Inspection of progress made in the provision
of safeguarding services in the London
Borough of Haringey
Care Quality Commission
HM Inspectorate of Constabulary
Ofsted
Age group: All
Published: 3 July 2009
Reference no: 309
© Crown copyright 2009
Website: www.ofsted.gov.uk
This document may be reproduced in whole or in part for non-commercial purposes, provided
that the information quoted is reproduced without adaptation and the source and date of
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Further copies of this report are obtainable from the local council or at www.ofsted.gov.uk
Inspection of progress made in the provision of safeguarding services
1
Contents
About the inspection
2
Evidence 2
Context 3
Overall judgement on progress since December 2008
4
Summary of key findings
4
Priorities for further improvement
5
Key findings
6
Managing the backlog of cases from pre-December 2008
6
Recording and tracking cases through the system
8
Support for front-line social workers
10
Performance
management
10
Establishing the ‘capacity to improve’ within the authority,
and the extent of effective working together amongst partners
in the Haringey area
12
Inspection of progress made in the provision of safeguarding services
2
About the inspection
1. The inspection was carried out by Ofsted, the Care Quality Commission
and Her Majesty’s Inspectorate of Constabulary at the request of the Secretary
of State for Children, Schools and Families. The Secretary of State asked the
inspectorates to provide a judgement on the progress made in relation to
specific areas of weakness identified in the special joint area review of
safeguarding carried out in November 2008 and which judged safeguarding
services to be inadequate. In particular, the inspection team was asked to
evaluate the evidence and judge progress made in the following areas:
managing the backlog of cases from pre-1 December 2008 where
insufficient action or poor assessments had been made previously
recording and tracking cases through the system, including looking at
a sample of recent cases
providing support for front-line social workers, and the impact this
has had on delivering a better quality service to children and young
people
developing effective performance management systems; and
establishing the ‘capacity to improve’ within the authority, and the
extent of effective working together amongst partners in the
Haringey area.
2. The inspection also took account of actions planned by the council and its
partners in the joint area review action plan submitted to Ofsted and the
Department of Children, Schools and Families in March 2009.
Evidence
3. Prior to the commencement of fieldwork, inspectors took into account
findings from the most recent and relevant inspection reports published by
Ofsted and its partner inspectorates and commissions. Inspectors also
considered evidence provided by the local authority and its partners, including
the joint area review action plan and the current Children and Young People’s
Plan. During the fieldwork, inspectors scrutinised a sample of 12 randomly
selected case files relating to children and young people receiving safeguarding
or child protection services. The council’s referral and assessment teams and
the safeguarding and children in need team were visited where a further 45
cases were selected at random, scrutinised and discussed with key social work
staff and managers. Inspectors also held discussions with children and young
people, elected members, senior officers, service managers and other key staff,
front-line social workers, healthcare professionals, the police and
representatives from the community and voluntary sector.
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Context
4. Since the publication of the joint area review on 1 December 2008, the
council in Haringey has undergone many significant changes, particularly
relating to its children’s social care services:
Following the suspension and subsequent replacement of the Director
of Children’s Services, management of the service was undertaken by
an experienced director seconded from another authority from 1
December 2008 until the appointment of the current, permanent
director on 1 January 2009.
An interim Deputy Director of Children’s Services was appointed on
28 January 2009 following the replacement of the substantive
postholder. More recently an interim Assistant Director for
Safeguarding was appointed on 7 May 2009.
The appointments of the current leader of the council and cabinet
member for children and young people’s services were confirmed by
an extraordinary council meeting on 9 December 2008 following the
resignations of their predecessors.
The Secretary of State for Children, Schools and Families directed the
appointment of the first independent chairperson to the Haringey
Safeguarding Children Board on 5 December 2008.
5. Operational management of the referral and assessment service within
children’s social care has been very unstable. This is linked to suspensions of
staff involved with the case of Baby Peter and also to staff sickness and special
leave. More recently further disruption has been caused by the restructuring of
the referral and assessment service and additional suspensions and dismissals
from post as the current senior management team began to tackle poor
practice and capability concerns about individual managers and social workers.
Key vacancies remain and a considerable proportion of posts, including some in
the senior management team, are filled by interim and agency managers.
6. Haringey authorities submitted an action plan to Ofsted in response to the
joint area review on 27 February 2009. The plan, subsequently strengthened
and supplemented by additional information, was agreed and approved by
Ofsted on 17 April 2009. It is a three-year plan designed to ensure that
Haringey’s service for children and young people becomes excellent by 31
March 2012. Alongside the joint area review action plan is a complementary
plan to improve the quality of inter-agency child protection practice. This was
produced as part of the re-commissioned serious case review following the
death of Baby Peter which was judged good by Ofsted on 7 April 2009. The
original serious case review was carried out before the current chair of the
Local Safeguarding Children Board took up post and was evaluated as
inadequate by Ofsted on 1 December 2008.
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Overall judgement on progress since December 2008
7. It is only six months since the last inspection and although progress can
be seen in some areas, the council and its partners have made limited progress
overall in addressing the areas of weakness identified in the November 2008
joint area review. Progress is evident in some important areas, such as in
developing strategic partnerships. However, overall this progress is limited
particularly in relation to improving key aspects of front-line social work practice
and management oversight. The timeliness and quality of decision making at
the referral and initial assessment stages and the quality assurance processes in
place to support those taking these decisions remain inconsistent and
insufficiently robust. These concerns are exacerbated by the serious capacity
issues of the council and some of its partners.
Summary of key findings
8. The council and its partners have made good progress in prioritising and
addressing thoroughly the backlog of unallocated cases identified by the council
in January 2009. A multi-agency taskforce, initially brought together to improve
the referral and assessment processes, worked with rigour and determination to
clear the backlog within a six-week period. In carrying out its work the task
force identified a number of serious concerns about the management of
referrals, particularly within children’s social care services. These included the
lack of competence and confidence in decision-making.
9. The council has made limited progress in improving the quality of social
work practice, supporting and assuring decision making and in developing case
recording and tracking processes. Despite persistent and concerted action,
significant shortcomings in staffing and in the capability of some managers and
social workers have restricted the rate of progress and children and young
people are not yet consistently safeguarded.
10. Progress in providing support for front-line workers is improving across the
partnership and is satisfactory overall. There is now more direct and
appropriately open communication with senior managers. However, the impact
of support in social care and health visiting services is more limited because of
continuing high vacancy levels among social work staff and continuing concerns
about the quality of aspects of front-line management in social care.
11. Progress in developing effective performance management systems is
satisfactory in the police and social care services but limited in the health
service. The police have taken robust steps to put in place systems to manage
and monitor individual cases and although progress has been made the
consistent application of these systems is not yet evident. The council has taken
extensive action to identify the extent of the problems in its data collection
systems which were highlighted as a major weakness in the 2008 joint area
review. However, despite some significant progress and continued action, key
areas of the service still do not benefit from having validated performance data.
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NHS provider trusts have not developed their approach to performance
management in a consistent and cohesive way thereby undermining their ability
to integrate data in ways that assist performance management or planning.
12. Capacity to improve within the council and across the partnership is limited
overall. The time available to tackle a challenging agenda for change has been
short and progress has been hampered by severe capacity limitations. There is
a realistic and accurate acknowledgement by the council and its partners that
they have not achieved sustained and consistent evidence of improved quality
across the service. However, good progress has been made in some aspects of
working together effectively among partners and there is a shared and strong
commitment and motivation to improve the quality of safeguarding services in
Haringey.
Priorities for further improvement
13. Priorities for further improvement:
The council and its partners should take immediate action to ensure
that all children and young people are adequately safeguarded.
The council and its partners should take immediate steps to
accurately establish the volume of demand for services and
strengthen the ability to prioritise responses so that the quality of the
work can be improved and statutory timescales can be achieved.
The Haringey Safeguarding Children Board should ensure that the
learning from the recent serious case review of Baby Peter is fully
disseminated to all front-line services with immediate effect.
The Metropolitan Police Service should ensure that borough police
activity is incorporated within and monitored through the
Metropolitan Police Service action plan.
The council’s children’s services should ensure that formal supervision
arrangements are consistently in place and that all case decisions
made in supervision are formally recorded on files.
The council’s children’s service should formally launch and
disseminate the revised procedure manual.
The council’s children’s service should ensure that supervision and
performance management are fully integrated in front-line social care
services.
The council’s children’s service should improve its use of the
Framework I computer system and investigate and take opportunities
to improve its effectiveness and ability to support good practice.
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The Children’s Trust should take immediate steps to develop a local
preventative strategy in accordance with the requirements of the
joint area review action plan, and strengthen the role of the voluntary
sector and wider partnership.
The council’s children’s service should strengthen its use of the
common assessment framework and formally implement its policy
relating to eligibility for access to services.
The NHS provider trusts should improve their collection and
management of data to improve the effectiveness of their
performance management capability.
Key findings
Managing the backlog of cases from pre-December 2008
14. The council has made good progress in managing the backlog of
unallocated cases.
15. Following the publication of the joint area review, in December 2008,
which highlighted poor recording practices and inadequate management
oversight the council began an extensive programme to establish the extent of
the demand upon children’s services and the quality of the work that was being
undertaken. By February 2009, a considerable backlog of approximately 400
cases had been identified, comprising work that had not been started and was
therefore significantly overdue and where initial and core assessments were
incomplete or of poor quality. An initial review of these cases demonstrated that
existing capacity within the children’s social care service was insufficient to
address the outstanding work. As a consequence, a multi-agency taskforce that
had originally been commissioned by the new interim Deputy Director of
Children’s Service diverted its focus from its original objectives which were to
address a range of issues relating to the multi- agency nature of the referral
and assessment processes. The taskforce under the close supervision of an
experienced social work service manager on loan from another local authority,
supported by police child abuse investigation officers and health staff
commenced work on the 16 March 2009 and completed its work over a six-
week period.
16. From the outset, this work was carried out with rigour and determination.
Systematic action by the taskforce was taken to audit and prioritise the cases
for action. Risks to children were identified, assessed and where necessary
further action was taken. In total, 200 cases were closed and 30 strategy
discussions were held in which the police, health and social care services
considered whether further protective work was required. Thirty home visits
were made to children and families and 19 family groups were identified where
an initial child protection case conference was required. Over 300 referrals were
made to the police child abuse investigation team as a result of multi-agency
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scrutiny, out of which about 15% resulted in a new crime being recorded. By
the end of the exercise the 100 unallocated cases that had been identified had
reduced to 15, all of which were assessed as low priority and have
subsequently been dealt with.
17. Work on clearing the original backlog enabled the task force to identify a
number of serious concerns about the management of referrals, particularly
within children’s social care services. These included:
the absence of a coherent management structure in the referral and
assessment teams
over-stretched managers and social workers
high caseloads for individual social workers
difficulties in case transfer between teams
poor communication between staff
lack of staff supervision and professional development
lack of competence and confidence in decision-making
lack of clear thresholds for referral
work on cases not being entered on the electronic recording system
an electronic recording system that did not provide robust
management information, so could not be relied upon to support
performance management
staff who lacked knowledge of other services available.
18. The police found some cases where the quality of the desk checks made
by the police public protection team had been poor. The experience of working
on this project, which the police elevated to the status of a major operation,
highlighted capacity pressures which have subsequently been addressed.
Relationships between key agencies were also found to be poor, typified by a
lack of trust and compounded by frequent staff changes and inadequate
communication, sometimes perceived to be obstructive. The timeliness of
contributions to enquiries and assessments by general practitioners was poor
and was in a number of cases of insufficient quality.
19. The work of the taskforce provided significant opportunities for rebuilding
confidence in multi-agency working and demonstrated clear commitment to this
end. It also contributed to the reorganisation of the referral and assessment
service. The taskforce produced a summary report of its findings with six
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recommendations for improvement which was shared by the Children’s Trust.
These recommendations are being addressed.
Recording and tracking cases through the system
20. The council has made limited progress in improving the quality of social
work practice and in developing effective case recording and tracking systems
and processes. Significant shortcomings remain which means that children and
young people in Haringey are not yet consistently safeguarded.
21. Staff and managers are working hard to improve the quality of work
undertaken in the referral and assessment teams and partner agencies report
improved communication. There is some recent evidence of effective work on
new cases which shows good decisions made by suitably competent managers
and better quality practice by front-line practitioners. However practice of this
quality is not typical and longer standing case files do not consistently contain
chronologies or comprehensive and coherent recording.
22. An effective new pathway into children’s social care and a single point of
entry for the Child and Adolescent Mental Health Service are proving effective in
enabling referrers to gain access to these services more easily.
23. Attendance of appropriate staff at child protection conferences has
improved and there is increased police attendance at child protection review
conferences. The police have introduced a system to rigorously oversee and
monitor their responsibilities set out in child protection plans and to ensure that
each of their case files has an up-to-date chronology enabling the officer
attending any conference to provide contemporary information. All child
protection conferences are timely, effectively chaired and, more recently, well
minuted. Child protection plans are adequate and, where they are not
implemented fully, chairs of conferences challenge those responsible. In
hospital settings, accident and emergency personnel now have 24-hour access
to updated child protection lists but are dependent on social work staff to
maintain the system. Consequently the absence for any reason of a hospital
based social worker is a significant risk to this process and there is no
contingency plan to cover this eventuality.
24. A significant number of case files examined by inspectors demonstrated
poor decision-making in relation to safeguarding. This is a matter of great
concern. From the 12 case files selected in advance of the inspection and a
further 45 selected at random during the inspection, eight cases (14%) judged
by the council as low priority were apparently unallocated and raised serious
safeguarding concerns. The council was asked to review the decisions that had
previously been made. These reviews resulted in the council agreeing with
inspectors that urgent and significant action should be taken with partner
agencies to secure the safety and well-being of the children involved in each of
the cases.
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25. Despite recent reductions for some social workers across the children’s
service, caseloads remain too high. This impacts on the ability of social workers
to carry out initial and core assessments that are timely and of good quality.
Management reports scrutinised and discussed by inspectors indicated that the
council had identified a further 400 initial assessments that had exceeded
statutory time limits, some dating from January 2009. In addition, a further 85
core assessments had not been completed within the statutory 35-day
timescale. These cases were not part of the backlog of cases which had been
discovered and cleared by the task force earlier in the year. A management
review of these cases carried out in response to inspectors’ questions revealed
concerns about the quality of practice in 21 of the cases involving core
assessments. Additional concerns were identified by senior managers among
the 134 cases that had been originally judged by the council to be of low
priority. These concerns ranged across a wide spectrum from those requiring
further information to inform decisions about case closure through to eight
cases which were considered as needing child protection enquiries to be made.
These findings highlight the lack of effective prioritisation and auditing practices
by managers, although inspectors noted that very recent steps have been taken
to address each of these issues in accordance with a recommendation of the
joint area review action plan. However, because a significant number of front-
line manager jobs are currently vacant or subject to changes of personnel, the
programme of case file auditing as part of the process of management
oversight and monitoring is not being carried out systematically.
26. The ineffective use of the common assessment framework and the lack of
implementation of a fully understood policy for service eligibility means that
social care services are accepting referrals for assessment when more
appropriate early interventions should be offered in the community. Whilst this
practice is understandable in the wake of the Baby Peter tragedy, it serves to
increase the capacity challenges in social care services and prevents children
and young people benefiting from early intervention services that should be
provided by partner agencies.
27. The council’s electronic system for recording key case decisions and action
is inefficient. Front-line staff report complex and time-consuming processes for
entering data on to the system. The risks arising from these system
dysfunctions are that data are unreliable, managers can not easily track
progress on cases and in some cases professionals who need access to the
system in the absence of the case holder do not have access to critical child
protection or safeguarding information. Opportunities to learn from other
councils using the same system, where improvements have been made, are
being taken.
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28. Recording and tracking of vulnerable children and young people by NHS
provider trusts are adequate. Community health staff use different paper files
and some have access to electronic systems of tracking. The electronic systems
are limited in their effectiveness by not having the capability to connect with
one another.
Support for front-line social workers
29. Progress in providing support for front-line workers is improving and is
satisfactory overall. There is now more direct and open communication with
senior managers that is re-building the confidence of staff. Social workers and
managers identify better senior management support than in the period
preceding the November 2008 joint area review. Evidence from cases over the
last six weeks demonstrates better social work management than has
previously been the case. However, the application of formal supervision that
challenges practice is more variable and management decision-making is not
consistently recorded, making it difficult to monitor and audit operational
practice in all cases.
30. Effective and stable deployment of social workers in front-line social work
services is proving difficult to achieve within a context of constrained and
limited resources. In some front-line social work teams, manager and social
worker vacancies, coupled with frequent staff turnover, mean line managers
lack the capacity to support workers in developing practice. Whilst
underperformance and poor practice are being addressed, the council
recognises that this task is not yet complete and that capacity will remain
constrained in the short term although the workforce strategy envisages
improvement from the autumn of 2009.
31. A new procedure manual is available for social care staff on the council’s
intranet. The procedures it contains are helpful and comprehensive but because
of poor dissemination few staff know of their existence. This limits their
effectiveness in tackling the inconsistent practice and leads to unnecessary time
demands being placed on managers in answering basic questions. Team
briefings have not been used for this purpose.
Performance management
32. Progress in developing effective performance management systems,
although recent, is satisfactory in social care and police services but limited in
NHS provider trusts.
33. A directorate and corporate performance management framework is in
place within the council and lines of reporting on progress and performance are
clear. The interim Joint Area Review Performance Management Group provides
the formal governance arrangement for programme implementation and
delivery in the absence of partnership performance management arrangements
through the Children’s Trust. A comprehensive initial report on progress against
the objectives of the action plan was produced in April 2009. This report is
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supplemented by highlight reports which examine in detail issues which
threaten the successful implementation of the action plan, for example the
significant risk facing the council and its partners until the integrity of all
performance information and data are assured.
34. Council officers have commissioned a fundamental overhaul of data
collection systems that has highlighted the full extent of the unreliability of
data. Cleansed and validated data are now being used appropriately by
partners for monitoring, evaluation and planning but in children’s social care,
data remain unvalidated in some critical areas. In health, the quality of data is
variable and is not used for analysis. A strategic commitment from health
services to introduce more rigour into the process is not yet apparent in
practice.
35. Budget reviews are ensuring that the implementation of the joint area
review action plan is supported by sufficient financial resources and that, where
necessary, additional resources are made available to meet new or
unanticipated costs. Monthly finance and performance summaries are subject to
scrutiny by senior officers and reported to the Chief Executive’s Management
Board and to Cabinet. The council has also created a Quality Outcomes Board,
with membership drawn from the senior management of external agencies, to
provide rigorous challenge to its plans and actions.
36. Challenge to officers from elected members on the quality of practice is
strengthening and reflects significant progress and a change of culture since
the 2008 joint area review. In addition to the traditional overview and scrutiny
panel, the council has recently formed a Safeguarding Policy and Practice Panel
to enable it to examine in more detail the work of children’s services. This panel
comprises a membership of councillors from the ruling and opposition groups
and will be supported by a recently appointed social care consultant.
37. Progress in developing and fully implementing robust supervision and
management arrangements is satisfactory and improving in the police service
although it is more limited in children’s social care, specifically in referral and
assessment and in the children in need and safeguarding teams.
38. The police service has taken robust steps to introduce weekly meetings to
performance manage their contribution to all cases in which children have child
protection plans. Actions are minuted and are monitored. However, much of the
change envisaged in the police service is identified in the Metropolitan Police
Service’s action plan. There is no separate borough action plan to capture the
range of activity developed at local level in response to the joint area review
action plan. Although borough police activity is currently consistent with the
Metropolitan Police Service action plan, it has not been formally incorporated
and is therefore not subject to the same level of monitoring and evaluation.
39. NHS provider trusts and their diverse professional groups have not been
engaged with other partners in developing their approach to performance
management. This has resulted in systems that lack consistency, cohesion and
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the ability to integrate data in ways that assist performance management or
planning.
40. Members have received appropriate training on safeguarding and are
better informed on key issues. They have commissioned independent,
evaluative reports on case file audits. When these reports require further action
to be taken or further information to be provided, the Director of Children’s
Services is charged with the responsibility for doing so.
41. Despite some improvements, overall performance management is not
embedded consistently in front-line practice. Use of the electronic system for
recording key case decisions and multi-agency action remains ad-hoc and
ineffective. Internal and external audits of case files show shortcomings but fail
to pinpoint the full extent of weaknesses in decision-making.
Establishing the ‘capacity to improve’ within the authority, and the
extent of effective working together amongst partners in the
Haringey area
42. Capacity to improve within the council and across the partnership is
limited. Despite significant and persistent efforts to improve recruitment, until
recently results have been slow. The time available to tackle a challenging and
ambitious agenda for change has been short and while members, senior
officers and partners show committed leadership, the council and its partners
acknowledge that they have not achieved improved quality across the children’s
service. Improving the quality of front-line services has proved to be particularly
challenging and, despite some recent progress, much remains to be done to
build a workforce of sufficient strength and provide it with an infrastructure that
supports best practice. Inspectors and the council identified serious concerns
about the safety of some children named in social care files and the council and
its partners accept that currently not all children are adequately safeguarded.
43. Members, officers and partners have a clear understanding of the extent
and depth of challenges facing the council and its partners. Some slippage in
the joint area review action plan timetable has occurred during work with
partners to understand fully new accountabilities and responsibilities. This work
is essential in enabling new or revised structures such as the Children’s Trust
and the Local Safeguarding Children Board to be developed on solid and
sustainable foundations. Elected members and senior managers reported a
change in culture in which relationships between officers, politicians and
partners are now based on professional honesty and integrity. Senior managers
are visible and accessible and a culture of openness, growing trust and
collective responsibility is emerging between staff, although this is at an early
stage and significant challenges remain.
44. Good progress has been made in some aspects of effective working
together among partners in the Haringey area. Professionals across all
agencies, including general practitioners and other independent practitioners,
share a strongly expressed commitment and motivation to improve
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safeguarding services within the borough. A shift in culture to one of openness
and honesty across the partnership is improving professional working
relationships and appropriate sharing of information. There are examples of
good practice, such as the recently introduced regular meeting between a
senior social care manager and their police counterpart, that is enabling trust
between the two agencies to be re-built following a significant fracture of their
relationship in the aftermath of the death of Baby Peter. However, it is too early
for recent developments such as these to demonstrate consistent and sustained
impact on performance.
45. While strategic partnerships are being built to secure a functional
Children’s Trust and Local Safeguarding Children Board, much remains to be
done to bring these to maturity. Schools, alternative providers of learning and
some voluntary sector and early preventative services contribute strongly to the
preventative agenda. Action to consolidate this into a formal local preventative
strategy is underway in accordance with the requirements of the joint area
review action plan. However, the role of the voluntary sector is under
developed overall and the effectiveness of preventative services is diminished
by having no functional common assessment framework arrangements or clear
eligibility criteria for access to services.
46. Child protection training for designated and named health and education
staff is of good quality and robust procedures are in place to monitor
safeguarding compliance in schools. Prompt action in some parts of the
children’s service ensured that the findings of a recent serious case review were
provided to some staff. However other front-line staff and managers remain
unaware of the key findings and recommendations and neither the Local
Safeguarding Children Board nor the Children’s Trust has yet organised a
systematic programme of dissemination following publication of the serious
case review.
47. In targeted schools, regular multi-agency meetings of professionals are
working well to identify children and young people at risk. Extended services
are moving in the right direction but their contribution to the preventative
agenda is at an early stage.
48. There is a recent and comprehensive workforce strategy within the
council. Central to its aims is a recruitment strategy which has been
implemented and is continuing with some early signs of success. This is also a
training and staff development plan which is at the launch stage. Both of these
components are seen as integral to the successful transformation of Haringey’s
children’s services.
49. Significant changes in personnel at all levels demonstrate the council’s
commitment to improving its services but the assessment and referral service in
particular remains vulnerable to staff vacancies. Decisive action has been taken
to recruit competent and capable social work managers and front-line staff but
this is not complete and is likely to take much more time to secure.
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50. Operationally, some very recent improvements in practice are
characterised by better assessment, line management and communication with
service users and stakeholders. However, capacity to deliver in some critical
functions is still compromised by the vacancy and turnover rates and the
capability of some staff.
51. Capacity and continuity are also severely limited by difficulties in recruiting
health visitors and permanent staff in children’s social care. Currently over one-
third of health visitor posts are unfilled, a figure that is incompatible with plans
to run a range of universal, targeted and specialist services. A third of social
care staff is from agencies and employed on a temporary basis. It is expected
that these staff will be replaced by permanent staff as they come into post.
Additional support for frontline staff has been provided and, as part of the
workforce strategy, the borough is currently seeking to fill vacant posts with
permanent staff. As part of this activity, ten qualified social workers have been
recruited and will take up posts in July 2009. The police service has moved to
significantly strengthen its officer complement to improve service delivery and
to ensure that it has the capacity to manage its workload.
