ABERDEEN CITY CHILD PROTECTION COMMITTEE

MULTI AGENCY PRACTICE AUDIT

How well do we use the National Risk Framework tools in assessing risk for children and young people?

1. INTRODUCTION

The Quality Assurance Framework (QAF) was agreed by the Chief Officers, Child Protection Committee (CPC) and Integrated Children’s Services Board (ICSB). The first QAF programme was intended to run for the year 1 April 2020 to 31 March 2021. However, due to the Coronavirus pandemic restrictions, it was put on hold until September 2020 to allow the development of an electronic means of carrying out such a multi-agency audit.

This is the first of the 2020/21 audit programme. Findings in the Joint Inspection 2019 and in local ICRs and SCRs have noted the variable use and quality of National Risk Framework tools and chronologies. These tools are found in the “National Risk Framework to Support the Assessment of Children and Young People” (2012). This audit topic and outline remit was agreed at the CPC to consider “How well do we use the National Risk Assessment Framework tools in assessing risk for children and young people?”

Representatives from health, social work, police, education, and the voluntary sector met through the digital platform Microsoft Teams to review 15 selected cases. The tool used in the process was based on the Care Inspectorate document "How well are we improving the lives of children and young people? A guide to evaluating services using quality indicators.”(2018)

The audit ensured that personal information was accessed and handled in compliance with the appropriate legislation and Scottish Government guidelines.

2. PURPOSE AND SCOPE

The purpose of the audit was to establish how well services use the National Risk Framework (NRF) tools in assessing risk for children and young people. The hypothesis was that the children’s services workforce routinely, but inconsistently, utilise chronologies, the resilience matrix, genograms and other NRF tools. Other additional or alternative tools from other sources may also be utilised.

The audit was conducted to establish: • What tools are used in the assessment of risk in the City

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• How effectively these tools are used

• How well is the use of risk assessment tools recorded on files

• Whether there is evidence of the use of the risk assessment tools to inform the child’s plan and

• What impact does the inconsistent use of risk assessment tools have in planning for children across the partnership?

Once the individual audits had been completed discussion sessions to look at the initial findings of individual audits conducted in pairs considered the key questions in the audit process: • How are we doing?

• How do we know?

• What are we going to do now?

The focus of the audit was:

• Use of the Risk assessment framework in planning for the child

The case file audit required access to information in the individual records of the child or young person held by social work to assess how services are working together to assess risk for children and young people. The case file audit did not look at adults’ personal records. The audit was conducted by reference to electronic files only. No interviews were undertaken.

This multi-agency case file audit adds to the existing single agency quality assurance processes.

3. SELECTION OF CASES

The cases identified represented children who had been on the Child Protection Register (CPR) on 1 January 2020 for at least 6 months. Case files were audited for the period between 1 October 2018 and 1 July 2020.

4. QUALITY INDICATORS

The quality indicators have been drawn from the Care Inspectorate ‘How Well Are We Improving the Lives of Children and Young People?’ 2018.

The case file audit focussed on specific quality indicators 2 and 5.

2.1 Impact on children and young people

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5.1 Providing help and support at an early stage

5.2 Assessing and responding to risks and needs

5.3 Planning for individual children and young people

5.4 Involving individual children, young people, and families

Evaluations have been made in accordance with the Care Inspectorate scale 1-6, ranging from unsatisfactory through to excellent.

1 Unsatisfactory 2 Weak 3 Adequate 4 Good 5 Very good 6 excellent

5. AUDIT TEAM

The case file audit was managed through the CPC Performance & Quality Assurance Sub Committee and was co-ordinated by the Quality Assurance and Audit Lead (IC&FS Development Team Manager).

The multi-agency case file audit process was carried out using the expertise of colleagues from each of the following agencies represented on the Child Protection Committee; NHS Grampian, Children’s Services Social Work (ACC), Education (ACC), Police Scotland and the 3rd Sector.

Availability was required for:

• Training • Planning and co-ordination of file delivery through a private Microsoft Teams channel and timely deletion of copied files and records. • File reading • Discussion of findings and agreeing evaluations • Write up of findings

6. METHODOLOGY AND PROCESS

6.1. Methodology

• Care Inspectorate quality assurance methodology was used. All auditors had been trained in the use of the methodology. 3

• 15 files were looked at by auditors in pairs.

• The files were drawn from those children on the Child Protection Register as at 1 January 2020 for 6 months or more.

• Files for the preceding 18 months were read i.e. from 1 October 2018 to 1 July 2020.

• The focus was on those files or parts of files which relate to child protection and risk assessment only.

• There was an equal (or near equal) split of gender.

• The files covered the age groups 0-4years, 5-11years and 12years+

• The files included at least two sibling groups.

• Re-registered children did not form part of this audit.

• Particular specialisms (which may have specialist risk assessment tools) will not form part of this audit.

6.2. Process

The file reading of the selected case files took place during an identified 2 week period in September 2020. Files were allocated to pairs of auditors. Files were read by auditors from across the partnership and discussed in their pairs before agreed findings were recorded on a common format Audit tool. The process itself was discussed in an open session of all auditors in October. The multi-agency audit team discussed issues/ findings/ outcomes of the file reading in a subsequent open session in November 2020. This report summarises the analysis and findings of the multi-agency audit team.

6.3. File Records audited

The records supplied for each child and young person included:

• The childcare social work record provided in pdf format from Carefirst.

• The electronic case file a copy of which was provided for the audit.

6.4. Organisations and personnel involved in the audit

The audit was led by Billy Nicol, the Quality Assurance and Audit Lead from Integrated Children & Family Services, Aberdeen City Council, with support from Stuart Lamberton, Lead Officer, Child Protection Committee and Kymme Fraser, Service Manager, IC&FS and Chair of the CPC’s Performance & Quality Assurance Sub Committee.

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Each agency identified a Single Point of Contact (SPoC) for this audit as liaison among their own agency and the QA and Audit Lead. This was not a significant role as this was an electronic audit: • NHS Grampian – Christine Masson • Education – Larissa Gordon • Children’s Social Work – Kymme Fraser • Third Sector- not required for this audit • Police – Fiona Topping • SCRA – not required for this audit • CPC interface – Stuart Lamberton

A team of 12 auditors was drawn from the same range of agencies. Refresh training in the methodology was delivered and led by Isabel McDonnell, Acting Lead Service Manager, Integrated Children & Family Services, Aberdeen City Council. The auditors for this audit were: • Children’s Social Work – Amanda Ivey • Children’s Social Work - Stephanie Wiehe • Children’s Social Work - Hazel Campbell • NHS - Lisa Lawrie • NHS – Chris Fox • NHS– Gerry Keogh • Police – Katy Townhill • Police – Keith Cruickshank • Education – Craig Mcdermott - QIM • Education – Shona Milne - QIM • Third Sector – Anna Garden – Service Manager, VSA • Third Sector – Loraine Cran – Service Manager - Barnardos • SCRA – not required for this audit

6.5. Administrative Arrangements and Support

• Microsoft Teams was used as the platform for audit meaning no venue was required. • Case files were copied to a private channel within Microsoft Teams and permission was given to the pair of auditors who were carrying out the audit. The audit tool was also uploaded into these channels for auditors to use. • Auditors for this audit were, in the main, already trained for the recent Joint Inspection. • SPoCs provided the practical interface with their individual agencies and arrangements for this multi-agency audit.

6.6. Timescales and Reporting arrangements

Training took place on 17 September 2020, file reading during the two weeks commencing 28 September 2020 , first feedback session 6 October and second discussion session 4 November 2020. This

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report will be made available to the Child Protection Committee on 10 December 2020 and Chief Officers Group on 15 December 2020.

6.7. Security and Confidentiality

All case files were handled in confidence by the auditors. Only the auditors allocated to the case were added to a private Microsoft Team channel where the one set of case records and the electronic file was contained. As part of the learning process, the issues from the case files were identified and shared - not the individual details of specific cases. Service users and workers will not be identified in this or any other reports produced. All information noted during the audit process has been anonymised.

It is the contention of the QAF team that this is a more secure auditing method than the traditional audit process which involves the movement and storage of multiple files from a range of agencies.

6.8. Evidence base

This report is evidence based. Findings were discussed across pairs of auditors before being submitted. Open discussion across the entire audit team took place in a further discussion session. The multi-agency nature of the auditors meant that there was a range of expertise available, across the team of professionals. A lot of evidence was gathered in the form of notes from the discussions and it is not appropriate or necessary to record it all here. This report intends to provide broad overview from a multi-agency perspective.

Auditors were looking for consistency in relation to the use of the risk assessment tools from the National Risk framework and clear links to planning for children.

The Care Inspectorate six-point scale was utilised.

7. FINDINGS

7.1. Total number of children

There were 15 children’s files audited. These files represented children who had been on the Child Protection Register on 1 January 2020 for at least 6 months. Case files were audited between 1 October 2018 and 1 July 2020.

7.2. Number of all files audited

15 files were audited in total. There were files for all 15 children from Children’s Social Work teams and units and Central Records.

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7.3. Ages of children audited (as at 1 January 2020)

Age Number

<1 1 1-2 5 3-4 2 5-10 4 11-17 3

7.4. Gender of children audited

8 of the children were Female and 7 were Male.

7.5. Ethnicity

Ethnicity was recorded on all 15 cases and split as below:

Ethnicity Number

Mixed or multiple ethnic groups 1 White Other British 1 White Polish 1 White Scottish 12

7.6. Disability

The auditors checked whether a child’s disability status was recorded, and results are as below:

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Disability recorded Number

Yes, recorded and child has no disability 11 Yes, recorded and child has a disability 2 Not recorded/not clear 2 The child’s disability status was clearly recorded in 13 of the 15 cases.

7.7. Status of Children at point of Audit 28 September 2020

Although all 15 children selected for audit had been on the Child Protection Register at 1 January 2020, only 5 remained on the Child Protection Register at the point of audit.

8 children had been deregistered, of which 2 had been reregistered. One child was receiving a service as a result of being referred back to the local authority by SCRA under s68(5) of the 2011 Act.

There were 4 children who were recorded as being looked after; one was looked after away from home in kinship care and the other three were away from home in foster care placement. One child was subject to permanency planning.

On the Child Protection 5 Register

De-registered 6

Looked After 4

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8. RESULTS AND DISCUSSION

The specific questions addressed by the audit team are reported on below

8.1. What tools are used in the assessment of risk in the City?

See below for a full list of tools used and a record of how many cases the tools were mentioned in. It is important to note that all cases had a chronology, albeit that in several cases it was reported that they were not truly multi-agency chronologies although other agencies were referred to in them. Genograms were utilised in 8 of the cases audited. Feedback suggests that they were not used to their full potential in most cases, being more a record of relationships within families rather than an analysis of the relationships and what these brought to the child’s safety (or not), so auditors felt that there was missed potential.

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The rest of the tools mentioned covered a range of issues e.g. risk assessments, resilience matrix, assessing protective factors, wellbeing wheel and SHANARRI to name but a few. Further discussion of some of these will be found in the section 8.4.

Number of cases NRF Tool name mentioning tool

Resilience Matrix 3 Genograms 8 Ecomaps 1 Chronologies 15 My World Triangle 5 Well-being wheel Risk indicators 3 Child Risk indicators 6 Wider world Risk indicators 5 Parent/guardian Risk assessment 6 Considered past Risk assessment 4 Considered present Risk assessment 2 Considered future Resistance 4 Was assessed Risk Indicator Sheets 0 Generic Risk Indicators (Child, Parent/Carer and Wider World) 1 Matrix Related Risk Indicators (Child, Parent/Carer and Wider World) 0 Resilience 4 Adversity 3 Vulnerability 0 Protective Resistance Related Risk Indicators (Child, Parent/Carer and Wider World) 1 Signs of safety 3 SHANARRI 7 Reflective tools to inform assessment 1 Risk assessment 1

8.2. How effectively these tools are used?

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Evidence of Stage 1: Collection and Collation of Information

Evidence of Stage 1 Stage I no evidence on file 0 8 unsatisfactory 0 6 weak 1 4 2 adequate 4 0

good 4 weak

very good 6 good

ry

excellent adequate

excellent 0 onfile

very good very unsatisfacto noevidence

There were 10 cases marked as very good (40%) or good (27%) by the audit team in the collection and collation of information for the child, a further four were adequate (27%) and one (6%) considered weak.

Evidence of Stage 2: Risk Analysis

Evidence of Stage 2 Stage 2 7 no evidence on file 0 6 5 unsatisfactory 0 4 3 weak 1 2 1 adequate 6 0

good 4 weak

very good 4 good

excellent

adequate onfile

excellent 0 good very noevidence unsatisfactory 8 cases were considered good (27%) or very good (27%) by the auditors in respect of risk analysis, six cases were considered adequate (40%) with one marked as weak (6%).

Evidence of Stage 3: Risk Management

Evidence of Stage 3 Stage 3 6 no evidence on file 0 5 unsatisfactory 0 4 3 weak 1 2 1 adequate 4 0

good 5 weak

very good 5 good

y

excellent adequate

excellent 0 onfile

very good very noevidence unsatisfactor

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Auditors reported that 10 of the cases audited managed risk as either good (33%) or very good (33%), with a further four being adequate (27%) and one as weak (6%).

In summary, the responses to the effective use of tools report that 66% of cases had good or very good collection and collation and information, 66% had good or very good risk analysis and 54% of cases had good or very good risk management evidenced in the case files. Only one case was recorded as weak across all three questions. The remaining cases were marked as adequate.

8.3. Is there clear evidence of the use of the risk assessment tools to inform the child’s plan?

In eleven cases (73%) the auditors found clear evidence of the use of the risk assessment tools, in one case (7%) this was recorded as moving from No to Yes, stating it was ‘a case of two halves’ and the remaining three (20%) there was no clear evidence.

Clear evidence in use of NRF 1

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Yes No No to yes

For the majority of cases (12) there was evidence of links between the use of risk assessment tools and the child’s plan, with one of the 12 cases moving from ‘no’ evidence to ‘yes’ when there was a transfer to a social work team who used the risk assessment framework tools. In the remaining three the information on the child’s plan was not focused on the child or lacked clarity and instead focused on the parents or family members.

In five particular cases (out of the 12) the feedback suggests that there was clear use of risk assessment framework tools and that these informed the child’s plan. In the remaining seven cases it was either unclear or lacked evidence. A word that came up frequently in the discussion after the audit had been completed was ‘inconsistency’. Where auditors looked at three cases, they tended to say that in two out the three cases there was good use of the tools and that they ‘informed’ the Child’s Plan, so this suggests anecdotally a 66% consistency rating. This correlates with the 66% reported against the earlier questions related to good or very good evidence of risk analysis.

In cases where they were used, genograms were reported as being used as a way to record a family’s relationships and the analytical side tended to be underused.

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Similarly, chronologies were often basic and simply recorded a list of events and the outcomes for a child, there was a lack of thorough analysis recorded in many of the cases. There was some discussion that an improved design of the chronology template might encourage better analysis of risk in a child’s life.

Text that was entered into the Audit tool in response to Question below:

Case No

1. YES: Risks outlined, lack of analysis. 2. YES: Use of wellbeing indicators in assessment section of child’s plan. Use of resilience matrix considerations to inform analysis. Use of ongoing gathering of assessment information and analysis of focussed work to inform risk management on longer term basis of work. 3. YES: The information is there however it is not clearly detailed how this has informed the work completed with the family. Additionally, it was felt the analysis could be, more thorough to inform management of risk. 4. YES: Clear pathway through information and evidence which outlines stages of assessment, effective working relationships with family and other professionals. Reports are clearly written & action plan evidence progress and mitigates risk. 5. YES: Action Plans ante and postnatally - fully linked concerns/risks throughout. Subsequent action plans included use of the extended columns to record no change/deterioration in risk. Stage 1 - Genogram and number of tools - shanarri, resilience and chronologies were all well documented and analysed, showing good collation of facts and multi-agency information. Stage 2 - Good use of risk analysis, partnership working and identifying short and long-term risks. Stage 3 - Action plan was linked to the risk assessment. Well thought of and again documented well. Added additional action as and when required. 6. YES: No text 7. YES: Really detailed information on the risks and the impact they had on the child. Risks easily identified. 8. YES: very prompt action taken to gather information across sectors to ensure the safety of this child. Use of wellbeing indicators. Use of resilience matrix considerations to inform the analysis undertaken. The resistance assessment information was analysed and this information informed child's plan. 9. YES: There is evidence of a risk assessment which has been completed. However, linking it to the NRF tools is not as clear. 10. NO: No sense of family being actively involved in assessment process, clear sense family hard to reach but no reflection on what team had done differently to address this, who could support engagement and discussions with family to explore this further. No use of genogram or eco map to look for family or community-based supports around child. lack of reflection of child’s day to day lived experiences and how risks of conflict, domestic violence could be mitigated. limited sense of effective working relationships between professionals. Lots of meetings but no sense of progress or reduction in risk. 11. NO: Initial plan seems clear but becomes less so after the early birth of the twins. There is a fairly dramatic change to the plan, which does not appear to be fully documented. 12. YES: No text. 13. NO: Information appears to be based on older siblings rather than specific to the child and how the risks impact him at his specific age and stage. 14. YES: There is an assessment of risk, with regard to events which have occurred and planning, however there is no detail relating to how the tools have informed the assessment. 15. NO to YES. This appeared to be a case of two halves: opportunities of risk management were missed early on, which resulted in crisis. This signifies a turning point where risk management and mitigation becomes much stronger. Active engagement with the family is markedly improved at this point. IFIT's role in this was significant.

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8.4. Please highlight any areas of good practice in the use of the NRF tools

In the majority of cases there was some evidence of good practice, including three cases having very good, detailed chronologies according to the feedback from the audit tool. The use of SHANARRI as a basis for assessing the risk in a case was apparent in some cases, and there was also some good use of genograms. Good practice in the form of cases pulling together protective factors and resilience as well as the risks was also apparent in some cases and the links between NRF tools and planning for the child were easy to follow. The cases where this was clear tended to result in action being taken quickly to minimise risk for the child. Three was also a richness of information reported in some child’s plans.

There were examples of really good risk assessments from partners pulling together protective factors with risks, use of the resilience matrix that then fed into the child’s plan. This translated into clear actions within a child’s plan. In one case which was suggested as an ‘exemplar’ there was very good practice, with clear use of the tools and the impact that these had on the outcomes for the child.

Changes to practitioners or teams in at least two cases had a positive effect and these changes initiated the use of tools from the risk assessment framework. For example, in one case discussed, there were initially a lot of meetings and a lot of case notes that centred around issues that family members, and/or parents were having. When the case was transferred to a new practitioner in a different Unit and the risk assessment tools such as ‘signs of safety’ were introduced, decisions became much clearer and the actions that resulted from this greatly improved outcomes for the child who became central to the case work.

Text that was entered into the Audit tool in response to Question below:

Case No

1. Chronology - detailed and regularly updated, Multi-agency working, worker knows the family well. Westburn involvement clear, Westburn's use of signs of safety and reframing positives. 2. good analysis of information gathered, which informed the overall plan. 3. Chronology was used well to identify the risk and patterns in the family. 4. Parents involved in assessment process. good use of reflective discussion tools to inform assessment. Good use of Genogram. Genuineness within writing style of reports. 5. When transferred the case from SW to the other, there was well documented handover. The transition smooth and they used all the same risk tools, and language. There was supervision of the case load. There was a good overview with the genogram - prior to reading the reports. The documentation was updated regularly 6. The social worker adjusted the focus back onto the service user which improved the chronology. Use of SHANNARI strengths and vulnerabilities very clear in child's plan 7. Analysis strong, lots of very relevant information, well presented 8. Initial information and assessment gathering was robust. Holistic analysis of risk and need identified. Prompt risk management actions identified, commissioned, undertaken, and completed to ensure safety of child. 9. Chronology was very detailed and highlighted the pattern of risk in the case. The action plans have also highlighted a good level of detail under the SHANARRI headings. 10. Significant improvement in case management once with CIN team and sense workers were actively endeavouring to engage with a hard to reach family and to work alongside them to make improvements. 11. No 12. In the final child's plan clear risk assessment and analysis was recorded 13. Worker aware of the risks within the family, worker know the family well. 13

14. There is no clear evidence relating directly to the use of NRF tools. 15. IFIT's signs of safety, particularly the scaling questions, were very successful at highlighting people's views, risks, mitigations, and the journey of the team around the child. Multi-agency chronology helped provide a holistic picture

8.5. To what extent did you notice the consistent use of risk assessment tools in planning for children across the partnership?

It was reported in response to this question in 60% of the cases audited, that there was evidence of the consistent use of the risk assessment framework tools being used in planning for a child. In response to question 8.2, the use of NRF tools for managing risk, 66% were marked as very good, or good.

In some cases, there was clear and good use of the NRF tools protecting the safety of the child. Over and above risk assessment tools there was helpful use of the ‘Munro model’ in the final closure summary mentioned. In some cases, there seemed to be a change of practice and in one the use of a chronology markedly improved and led to effective multi agency working. Consistent use of NRF tools enabled practitioners to improve their analysis of the impact of parent’s behaviour on one service user.

There were issues reported that the tools were sometimes predominantly social work led and lacked a multi-agency aspect. The use of the risk assessment framework was not consistent across the board. In some cases, the child’s plan was written in a way that strongly suggested that the tools had been used, but the evidence of the actual tools was not in the case file. In some cases, risks were overlooked and due to the tools being different across partners risks were presented differently between health and social work.

Consistency would be helped across the partnership if there was standardisation of the tools used and one system that all agencies could access and write to. During discussions, one auditor suggested that systems are built around an assumption that consent is on a single agency basis and we need to move to multi-agency assumption for this to work. Testing shared tools through CPC was recommended as there is a multi-agency information sharing protocol in place.

Text that was entered into the Audit tool in response to Question below:

Case

1. No note 2. where the paperwork (child’s plan or health report) includes shanarri/vuln matrix, plan this is clearly used. However, "narrative" of contacts was not explicit in use of assessment/analysis of ongoing risks, or of planning to reduce risk 3. There is evidence of the NRF tools being used in the various reports from partner’s however the different templates of forms make it difficult to identify the consistency of how the tools are being used. 4. it was clear that positive working relationships had been established and this was reflected in the quality of support, level of meaningful engagement and progress made. Recording over COVID tight and ongoing care plan and SCRA report clear and succinct. Helpful to have PRAGS grade and care plan clear within the Carefirst.

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5. It was consistently used throughout and was clear during review. Clearly highlighting the different partners involved 6. Social work reporting on others input no evidence of other service chronologies. The later consistent use enabled practitioners to see Stella and improve their analysis of the impact of the parent’s behaviour on her. 7. No note 8. where tools are built in i.e. child’s plan/health reports they are clearly used 9. There is a consistency in the information provided form health and social work with regard to the risk of the child. However due the different tools used in health and social work it is identified differently. 10. Helpful use of Munro model in final closure summary. Chronology markedly improved with effective multi agency working evidenced later in the case. 11. Risk assessments - heavily SW led. Although reference to previous concerns and similar traits, seems to have been referenced but possibly minimised - or it may just be that it has been more difficult to understand/review. Possibly been made more difficult with the early birth, the changes of houses and transfers between staff and Covid 12. Some risks appeared to be overlooked i.e. Mother's emotional health and prioritising her own needs. Some risks were identified but no link made by impact on child evidence through child being on register since birth. 13. No note 14. There is limited information detailing partnership working with regard to risk, therefore unable to assess any consistent work throughout the partnership. 15. IFIT's involvement created coherence within the Team Around the Child. Similarly, they were able to support Mum alongside signposting what needs to happen next in order for continued success to be evidenced.

8.6. What impact does the inconsistent use of risk assessment tools have in planning for children across the partnership?

Based on an approximation referenced in section 8.5 that 60% of the responses suggested a consistent use of the tools in the NRF, then 40% of cases audited used these inconsistently. Examples of inconsistency are lack of analysis, single agency chronologies, making a case difficult to follow. The lack of analysis can lead to poor decision making. The feedback suggests that this can lead to a lack of shared understanding of risk and again there was limited information showing partnership working in some cases. If tools are not used consistently, then although there can be evidence of meetings in some cases, there seemed to be less clarity around decisions being made based on assessed risk. The resulting case notes then centre around a family’s issues as opposed to what the child needs. Only a couple of cases had truly multi-agency chronologies, with one case mentioning several single-agency chronologies. This could in part due to the tool being different across partner agencies and having no single repository for the tool to be shared and added to by all agencies involved.

In one case there was a really detailed multi-agency chronology for the older sibling, but personalisation was lost for the younger sibling, again inconsistent use hampering clear use of the tools. The auditor for this case suggested that the design of the tool could be part of the reason and suggested a review of the template. This was mentioned by several auditors during the discussion.

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The impact of training to improve consistency was also mentioned during discussion.

Text that was entered into the Audit tool in response to Question below:

Case

1. No note 2. lack of agreed understanding of overall risk and outcomes for child, keeping child at centre 3. It makes it difficult to identify how the risk is being managed, there is a lack of analysis from the reports. Additionally, the different templates of forms identify the risk differently. It was felt that the social work forms do not support the possibility to identify the use of NRF tools, it was noted that this was clearer from the NHS form. 4. Genogram could have had greater input from health to inform assessment. This was however reflected in other areas of the file. 5. It was used consistently throughout in this case and both feel that this has not been an issue. 6. the early focus on the child is lost and planning for children across the partnership may be impacted by disjointed working and distracted by parental resistance. If tools such as chronologies are not reviewed, embracing a full multi-agency approach, and patterns explored then planning for children across the partnership may be taken up with addressing chronic situations with long term poor implications for children rather than more effective, early child focussed, interventions considering a child's stage of development. 7. No note 8. No note 9. The inconsistency of the use of tools, regards the risk in a different manner and leads to inconsistent planning. There was limited full analysis to identify the different risks to the child and mother which has impacted on the planning for the child. 10. inconsistencies were reflected in the limited progress made with case. Writers left with sense this child was going to present with further difficulties and of missed opportunities to have improved outcomes. 11. Difficult to follow and therefore it is hard to know if a partner or multi-agency partners have been able to fully understand the risks identified and the mitigating factors thereafter. It is more likely that a risk is missed, minimised, or not considered during the case/partnership. There is particular reference within the misc. folder - towards the middle child - which evidenced mothers lack of emotional intelligence towards the child - contact was stopped. There was nothing to say it was shared with partner agencies. Agencies would have limited info going forward when assessing the full risks thereafter. 12. The delay in early intervention can result in children's outcomes not being improved. This is best evidence here in the early lack of focus on parental resistance and behaviour on Ellie's wellbeing. 13. No note 14. There is limited information detailed about partnership working. This has made it difficult to assess any inconsistencies which would impact planning and how the risk is being managed. 15. There is a lot of information, but a lack of analysis early on. This results in neglect compounding and accruing over time, which led to a crisis point e.g. missed medical appointments and mismanagement of medical care. There is little evidence of scrutiny early on. The file contains multiple single-agency chronologies, which is not helpful from a risk analysis perspective.

9. SUMMARY

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9.1. Use of National Risk Framework

The hypotheses that the children’s services workforce routinely, but inconsistently, utilise chronologies, the resilience matrix, genograms, and other National Risk Framework (NRF) tools was supported. When the NRF tools were used well, the assessment and analysis of risk was clear. The resulting decisions and actions taken for children were then clear and links could be seen between the child’s plan and the tools used in these cases. Where NRF tools were utilised, the decisions and actions were focused and centred around the child, and this avoided drift.

In a minority of cases where there was no clear evidence of the use of risk assessment tools to make decisions about the child, there was a lack of clear decision making. These cases were reported as having evidence of meetings, which centred around the family issues as opposed to analysis of risk around the child. Those cases could have benefited from the use of the NRF tools. Indeed, in one case when a child moved teams, the change in practice to the utilising of the NRF tools made a remarkable difference in the decisions and ensuing actions taken to improve outcomes for the child.

Chronologies were present in each case, however, in many they were simple lists of activities and no real analysis was present. Similarly, with genograms, if present they tended to be basic and contained little analysis. Risk assessments of various types where used were, in the main, of a good standard, but there was not consistent use across the cases or the partnership. Opportunities to capture good work and good practice were missed. Where there was no copy of a tool in a case file, there was often still evidence that tools had been used in many cases on the child’s plan, they just had not been saved in the case files. This was seen as practitioners ‘selling themselves short’ at times.

The consensus was that there was a real commitment to good partnership working across Aberdeen City. The cases audited also demonstrated a real commitment to Aberdeen’s children. There was good input to the children’s lives, and some was excellent. There were inconsistencies, but where tools had been used, they were used well. There was only one case where use of the NRF was marked as weak.

Finally, it was clear that people had worked hard during the coronavirus pandemic to be as creative as possible in ways to support children and auditors wished this to be acknowledged in this report.

10. CONCLUSIONS AND RECOMMENDATIONS

How are we doing? And How do we know?

10.1. Key Strengths

• In the majority of cases audited, some good or very good practice in the use of NRF tools was found. None were marked as unsatisfactory and none said that there was no evidence on file.

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• Linking analysis of risk using the NRF tools to the Child’s Plan was generally good or very good across the cases audited.

• There was evidence of effective partnership working and relevant information sharing across the multi-agency partners

• The audit team noted that overall, there was a willingness to follow best practice across the partnership. All but one file was adequate or above in the use of risk assessment tools. Consistent utilisation of available multi-agency training would support ongoing improvement.

10.2. Key areas for improvement

• Consistent use of the National Risk Framework is needed across partners in order to ensure that the persistent focus is on the child, family and their wider world.

• A standardised suite of risk assessment tools under the CPC banner, with a user-friendly guide and accompanying training for use across multi-agency partners in the city, would support improved practice.

• Understanding of the child’s whole circumstances would be aided by extending the use of technology to allow sharing of the tools across partners, such as through Microsoft Teams.

What are we going to do now?

10.3. The Child Protection Committee is asked to

• Disseminate the findings from this audit in order to reinforce the consistent use of NRF tools

• Progress a standardised suite of risk assessment tools under the CPC banner, with a user-friendly guide and accompanying multi-agency training.

• Progress the adoption of appropriate technology across the partnership which supports the sharing of these NRF tools

Report authors

Billy Nicol, the Quality Assurance and Audit Lead, Integrated Children and Family Services, Aberdeen City Council

Stuart Lamberton, Lead Officer, Aberdeen City Child Protection Committee and

Kymme Fraser, Service Manager, IC&FS and Chair of the CPC’s Performance & Quality Assurance Sub Committee

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Appendix I – audit tool

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