug and
alcohol services.

Adult and child services working together

4.4 It is estimated at least 200,000 children live in households where there
is a known high risk case of domestic abuse and violence, with very
many more affected at some point in time.40 Approximately 450,000
parents41 are estimated to have mental health problems; an estimated
250,000 – 350,000 children42 have parents who are problematic drug
users, and around 1.3 million children43 live with parents who are
thought to misuse alcohol. In this context, it is vital that professional
staff working with adults are trained to identify and assess the needs
of, and risk of harm to, children and young people. These issues are a
consistent feature of Serious Case Reviews, 44 demonstrating how
seriously they put children at risk of significant harm. There are some

40 Figures provided by Co-ordinated Action Against Domestic Abuse (CAADA)

41 Morris, J and M Wates, ‘Supporting Disabled Parents and Parents with Additional Support
Needs’ in Adult’s Services Knowledge Review 11 (Social Care Institute for Excellence, 2006)
42 Advisory Council on the Misuse of Drugs, Hidden Harm: Responding to the Needs of Problem
Drug Users (2003)
43 Prime Minister’s Strategy Unit, Alcohol Harm Reduction Project – Interim Analytical Report
(2003)
44 Brandon, Marion, Pippa Belderson, Catherine Warren, David Howe, Ruth Gardner, Jane
Dodsworth, Jane Black, Analysing Child Deaths and Serious Injury though Abuse – What can we
Learn? A Biennial Analysis of Serious Case Reviews 2003–05, HM Government (2008)
 Interagency working 39

examples of good practice of adult and children’s services working

together to ensure that the protection of children is paramount in
contact with adults. However, there are too many examples of referral
and assessment processes that do not adequately identify and assess
the risk of harm to children or take the necessary action to support
those children.
4.5 These are complicated matters and they need to be handled with
great care. It is vital to ensure that, in creating a robust system of
identifying and supporting these children appropriately, crude systems
of referral are not used that deter victims of domestic violence or
those suffering with mental health illness from seeking help, for fear
that this would automatically put in jeopardy their right to care for
their child. Sound referral systems must be based on proper
assessment and judgement. The answer must lie in joint working
between police, health and children’s services to ensure that the risk
of harm to children is well understood, assessed and acted upon as
appropriate in every case. Local areas need further support in
consistently developing such robust arrangements, and the National
Safeguarding Delivery Unit should address this as one of its earliest
priorities.

Case study C
Multi-agency working – an example from one local
authority
In one local authority, doing the ‘basics’ well has enabled the
Local Safeguarding Children Board (LSCB) to develop a strong and
mature partnership. The LSCB benefits from a personal
commitment from Executive Directors across each of the health
trusts. Four Health Trusts (two acute, one mental health and one
Primary Care Trust (PCT) have their own safeguarding boards
which meet quarterly, and are led by their respective Executive
Directors. The function of the health safeguarding boards is to
co-ordinate safeguarding practice across the trusts, ensuring a
‘two way learning and improvement dialogue’ with the LSCB.
These arrangements also support an annual event to consider
cross boundary issues, across the trusts and two local authority
areas. This has led to implementation of the same protocols
regardless of the local authority area where a child or family live.
40 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

One trust has recently established an operational multi-agency

safeguarding team across children and adult services. There are
weekly multi-disciplinary case review meetings with partners and
multi-agency audits. The Accident and Emergency department
holds a weekly psycho-social meeting, to discuss attendances in
the previous week with representation from hospital and social
care staff. Robust screening is universally applied for safeguarding
issues including domestic violence, all attendances at hospital are
notified to the health visitor, school nurse, GP, and social worker,
and a rigorous risk assessment is undertaken before any child is
discharged.
Vulnerable children are ‘flagged’ in GP practices, there is a named
safeguarding GP in each practice, and there is also a GP with a
special interest in safeguarding contributing to the PCT’s strategic
safeguarding work and acting as a key conduit to GP practices.
Regular training is provided by designated and named
professionals to GPs to maximise their contribution to the
safeguarding agenda.
Health Trusts are represented on the seven sub-committees of the
LSCB, which enables them to influence any training programmes,
identify likely barriers to change, and exploit the full impact of
interagency working. The value of interagency audit has been
particularly important in driving change and creating a culture of
continuous improvement.

Information sharing
4.6 Despite the fact that the Government gave clear guidance on
information sharing in 2006 and updated it in October 2008,45 there
continues to be a real concern across all sectors, but particularly in
the health services, about the risk of breaching confidentiality or data
protection law by sharing concerns about a child’s safety. The laws
governing data protection and privacy are still not well understood
by frontline staff or their managers. It is clear that different agencies
(and their legal advisers) often take different approaches.
4.7 Whilst the law rightly seeks to preserve individuals’ privacy and
confidentiality, it should not be used (and was never intended) as a
barrier to appropriate information sharing between professionals.
The safety and welfare of children is of paramount importance, and
45 HM Government, Information sharing: Guidance for practitioners and managers (2008)
 Interagency working 41

agencies may lawfully share confidential information about the child

or the parent, without consent, if doing so is in the public interest.
A public interest can arise in a wide range of circumstances, including
the protection of a child from harm, and the promotion of child
welfare. Even where the sharing of confidential medical information
is considered inappropriate, it may be proportionate for a clinician to
share the fact that they have concerns about a child.

“The key factors in deciding whether or not to share confidential

information are necessity and proportionality, ie whether the
proposed sharing is likely to make an effective contribution to
preventing the risk and whether the public interest in sharing
information overrides the interest in maintaining confidentiality.
In making the decision you must weigh up what might happen if
the information is shared against what might happen if it is not
and make a decision based on professional judgement.”
Information sharing: Guidance for practitioners and managers
HM Government (2008)

4.8 Those who have local accountability for keeping children safe should
ensure that all staff in every service, from frontline practitioners to
legal advisers and managers in statutory services and the voluntary
sector, understand the circumstances in which they may lawfully share
information about both children and parents, and that it is in the
public interest to prioritise the safety and welfare of children. Agencies
should regularly test their local information sharing arrangements to
satisfy themselves that their procedures are understood and working
properly to protect children.

Recommendation
Every Children’s Trust should assure themselves that partners
consistently apply the Information Sharing Guidance published
by the Department for Children, Schools and Families and the
Department for Communities and Local Government to
protect children.
42 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

Common Assessment Framework

4.9 The Common Assessment Framework (CAF) is a tool designed to aid
the assessment of a child’s needs where more than one practitioner is
likely to be involved in meeting those needs. It is designed for the
early intervention end of the spectrum of need rather than for children
who are at risk of significant harm. It is still too early to make a
judgement on the effectiveness of the CAF in improving outcomes for
children and young people, and opinion from contributors to this
report has been divided. There has been some evidence that the CAF
has been helpful in bringing together a wider range of professionals
to make joint assessments that are both positive in achieving better
assessments of a child and as a learning experience for staff. However,
it is in danger, like other tools, of becoming process-focused or, even
worse, a barrier to services for children where access to services
depends on a completed CAF form. All agencies need further help in
using the CAF effectively and consistently. They also need further
support in managing the role of lead practitioners to ensure that all
those who undertake this role have the time, training and
relationships needed to allow them to support children effectively.

Views on CAF from contributors to this Progress

Report
“The CAF has made a huge difference in this area to the early
identification of children and young people in need.”
Local authority managers during a fieldwork visit
“The CAF can be very effective in building bridges and shared
understanding between different professional groups.”
Police organisation in written evidence
“The CAF has caused a lot of confusion and is burdensome to
complete, not least because not all agencies know how to feed
their information into it.”
Voluntary organisation in written evidence
CHAPTER 5 43

Children’s Workforce

“All kids need is a little help, a little hope and somebody who
believes in them.”

Earvin ‘Magic’ Johnson46

5.1 Few careers are as demanding or rewarding as that of working with
children, young people and their families. People who enter the
children’s workforce, be it in the health services, the police, education,
youth work or social work, do so to make a difference to other
people’s lives. Every day, thousands of children are helped, supported
and in some cases have their lives saved by these staff. However,
rather than feeling valued for their commitment and expertise
professionals across these services often feel undervalued,
unsupported and at risk. Morale amongst social workers in services
for children is particularly low. There is a desperate need for more
health visitors, and many paediatricians and police officers report
that child protection work is often of low status in contrast to the
challenges that accompany it. As a result, children may be being put
at risk of suffering harm.

Progress so far
5.2 The issues facing all the staff working with children remain very real.
Vacancies for children’s social workers in local authorities stood at
9.5 per cent in 2006, 47 compared with 0.7 per cent for teachers.48
Turnover rates were also high at 9.6 per cent. 64 per cent of local
authorities reported difficulties in recruiting children’s social workers
in 2008, and 39 per cent had difficulty in retaining them, although
progress has been made since 2006.49 In some authorities visited in

46 Earvin ‘Magic’ Johnson (1959 –), US basketball player

47 Children’s, Young People’s and Families’ Social Care Workforce Survey 2006, Local Authority
Workforce Intelligence Group
48 618G survey (annual, DCSF), full-time vacancy rate for maintained nursery/primary, secondary
and special schools in England
49 Local Government Workforce Survey 2008 (available on line at www.lga.gov.uk/lga/core/page.
do?pageId=1095305)
44 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

the preparation of this report over half of social workers are newly
qualified with less than a year’s experience. One survey suggested that
nearly three-quarters of children’s social workers report that average
case-loads have increased since 2003.50 Equally worryingly, the
number of health visitors is at its lowest in 14 years.51 Research for
Community Care as part of the ‘Children in Focus’ series back in 2002
suggests that working in child protection teams within the police
service is seen as being low status.52 This was a view repeated by a
number of police service representatives in the evidence to this Report.
5.3 In December 2008, the Department for Children, Schools and Families
(DCSF) published the 2020 Children and Young People’s Workforce
Strategy, 53 setting out the Government’s vision for all those working
with children. Moreover, the Secretary of State for Children, Schools
and Families established the Social Work Task Force (SWTF) to focus
particularly on the roles of those working in frontline social work
services for children and young people. The Workforce Strategy and
the SWTF are very welcome responses to the current challenges in
social work. They demonstrate a recognition that, whilst there have
been significant improvements in some parts of the children’s
workforce, these have focused primarily on universal services,
particularly education, and have not yet reached social workers.

Social workers
5.4 Frontline social workers and social work managers are under an
immense amount of pressure. Low staff morale, poor supervision,
high case-loads, under-resourcing and inadequate training each
contribute to high levels of stress and recruitment and retention
difficulties. Many social workers feel the size of the task in protecting
children and young people from harm is insurmountable and this
increases the risk of harm. Social work and, in particular, child
protection work is felt to be a ‘Cinderella’ service within other parts of
the children’s workforce. It is noticeable that education has received
substantially more investment over the last decade. Public vilification
of social workers has a negative effect on staff and has serious
implications for the effectiveness, status and morale of the children’s
workforce as a whole. There has been a long-term appetite in the

50 UNISON, Still slipping through the net? Frontline staff assess children’s safeguarding progress
(2008)
51 Unite/Community Practitioners’ and Health Visitors’ Association Omnibus Survey, 2008
52 Sally Gillen (available online at www.communitycare.co.uk/Articles/2002/05/23/36528/child-
protection-blues.html)
53 HM Government (DCSF), 2020 Children and Young People’s Workforce Strategy (December 2008)
 Children’s Workforce 45

media to portray social workers in ways that are negative and

undermining. Inevitably, other ways of helping children, young people
and families often look more appealing to staff. However, without
highly motivated and confident social workers the reality is that more
children will be exposed to harm.

A national supply strategy for social work

5.5 The issues outlined above have resulted in a recruitment and retention
crisis within social work. There is a national and local shortage of
qualified social workers able and willing to undertake the skilled
safeguarding and child protection work required. Many authorities are
reliant on agency social workers, despite this being a short-term
solution. Together with the high turnover of permanent staff and use
of staff from abroad, it fails to provide vulnerable children with the
continuity of the same worker with whom they can form a long-term
relationship. Good local leadership will not of itself be enough to
overcome these issues, although it will play a crucial role.

Case study D
Recruitment and retention of social workers
Managers in one local authority wanted to look at opportunities
to improve the recruitment and retention of social workers.
A range of innovative and effective solutions have been found.
A strategy has been drawn up, evaluated and the following key
points have been identified as important in retaining and
recruiting social workers:
●● a clear induction programme for new staff with a strong
emphasis on development;
●● a new ‘consultant’ role within the organisational structure for
experienced social workers to support newly qualified staff,
increasing practitioner confidence, skills and assertiveness, and
leading to increased direct work with children and families;
●● a strong supervision policy where workloads and case
management are regularly discussed and assessed;
●● a new pilot with a local university to sponsor places on training
programmes; and
46 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

●● the creation of a joint safeguarding service bringing together

staff from three previously separate teams (social care,
education and health), emphasising the authority’s commitment
to integrated working, and including an expert-staffed advice
line for professionals.

5.6 DCSF, with support from the SWTF, should develop a strategy to raise
the profile of social work and positively seek to overcome the current
media and public misunderstandings about the important contribution
that social workers make to keeping children safe. It needs to forecast
and plan to meet projections for social workers over future years,
taking into account the complexity and weight of case-loads, and
supervision and training needs. There should be clearer and more
attractive entry routes into social work for those unqualified staff who
would like to progress into qualified social work roles. Building on
work currently being developed by the Children’s Workforce
Development Council (CWDC), there should also be efforts to engage
professionals in mid-career in other sectors to retrain to enter the
social care workforce and reward them for doing so. Further
consideration needs to be given to how best to retain experienced
staff enabling them to continue to be available to work with children
and families on the frontline by making effective use of the advanced
practitioner status to be introduced later this year. This will not be an
easy task or one that comes without a significant financial
commitment, but a comparison should be made with the resources
provided to achieve similar outcomes in the teaching profession, if
safeguarding and child protection services really are to be effective in
keeping children safe.

Remodelling social work

5.7 There are similarities between the current pressure, overload and
dissatisfaction that many social workers feel, and that of the teaching
workforce ten years ago. Case-loads are consistently high, increasing
the risk of harm to children and creating anxiety for social workers.
The introduction of teaching assistants and advanced skills teachers,
protected preparation time and other elements of remodelling have
made great strides in overcoming these issues in education.
 Children’s Workforce 47

5.8 Some similar steps, led by CWDC, are now being taken for social
workers, with the introduction, for example, of the Newly Qualified
Social Worker Status and the development of a career progression
framework for social workers. However, there remains a real need for
a determined and well-resourced national remodelling strategy for
social work. A programme to remodel children’s social work could
include the introduction of multi-skilled teams with shared ownership
of a manageable case-load. Within a team there could be a mix of
junior and more experienced social workers along with administrative
and multi-disciplinary support. There should be a focus on efficient
case management using the skills of all members of the team. This
approach, already used in some areas, ensures continuity of service to
the child and that social workers are not isolated in their contact with
the child and their family, and have others around them with whom
they can discuss concerns and make decisions together or undertake
joint visits. Skilled administrative support also allows social workers to
focus on their areas of expertise, as can other professionals in the
team. An effective remodelling programme will ensure that
experienced and skilled staff are recognised and motivated, using the
role of advanced practitioner due to be introduced later this year, with
the importance of their role reflected through a pay structure that is
comparable to others with similar skills and experience elsewhere in
the children’s workforce. Within this context, practitioners, teams and
individuals should all have a mixed case-load of both child protection
and children in need work. No social worker should handle only the
more complex and emotionally demanding child protection cases.
The case study on page 50 shares the experience of one local
authority that has devised a new arrangement to ensure continuity of
help to the families and to support frontline staff. These are issues
which many authorities will face and will have varied ways of dealing
with.
48 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

Case study E
Remodelling social work
“If the people working with children and their families are not
competent, then the infrastructure to support them will make no
difference or add any value.”
Local authority Deputy Director
It is this starting point which led one local authority to ‘reclaim
social work’. Observing that social work as a profession has
lost it way, lacks confidence, expertise and gravitas, is over-
bureaucratised and risk averse they suggest that whilst assessment
should remain central to planning and decision making, more
time should be spent on direct intervention with families to effect
positive change. In order to achieve this, they state that clear
professional accountability, clinical support and high calibre
practitioners are fundamental.
At the heart of the model is the Social Work Unit (SWU). Under
the leadership of a consultant social worker (CSW), members of
the SWU (a social worker, a children’s practitioner, a family
therapist and a unit co‑ordinator) work to deliver the service.
Key aims of the SWUs are to use systemic approaches and social
learning theory interventions to create change in families.
Families and children want consistency and this approach goes a
long way to securing that. This requires SWUs to be flexible and
responsive in the roles and tasks they undertake.
The CSW has full responsibility for all cases allocated to their SWU.
“If you have excellent social workers, you don’t stop them
practising. That’s why we now have consultant social workers.”
 Children’s Workforce 49

Each family, child and young person is known to each member of

the SWU. Each SWU meets weekly to agree the tasks needed to
be undertaken that week. The families are discussed and tasks are
allocated to members of the SWU according to availability, skill,
and knowledge of and relationship to the family. Direct work is
undertaken by everyone as appropriate (including the CSW).
The SWU is given a high degree of autonomy and is expected to
take responsibility for the decisions made and the actions taken.
All practitioners in the SWUs have delegate authority for some
limited financial spend. It operates as a whole. The CSW line
manages the social worker and children’s practitioner. The
Clinician receives clinical supervision and line management from
the Supervising Clinicians within Family Support. The SWU
co‑ordinators are line managed by administration managers
within each service area.
This is a new paradigm for social work. The SWUs have to have
both a good understanding of evidence-based interventions and
at the same time understand and be able to manage risk. At the
centre of all the work is to focus on the need to protect children
from significant harm.
There is a commitment to creating a culture where good social
work thrives. This means reducing the bureaucratic burdens on
units and creating a new relationship between CSW and
managers.
“No professional social work practitioner or manager gets a job in
this authority without being successful at an interview panel
always chaired by either the deputy director or assistant director.”
In the words of one consultant when talking about a complex
case the Unit had worked with, “I feel the whole family has
benefited … it’s enormously satisfying and professionally
invigorating”.
50 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

Recommendations
The Social Work Task Force should:
●● develop the basis for a national children’s social worker supply
strategy that will address recruitment and retention difficulties,
to be implemented by the Department for Children, Schools
and Families. This should have a particular emphasis on child
protection social workers;
●● work with the Children’s Workforce Development Council and
other partners to implement, on a national basis, clear
progression routes for children’s social workers;
●● develop national guidelines setting out maximum case-loads of
children in need and child protection cases, supported by a
weighting mechanism to reflect the complexity of cases, that
will help plan the workloads of children’s social workers; and
●● develop a strategy for remodelling children’s social work which
delivers shared ownership of cases, administrative support and
multi-disciplinary support to be delivered nationally.
Children’s Trusts should ensure a named, and preferably
co‑located, representative from the police service, community
paediatric specialist and health visitor are active partners within
each children’s social work department.
 Children’s Workforce 51

Social work initial training

5.9 The introduction in 2003 of the degree course in social work is widely
acknowledged to be a great advance in improving social workers’
skills. However, the quality and content of degree courses are not yet
sufficiently well developed and there is no rigorous assessment regime
in place to ensure that standards are being met by providers. The
degree course should ensure social workers are prepared for the
realities of working with children and families who may have complex
needs and parents who, in some cases, may be intentionally deceptive
or manipulative. Social workers themselves do not think that their
training is equipping them to take on the responsibilities for which
they are being trained – two-thirds of newly qualified social workers
felt that the degree prepared them just enough or not at all for their
current role.54
5.10 At the heart of the difficultly in preparing social workers through a
degree course is that, without an opportunity to specialise in child
protection work or even in children’s social work, students are
covering too much ground without learning the skills and knowledge
to support any particular client group well. There are few placements
offered in children’s services and fewer still at the complex end of child
protection or children ‘in need’. It is currently possible to qualify as a
social worker without any experience of child protection, or even of
working within a local authority, and to be holding a full case-load of
child protection cases immediately upon appointment. The current
degree programme should be reformed to allow for specialism after
the first year, with no graduate entering frontline children’s social
work without having completed a specialised degree including a
placement within a frontline statutory children’s social work team,
or having completed further professional development and children’s
social work experience to build on generic training.

54 Children’s Workforce Development Council Research Team, Newly Qualified Social Workers.
A report on consultations with newly qualified social workers, employers and those in higher
education (unpublished preliminary findings)
52 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

“I was astonished … to find that a new graduate is immediately

a qualified social worker and can work unsupervised. If you
compare that with other professions – medicine or dentistry,
optometry, pharmacy, or teaching – they have a period of one or
two years during which you go out on placement and acquire,
under supervision, the general practical ability and experience that
will enable them to practise successfully … If either a doctor or
nurse were going to specialise in work with children, for example,
they would need to undergo accredited specialist training, and
they would have a mark on the register saying they had such
training.”
From an interview with Rosie Varley, chair of the General Social
Care Council, in The Guardian (4 February 2009)

5.11 A specialist children’s social work degree would need to provide

students with an in-depth understanding of child development as well
as more practical skills. Social workers need good observation and
analytical skills in order to be able to understand the nature of the
relationship between a parent and child, to understand signs of non-
compliance, to work alongside a family, and to come to safe and
evidence-based judgements about the best course of action. They
need to develop the emotional resilience to manage the challenges
they will face in dealing with potentially difficult families. They need to
know how to record information clearly, present key case information,
reflect and analyse on what they are seeing, and to communicate it
clearly to colleagues and other professionals. Furthermore, social
workers need a thorough understanding of the legal framework
surrounding safeguarding and child protection. The social work
degree needs to be developed to provide these skills.
 Children’s Workforce 53

Recommendations
The General Social Care Council, together with relevant
government departments, should:
●● work with higher education institutions and employers to raise
the quality and consistency of social work degrees and
strengthen their curriculums to provide high quality practical
skills in children’s social work;
●● work with higher education institutions to reform the current
degree programme towards a system which allows for
specialism in children’s social work, including statutory
children’s social work placements, after the first year; and
●● put in place a comprehensive inspection regime to raise the
quality and consistency of social work degrees across higher
education institutions.

Newly qualified social workers

5.12 Social workers must have guaranteed support and supervision during
their first year to enable them to develop their skills and their
confidence as a professional in a relatively safe learning environment
whilst still having exposure to children in complex and difficult
circumstances. CWDC’s Newly Qualified Social Worker pilot is
currently providing 1,000 new social workers in 90 local authorities
with protected time for training and development and better quality,
more frequent supervision in their first year of practice. 1,000 more
newly qualified social workers will receive this from September.
Working with CWDC, the SWTF should take action to ensure that all
newly qualified social workers receive this level of support.

Continuing professional development (CPD) for

social workers
5.13 This Progress Report has heard much about the complexity and
challenges facing frontline staff working with children and families to
protect children from harm. No two cases are the same and each case
should be considered as a learning opportunity, through which the
social worker develops his or her skills and knowledge base. It is
important to develop a culture of continuous learning and
development as a natural part of social work practice.
54 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

5.14 However, in order to carry out their roles effectively, social workers
and their managers need access to good quality post-qualifying
training. It is particularly important that those working in child
protection regularly refresh their skills and knowledge base, ensuring
they are fully aware of and competent in undertaking evidence-based,
effective assessments and appropriate interventions. There are,
however, shortfalls in CPD and post-qualifying training for social
workers, together with reticence from employers to release and
sponsor staff to take up such opportunities. There is currently no
national framework for CPD. Nor are there clear links between CPD
and career progression. This impacts upon staff morale and their
motivation to remain in post and develop their careers. Training
opportunities across local authorities are varied and locally sourced,
particularly for first line managers. This should be addressed to ensure
social workers have the continuing support to be competent and
confident in their roles and managers are able to provide effective
oversight of casework and provide high-quality supervision.
5.15 As a first step, a post-graduate qualification in safeguarding children
is needed that is practice-based, focusing on the key skills required for
effective working with children and families and protecting children
from harm. All children’s social workers should be expected to
complete this postgraduate qualification as soon as is practicable.
It will need to be funded centrally and with protected study time
made available.

Recommendation
The Department for Children, Schools and Families and the
Department for Innovation, Universities and Skills should introduce
a fully-funded, practice-focused children’s social work
postgraduate qualification for experienced children’s social
workers, with an expectation they will complete the programme
as soon as is practicable.

Qualifications for overseas social workers

5.16 There are relatively high numbers of social workers who were trained
outside the UK with 6,40055 registered with the General Social Care
Council (GSCC) in 2007 (8 per cent of all social work staff

55 Moriarty, Manthorpe, Hussein and Cornes, Staff Shortages and Immigration in the Social Care
Sector (a paper prepared for the Migration Advisory Committee, Kings College London (2008))
 Children’s Workforce 55

registered).56 Their contribution to safeguarding children in the UK is

welcomed and valued with many local authorities relying heavily on
their contribution and praising the training they have received abroad.
Many social workers who qualified overseas take it upon themselves
to ensure they are familiar with the safeguarding framework in the
UK. However, this training must become consistent for every overseas
qualified social worker, as must their English language capability for
the minority for whom English is not their first language. The DCSF,
together with the GSCC and CWDC, and partners, should explore
how this can best be achieved through a national framework of in-
house and external training, leading to a conversion qualification.

Recommendation
The Department for Children, Schools and Families, working with
the Children’s Workforce Development Council, General Social
Care Council and partners should introduce a conversion
qualification and English language test for internationally qualified
children’s social workers that ensures understanding of legislation,
guidance and practice in England. Consideration should be given
to the appropriate length of a compulsory induction period in
a practice setting prior to formal registration as a social worker
in England.

Training across all agencies

5.17 Training for social workers, police, teachers, health visitors, GPs and
paediatricians all have different professional starting points on
engaging with children and young people, governed by the nature
of the service they provide. Yet it is essential that all professionals
working with children have a solid understanding of child
development. All those who work with children need to be able to
identify the signs that suggest a child may be suffering from abuse
or neglect and know what actions to take to safeguard the child’s
welfare. This would include knowing when a child is not developing
as would be expected for their age.

56 Not all of these would go on to practise as social workers and only some would become
children’s social workers
56 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

Recommendation
Children’s Trusts should ensure that all staff who work with
children receive initial training and continuing professional
development which enables them to understand normal child
development and recognise potential signs of abuse or neglect.

5.18 Multi-agency training is important in helping professionals understand

the respective roles and responsibilities and the procedures of each
agency involved in child protection, in developing a joint
understanding of assessment and decision making practices, and in
learning from Serious Case Reviews. However, the scale and quality of
multi-agency training needs to be substantially improved to ensure
that all those organisations who are part of a child’s life, such as early
years providers, schools, youth services, health, and the police, social
workers, paramedics and others who step in when problems arise,
have this understanding.

Recommendation
All Children’s Trusts should have sufficient multi-agency training in
place to create a shared language and understanding of local
referral procedures, assessment, information sharing and decision
making across early years, schools, youth services, health, police
and other services who work to protect children. A named child
protection lead in each setting should receive this training.

5.19 The introduction of the Common Core of Skills and Knowledge57 in

2005 aimed to provide a common language for working with
children. However, following concerns about the extent to which the
Common Core addresses issues of integrated working; working with
families to support vulnerable children and young people; and how
well embedded it is in some parts of the workforce such as the health
sector or the police, the 2020 Children and Young People’s Workforce
Strategy has called for a review, which is welcomed.

Employer and social worker codes of practice

5.20 The GSCC has developed codes of practice for social workers and for
their employers which provide the basis for a national ‘contract’ to
develop the profession. However, it appears that the codes are in need
of updating to be more effective in protecting children. The Code of
57 HM Government, Common Core of Skills and Knowledge for the Children’s Workforce (2005)
 Children’s Workforce 57

Practice for Social Care Workers should be reviewed to ensure the

needs of children are paramount, regardless of whether the social
worker is in adult or children’s services. The employer code provides an
important basis for a national standard for employers, and therefore
should be revised to clarify expectations around accountability, quality
and amounts of supervision, reflective practice and support, and
commitment to staff training and CPD. The employer code should be
made statutory for all employers of social workers.

Recommendation
The General Social Care Council should review the Code of
Practice for Social Workers and the employers’ code ensuring the
needs of children are paramount in both and that the employers’
code provides for clear lines of accountability, quality supervision
and support, and time for reflective practice. The employers’ code
should then be made statutory for all employers of social workers.

Health professionals
5.21 Health visitors play a key role in child protection, particularly for very
young children who are unable to raise the alarm when suffering from
abuse or neglect. The evaluation of 161 Serious Case Reviews58 shows
that 47 per cent of children were under one year of age but only
12 per cent were subject to a child protection plan.59 Those who were
not could have been receiving less intensive support, or may not have
been identified as in need. In this context, the role of health visitors as
a universal service seeing all children in their home environment with
the potential to develop strong relationships with families is crucially
important. A robust health visiting service delivered by highly trained
skilled professionals who are alert to potentially vulnerable children
can save lives.
5.22 Despite this, the number of health visitors has dropped by 10 per cent
in the last three years60 and case-loads are significantly higher than the
recommended 300 families or 400 children,61 with 40 per cent of
health visitors handling case-loads of over 500 children and 20 per

58 Brandon, Marion, Pippa Belderson, Catherine Warren, David Howe, Ruth Gardner, Jane
Dodsworth, Jane Black, Analysing Child Deaths and Serious Injury though Abuse – What can
we Learn? A Biennial Analysis of Serious Case Reviews 2003–05 (HM Government [DCSF], 2008)
59 Ofsted, Analysing Child Deaths and Serious Injury through Abuse: What can we Learn?
A Biennial Analysis of Serious Case Reviews 2003–2005
60 Unite/Community Practitioners’ and Health Visitors’ Association Omnibus Survey, 2008
61 As recommended by the Community Practitioners’ and Health Visitors’ Association
58 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

cent over 1,000 children62. 69.2 per cent of health visitors say that
they no longer have the resources to respond to the needs of the
most vulnerable children.63 Health visitors need time to properly
support and assess children and to be competent and confident in
doing so. There are very real risks to the welfare of children if this does
not happen. The commitment to increase the number of health
visitors in Healthy lives, brighter futures64 is a helpful one but priority
and resources need to be committed to achieving this aim.
5.23 Furthermore, there is confusion about the role of health visitors who
provide a universal service and yet often are called upon to support
families with complex needs. As the case-loads of social workers have
risen there is also concern that health visitors are carrying child
protection issues that once would have been referred on to children’s
social care services. This is both inappropriate and unmanageable for
health visitors and needs to be addressed.

Recommendations
The Department of Health should prioritise its commitment to
promote the recruitment and professional development of health
visitors (made in Healthy lives, brighter futures) by publishing a
national strategy to support and challenge Strategic Health
Authorities to have a sufficient capacity of well trained health
visitors in each area with a clear understanding of their role.
The Department of Health should review the Healthy Child
Programme for 0–5-year-olds to ensure that the role of health
visitors in safeguarding and child protection is prioritised and has
sufficient clarity, and ensure that similar clarity is provided in the
Healthy Child Programme for 5–19-year-olds.

5.24 The engagement of health professionals, particularly GPs in Children’s

Trusts, Local Safeguarding Children Boards, and other multi-agency
forums for safeguarding children is very varied. A common concern
raised during the production of this report is the difficulty in attracting
‘designated’ and ‘named’ health professionals, both in primary and
secondary care, with responsibility for child protection. It appears that
the safeguarding of vulnerable children is often not viewed as a
priority for GPs in some areas. A range of measures has been

62 Unite/Community Practitioners’ and Health Visitors’ Association Omnibus Survey, 2008

63 Unite/Community Practitioners’ and Health Visitors’ Association Omnibus Survey, 2008
64 HM Government, Healthy lives, brighter futures – the strategy for children and young people’s
health (2009)
 Children’s Workforce 59

introduced to support GPs and child health professionals by the

Department of Health, through the Care Services Improvement
Partnership, and by many of the Royal Medical Colleges including the
Royal College of General Practitioners (RCGP) and the Royal College
for Paediatrics and Child Health. These support measures include a
toolkit for GPs developed in partnership with the NSPCC, a secure
website to enable ‘named’ and ‘designated’ professionals to share
practice, the establishment of regional learning networks, and the
piloting of an ‘Influencing for Leadership’ course. However, more
needs to be done to ensure GPs are proactive in doing all they can to
keep children safe. There needs to be suitable rigour in the child
protection training for each GP which enables them to contribute
effectively to a multi-agency approach to the well-being of children.
This should include appropriate referral and information sharing
training.

Recommendation
The Department of Health should promote the statutory duty of
all GP providers to comply with child protection legislation and to
ensure that all individual GPs have the necessary skills and training
to carry out their duties. They should also take further steps to
raise the profile and level of expertise for child protection within
GP practices, for example by working with the Department for
Children, Schools and Families to support joint training
opportunities for GPs and children’s social workers and through
the new practice accreditation scheme being developed by the
Royal College of General Practitioners.

5.25 Evidence to this report suggested that paediatricians are sometimes

reluctant to become involved in child protection work. The
Department of Health should take forward further work with
paediatricians to understand and respond to their concerns and to
enable them to become confident in carrying out their role.
60 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

Recommendation
The Department of Health should work with partners to develop a
national training programme to improve the understanding and
skills of the children’s health workforce (including paediatricians,
midwives, health visitors, GPs and school nurses) to further
support them in dealing with safeguarding and child protection
issues.

Police services
5.26 Concerns about the resourcing of child protection teams exist within
a large number of police forces, particularly since other issues have
taken on greater national significance.65 Although not general, there
is clearly an issue that, in a number of forces, child protection work is
accorded low status and does not attract the most able and
experienced police officers. Some forces that contributed to this report
also described high vacancy rates within child protection teams and
others have seen significant reductions in posts in the years since the
initial response to Victoria Climbié.
5.27 Police services should take immediate action to review the staffing of
child protection teams to ensure they are well resourced to ensure
children’s safety is not compromised. As with other professions, police
officers must receive specialist training to work on child protection
over and above core police training, including that of how best to talk
and listen to children and young people often in distress.

Recommendation
The Home Office should take national action to ensure that police
child protection teams are well resourced and have specialist
training to support them in their important responsibilities.

65 Gardner, Ruth, and Marian Brandon, ‘Child protection: crisis management or learning curve?’ in
Public Policy Research (December 2008 – February 2009)
CHAPTER 6 61

Improvement and challenge

“There are only two lasting bequests we can hope to give our
children. One is roots; the other, wings.”

Hodding Carter66
6.1 There is a clear need for a determined focus on improvement of
practice in child protection across all the agencies that support
children. New ways should be created to share good practice and
learn lessons when things go wrong. Within that context there is a
need to strengthen the inspection processes of each of the services
responsible for the safety of children. Inspection should not be a
stand-alone activity. It should not be only an isolated snapshot.
It must be accompanied by a robust developmental process aimed
at achieving higher standards of service provision.

Inspection
6.2 Since April 2007, Ofsted have had responsibility for inspecting all local
authority children’s services, including safeguarding and child
protection. This responsibility was previously held by the Commission
for Social Care Inspection (CSCI). From 2005 to 2008, Ofsted (along
with CSCI until 2006) undertook Annual Performance Assessments of
local authorities’ children’s services which were largely paper-based
and reported a performance rating for staying safe. Local authorities
said in their evidence to this report that they were often dissatisfied
with the rigour and quality of these assessments. In addition, Ofsted
worked with the Healthcare Commission, Audit Commission and HMI
Probation to undertake Joint Area Reviews (JARs) of children’s services
every three years. JARs looked at the performance of all local partners
in safeguarding children. They involved a short on-site inspection
fieldwork but the evidence to this report was critical about the depth
and breadth of the fieldwork.

66 Hodding Carter (1907–72), US journalist and author

62 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

6.3 On 10 February 2009 Ofsted announced changes to the inspection of

safeguarding from April 2009. In future they will undertake annual
unannounced on-site inspections of the quality and effectiveness of
arrangements for contact, referrals and assessment processes for
safeguarding and child protection work. A full, announced,
inspection will take place every three years (more often where
services are inadequate) to evaluate the impact of the local authority,
partners, and of the Local Safeguarding Children Board (LSCB) and
Children’s Trust in improving safeguarding outcomes. The three-yearly
inspection programme will be carried out by inspectors from Ofsted
and the new Care Quality Commission (that will take on the
responsibilities of the Healthcare Commission on 1 April 2009). HMI
Constabulary is considering its capacity to contribute to this
programme. The inspections will include analysis of local audits of
need and their role in driving services as well as on-site visits to
scrutinise practice, case-loads, training and support for staff,
management oversight, the impact of the LSCB and Children’s Trust,
and the views of children and young people and of stakeholders.
These changes are very much needed and potentially pave the way
for more effective challenge of safeguarding and, particularly, child
protection services.
6.4 Due to the multi-agency nature of child safeguarding and protection
it is vital that other inspectorates follow the lead of Ofsted in
improving the rigour of their inspection of police and health services
for safeguarding and child protection. Inspectorates should also
demonstrate more joint working to prepare and follow up inspections
ensuring that safeguarding services as a whole are understood and
improved.

Recommendation
The Care Quality Commission, HMI Constabulary and HMI
Probation should review the inspection frameworks of their
frontline services to drive improvements in safeguarding and child
protection in a similar way to the new Ofsted framework.

6.5 To be effective and respected in challenging the status quo, any

inspection process needs to be able to demonstrate expert knowledge
and understanding of the subject under consideration. In the past,
weaknesses in some inspection processes have been as a result of lack
of expertise and limited experience in child protection in the key
inspection bodies, most notably within Ofsted. There is a shared view
 Improvement and challenge 63

of those undergoing inspection that Ofsted’s primary expertise lies in

the education field and that, whilst some specialist child protection
and social care inspectors transferred into Ofsted from the CSCI, many
senior inspection managers and experienced inspectors were lost in
the move. This needs to be addressed as a matter of urgency if the
new inspection framework is to be effective.

Recommendation
Ofsted, the Care Quality Commission, HMI Constabulary and HMI
Probation should take immediate action to ensure their staff have
the appropriate skills, expertise and capacity to inspect the
safeguarding and child protection elements of frontline services.
Those Ofsted Inspectors responsible for inspecting child protection
should have direct experience of child protection work.

Serious Case Reviews (SCRs)

6.6 SCRs are an important tool for learning lessons from the death of,
or a serious incident involving, a child. They are now generally well
established and have, in principle, support from all services. However,
the purpose and processes of SCRs can be further developed to
strengthen their impact on keeping children safe from harm.

The purpose of SCRs

6.7 Working Together to Safeguard Children set out the purpose of SCRs67
both in identifying lessons about how professionals and agencies work
together to safeguard and promote the welfare of children, and
ensuring interagency working is improved as a result. Whilst reviewing
lessons for interagency working is important, the evidence to this
report has identified that weaknesses also exist within individual
organisations from which lessons could be learned to protect children
better from harm. To be effective, an SCR must include consideration
of the lessons that can be learned within each of the services involved
in a case, as well as how they cooperate together where there has
been the death or serious harm of a child. This is not intended to
change the purpose of SCRs as a learning exercise or to suggest they
should become involved in blame or disciplinary proceedings. But the
current remit of SCRs as set out in Working Together to Safeguard
Children is too narrow and is at risk of not being sufficiently explicit

67 HM Government, Working Together to Safeguard Children: A guide to interagency working to

safeguard and promote the welfare of children (2006), Paragraph 8.3
64 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

about the role of SCRs in learning lessons for individual organisations

to allow a proper understanding of how children can be better
protected from harm to be developed.

Recommendation
The Department for Children, Schools and Families should revise
Working Together to Safeguard Children so that it is explicit that
the formal purpose of Serious Case Reviews is to learn lessons for
improving individual agencies, as well as for improving multi-
agency working.

Conducting an SCR
6.8 Evidence submitted to this report indicates that the primary purpose
of SCRs as a learning process to protect children more effectively in
the future is in danger of being lost. This is a result both of confusion
about the purpose of SCRs, which are sometimes perceived as holding
individuals or agencies to account, and as a result of the SCR process
itself, which does not currently lend itself to quick, effective reflection
and the sharing of learning following a serious or tragic incident.
6.9 SCR panels have no powers to demand access to documents from
agencies, and are entirely dependent upon the willing cooperation of
all concerned. This presents a real difficulty for SCR panels in gathering
all the information they need to understand a case properly and make
recommendations on how similar tragedies can be avoided in future.
The framework for SCRs needs to be reviewed to ensure that the SCR
panel chairs have access to all of the relevant documents and staff they
need to conduct a thorough and effective learning exercise.

Recommendation
The Department for Children, Schools and Families should revise
the framework for Serious Case Reviews to ensure that the
Serious Case Review panel chair has access to all of the relevant
documents and staff they need to conduct a thorough and
effective learning exercise.

6.10 Concerns have also been raised that the SCR process has become too
focused on the writing of an often long and unwieldy report with
insufficient focus by LSCBs on whether lessons are being learned from
a child’s death or serious injury and whether action plans are
subsequently implemented. This needs to be addressed urgently to
 Improvement and challenge 65

create a more streamlined learning process. Of the 45 SCRs which

Ofsted assessed between April 2007 and March 2008 only 31per cent
were completed within one year.68 The guidance in Working Together
to Safeguard Children that lessons should be implemented as soon as
practicable needs strengthening to encourage LSCBs not to wait until
an SCR is completed before doing so. To this end, there is good
practice that can be adapted from the Metropolitan Police’s Homicide
Task Force and the National Patient Safety Agency‘s Root Cause
Analysis Toolkit.69

Recommendation
The Department for Children, Schools and Families should revise
Working Together to Safeguard Children to ensure Serious Case
Reviews focus on the effective learning of lessons and
implementation of recommendations and the timely introduction
of changes to protect children.

Ofsted evaluation of SCRs

“Ofsted are evaluating SCRs as if they were an academic exercise.
The real skill is in cascading the lessons to be learnt across all the
multi-agency partners.” LSCB Board Member
6.11 Many of those who contributed to this report felt unsure about how
Ofsted were making judgements on SCRs, or were concerned that too
much emphasis was placed on the quality of the written report rather
than on the SCR as an effective learning tool. Ofsted evaluation
should focus on the quality of the process of the review, the adequacy
of learning and change, professional practice, and the quality of
recommendations in protecting children to ensure that they are
actively driving improved outcomes and better safeguarding systems
and this focus should be properly communicated to LSCBs.

68 Ofsted, Learning lessons, taking action: Ofsted’s evaluations of serious case reviews 1 April 2007
to 31 March 2008 (December 2008)
69 These single agency processes are still useful comparators in learning lessons quickly from
serious incidents. The National Patient Safety Agency’s Root Cause Analysis Toolkit can be found
at www.npsa.nhs.uk/nrls/improvingpatientsafety/patient-safety-tools-and-guidance/
rootcauseanalysis/
66 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

Recommendation
Ofsted should focus its evaluation of Serious Case Reviews on the
depth of the learning a review has provided and the quality of
recommendations it has made to protect children.

Case study F
Learning lessons from Serious Case Reviews
One local authority had experienced a number of child deaths and
recognised the importance of learning lessons from each event,
and of noticing trends over a number of SCRs.
The local authority has introduced a number of innovative
methods to help practitioners and managers learn from previous
cases. These have included the facilitation of workshops which
have captured local and national issues and themes arising from
SCRs, and the production of a highly effective CD recorded by six
student social workers featuring the stories of children and young
people who have died. The stories were taken from case material
and told from the child’s own perspective. They are a valuable
though emotionally hard-hitting tool for further understanding
the voices and views of the child, an issue important for all
professionals involved in frontline services. Through these and
other learning events, the local authority is able to evidence
change and improvement through learning lessons and
recognising recurring themes in their own SCRs. The learning is
shared across agencies and is proving beneficial to social workers
and health visitors especially.

The importance of confidentiality

6.12 SCRs inevitably include a great deal of case material that should
remain confidential, not only to protect vulnerable people, but also
because SCRs depend upon the cooperation of witnesses, often in
a highly charged situation. Without this assurance many would be
reluctant to participate in the process, rendering the task worthless.
The future of SCRs depends, to a large degree, on the guarantee of
confidentiality. Full reports should, therefore remain confidential
beyond the immediate partners involved in a case, the relevant
inspectorates, Government Offices and the relevant government
departments.
 Improvement and challenge 67

Executive summaries of SCRs

6.13 The confidentiality of full SCRs makes the provision of a high-quality
executive summary all the more important. Executive summaries
should provide an accurate reflection of all the main points in the full
report, include a copy of the full action plan, and provide the names
of all the SCR panel members so that the public can have confidence
that a senior and multi-agency panel, as well as an independent chair
and independent author, have been in charge of the process.

Recommendation
The Department for Children, Schools and Families should revise
Working Together to Safeguard Children to underline the
importance of a high quality, publicly available executive summary
which accurately represents the full report, contains the action
plan in full, and includes the names of the Serious Case Review
panel members.

When to conduct an SCR

6.14 There have been a number of calls for greater clarity in the guidance
provided in Working Together to Safeguard Children on when an SCR
should be conducted. DCSF data shows that there is considerable
variation in the number of SCRs initiated in each region.70 It is the
conclusion of this report that further guidance on when to instigate
an SCR would not be helpful due to the complexity and variety of
cases for which an SCR may be conducted. However, Government
Offices must continue to take a role in challenging SCR panels and
LSCBs where they think inappropriate decisions have been made
about conducting an SCR. Importantly, they should be certain that the
cost and complexity of carrying out an SCR should not influence the
decision of whether to conduct one. As SCRs are part of a learning
process, the culture should be to encourage the undertaking of an
SCR and no criticism should be made of an LSCB that chooses to carry
out more SCRs. Such a review may also be used when a serious
incident has been avoided to ensure lessons are learned about how to
protect children better in future. There is a statutory requirement for
every local area to have a child death overview panel which will
consider every child death in the area, including those that may or
may not be the result of an unavoidable accident or due to natural
causes. The panel may decide to make a recommendation to the LSCB

70 DCSF, Child Protection Database

68 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

for an individual case to be looked at further by, for example, the

LSCB commissioning an SCR. This may result in more SCRs being
undertaken and further learning about when it is appropriate to
commission an SCR.

Chairing of SCR panels

6.15 In carrying out an SCR it is important that the chairing and writing
arrangements offer adequate scrutiny and challenge to all the
agencies in a local area. For this reason, the chair of an SCR panel
must be independent of all of those local agencies that were, or
potentially could have been, involved in the case. A panel may be
chaired by someone with similar responsibilities in another Children’s
Trust or may be fully independent of statutory services. However, they
will need to be fully prepared for their role in conducting an effective
scrutiny of each aspect of how the agencies responded to the needs
of the child or young person. There should be training for SCR panel
chairs available nationally and Government Offices must take the lead
in ensuring there are enough people within a region who are trained
and able to chair SCRs when the need arises. It is important that
throughout the process, the SCR panel chair and all its members
maintain the principle that the views of all partners are valid and equal
so that appropriate challenge and robust dialogue can take place.

Independent authors
6.16 Similarly, a greater emphasis is needed on building a cohort of people
skilled and able to write effective SCR reports. Many authorities have
had difficulties in recruiting good quality authors and this has led to
both delays and poor quality reports. SCR authors must be
independent of those local agencies that were, or potentially could
have been, involved in the case. An SCR author may or may not be
the same person who chairs the SCR panel. The decision should be
made according to the individual needs of the case in question.
Training should be made available nationally for SCR authors and
Government Offices should take the lead in ensuring they have
enough high-quality trained authors in their region. It will remain the
responsibility of the LSCB to take up references on those who have
completed the training before appointing an independent author.
 Improvement and challenge 69

Recommendations
Local Safeguarding Children Boards should ensure all Serious Case
Review panel chairs and Serious Case Review overview authors are
independent of the Local Safeguarding Children Board and all
services involved in the case and that arrangements for the
Serious Case Review offer sufficient scrutiny and challenge.
All Serious Case Review panel chairs and authors must complete
a training programme provided by the Department for Children,
Schools and Families that supports them in their role in
undertaking Serious Case Reviews that have a real impact on
learning and improvement.
Government Offices must ensure that there are enough trained
Serious Case Review panel chairs and authors available within
their region.

Sharing SCRs with Inspectorates

6.17 To ensure that the learning from SCRs is driving safer systems and
processes for children and young people, Ofsted, the Care Quality
Commission, HMI Constabulary and HMI Probation (when
appropriate) should have access to the full reports and should use
them in the preparation for local inspections of children’s services,
health, police and probation where appropriate. This will ensure that
the consequences of an inadequate SCR are felt by all partner
agencies and not just the local authority. It should ensure also that
inspectorates of the other agencies are able to assess whether the
recommendations have been implemented.

Sharing learning from SCRs

6.18 Learning from SCRs needs to be shared quickly so that lessons are
learned across different areas and agencies as quickly as possible. This
should include the timely sharing of the executive summaries of SCR
reports between local authorities, with the Association of Chief Police
Officers, with Primary Care Trusts and with Strategic Health
Authorities. In addition to this, Ofsted should produce more regular
reports bringing together the lessons from SCR reports as well as
drawing upon practice evaluated as part of their inspection function.
70 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

Recommendations
Ofsted should:
●● share full Serious Case Review reports with HMI Constabulary,
the Care Quality Commission, and HMI Probation (as
appropriate) to enable all four inspectorates to assess the
implementation of action plans when conducting frontline
inspections;
●● share Serious Case Review executive summaries with the
Association of Chief Police Officers, Primary Care Trusts and
Strategic Health Authorities to promote learning; and
●● produce more regular reports, at six-monthly intervals, which
summarise the lessons from Serious Case Reviews.

The role for a National Safeguarding Delivery Unit

6.19 In addition to the challenge that inspection systems provide and the
learning that is shared when there is a tragic failure to protect a child
from harm, there must be a continuing drive for improvement in the
protection of children and young people that ensures the systems and
practices become the best in the world at keeping children safe. It is
clear that within the existing landscape every organisation has only a
partial view. There is none that has the breadth of vision across
frontline agencies responsible for keeping children safe from harm,
or the authority to achieve improvements across all the services with
responsibility for safeguarding and promoting the welfare of children.
6.20 Therefore a National Safeguarding Delivery Unit should be established
that can work flexibly to take urgent action to challenge and support
local services to improve provision for children and young people. The
unit does not have to be a permanent presence in the landscape of
safeguarding, but should be an authorative, agile organisation with an
initial remit for three years, and sufficient programme resources, to
create a real and early impact across children’s services, health and
police services, and in every Children’s Trust across the country.
6.21 In order to have the authority to drive such changes the National
Safeguarding Delivery Unit should report on progress every three
months directly to the Cabinet Sub-Committee on Families, Children
and Young People. In addition it should provide Parliament with an
annual report on progress in improving the effectiveness and
efficiency of child protection systems in this country.
 Improvement and challenge 71

6.22 The unit should be led by someone with the expertise, authority and
ambition to drive change in safeguarding services. It should draw
upon expertise from practising senior staff with frontline experience in
safeguarding across children’s services, police and health and other
partners, and with experience of bringing about large-scale change in
performance and culture. It should do this through secondments and
project groups, ensuring that the most up-to-date expertise always
informs its work.

Recommendation
The remit of the National Safeguarding Delivery Unit should
include:
●● working with the Cabinet Sub-Committee on Families, Children
and Young People to set and publish challenging timescales for
the implementation of recommendations in this report;
●● challenging and supporting every Children’s Trust in the country
to implement recommendations within the agreed timescales,
ensuring improvements are made in leadership, staffing,
training, supervision and practice across all services;
●● raising the profile of safeguarding and child protection across
children’s services, health and police;
●● supporting the development of effective national priorities on
safeguarding for all frontline services, and the development of
local performance management to drive these priorities;
●● leading a change in culture across frontline services that enables
them to work more effectively to protect children;
●● having regional representation with expertise on safeguarding
and child protection that builds supportive advisory
relationships with Children’s Trusts to drive improved outcomes
for children and young people;
●● working with existing organisations to create a shared evidence
base about effective practice including evidence-based
programmes, early intervention and preventative services;
72 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

●● supporting the implementation of the recommendations of

Serious Case Reviews in partnership with Government Offices
and Ofsted, and put in place systems to learn the lessons at
local, regional and national level;
●● gathering best practice on referral and assessment systems for
children affected by domestic violence, adult mental health
problems, and drugs and alcohol misuse, and provide advice to
local authorities, health and police on implementing robust
arrangements nationally; and
●● commissioning training on child protection and safeguarding
and on leading these services effectively for all senior political
leaders and service managers across those frontline services
responsible for safeguarding and child protection.
CHAPTER 7 73

Organisation and Finance

“My first social worker was lovely, she was kind... I think she
liked me”

Girl, 1271

Local Safeguarding Children Boards

7.1 Despite Local Safeguarding Children Boards (LSCBs) being relatively
new, they are already having a positive impact on services for
protecting children. Ofsted published 21 Joint Area Reviews of
children’s services between April to June 2008 and in 18 of those they
reported that LSCBs are already making a significant positive
difference to their local services. In many areas, LSCBs provide a vital
role in building stronger partnership relationships, and in providing a
central point of focus within local areas for safeguarding children.
However, it is inevitable that, being newly developed, there is greater
potential to drive improvements, particularly around an increase in
their ability to challenge the standard of practice and in strategic
leadership.
7.2 There is no single model for how an LSCB operates. The Department
for Children, Schools and Families (DCSF) and the Department of
Health have commissioned research from the Loughborough
University into the structures and working arrangements of LSCBs.72
Early results demonstrate that their scope, structures, membership,
resourcing, and ways of working vary considerably from area to area
with some models likely to be more effective than others. Despite the
positive feedback about LSCBs from contributors to this report, it is
evident that many LSCBs would welcome further advice on these
issues to help them maximise their impact on outcomes for children.
The interim findings of the research from Loughborough University
will be published in spring 2009 and it will greatly assist in

71 Quotation taken from findings of research with children undertaken by 11 Million in January
2009 specifically for this report
72 Publication forthcoming
74 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

understanding the differences in practice emerging in LSCBs. This

should be used to provide further guidance to local areas to assist
them making the arrangements for their LSCB as effective as possible.

Recommendation
The Department for Children, Schools and Families must provide
further guidance to Local Safeguarding Children Boards on how
to operate as effectively as possible following the publication of
the Loughborough University research on Local Safeguarding
Children Boards later this year.

7.3 Whilst recognising the value of local flexibility, there must be a clear
distinction between the roles and responsibilities between LSCBs and
Children’s Trusts to ensure appropriate challenge, scrutiny and
impartiality. Where the Director for Children’s Services (DCS) chairs the
LSCB they must not also chair the Children’s Trust. Where chairs are
independent of the local authority they must be sufficiently
experienced in statutory safeguarding and child protection services
and should have access to training and support to enable them to
carry out their role effectively. To support the role of the LSCB chair
in challenging the work of the Children’s Trust, it is important that the
chair is selected with the agreement of a group of partners
representing the key services involved in safeguarding and child
protection locally and should not be removed without consultation
with those partners.

Recommendations
The Children’s Trust and the Local Safeguarding Children Board
should not be chaired by the same person. The Local Safeguarding
Children Board chair should be selected with the agreement of a
group of multi-agency partners and should have access to training
to support them in their role.
Local Safeguarding Children Boards should include membership
from the senior decision makers from all safeguarding partners,
who should attend regularly and be fully involved as equal
partners in Local Safeguarding Children Board decision making.
 Organisation and Finance 75

7.4 It is important that there is a strong relationship between the LSCB

and the Children’s Trust. Ultimately it is the Children’s Trust that is
responsible for improving the well-being of children in the area across
all five Every Child Matters outcomes, including keeping children safe.
The responsibilities of the LSCB, in ensuring that the multi-agency
partners in each local area are co-operating to safeguard and promote
the welfare of children effectively, are a fundamental part of the
overarching responsibilities held by the Children’s Trust. The LSCB
should report to the Children’s Trust on the effectiveness of
safeguarding and promoting the welfare of children and should
publish a report on improving outcomes for children on an annual
basis. Their report, and regular dialogue between the Children’s Trust
and the LSCB, should demonstrate that all the functions of both the
LSCB and the Children’s Trust as set out in Working Together are being
effectively discharged. This must include effective policies and
procedures to keep children safe, including the policies and
procedures for the safe recruitment of frontline staff, ensuring staff
receive suitable training, and commissioning Serious Case Reviews
when appropriate. The commitment by Ofsted to inspect the impact
of LSCBs on outcomes for children from April 2009 is very welcome.

Recommendation
Local Safeguarding Children Boards should report to the Children’s
Trust Board and publish an annual report on the effectiveness of
safeguarding in the local area. Local Safeguarding Children Boards
should provide robust challenge to the work of the Children’s
Trust and its partners in order to ensure that the right systems and
quality of services and practice are in place so that children are
properly safeguarded.

Funding safeguarding and child protection

7.5 Local authority expenditure on children’s social care has increased
greatly in recent years, from £2.9 billion in 2000/01 to £5.5 billion in
2007/08.73 This is combined with significant increases in funding for
preventative help and support for children and young people in the
form of children’s centres, extended schools, targeted youth support
and family and parenting support, which are indicative of the
Government’s commitment. However, there is a danger that these

73 NHS Information Centre, Personal Social Services Expenditure and Unit Costs: England 2006/07
(available online at www.ic.nhs.uk/statistics-and-data-collections/social-care/adult-social-care-
information/personal-social-services-expenditure-and-unit-costs:-england-2006-07)
76 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

worthwhile initiatives have drawn resources away from the challenges

of child protection. Protecting children from harm demands skill,
determination and, quite often, courage. It is a vitally important work
that deserves our full support.
7.6 It is imperative that those making financial decisions on the
safeguarding of children at national and local level accurately plan
adequate provision around real need and risk factors, rather than
historic spending or even numbers of children who are the subject of
child protection plans. In doing so, they should ensure that sufficient
resources are in place to support early intervention and preventative
services in addition to ensuring child protection work is properly
resourced. These two very critical functions of any children’s services
department should not be in competition for resources. The Children’s
Trust should also have responsibility in understanding how the
budgets of other agencies support safeguarding and child protection,
and the benefits of pooling resources to provide maximum effect.
7.7 There is particular pressure on safeguarding budgets as a result of
funding arrangements for local authorities. Whilst 82 per cent of
schools funding is provided through the Dedicated Schools Grant,74
a ring-fenced grant, finance allocated for safeguarding children is not
made through a specific protected grant. So there is no guarantee
that funding provided by government for the purposes of keeping
children safe from harm, and improving their well-being is used for
these purposes. The lack of protection around budgets for
safeguarding children has also left them at risk from the pressure
upon councils to deliver efficiency savings under the 2004 Gershon
Review of Public Sector Efficiency.75 The Government should therefore
take decisive action to protect budgets for safeguarding children,
thereby ensuring consistent appropriate levels of investment across
England in both early intervention and statutory child protection
services.

74 Figure obtained from the Department for Children, Schools and Families
75 Gershon, Sir Peter, Releasing resources for the frontline: Independent Review of Public Sector
Efficiency (HM Treasury, 2004)
 Organisation and Finance 77

Recommendations
The Department for Children, Schools and Families, the
Department of Health, and the Home Office, together with
HM Treasury, must ensure children’s services, police and health
services have protected budgets for the staffing and training for
child protection services.
The Department for Children, Schools and Families must
sufficiently resource children’s services to ensure that early
intervention and preventative services have capacity to respond
to all children and families identified as vulnerable or ‘in need’.
A national annual report should be published reviewing
safeguarding and child protection spend against assessed needs
of children across the partners in each Children’s Trust.
78 CHAPTER 8

Legal

“Every child should be listened to, no matter how difficult they

are to talk to.”

Girl, 1576

Understanding the law

8.1 In this country there is a comprehensive legislative framework for
protecting children and keeping them safe from harm. The Children
Act 1989 reformed the law and was “the most comprehensive and far
reaching reform of child law”.77 The Children Act 2004 introduced a
statutory duty on local authorities and their partner agencies to
cooperate to improve the well-being of children and embedded the
five Every Child Matters outcomes in law. Further legislative change is
not what is needed to protect children. However, it is vital that all
professionals with responsibility for the welfare of children fully
understand the legislative framework in relation to safeguarding and
child protection, and have a clear understanding of their
responsibilities in the process. This includes ensuring that legal advisers
within a local authority receive high-quality initial training and
continuing professional development in this area of law.

Who makes a care order?

8.2 It is for the local authority to decide whether they should take action
to safeguard and promote the child’s welfare such as applying for a
care order. However, it is for the court to decide whether the threshold
criteria are met and a care order should be made with respect to the
child. As Baroness Hale of Richmond said in Re B (A Minor) (AP)
“It is to confuse the role of the local authority, in assessing and
managing risk, in planning for the child, and deciding what action to
initiate, with the role of the court in deciding where the truth lies and

76 Quotation taken from findings of research with children undertaken by 11 Million in January
2009 specifically for this report.
77 Per Lord Mackay Children Bill (Hansard, H.L. Vol. 502, col. 488; 6 December 1988)
 Legal 79

what the legal consequences should be. I do not under-estimate the

difficulty of deciding where the truth lies but that is what the courts
are for.”

Pre-proceedings – the role of the local authority

8.3 New guidance for local authorities was issued in April 200878 that sets
out the processes to be followed in making an application for a care
or supervision order. It is essential that the local authority can put the
evidence on which their decision to make the application is based
before the court. This is the reason for the pre-proceedings checklist.
Good preparation enables a case to proceed more quickly and to
reach a permanent solution for the child. It is essential that the court
is well-informed about the work that has taken place with families.
The evidence should demonstrate that the parents understand the
concerns that have been raised, the objectives and goals of any
intervention, and the action taken by parents and the local authority
and when such actions were reviewed.
8.4 However, whilst it is important that the correct documentation is in
place for each case, the local authority should not delay making an
application because of paperwork considerations if there is concern
for a child that requires swift action in order to safeguard their
welfare.

Public Law Outline

8.5 In April 2008 the Public Law Outline (PLO), a new approach to case
management, was introduced to reduce delay in care proceedings. It is
too soon to be clear about the impact of the introduction of the PLO,
and in particular whether or not it has increased workloads and added
to delays in the process. There is currently conflicting evidence, for
instance, whilst a number of contributions to this report raised
concerns about the impact of the PLO, in London, the number of care
proceedings cases being completed in under 40 weeks in care centres
has risen from 22 per cent to 36 per cent when comparing the data
for the quarter before the introduction of the PLO with the latest data
following its implementation.79

78 The Children Act 1989: Guidance and Regulations: Volume 1: Court Orders
79 From June 2007, the draft PLO was tested in ten ‘initiative’ areas selected by the President of
the Family Division. In autumn 2007 the President sought feedback from Designated Family
Judges in the initiative areas about how the draft PLO was operating. The information and
experiences from these areas and a consultation (between June and September 2008) helped to
inform the final version of the PLO
80 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

Court proceedings
8.6 A number of social workers and other professionals struggle with the
adversarial nature of court proceedings. Appearing in court can be an
intimidating experience for social workers and other professionals, and
managing this alongside a continuing relationship with a family is
challenging. It is therefore important that all staff are adequately
trained before going to court. This should be part of both specialist
child protection training and continuing professional development.

Court case delays

8.7 On average care proceedings take 45 weeks in the Family Proceedings
courts and 56 weeks in County and High Courts.80 It is clear that for
many children the length of delay in a court case is unacceptable.
Research shows there are a number of possible reasons for delays,
including, for example, delays in completing reports, the need to
balance the case-loads of children’s guardians over time, the need to
explore and test family placements, and delays in obtaining expert
evidence. 81 The view of the Judiciary is that in the vast majority of
cases the expertise of the professionals already involved with the child
should be sufficient expertise and a national expert is rarely required
to add weight to a case.
8.8 The Ministry of Justice needs to take immediate action to address the
length of delays in care proceedings to ensure that it is delivering its
commitment to meet the timetable for the child. The aim to have a
case progression function in all courts will help ensure that courts are
used most effectively. In addition to this, listing arrangements of
hearings should be more effectively business managed to ensure that
the time of all staff involved in family court proceedings is used most
effectively. Particular thought should be given to the use of expert
witnesses to ensure they are used only when appropriate and do not
delay proceedings unnecessarily.

80 Family Court, County and High Courts 2008/09 provisional data, Ministry of Justice, England
and Wales. Notes:
(1) Family Court data is from Family Case Tracker and FamilyMan. County Court and High
Court data is from FamilyMan.
(2) Figures are for April to September 2008
(3) Care and supervision orders are included and are counted by child for Family Court figures
and by order for County Court and High Court.
81 Masson, Judith, Julia Pearce and Kay Bader, Care profiling study (Ministry of Justice, March
2008): references the three studies as Booth, 1996; Lord Chancellor’s Department, 2002; Finch,
2004
 Legal 81

Court fees
8.9 Where a local authority intervenes in the interests of protecting a
child, it is clearly inappropriate that court fees might be a factor in
that decision. These matters must be handled with very great care and
in the interests of the child. Placing a child in the care of the local
authority is a serious step, and local authorities should be encouraged
to bring cases to court where they believe a care order may be
necessary to safeguard the child. A local authority’s role in
safeguarding children is of vital importance, and no barrier, however
small, should stand in the way of local authorities exercising this
function.
8.10 It is of concern that the need to pay a fee might sometimes present a
barrier that could influence a local authority’s decision as to whether
or not to commence care proceedings, despite the fact that they are
very small in comparison to the overall costs of obtaining a care order.
It is likely that a large proportion of the reduction in care applications
in spring 2008 was as a result of the introduction of the PLO, as local
authorities familiarised themselves with the new guidelines. It is also
clear that the Government did not take the decision to increase these
court fees lightly and it was helpful, to an extent, that funding was
transferred from the Ministry of Justice to local authorities in
recognition of the increased fees. However, if, even in one case, a
local authority is deterred in taking action, that is one case too many.
8.11 Given the level of concern expressed about this issue, it may well be
that abolition of fees altogether in these cases would be the safest
course. For this reason, the Ministry of Justice should undertake to
hold an independent review of the impact of the fees in the coming
months. Unless this review provides incontrovertible evidence that the
fees were not acting as a deterrent, the fees should then be abolished
for the financial year 2010/11 and the ensuing years, with the funding
transferred from the local government settlement to the Ministry of
Justice.
82 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

Recommendations
The Ministry of Justice should:
●● lead on the establishment of a system-wide target that lays
responsibility on all participants in the care proceedings system
to reduce damaging delays in the time it takes to progress care
cases where these delays are not in the interests of the child;
and
●● appoint an independent person to undertake a review of the
impact of court fees in the coming months. In the absence of
incontrovertible evidence that the fees had not acted as a
deterrent, they should then be abolished from 2010/11
onwards.
CHAPTER 9 83

COMPLETE LIST OF RECOMMENDATIONS

1. The Home Secretary and the Secretaries of State for Children, Schools
and Families, Health, and Justice must collaborate in the setting of
explicit strategic priorities for the protection of children and young
people and reflect these in the priorities of frontline services.
2. A National Safeguarding Delivery Unit be established to report directly
to the Cabinet Sub-Committee on Families, Children and Young
People. It should have a remit that includes:
●● working with the Cabinet Sub-Committee on Families, Children and
Young People to set and publish challenging timescales for the
implementation of recommendations in this report;
●● challenging and supporting every Children’s Trust in the country to
implement recommendations within the agreed timescales,
ensuring improvements are made in leadership, staffing, training,
supervision and practice across all services;
●● raising the profile of safeguarding and child protection across
children’s services, health and police;
●● supporting the development of effective national priorities on
safeguarding for all frontline services, and the development of local
performance management to drive these priorities;
●● leading a change in culture across frontline services that enables
them to work more effectively to protect children;
●● having regional representation with expertise on safeguarding and
child protection that builds supportive advisory relationships with
Children’s Trusts to drive improved outcomes for children and young
people;
●● working with existing organisations to create a shared evidence
base about effective practice including evidence-based
programmes, early intervention and preventative services;
84 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

●● supporting the implementation of the recommendations of Serious

Case Reviews in partnership with Government Offices and Ofsted,
and put in place systems to learn the lessons at local, regional and
national level;
●● gathering best practice on referral and assessment systems for
children affected by domestic violence, adult mental health
problems, and drugs and alcohol misuse, and provide advice
to local authorities, health and police on implementing robust
arrangements nationally; and
●● commissioning training on child protection and safeguarding and
on leading these services effectively for all senior political leaders
and service managers across those frontline services responsible for
safeguarding and child protection.

Leadership and accountability

3. The Cabinet Sub-Committee on Families, Children and Young People
should ensure that all government departments that impact on the
safety of children take action to create a comprehensive approach to
children through national strategies, the organisation of their central
services, and the models they promote for the delivery of local
services. This work should focus initially on changes to improve the
child-focus of services delivered by the Department of Health, Ministry
of Justice and Home Office.
4. The Government should introduce new statutory targets for
safeguarding and child protection alongside the existing statutory
attainment and early years targets as quickly as possible. The National
Indicator Set should be revised with new national indicators for
safeguarding and child protection developed for inclusion in Local
Area Agreements for the next Comprehensive Spending Review.
5. The Department of Health must clarify and strengthen the
responsibilities of Strategic Health Authorities for the performance
management of Primary Care Trusts on safeguarding and child
protection. Formalised and explicit performance indicators should be
introduced for Primary Care Trusts.
6. Directors of Children’s Services, Chief Executives of Primary Care
Trusts, Police Area Commanders and other senior service managers
must regularly review all points of referral where concerns about a
child’s safety are received to ensure they are sound in terms of the
quality of risk assessments, decision making, onward referrals and
multi-agency working.
 complete list of recommendations 85

7. All Directors of Children’s Services who do not have direct experience

or background in safeguarding and child protection must appoint a
senior manager within their team with the necessary skills and
experience.
8. The Department for Children, Schools and Families should organise
regular training on safeguarding and child protection and on effective
leadership for all senior political leaders and managers across frontline
services.
9. Every Children’s Trust should ensure that the needs assessment that
informs their Children and Young People’s Plan regularly reviews the
needs of all children and young people in their area, paying particular
attention to the general need of children and those in need of
protection. The National Safeguarding Delivery Unit should support
Children’s Trusts with this work. Government Offices should
specifically monitor and challenge Children’s Trusts on the quality of
this analysis.

Support for children

10. Ofsted should revise the inspection and improvement regime for
schools giving greater prominence to how well schools are fulfilling
their responsibilities for child protection.
11. The Department for Children, Schools and Families should revise
Working Together to Safeguard Children to set out clear expectations
at all points where concerns about a child’s safety are received,
ensuring intake/duty teams have sufficient training and expertise to
take referrals and that staff have immediate, on-site support available
from an experienced social worker. Local authorities should take
appropriate action to implement these changes.
12. The Department of Health and the Department for Children, Schools
and Families must strengthen current guidance and put in place the
systems and training so that staff in Accident and Emergency
departments are able to tell if a child has recently presented at any
Accident and Emergency department and if a child is the subject of a
Child Protection Plan. If there is any cause for concern, staff must act
accordingly, contacting other professionals, conducting further
medical examinations of the child as appropriate and necessary, and
ensuring no child is discharged whilst concerns for their safety or
well-being remain.
13. Children’s Trusts must ensure that all assessments of need for children
and their families include evidence from all the professionals involved
86 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

in their lives, take account of case histories and significant events

(including previous assessments) and above all must include direct
contact with the child.
14. Local authorities must ensure that ‘Children in Need’, as defined by
Section 17 of the Children Act 1989, have early access to effective
specialist services and support to meet their needs.
15. The Social Work Task Force should establish guidelines on guaranteed
supervision time for social workers that may vary depending on
experience.
16. The Department for Children, Schools and Families should revise
Working Together to Safeguard Children to set out the elements of
high quality supervision focused on case planning, constructive
challenge and professional development.
17. The Department for Children, Schools and Families should undertake
a feasibility study with a view to rolling out a single national
Integrated Children’s System better able to address the concerns
identified in this report, or find alternative ways to assert stronger
leadership over the local systems and their providers. This study should
be completed within six months of this report.
18. Whether or not a national system is introduced, the Department for
Children, Schools and Families should take steps to improve the utility
of the Integrated Children’s System, in consultation with social
workers and their managers, to be effective in supporting them in
their role and their contact with children and families, partners,
services and courts, and to ensure appropriate transfer of essential
information across organisational boundaries.

Interagency working
19. The Department for Children, Schools and Families must strengthen
Working Together to Safeguard Children, and Children’s Trusts must
take appropriate action to ensure:
●● all referrals to children’s services from other professionals lead to an
initial assessment, including direct involvement with the child or
young person and their family, and the direct engagement with,
and feedback to, the referring professional;
 complete list of recommendations 87

●● core group meetings, reviews and casework decisions include all

the professionals involved with the child, particularly police, health,
youth services and education colleagues. Records must be kept
which must include the written views of those who cannot make
such meetings; and
●● formal procedures are in place for managing a conflict of opinions
between professionals from different services over the safety of a
child.
20. All police, probation, adult mental health and adult drug and alcohol
services should have well understood referral processes which
prioritise the protection and well-being of children. These should
include automatic referral where domestic violence or drug or alcohol
abuse may put a child at risk of abuse or neglect.
21. The National Safeguarding Delivery Unit should urgently develop
guidance on referral and assessment systems for children affected by
domestic violence, adult mental health problems, and drugs and
alcohol misuse using current best practice. This should be shared with
local authorities, health and police with an expectation that the
assessment of risk and level of support given to such children will
improve quickly and significantly in every Children’s Trust.
22. The Department for Children, Schools and Families should establish
statutory representation on Local Safeguarding Children Boards from
schools, adult mental health and adult drug and alcohol services.
23. Every Children’s Trust should assure themselves that partners
consistently apply the Information Sharing Guidance published by the
Department for Children, Schools and Families and Department for
Communities and Local Government to protect children.

Children’s workforce
24. The Social Work Task Force should:
●● develop the basis for a national children’s social worker supply
strategy that will address recruitment and retention difficulties,
to be implemented by the Department for Children, Schools and
Families. This should have a particular emphasis on child protection
social workers;
●● work with the Children’s Workforce Development Council and
other partners to implement, on a national basis, clear progression
routes for children’s social workers;
88 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

●● develop national guidelines setting out maximum case-loads of

children in need and child protection cases, supported by a
weighting mechanism to reflect the complexity of cases, that will
help plan the workloads of children’s social workers; and
●● develop a strategy for remodelling children’s social work which
delivers shared ownership of cases, administrative support and
multi-disciplinary support to be delivered nationally.
25. Children’s Trusts should ensure a named, and preferably co-located,
representative from the police service, community paediatric specialist
and health visitor are active partners within each children’s social work
department.
26. The General Social Care Council, together with relevant government
departments, should:
●● work with higher education institutions and employers to raise the
quality and consistency of social work degrees and strengthen their
curriculums to provide high quality practical skills in children’s social
work;
●● work with higher education institutions to reform the current
degree programme towards a system which allows for specialism in
children’s social work, including statutory children’s social work
placements, after the first year; and
●● put in place a comprehensive inspection regime to raise the quality
and consistency of social work degrees across higher education
institutions.
27. The Department for Children, Schools and Families and the
Department for Innovation, Universities and Skills should introduce a
fully-funded, practice-focused children’s social work postgraduate
qualification for experienced children’s social workers, with an
expectation they will complete the programme as soon as is
practicable.
28. The Department for Children, Schools and Families, working with the
Children’s Workforce Development Council, General Social Care
Council and partners should introduce a conversion qualification and
English language test for internationally qualified children’s social
workers that ensures understanding of legislation, guidance and
practice in England. Consideration should be given to the appropriate
length of a compulsory induction period in a practice setting prior to
formal registration as a social worker in England.
 complete list of recommendations 89

29. Children’s Trusts should ensure that all staff who work with children
receive initial training and continuing professional development which
enables them to understand normal child development and recognise
potential signs of abuse or neglect.
30. All Children’s Trusts should have sufficient multi-agency training in
place to create a shared language and understanding of local referral
procedures, assessment, information sharing and decision making
across early years, schools, youth services, health, police and other
services who work to protect children. A named child protection lead
in each setting should receive this training.
31. The General Social Care Council should review the Code of Practice
for Social Workers and the employers’ code ensuring the needs of
children are paramount in both and that the employers’ code provides
for clear lines of accountability, quality supervision and support, and
time for reflective practice. The employers’ code should then be made
statutory for all employers of social workers.
32. The Department of Health should prioritise its commitment to
promote the recruitment and professional development of health
visitors (made in Healthy lives, brighter futures) by publishing a
national strategy to support and challenge Strategic Health Authorities
to have a sufficient capacity of well trained health visitors in each area
with a clear understanding of their role.
33. The Department of Health should review the Healthy Child
Programme for 0–5-year-olds to ensure that the role of health visitors
in safeguarding and child protection is prioritised and has sufficient
clarity, and ensure that similar clarity is provided in the Healthy Child
Programme for 5–19-year-olds.
34. The Department of Health should promote the statutory duty of all GP
providers to comply with child protection legislation and to ensure
that all individual GPs have the necessary skills and training to carry
out their duties. They should also take further steps to raise the profile
and level of expertise for child protection within GP practices, for
example by working with the Department for Children, Schools and
Families to support joint training opportunities for GPs and children’s
social workers and through the new practice accreditation scheme
being developed by the Royal College of General Practitioners.
35. The Department of Health should work with partners to develop a
national training programme to improve the understanding and skills
of the children’s health workforce (including paediatricians, midwives,
90 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

health visitors, GPs and school nurses) to further support them in

dealing with safeguarding and child protection issues.
36. The Home Office should take national action to ensure that police
child protection teams are well resourced and have specialist training
to support them in their important responsibilities.

Improvement and challenge

37. The Care Quality Commission, HMI Constabulary and HMI Probation
should review the inspection frameworks of their frontline services to
drive improvements in safeguarding and child protection in a similar
way to the new Ofsted framework
38. Ofsted, the Care Quality Commission, HMI Constabulary and HMI
Probation should take immediate action to ensure their staff have the
appropriate skills, expertise and capacity to inspect the safeguarding
and child protection elements of frontline services. Those Ofsted
Inspectors responsible for inspecting child protection should have
direct experience of child protection work.
39. The Department for Children, Schools and Families should revise
Working Together to Safeguard Children so that it is explicit that the
formal purpose of Serious Case Reviews is to learn lessons for
improving individual agencies, as well as for improving multi-agency
working.
40. The Department for Children, Schools and Families should revise the
framework for Serious Case Reviews to ensure that the Serious Case
Review panel chair has access to all of the relevant documents and
staff they need to conduct a thorough and effective learning exercise.
41. The Department for Children, Schools and Families should revise
Working Together to Safeguard Children to ensure Serious Case
Reviews focus on the effective learning of lessons and implementation
of recommendations and the timely introduction of changes to protect
children.
42. Ofsted should focus its evaluation of Serious Case Reviews on the
depth of the learning a review has provided and the quality of
recommendations it has made to protect children.
43. The Department for Children, Schools and Families should revise
Working Together to Safeguard Children to underline the importance
of a high quality, publicly available executive summary which
accurately represents the full report, contains the action plan in full,
and includes the names of the Serious Case Review panel members.
 complete list of recommendations 91

44. Local Safeguarding Children Boards should ensure all Serious Case
Review panel chairs and Serious Case Review overview authors are
independent of the Local Safeguarding Children Board and all services
involved in the case and that arrangements for the Serious Case
Review offer sufficient scrutiny and challenge.
45. All Serious Case Review panel chairs and authors must complete a
training programme provided by the Department for Children, Schools
and Families that supports them in their role in undertaking Serious
Case Reviews that have a real impact on learning and improvement.
46. Government Offices must ensure that there are enough trained
Serious Case Review panel chairs and authors available within their
region.
47. Ofsted should share full Serious Case Review reports with HMI
Constabulary, the Care Quality Commission, and HMI Probation
(as appropriate) to enable all four inspectorates to assess the
implementation of action plans when conducting frontline
inspections.
48. Ofsted should share Serious Case Review executive summaries with
the Association of Chief Police Officers, Primary Care Trusts and
Strategic Health Authorities to promote learning.
49. Ofsted should produce more regular reports, at six-monthly intervals,
which summarise the lessons from Serious Case Reviews.

Organisation and finance

50. The Department for Children, Schools and Families must provide
further guidance to Local Safeguarding Children Boards on how to
operate as effectively as possible following the publication of the
Loughborough University research on Local Safeguarding Children
Boards later this year.
51. The Children’s Trust and the Local Safeguarding Children Board should
not be chaired by the same person. The Local Safeguarding Children
Board chair should be selected with the agreement of a group of
multi-agency partners and should have access to training to support
them in their role.
52. Local Safeguarding Children Boards should include membership from
the senior decision makers from all safeguarding partners, who should
attend regularly and be fully involved as equal partners in Local
Safeguarding Children Board decision making.
92 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT

53. Local Safeguarding Children Boards should report to the Children’s

Trust Board and publish an annual report on the effectiveness of
safeguarding in the local area. Local Safeguarding Children Boards
should provide robust challenge to the work of the Children’s Trust
and its partners in order to ensure that the right systems and quality
of services and practice are in place so that children are properly
safeguarded.
54. The Department for Children, Schools and Families, the Department of
Health, and the Home Office, together with HM Treasury, must ensure
children’s services, police and health services have protected budgets
for the staffing and training for child protection services.
55. The Department for Children, Schools and Families must sufficiently
resource children’s services to ensure that early intervention and
preventative services have capacity to respond to all children and
families identified as vulnerable or ‘in need’.
56. A national annual report should be published reviewing safeguarding
and child protection spend against assessed needs of children across
the partners in each Children’s Trust.

Legal
57. The Ministry of Justice should lead on the establishment of a system-
wide target that lays responsibility on all participants in the care
proceedings system to reduce damaging delays in the time it takes
to progress care cases where these delays are not in the interests of
the child.
58. The Ministry of Justice should appoint an independent person to
undertake a review of the impact of court fees in the coming months.
In the absence of incontrovertible evidence that the fees had not
acted as a deterrent, they should then be abolished from 2010/11
onwards.
APPENDIX 1 93

LETTER TO LORD LAMING

FROM THE SECRETARY OF STATE FOR CHILDREN,
SCHOOLS AND FAMILIES
94 THE PROTECTION OF CHILDREN IN ENGLAND: A PROGRESS REPORT
LETTER TO LORD LAMING 95
96 APPENDIX 2

GLOSSARY OF ABBREVIATIONS

ACPO Association of Chief Police Officers

BBC British Broadcasting Corporation
CAF Common Assessment Framework
CAFCASS Children and Family Court Advisory Support Service
CLG/DCLG Communities and Local Government
CPD Continuing Professional Development
CSCI Commission for Social Care Inspection
CWDC Children’s Workforce Development Council
DA(FCY) Domestic Affairs (Families, Children and Young People)
DCS Director of Children’s Services
DCSF Department for Children, Schools and Families
GP General Practitioner
GSCC General Social Care Council
ICS Integrated Children’s System
JAR Joint Area Review
LGA Local Government Association
LSCB Local Safeguarding Children Board
MP Member of Parliament
NHS National Health Service
NQSW Newly Qualified Social Worker
NSPCC National Society for the Prevention of Cruelty to Children
PCT Primary Care Trust
PLO Public Law Outline
RCGP Royal College of General Practitioners
 GLOSSARY OF ABBREVIATIONS 97

SCIE Social Care Institute for Excellence

SCR Serious Case Review
SHA Strategic Health Authority
SOLACE Society of Local Authority Chief Executives and Senior
Managers
SWTF Social Work Task Force
UN United Nations
98 APPENDIX 3

LIST OF LORD LAMING’S SECRETARIAT

AND ADVISERS

Secretariat to the Lord Laming Report

Jenny Lawrence
Sharon McHale
Anne Mason
Benjamin Nicholls
Katharine O’Brien
Victoria Saunders
Advisers to the Report
Ann Baxter Director of Children’s Services, London Borough of Camden
Jacky Tiotto Senior National Adviser, Improvement and Development
Agency (IDeA)
Lord Laming is also grateful for contributions from
Dan Cooke, Anne Gair, Roger Parr, Sarah Wolstenholme

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