Showing posts with label safeguarding. Show all posts
Showing posts with label safeguarding. Show all posts

Saturday 19 June 2021

Time to put pupils' needs first at JFS rather than play the blame game

 

Last Saturday LINK I reported the news that Sir Michael Wilshaw had taken over as Interim Executive Headteacher at JFS secondary school, a Jewish orthodox religious school in Brent but with a much wider catchment.  JFS’s foundation body is the United Synagogue and its religious authority is the Chief Rabbi of the United Hebrew Congregations of the Commonwealth. The headteacher had resigned and it appeared that the safeguarding of pupils was an issue.

On Tuesday of this week in an interview with Jewish News LINK, Wilshaw claimed to have already improved the school but blamed Brent Council for not intervening earlier:

When they knew there were issues around safeguarding and mental health issues, they should have been in here monitoring the situation – well before Ofsted. The local council has failed this school, there is no question about that in my mind.

This was followed on Wednesday by publication of  unattributed responses from Brent Council published in Jewish News LINK.

But it is understood that senior figures within Brent Council have reacted with “outrage” at the interim headteacher’s claims.

Sources within the local authority point to the 2016 Ofsted report into JFS, that was published during Wilshaw’s stint as chief executive with the official education inspectors.

They pointed to the fact that the 2016 report described safeguarding at JFS as “effective” and added that pupils “knew where to seek help” if needed.

They same sources also insisted it has been Brent who had intervened “very recently” to ask Ofsted to look at the school over safeguarding concerns.

One source added: “It is laughable to read Michael Wilshaw suggesting he has managed to turn a school around in a matter of weeks.

“Senior figures at Brent are meeting to decided how to respond to his comments, but the feeling is there are far bigger issues at stake here that Mr Wilshaw.”

On Thursday  Jewish News in an 'Exclusive' LINK published extracts from the Ofsted report on JFS which deemed the school 'Inadequate'. The report has not yet been published on the Ofsted website so please treat their summary with caution:

KEY FINDINGS FROM OFSTED REPORT: 

  • School leaders “do not ensure that all pupils are safe from harm”
  • Pupils don’t observe “appropriate boundaries”
  • Student relationships damaged “by unchallenged, inappropriate behaviour…including sexual harassment.”
  • JFS “does not adequately provide for pupils’ wider personal development”, including PSHE, RSE and LGBT issues
  • School in special measures for “failing to give its pupils an acceptable standard of education
  • Persons responsible for leading the school “are not demonstrating the capacity to secure the necessary improvement”

A spokesperson for the United Synagogue told Jewish News: 

This is a very distressing Ofsted report and one which we know will make very troubling reading for parents, students and staff. Notwithstanding the positive findings about the school’s education and sixth form, the serious failings found by Ofsted demand urgent attention. We acknowledge the governors recognise this and have already taken steps to improve safeguarding in particular. We will be working with the school to ensure the programme of improvements continues at pace.

In my view there appears to be some singling out of Brent Council for blame in the media when responsibility should be much more widely shared. The 'blame game' should not divert the partners involved from the main priority of safeguarding pupils and putting measures in place for addressing the mental health of those pupils who have suffered from sexual harassment in the past.

 


 



Tuesday 11 June 2019

Brent Scrutiny to examine progress since the 'Adult B' Safeguarding Adult Review

The Community and Wellbeing Scrutiny Committee will tonight (6pm Brent Civic Centre) receive an update and progress report LINK resulting from the Safeguarding Adult Review (SAR) of Adult 'B' whose case was covered on Wembley Matters and in some of the national press. The Review was triggered because there was evidence that Adult B had experienced abuse and/or neglect and that there was concern about how agencies had worked together to safeguard and promote her well being.

The report to Scrutiny by Michael Preston-Shoot, Independent Chair of the Brent Safeguarding Adults Board, sets out in details what has been done locally as a result of the Review as well as the national context.

His final remarks summarise the current position:
 
The purpose and terms of reference for the Adult B SAR are detailed in the review itself, which is an appendix to this report LINK. Put succinctly, the SAR’s purpose was to identify good practice and shortcomings in Adult B’s care and support provision and to learn lessons about the care and support provided to a person with learning disabilities, protection planning and the use of the Mental Capacity Act 2005.

It is clearly laid out in the SAR that what had been provided to Adult B over a considerable number of years had been very limited. She had been provided with accommodation and her basic needs had been met. However, with reference to the components of wellbeing in section 1 (Care Act 2014), provision had been limited. The SAR therefore challenges all those involved with arrangements for the care and support of learning disabled people with respect to what the vision and ambition is for service provision.

 If residential care is to be provided to people with learning disabilities, then this needs to be accompanied by other forms of service provision in order to deliver on all aspects of wellbeing. It is questioning whether, in all cases where care and support is being provided, relying just on annual reviews is sufficient to ensure that people’s needs continue to be met and their wellbeing enhanced.

Concerns about provision for learning disabled people are not unique to Brent. There have been other SARs that have highlighted shortcomings, of which Winterbourne View (South Gloucestershire SAB) and Mendip House (Somerset SAB) are particularly noteworthy.

In relation to the recommendations, detailed advice was taken by Adult Social Care in relation to the other residents in the care home and that advice has been acted on, with plans implemented to ensure their health and wellbeing. The first recommendation has, therefore, been completed although work obviously is on-going with respect to monitoring the quality of the new arrangements.

Adult B now has an allocated social worker. Adult B and her mother were provided with considerable support in the run-up to her move and this support has continued. Adult B is safe and well, and is making good progress in her new placement. The second recommendation has, therefore, also been completed but work is on-going with respect to monitoring the quality and outcomes of the new arrangements.

The third and fourth recommendations relate to the development of services generally for learning disabled people and the SAB’s role in seeking reassurance that the lessons from the Adult B SAR have been embedded. The SAB will receive regular updates from Adult Social Care and the CCG regarding the development of services for learning disabled people, the management of provider concerns, and the provision of primary care healthcare checks. The SAB also receives regular updates of the outcomes locally of reviews of deaths of learning disabled people (the Learning Disability Mortality Review Programme), which means that the case of Adult B is not seen in isolation.

The responsibility for overseeing the outcome of the recommendations rests with the SAB and ultimately myself as Independent Chair. I have facilitated dissemination events and will continue to do so in order to ensure that the lessons from the Adult B SAR, and from other SARs nationally involving learning disabled people, are known and the findings reflected in good practice locally. 

The last SAB annual conference deliberately included a keynote presentation on SAR findings and another on good practice with learning disabled people. The SABs strategic plan, a statutory requirement from the Care Act 2014, is being updated for 2019/2021 and there will be a strategic priority that focuses on learning disabled people to ensure a focus on service improvement in this field of practice.

Adult B and her mother will continue to receive support from a social worker and GP to ensure that her health and social care needs are met. Adult B’s mother was consulted during the SAR process, so that her views were incorporated fully. She was also fully involved in discussions about publication of the SAR and was supportive of publication to ensure that lessons are learned both locally and nationally.


Tuesday 29 January 2019

The Brent Council 'Cassie' safeguarding case revisited.

This story, which appears to have hit the press again, was first reported by Wembley Matters in October last year. I reprint it here as it provides a much fuller account and at the end Brent Council's response to the Review findings and recommendations,

A Safeguarding Adult Review published by Brent Council LINK raises serious issues about the service provided by the Council and bought-in providers to people with an autistic spectrum condition.
The case concerns ‘Cassie’ (not her real name) a Black woman in her mid-50s who has lived in services for people with learning disabilities and autism since she was a child. Information about Cassie was limited to her clinical classifications and records held by health and social care services, including the Independent Provider, the autism specialist residential home at which she has lived since 1990.
Cassie was found to be HIV positive in 2016 which triggered a safeguarding meeting. The Infectious Diseases Team confirmed that it was sexually transmitted at some point between 2007 and 2015 while Cassie was resident with the independent provider commissioned by Brent Council. It was confirmed that Cassie did not have the capacity to consent to having sexual relations and a police investigation was agreed. During March 2017 the Safeguarding Adults Board was informed that the police investigation had been closed. Cassie was moved to a different home that was managed by the same provider.
The report outlines the poor quality of Cassie’s provision:
It is remarkable that Cassie’s many years of residing in long stay hospitals and latterly, at the Independent Provider, reveal so little about her. Whatever the names of the hospitals she has lived in, observers and some former residents have commented on the bleak and unstimulating environments of large institutions. There were no opportunities for children with severe learning disabilities to learn functional skills, including basic communication skills, or to prepare for life beyond the institutions.
It is noteworthy that the single sign which Cassie was consistently encouraged to use was “Thank you.” 

Knowledge of Cassie is primarily based on clinical interpretation and classification and these do not help in deciphering the ways in which she engages with others or with objects. There is neither a simple nor consistent description of her. Yet support staffs’ understanding of Cassie determines how she spends her days. The challenges Cassie faces in figuring out the world are unfamiliar since so little is known of her developmental path. The records suggest only partial accounts of her behaviour or aspects of particular actions. How her interest in paper tearing is defined is critical.
During her adulthood, Cassie began to create scatterings of torn paper. The Independent Provider notes that she becomes distressed when she is required to pick up and put the pieces of paper in the bin. This prompts the question: Is this the only possible intervention? It is clear that Cassie can communicate intention. For example, she takes people to the kitchen when she is hungry and she gets her coat when she wants to go out. It is known too that she needs a lot of help in terms of her personal and intimate care. This does not preclude her having unique forms of communication, demonstrating awareness 
of others and desiring to belong and participate. For example, she enjoys her mother’s visits and she likes to sit with staff.

The records suggest that during the weeks prior to Cassie’s HIV diagnosis, her world experience appeared to be confined to her bedroom and the living room and, specifically, the sofa.
Cassie’s mother told the Review:
‘When Brent closed its day centres I was told, “We’ll make a programme for her so she can got out, meet people, walk around - we’ll put a programme together and include shopping and visiting you.” Nothing materialised...’I was told that one place Cassie could go to - the Independent Provider’s Day Centre was being “repaired.” She got a place there but it didn’t last long. I had a letter saying that Brent had cut the grant and she didn’t go back no more.  She’s bored. It was better when she went to the centre. Now they just sit in the living room with the music channel on the TV. There are only three of them and that’s what they all do.’
Naturally Cassie’s HIV diagnosis was devastating for her mother.  The HR person at the provider told her that the incident must have happened at night: ‘This is all I know. This rape, which I can’t talk about or tell anyone about, this rape happened. Cassie had no control over her body and this man takes over her body. You can’t get them to take tests because of their human rights, What chance have you got. I asked the police if they could offer a reward. They said “No” because people tend to close ranks.’
The review states that the majority of the Independent Provider’s Risk Assessment date from the months of Cassie’s diagnosis. There are many gaps in the ‘monthy reports’ and other information: ‘The notes convey only biographical fragments, The monthly reports contain a lot of repetition and evidence of “cut and paste.” This renders problematic the claim that these will be subject to “trend analysis.”
 
General Practitioners who cared for Cassie said they were shocked when the Infectious Diseases Team made their diagnosis because Cassie is ‘so very vulnerable.’ As a patient she is sometimes compliant but there are a lot of barriers to investigating what is wrong. Cassie’s cooperation depended on how calm her carers were and this varied.
There is much more on the medical history in the report but significantly it is reported that Cassie did not benefit from annual reviews with none undertaken during 2008, 2011, 2013 and 2014.  She has contact with the Learning Disabilities Community Health Team for psychiatric and a brief period of physiotherapy support and is reviewed in outpatients every 6 months.
The report summarises the ‘best interests of the person’ provisions in the Mental Capacity Act (MCA) 2005:
·      Equal consideration and non-discrimination
·      Considering all relevant circumstances
·      Regaining capacity
·      Permitting and encouraging participation
·      Special consideration for life sustaining treatment
·      The person’s wishes and feelings, beliefs and values
·      The views of others
The report notes, ‘There is no reference to the MCA in relation to Cassie’s care and support. Although the Independent Provider cites ‘best interest meetings’ there are no documented examples  examples of any such meetings.’
 
Later it states, ‘Irrespective of the seriousness of Cassie’s HIV diagnosis, no individual or agency has undertaken to determine her best interest in relation for a achieving a consensual approach to decision making concerning invasive treatment or even essential treatment.’
In a telling passage the report says:
‘The absence of a credible life story is stark, that is one which goes beyond setting out Cassie’s likes, dislikes and challenging behaviour, for example. Without the account of Cassie’s mother and her GP’s descriptions of what they have earned from supporting her, Cassie’s life-long history of being supported by services is reduced  to a disheartening short list of home based activity. Although it is known that Cassie loves to walk and her impulse to get out is undiminished, at the provider’s centre this is given expression in her fast paced restlessness. Cassie’s life story is not known. That is to say, the relevant parts of her past and present have not been recorded. The services to which Cassie is known appear not to have any processes for eliciting stories about her and her family as a means of connecting her life to her present circumstances and the people who are significant.’
The report issues a number of challenges to Brent Council:
Since Brent’s commissioning did not ensure that the Independent Provider established the necessary conditions to support Cassie, this is an opportune time for Brent to initiate a fresh approach to the support of people with autism. What ‘autism specialism’ is Brent seeking? It cannot be credible that faith is invested in a service which advertises itself as specialist. Brent has a responsibility to identify and monitor the tasks required ti address Cassie’s considerable support needs and those of others with autism and learning disabilities, What arrangements are in place in Brent to provide support to the families of people with autism at times of transition and to ensure that workforce planning, training and retraining arrangements are effective? The test of such investment will be in the improvements they bring to the lives of people with autism and learning difficulties.
Concluding the review, Dr Margaret Ryan states that Cassie has been failed by services and that by exposing her to sexual abuse by a third party without appropriate care planning and risk assessment  was professionally negligent and possibly in breach of the duty of care: ‘The evidence suggests a possible breach of the right to respect for private and family life and potentially a breach of the right to protection from inhuman and degrading treatment.’
Dr Ryan goes on to express disappointment that the Independent Provider states that the organisation is unable to comment on the assertion that Cassie was infected as a result of sexual assault as they has ‘seen no evidence of this.’  The documentation does not support the assertion that Cassie was solely supported by women staff.
At the time of the report Cassie remained with the provider, albeit in different accommodation, and her mother is unhappy with the arrangement  and wants urgency in seeking an alternative placement. Dr Ryan states that, ‘thus far, there is no evidence of attentive external scrutiny of her post-diagnosis care plan. Since the documentation shared by the provider and service reviewer is limited it is possible that these are systemic matters.’
Dr Ryan suggest that Brent Council has to undertake a great deal of work concerning the use of the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards: ‘Cassie’s health is compromised and is vulnerable to deterioration. It is not clear what “practicable steps” were taken to support Cassie’s decision-making in advance of a determination of incapacity.’
The Review’s Recommendations:
1) Since there is cause for concern and uncertainty concerning the HIV status of the five residents at the care home, Brent requests the Court of Protection to give direction in this matter 

2) Cassie should be provided with additional interim support until she moves to another service. Such support should be informed by the principles an management of care as set out by NICE guidance

3) Brent’s Safeguarding Adults Board seeks reassurance that:
·      The Transforming Learning Disability Services’ initiative of the CCGs, permits and 
establishes with Brent’s Adult Social Care an ambitious path which promotes greater attention to individual support needs which credibly involves (i) self- advocates and (ii) engagement with the families of people with complex support needs, most particularly in ensuring that account is taken of people’s life stories and their future aspirations 

·      Future changes (that result in discontinuities of personnel and functions) in respect of reviewing and monitoring long-term placements must ensure that (i) people funded by public services are better off or at least not worse off, (ii)  http://www.lawcom.gov.uk/wp-content/uploads/2017/03/Mental_Capacity_Report_Summary.pdf (accessed on 6 July 2017)
 NICE (2012) Autism spectrum disorder in adults: diagnosis and management (CG142reviewing is annual and (iii) goals or “ends” for people receiving services are not displaced by undue attention to “means”
·      The Transforming Learning Disability Services’ initiative adopts a proactive and 
questioning approach to the scrutiny and oversight of all placements. Critical skills should be evidenced such as: collaborating with people with autism and their families; knowledge of effective care planning; knowledge of safeguarding and, specifically, how to record safeguarding concerns; identifying potential community collaborators; and because several medical conditions are significantly more prevalent among people with autism compared with people who do not have autism,ensuring that medical appointments are prioritised 

·      The operational competences and track records of specialist providers are known to service commissioners in term of the recorded outcomes realised for individual people with autism 

·      The Learning Disabilities Community Health Team and specialist providers can provide evidence that they are (i) instrumental in working with GPs in detecting health problems which would otherwise result in unnecessary suffering; (ii) make it possible for residents to develop health routines such as accessing health screening and health promotion activities; and (iii) are persistent and creative advocates for people’s improved health and health care – paying particular attention to the challenge of “diagnostic overshadowing” 

·      The Learning Disabilities Community Health Team assumes a lead role in promoting positive practice in the use of the Mental Capacity legislation 

·      The signs being taught to people with compromised communication skills include the sign for “No!” 

4) Brent’s Safeguarding Adults Board may wish to consider advising service commissioners that questions must be asked about the mechanisms in place to ensure the safety of people with limited articulacy, in particular those who are supported by male workers.
Brent Council in a statement to Wembley Matters said:
“All of the partners on the Safeguarding Adults Board, including the Council, have expressed our deep and sincere regret to both Cassie and her family.   We can confirm that Cassie is now safe and happy and is having all her health and care needs met. 
“As soon as the Council became aware of the situation the Safeguarding Adults Team took immediate action to ensure that Cassie was safe and receiving the support she needed, and further steps were taken to ensure no other person was at risk.  The matter was reported to the police, who undertook a full investigation. 
“Following these immediate actions, the Council asked the Safeguarding Adult Board to consider commissioning an independent Safeguarding Adult Review (SAR).    A SAR is a nationally recognised process, under the Care Act 2014.   The Board and the Independent Chair agreed this met the criteria for a SAR because there had been serious harm in a complex case which involved a wide range of statutory and voluntary agencies.  The purpose of a SAR is to ensure the independent consideration of the facts, and to use these facts to identify and promote effective learning across all agencies.  It is a key part of improving services in order to prevent serious harm occurring again.  The function of SARs is not to apportion blame or make judgements about negligence.
“As a result of the SAR, the Safeguarding Adults Board has a multi-agency action plan.  This will be monitored by the Board and the Board’s Independent Chair, who will ensure that the lessons have been learnt across all the agencies involved.   
“The Council has fully supported this process.  We have already delivered a range of actions to improve the support we provide to vulnerable adults in Brent, including setting up a team that specifically focuses on reviewing the quality of care and support for individuals in residential placements, and integrating the health and social care learning disability teams into a single team providing holistic support to adults with a learning disability. 
“Cassie continues to do well in her new home and we continue to ensure that she is getting the support that she needs.”
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Friday 2 January 2015

Brent Council Risk Register reveals potential impact of the cuts

The Corporate Risk Register is an important document that highlights the risks of Council services not being delivered effectively and the actions taken to overcome that risk.

As the budget is reduced and cuts in staffing take place, as well as out-sourcing of services, it is important to keep an eye on the Register which flags up potential issues.

The full document is available HERE but below I have set out some of the main areas. The wording is from the original, except for the correction of some typos and spelling mistakes, with my comments in red.

Under each heading the risk is set out, the impact, and (in italics)  the most recent action undertaken to reduce the risk:


Monday 12 November 2012

Meanwhile Coalition proposals increase risk to abused children claim experts

In all the controversy over Jimmy Savile and Newsnight the media have ignored proposals from the Coalition that, as part of their anti-red tape anti-health and safety agenda and privatisation agenda, could increase risks to children.

In a piece of research for the trade union Prospect LINK Dr Liz Davies, reader in Child Protection at London Metropolitan University and Roger Kline, Social Care spokesman for the Aspect group of Prospect. claim that the Working Together revision documents are 'not fit for purpose'. These documents have been the backbone for child protection work for many years.

In the light of recent revelations and in the current economic climate where there are increased pressures on adults through benefit cuts, low wages and unemployment, children are likely to become more susceptible to abuse and neglect.

Summarising their concerns, Davies, Kline and their co-authors argue:
1. The current proposals to revise Working Together are seriously flawed and dangerous. There are significant, and fundamental misunderstandings of what is required to protect children from harm. We are convinced the proposals will undermine multi-agency and multidisciplinary working. The failure to be sufficiently prescriptive and mandate certain measures will lead not only to confusion and mistakes but will undermine the ability of staff within each agency to prioritise and access resources to support the work of child protection.

2. The proposals appear to be driven by a desire to, ‘cut red tape’ but are undoubtedly part of the Government’s localism agenda. Through deregulation and the privatisation of services the proposals are just one aspect of the rolling back of the Welfare State. No evidence has been provided that such fundamental changes will improve child protection or responses to children in need, or that even the status quo will be maintained. We believe that, in fact, the proposed changes constitute a serious risk to vulnerable children. We strongly recommend that this revision be withdrawn so that a more considered, evidence based discussion can take place about what changes might be needed to Working Together in order to support good practice by the national provision of proportionate and relevant statutory guidance that is fit for purpose.

3. The objectives of the Revision include, ‘to provide the essentials that will enable and encourage good cross-agency working – so that all organisations understand what they should do to provide a coordinated approach to safeguarding’ (DfE 2012). In this submission we argue that, should it be approved as guidance, it will achieve the exact opposite. It is a non-evidence based attempt to drastically reduce the statutory guidance and we believe it will certainly leave the most vulnerable children at risk of harm unprotected as well as risk a reduction in services for those assessed as children in need.

4. The Revision promotes a form of professional dangerousness where children are placed at risk by the actions and omissions of policy makers. For reasons, presumably, of expediency, the guidance appears to have been cut merely to reduce page length and the impact assessments (2012 a&b) are clear that the changes would lead to cost cutting. The Revision sits well with government agendas of privatisation, deregulation and cuts. As the campaign Every Child in Need cites, ‘basic minimum national standards and requirements are essential. A hands-off approach, allowing local authorities to do what they want, when they want, is dangerous. Even the Government’s own impact assessment recognises this – it accepts that, “there is a risk of negative impact on children if central government is less prescriptive (DfE 2012b) That is not a risk we should be taking(Every Child in Need Campaign 2012).

5.. These changes come at a time when there is evidence of unprecedented increase in serious crime against children. Child abuse occurs within families and this context provided the focus of the Laming and Munro reviews (2009 and 2011). However, there is a vast international child abuse industry that exploits children and includes trafficking for commercial, domestic and sexual exploitation, online abuse, the illegal adoption trade, the illegal organ trade, forced marriage and the trade in abusive images. These are not marginal issues but are addressed by child protection professionals on a regular basis and yet the Laming and Munro reviews (2009 and 2011) were narrow in focus relating only to abuse within the family. Therefore the Revision, which is based on models of practice recommended in these recent reviews, omits examination of complex joint investigative work required to identify and target perpetrators and protect numbers of children in the context of organised crime. Ironically, the government only recently published an action plan with regard to child sexual exploitation (DfE 2011a) and yet comprehensive, existing Working Together guidance is being discarded (DfES 2009).
With the history of serious child abuse cases in Brent, and indeed deaths of children such children, it is imperative that Brent Council takes on these concerns and ensure that their procedures are effective and go beyond the Coalition's suggestions and urge the London Safeguarding Board to do the same.
 
Department for Education (DfE)(2011a) Tackling child sexual exploitation. Action Plan. London. DfE . Available from: http://www.education.gov.uk/childrenandyoungpeople/safeguardingchildren/a00200288/tackling-child-sexual-exploitation
Department for Education (2011b) Tim Loughton M.P. response to parliamentary question by Andrea Leadsom M.P. 13th December 086572. Available from; http://www.rcn.org.uk/__data/assets/pdf_file/0006/423978/Munro_report_progress_15kb.pdf
Department for Education (DfE) (2012a) Impact assessment. Revision of Working Together to
http://media.education.gov.uk/assets/files/pdf/i/impact%20assessment%20managing%20individual%20cases%20%20%20framework%20for%20assessment.pdf
Department for Education (DfE) (2012b) Impact assessment. Managing individual cases.Framework of Assessment. Available from: http://media.education.gov.uk/assets/files/pdf/i/impact%20assessment%20%20%20working%20together%20to%20safeguard%20children.pdf
Department of Children, Schools and Families (DCSF) (2009) Safeguarding children and
young people from sexual exploitation. London. The Stationery Office