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Safeguarding Children Case File Audit:

Health Visitor and School Nurse records ‐ 2012

Jackie Wilkinson & Vicki Spencer Safeguarding Leads LPT

Audit Period: January 2012– March 2012 Report Date: June 2012

Safeguarding Children Case File Audit: | Contents 2 of 22

Contents Page Page

Contents ............................................................ 2

Abbreviations 2

Summary ........................................................... 3

Background ....................................................... 4

Aim .................................................................... 4

Standards .......................................................... 4

Method ............................................................. 4

Sample & data source 4

Data collection & analysis 4

Findings ............................................................. 5

Sample 5

Referrals 5

Post‐referral 5

Multi‐agency working 6

The child protection process 8

Comments ......................................................... 9

Key findings: 9

Areas of good practice: 9

Areas where practice could be improved: 10

Recommendations .......................................... 10

References ...................................................... 11

Appendix 1 Audit tool ................................ 12

Appendix 2 Results table ........................... 19

Appendix 3 Distribution list ....................... 21

Appendix 4 Action Plan .............................. 22

Abbreviations

LPT Leicestershire Partnership NHS Trust

LSCB Local Safeguarding Children Board

S47 Section 47 of the Children Act 1989

LCCHS Leicester City Community Health Service

LCRCHS Leicestershire County and Rutland Community Health Service

CAF Common Assessment Framework

TCS Transforming Community Services

Safeguarding Children Case File Audit: | Summary 3 of 22

Summary

Reason for audit

Case file audit of HV and SN reports on children with safeguarding plans is undertaken on an

annual basis, against s11 Children Act 2004 requirements, LSCB procedures and internal

policies and protocols as an assurance check on standards.

Objectives

To continually improve the quality of safeguarding practice, through a cycle of audit action

planning and review

Methodology

The audit was conducted on a sample of 49 health visitor and school nurse records, on

children with safeguarding plans, located on SystmOne.

The children included in the case‐file audit were randomly selected from the 1,000 children

living within Leicester, Leicestershire and Rutland with safeguarding plans. The case‐files and

details of the children’s records reviewed have been anonymised to protect identity.

Key Findings

Section Average compliance 2011‐12

Rating

Pre‐referral 86% Good practice

Post‐referral 85% Good practice

Multi‐agency working 92% Excellent practice

The child protection process 88% Good practice

Improved outcomes for the child 90% Excellent practice

Key Actions

Management oversight of Safeguarding Supervision Arrangements for HV and SN staff needs

to be strengthened. The named nurse team will develop an agreed Policy for Supervision

across LPT following TCS and implement this across services. Each staff member will have an

allocated supervisor and engagement will be monitored by the Named Nurse Team. Any

exceptions will be reported to line managers.

Staff will be reminded of the importance of recording ethnicity, language on children’s records

– this will be monitored through the record standards audit.

The Trust Lead for Safeguarding will present the Audit findings at both Leicester City and

Leicestershire County & Rutland LSCB effectiveness sub‐groups:

a) 45% of case files audited demonstrated a strategy discussion took place with health staff

following safeguarding referral – this needs to be raised with local authorities as an area

for improvement.

b) 2 of the case‐files audited health staff had not been invited to the initial case conference.

Areas of good Practice arising from the report and recommendations are communicated with

staff. Including the importance of face to face contact with children within health assessment

processes – to hear the voice of the child

Safeguarding Children Case File Audit: | Background 4 of 22

Re‐audit Date (TBC)

TBC

Background

This audit was conducted in the context of Working Together to Safeguard Children, HMO 2010

which sets out the relevant statutory and non‐statutory guidance for all organisations. The audit is

led by safeguarding leads working across LPT with support from the named professionals and the

audit team.

Clinical audit is an important assurance process for health organisations to check the quality of the

safeguarding records and that internal and multi‐agency procedures have been followed.

Aim

To continually improve the quality of safeguarding practice, through a cycle of audit action planning

and review.

Standards

This audit checked compliance with s11 of Children Act 2004 and essential standards registration,

Care Quality Commission 2010.

Method

Sample & data source

The audit was conducted on a sample of 49 health visitor and school nurse records regarding

children who had been referred under s47 arrangements because of safeguarding concerns. Health

visiting and school nursing records are held on the SystmOne electronic patient record.

The population consisted of approximately 1,000 children living within Leicester, Leicestershire and

Rutland who were identified as being under s47 arrangements (either by were core assessments

were taking place or were children with safeguarding plans). The sample of 49 records were selected

at random from this population.

Data collection & analysis

Case notes for the 49 samples were reviewed by the auditors, who are the trust Safeguarding Leads,

against the LSCB case file audit tool for health agencies (Appendix 1, p. 12).

This audit was originally scheduled as part of the LCCHS (City Community Health Services), but since

the merger between LCCHS, LCRCH & LPT in April 2011, was broadened to include the whole of

Leicester, Leicestershire and Rutland.

The case‐files and details of the children’s records reviewed have been anonymised to protect

identity.

Safeguarding Children Case File Audit: | Findings 5 of 22

Findings

Sample

The sample included 27 school nurse records and 21 health visitor records. 21 children live within

Leicester City, 23 Leicestershire County, 4 Rutland –supported by each of our 3 local authorities.

Referrals

10% of the children in the case‐file sample had a Common Assessment Framework (CAF) in place

prior to safeguarding referral; demonstrating that agencies identified families and children’s needs

and had tried early family support, before then generating a s47 referral, at a point where concerns

of significant harm to a child, see table (1).

80% (n=39) of safeguarding children referrals were generated by public or agencies other than

health to social care, health professionals generated 20% safeguarding referrals on the case‐file

audit sample selected, based on concerns of significant harm to a child.

Post‐referral

45% of health professionals contributed to an initial strategy meeting arising from the safeguarding

referrals made on these children. Strategy meetings or discussions are initiated by the local

authorities responsible for investigation of the referral; the figure of 45% is lower than would be

expected, as health services provide universal services to children locally, all involved agencies

should be involved in strategy discussions.

Once a referral was communicated to health professionals, 67% of these children were then in

receipt of continued health support; 27% of these were not applicable as following a health

assessment a number of school aged children may be assessed as having no unmet health needs and

therefore the school nurses would not be active members of the core‐group, see Figure 1 and Table

1.

Figure 1 – Post‐referral


Case‐file audit Yes No N/a Blank

Did the health professional contribute to any strategy meeting or discussion?

45% 41% 12% 2%

Was continued health support provided to the child and family following the safeguarding referral?

67% 4% 27% 2%

Table 1‐ Post referral

67% of children within the sample had a safeguarding plan in place prior to the first case conference.

These plans were drawn up through strategy meetings. 25% of children (n=12) did not have

safeguarding plan in place prior to first conference, but these meetings were held within 10 working

days of a safeguarding referral being made, adhering to LSCB procedures.

55% (n=27) of the case files demonstrated that social care was updated from health professionals on

relevant new information on the child. 35% (n=17) there was no new relevant information to

communicate to local authority key workers; this provides good assurance of effective

communication systems in place between health professionals and key workers, see Figure 2.

Multi‐agency working

Figure 2 – Multi‐agency working

67% of the cases had a safeguarding plan in place prior to first case conference, of these, all but one

record demonstrated Specific, Measurable, Realistic and Timely (SMART) safeguarding action plans

in place. This demonstrates that supervision arrangements and safeguarding training within LPT is

effectively supporting practitioners with health action plans.


Yes No N/a Blank

Prior to first case conference / Is there a safeguarding plan in place? 67% 25% 6% 2%

Does the plan identify the actions needed to improve outcomes for the child / family, are they SMART? (specific, measurable, achievable, realistic and timely)

63% 2% 31% 4%

Is there evidence of appropriate information sharing within multi‐agency meetings?

82% 4% 12% 2%

Is there a Child Protection Plan within the record? 71% 8% 16% 4%

Was the health professional invited to the Review Case Conference? 59% 6% 33% 2%

Are review case conference reports/safeguarding plans evidenced within the record?

57% 6% 35% 2%

Table 2 ‐ Multi‐agency working

84% of the case‐study sample records evidenced dates and outcomes from multi‐agency meetings

held to safeguard the child. In only one case‐file did the auditors find no evidence of this information

sitting within the record, the child had recently transferred into the area with an existing Child

Protection Plan from an outside local authority. There is sometimes a delay in the transfer of paper

records from outside areas, but the child’s safeguarding needs were flagged on our electronic child

health records.

82% of records demonstrated appropriate information sharing within multi‐agency meetings. There

were only two cases where this was not evident; one case the practitioner was invited to the initial

case‐conference, the second case the initial case conference had not yet taken place, so information

sharing had occurred during strategy discussion only.

55% of records audited had initial child protection case conference records scanned onto the child’s

records. In 18% of cases this was not applicable, because the initial case conference had not taken

place. For 22% of records the initial case conference record was not available; there can a period of

delay between case conference and local authority sending out case conference report to staff, and

this can be a period of up to two months. However these staff has recorded their attendance and

outcomes from the multi‐agency meeting within the child’s SystmOne records to support

communication and information sharing, see Graph 3.

Figure 3 – Case conference report in the records


In 69% (n=34) cases the health professional attended and contributed to the initial case conference.

For 24% (n=10) records this was not applicable, either because these cases were audited prior to

initial conference, or still subject to strategy discussions or child was in receipt of s17 family support.

There were four records which did not evidence health visitor or school nurse attendance. Two case

files audited recorded that the health professional was not invited; mother had a disability so the

most relevant professional was the adult neurology nurse who attended the conference in place of

the school nurse. The other case‐file evidenced that the conference was cancelled due to

improvements within the family.

59% (n=28) of the records audited demonstrated that health professionals were invited to Review

Case Conferences, these multi‐agency meetings were well attended by staff, with case conference

reports identified in the case‐files. 37% (n18) records this was not applicable because the school

nurses had identified no unmet health needs so they were not members of core groups or on‐going

multi‐agency meetings.

82% (n=40) case files audited recorded that children had received a recent health assessment

(previous 3 months) within the SystmOne record.

The child protection process

Figure 4 – The child protection process

67% (n=33) of the records audited demonstrated that the practitioner had supported the “voice of

the child” within the safeguarding process. 16% (n=8) this was not applicable because these related

to pre‐birth multi‐agency work, or to babies. 12% (n=6) of records the child’s voice was not

supported within the safeguarding process, two records stated the practitioner had no opportunity

to see the child, 1 record this related to a baby, one child with disabilities likely to affect their

communication.

Health care services delivered in a culturally sensitive manner, 76% of the records demonstrated

that there was evidence within the record of family needs being recorded or supported within the

child’s records. The trust is striving to improve this.

Safeguarding Children Case File Audit: | Comments 9 of 22

59% of the case‐files audited identified that health professional’s demonstrated “respectful

uncertainty” in their work supporting the family. Lord Laming in the inquiry into death of Victoria

Climbié identified the need for professionals to remain vigilant and objectively check out new

information provided by parents when working with family’s, he termed this phrase as remaining

“respectfully uncertain”. It is positive that this was demonstrated so positively within the audit,

because it has been a feature of our safeguarding children’s training programmes for over 3 years.

34.7 % of cases audited recorded this as “not applicable” as no new relevant information was

disclosed by families which then needed to be checked out with other agencies.

Safeguarding supervision was evidenced within 76% (n=37) of the records audited. It was not

applicable for 16% (n=8) as these cases had not yet reached timeframes for supervision to take place

10 days post conference. There were 6% (n3) of records where supervision was not evidenced, one

case the health visitor was represented at initial conference by a school nurse but then did not seek

supervision on the case following this, one because of sickness absence of staff and was

unavoidable. There needs to be improvements in management oversight of SN & HV supervision

arrangements by named nurses across the trust

Comments This case file audit utilised the approved Leicestershire County LSCB audit tool for health to examine

all areas of the safeguarding process for children, record standards, with lessons from national

serious case reviews for practice around listening to the voice of the child and demonstrating

respectful uncertainty when families present practitioners with new information.

This audit has positively included children on health visiting and school nursing records across

Leicester, Leicestershire and Rutland, which is an appropriate development following the

Transforming Community Services (TCS) changes and the new divisional arrangements.

This audit was conducted six months after TCS and the merger of city and county community

services. It needs to be recognised that the health visitor and school nurse teams are still embedding

SystmOne records, as the previous year has seen revisions of safeguarding templates and guidance

in relation to records. There are capacity issues across health and local authority agencies in a

context of increased Safeguarding / Child Protection activity being experienced both locally and

nationally. These include delays in allocating social workers, delays in receiving Child Protection

Conference Decisions and Recommendations, cancelled Core Groups.

Key findings:

There is a need to improve the timeliness of scanning and recording of child protection

information on SystmOne

There is a need to maintain and continue to improve timeliness and quality of supervision and

ensure work to match health visitors, school nurses and other members of the children’s

workforce to a child protection supervisor is a continuous process.

Health Professionals are not routinely being included in Strategy Discussion in relation to

Safeguarding Concerns with children – the case file audit identified that this was evidenced in

only 45% of the sample across the area. This finding needs to be raised at both LSCB

effectiveness sub‐groups.

Areas of good practice:

81.6% of records demonstrated appropriate information sharing within multi‐agency meetings.

Safeguarding Children Case File Audit: | Recommendations 10 of 22

83.7% of the case‐study sample records evidenced dates and outcomes from multi‐agency

meetings held to safeguard the child

79% case files demonstrated that the practitioner had supported the “voice of the child” within

the safeguarding process, appropriately according to the stage of the child’s developmental

needs and ability to communicate.

90% of records audited demonstrated staff had applied “respectful uncertainty” in checking out

information from families with safeguarding concerns, when this arose. .

Examples of good practice in case‐files : children’s needs and improving outcomes SN

represented at all multi‐agency meetings, good assessment and engagement of the child and

parents, response with referral to CAMHs to support mental health needs.

Example of HV engaging with family in ante‐natal period, attended safe discharge planning

meetings prior to discharge. Mother has learning disabilities, HV documented she supported

communication with pictorial aids to support health messages around parenting.

Areas where practice could be improved:

24.5% of the records audited demonstrated that ethnicity was not recorded within a child’s

records, this this should always be recorded to support care assessment and delivery.

School Nurses should ensure they have a face to face to contact with the child and not rely solely

on parents reporting children’s “health needs” when they move into the area and require a

health assessment.

Three practitioners had not accessed safeguarding supervision according to the agreed guidance

/ protocols in place. Management oversight of supervision arrangements and systems need to

be strengthened.

2 case‐files identified health staff had not been invited to initial case‐conferences by the local

authority for the child.

Recommendations 1. Management oversight of Safeguarding Supervision Arrangements for HV and SN staff need to

be strengthened. The named nurse team will develop an agreed Policy for Supervision across

LPT following TCS and implement this across services. Each staff member will have an allocated

supervisor and attendance will be monitored by the Named Nurse Team. Any exceptions will be

reported to line managers.

2. Staff will be reminded of the importance of recording ethnicity, language on children’s records –

this will be monitored through the record standards audit.

3. The Trust Lead for Safeguarding will present the Audit findings at both LSCB effectiveness sub‐

groups:

45% of case files audited demonstrated a strategy discussion took place with health

staff following safeguarding referral – this needs to be raised with local authorities

as an area for improvement.

2 of the case‐files audited health staff had not been invited to the initial case

conference.

Safeguarding Children Case File Audit: | References 11 of 22

4. Areas of good Practice arising from the report and recommendations are communicated with

staff. Including the importance of face to face contact with children within health assessment

processes – to hear the voice of the child

References

Children Act 1989 & 2004

DcSF (2008) Information sharing – pocket guide DcSF ( 2010) Working together to safeguard children; a guide to inter-agency working to safeguard and promote the welfare of children www.education.gov.uk/publications/standard/publicationdetail/page1/DCSF-00305-2010 Ofsted (2011) The voice of the child: learning lessons from serious case reviews


Appendix 1 Audit tool

CASEFILEaudit–HealthRecords 1. All files should be audited on all area’s that are relevant to that file, but it is

expected that the following will apply:

General Information & Identifying Details The Child Protection Process Closure of the case Involvement of the family & line management

2. In addition, there is space to record quality issues on the right hand side. The

information contained in these boxes should be used as prompts and any additional information in relation to the quality of safeguarding interventions / recording should also be included.

3. Each box on the audit tool should be completed although if there is no

information to be included, auditors should mark this on the form and not leave empty boxes. Additionally, the N/A section on the scored boxes should be used minimally.

4. Each audit will be commissioned and scoped on an individual basis in order to

meet identified aims and learning outcomes. Ethnicity Codes:

Asian or Asian British Mixed A1 Indian M1 White & Black Caribbean A2 Pakistani M2 White & Black African A3 Bangladeshi M3 White & Asian A4 Other Asian Please Specify) M4 Other Mixed (Please Specify)

Black or Black British White B1 Black Caribbean W1 British B2 Black African W2 Irish B3 Other Black W3 Other White

Chinese or other Racial Group C1 Chinese C2 Other Ethnic Group G1 Gypsy / Roma T1 Traveller of Irish heritage U1 Unknown


General Information and Identifying Details

Name of auditor: Health Agency: Date of Audit: Looked After Child: yes/no Type of placement: Subject to child protection plan: yes/no Child’s Date of Birth: Gender: Ethnicity Code: Child Disability: Yes / No If yes / specify:

Safeguarding Children Case File Audit: | Appendices | Audit tool 14 of 22

The Safeguarding / Child Protection Process health records; consideration of the following information

Yes No N/A Quality Issues What evidence is there of work undertaken with the child and family before the referral in relation to early intervention? Were there any previous concerns raised or referrals made?

Pre referral: Was there a current Common Assessment Framework (CAF) prior to referral?

Was the assessment framework used?

Is the lead professional identified?

Is there a multi-agency action plan in the records?

Was the safeguarding referral discussed with parents / carers and child if age appropriate?

Was the referral discussed with the line manager or named nurse prior to referral?

Post- referral:

yes no n/a Quality issues Is there evidence of information sharing between the agencies throughout the Child Protection Process? Is there any evidence of any disagreements in relation to decision making through the process? What examples of safeguarding interventions and continued




support are there?

Did the health professional contribute to any strategy meeting or discussion?

Was the telephone referral to specialist services (formerly children’s social care in the child’s health record?

Was an intra-agency safeguarding referral form sent to specialist children services or CYPS within 24 hours?


Were Specialist Children’s Services (formally children’s social care) updated with any new information from the agency?




Multi Agency Working:

yes No n/a Quality Issues: Which agencies are involved in the child’s plan (including voluntary sector and adult services) and are these appropriate to the child’s needs? Are there any cross authority issues and how have these been dealt with?

Is there a safeguarding plan in place?


Are multi-agency meetings recorded?

Did the family attend and contribute to multi- agency meetings?

Was a discharge planning meeting held prior to child’s transfer from hospital / CAMHS inpatient care to community?

If yes, did the health professional contribute to the discharge planning meeting?

Is there evidence of appropriate information sharing within multi-agency meetings?




The Child Protection Process:

yes No n/a Quality Issues What is the agency involvement within the child protection process? Are they undertaking actions within the child protection plan and are fully involved within discussions with Social Care? Are any disagreements with decisions made at conferences recorded?

Is there a case conference report for Initial Child Protection Case Conference (ICPC) within the child’s records?

Did the health agency attend and contribute to the initial child protection conference?

Is there a Child Protection Plan within the record?

Is the health professional a member of the core-group?

Are they attending / or sending a report to core-group meetings?

Has information been shared with involved professionals?

Was the health professional invited to the Review Case Conference?

Did the health professional attend / or send a report to the Review Case Conference?

Are review case conference reports / safeguarding plans evidenced within the record?




Improved outcomes for the child

yes no n/a Quality Issues Practitioner’s should ensure that actions take account of children and young people’s views, recognise behaviour as a means of communication, understand and respond to behaviour indictors of abuse, sensitively balance children’s and young people’s views with safeguarding their welfare

Did we ascertain the child’s views within the safeguarding process?

Were healthcare services delivered in a culturally sensitive manner? (evidenced within the child’s record that language, religion & ethnicity are recorded)

Did the child or young person receive a health assessment to identify needs?

Were/ are the child’s or young person’s health care needs met?

Did safeguarding Supervision take place and was this recorded within the records?

Safeguarding Children Case File Audit: | Appendices | Results table 19 of 22

Appendix 2 Results table Pre‐referral Compliance

Was there a current Common Assessment Framework (CAF) prior to referral? 11%

Was the assessment framework used? 82%

Is the lead professional identified? 100%

Is there a multi‐agency action plan in the records? 68%

Was the safeguarding referral discussed with parents / carers and child if age appropriate?

30%

Was the referral discussed with the line manager or named nurse prior to referral? 57%

Post‐ referral: Compliance

Did the health professional contribute to any strategy meeting or discussion? 51%

Was the telephone referral to specialist services (formerly children’s social care in the child’s health record?

100% *

Was an intra‐agency safeguarding referral form sent to specialist children services or CYPS within 24 hours?

100% *


92%

Were Specialist Children’s Services (formally children’s social care) updated with any new information from the agency?

84%

* In the 3 cases where the referral was made by a member of LPT staff this was appropriate for one

child.

Multi Agency Working: Compliance

Is there a safeguarding plan in place? 86% **


91%

Are multi‐agency meetings recorded? 95%

Did the family attend and contribute to multi‐ agency meetings? 83%

Was a discharge planning meeting held prior to child’s transfer from hospital / CAMHS inpatient care to community?

27%

If yes, did the health professional contribute to the discharge planning meeting? 100% ***

Is there evidence of appropriate information sharing within multi‐agency meetings? 93% ** In 32 out of 37 cases.

*** In 3 out of 3 cases.

The Child Protection Process: Compliance

Is there a case conference report for Initial Child Protection Case Conference (ICPC) within the child’s records?

68%

Did the health agency attend and contribute to the initial child protection conference? 87%

Is there a Child Protection Plan within the record? 85%

Is the health professional a member of the core‐group? 89%

Are they attending / or sending a report to core‐group meetings? 89%

Has information been shared with involved professionals? 93%

Was the health professional invited to the Review Case Conference? 88%

Did the health professional attend / or send a report to the Review Case Conference? 87%

Are review case conference reports / safeguarding plans evidenced within the record? 88%

Safeguarding Children Case File Audit: | Appendices | Results table 20 of 22

Improved outcomes for the child Compliance

Did the practitioner support the child’s voice within the safeguarding process? 80%

Did we ascertain the child’s views within the safeguarding process? 88%

Were healthcare services delivered in a culturally sensitive manner? (evidenced within the child’s record that language, religion & ethnicity are recorded)

91%

Did the child or young person receive a health assessment to identify needs? 98%

Were/ are the child’s or young person’s health care needs met? 91%

Did safeguarding Supervision take place and was this recorded within the records? 90%

Calculation of compliance:

Standards To help differentiate between excellent practice, good practice and practice which requires improvement, the following arbitrarily‐set standards and colour‐coding have been used: 90% ‐ 100% Excellent practice 80% ‐ 89% Good practice 79% and below Practice requiring improvement Grey coloured criteria indicate that the practice being measured is not totally within the remit of LPT.

Safeguarding Children Case File Audit: | Appendices | Distribution list 21 of 22

Appendix 3 Distribution list Target audience To (for action)

name, designation Cc (for info)

name, designation

Clinical Audit & Effectiveness sub‐group members. For review and adoption of the report and action plan.

Divisional Clinical Governance Lead To add to CASE agenda and to circulate to members.

Safeguarding Children Case File Audit: | Appendices | Action Plan 22 of 22

Appendix 4 Action Plan Objective Level

of Risk L|M|H

Agreed Action Level of Recommendation

Individual, Team, Directorate, Organisation

Person

responsible

Action by

date

Resources

required

Action

Status

Management oversight

of Safeguarding

Supervision

Arrangements for HV and

SN staff need to be

strengthened.

L The named nurse team will develop an agreed Policy for Supervision across LPT following TCS and implement this across services. Each staff member will have an allocated supervisor and attendance will be monitored by the Named Nurse Team. Any exceptions will be reported to line managers.

FYPC Vicki Spencer

July 2012

Supervision policy

Data collection systems

established

Amber

Improve the recording of ethnicity on children’s records

L Brief staff on required record standards Embed within future record audit SN/ HV services

Children’s Services

Named Nurses Katie Willetts

July 2012 February 2013

Staff briefing

The Trust Lead for Safeguarding will present the Audit findings at both Leicester City and Leicestershire County & Rutland LSCB effectiveness sub‐groups

L

Discuss the findings and actions arising from the audit,

Strategy discussions not consistently including health professionals

Non‐ invites to case conferences. Agree actions across agencies.

Organisational

Jackie Wilkinson

August 2012

Agenda item at both City & County LSCB effectiveness meeting

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