Safeguarding JSNA | Boltons Health Matters
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Safeguarding JSNA

Abstract

This is the JSNA chapter on safeguarding. Theme chapters summarises implications for commissioning, who is at risk and why, the level of need in the population, service provision and use, unmet needs, what works in terms of evidence, community views and priorities, any related equality impact assessments, unmet service needs/gaps and recommendations for further needs assessment work. 

Introduction

This chapter is concerned with the safeguarding of children, and more specifically with child protection.  The protection of children from accidental injury, which is another key component of safeguarding, is addressed in a dedicated chapter while the safeguarding of adults is addressed within other JSNA chapters.

On average, every week in England and Wales at least one child is killed at the hands of another person .
The maltreatment of children – physically, emotionally, sexually, or through neglect - can have major long-term effects on all aspects of a child’s health, development, and wellbeing. The immediate and longer-term impact can include anxiety, depression, substance misuse, eating disorders and self-destructive behaviours, offending and anti-social behaviour. Maltreatment is likely to have a deep impact on the child’s self-image and self-esteem, and on his or her future life. Difficulties may extend into adulthood: the experience of long-term abuse may lead to difficulties in forming or sustaining close relationships, establishing oneself in work, and to extra difficulties in developing the attitudes and skills necessary to be an effective parent. 

The social context within which child abuse occurs is complex and there is no easy way of predicting where abuse is more or less likely to take place.  Corby et al  describe a very wide range of potential contributory factors to the abuse of children.

During the year 2011/12, Bolton Council’s social care services received almost 4,000 referrals.  For 252 of those referrals, the risk to children’s safety was severe enough to warrant drawing up a Child Protection Plan for the child or children concerned. 

Implications for Commissioning

• To continue to influence and challenge new and existing partnership and commissioning arrangements e.g. Health and Wellbeing Board, CCG, Children's Trust.
• To drive forward our evaluation of the impact, effectiveness and outcomes for children from services/partners/projects developed locally to safeguard children from all communities, including an outcomes framework for BSCB and the effectiveness of early help.
• To maintain safeguarding standards  in a challenging financial climate - lead practice and quality assure.
• The challenge to Local Safeguarding Children Boards is to ask what they are doing to safeguard and promote the welfare of children at risk of sexual exploitation.  The Government’s action plan is clear that LSCBs have the key responsibility for ensuring that relevant organisations cooperate effectively to safeguard and promote the welfare of children. 
• Manage BSCB business effectively and efficiently.
• To improve communication of BSCB work to workers and wider community.
• Continue to improve challenge role.

Who's at Risk and Why?

Children are at risk of abuse because they are vulnerable.  Depending on their age and development, children rely on adults to protect them and meet their needs.  High profile cases such as those of Victoria Climbié in 2000 and Peter Connelly in 2008 influence safeguarding policy and practice.  The case of Victoria Climbié resulted in a major change in government policy to improve outcomes for children.  Since the court case following the death of Peter Connelly there has been a significant increase in the number of children in need of a child protection plan.
Research cited by Ofsted in the report available at this link suggests that disabled children are more at risk of being abused than non-disabled children.  However, they are less likely than other children in need to become the subject of child protection plans.
Parental factors such as domestic abuse, substance misuse, parental learning difficulties, and mental health issues can impact on the safety and health of children.

Physical Abuse
Physical abuse can lead directly to neurological damage, physical injuries, disability or, at the extreme, death.  Harm may be caused to children both by the abuse itself and by the abuse taking place in a wider family or institutional context of conflict and aggression, including inappropriate or inexpert use of physical restraint. Physical abuse has been linked to aggressive behaviour in children, emotional and behavioural problems and educational difficulties.  Violence is pervasive and the physical abuse of children frequently coexists with domestic violence .

Emotional Abuse
There is increasing evidence of the adverse long-term consequences for children’s development where they have been subject to sustained emotional abuse, including the impact of serious bullying .  Emotional abuse has an important impact on a developing child’s mental health, behaviour, and self-esteem.  It can be especially damaging in infancy.  Underlying emotional abuse may be as important, if not more so, as other more visible forms of abuse in terms of its impact on the child.  Domestic violence is abusive in itself.  Adult mental health problems and parental substance misuse may be features in families where children are exposed to such abuse.

Sexual Abuse
Disturbed behaviour – including self-harm, inappropriate sexualised behaviour, sexually abusive behaviour, depression, and a loss of self-esteem – has been linked to sexual abuse.  Its adverse effects may endure into adulthood.  The severity of impact on a child is believed to increase the longer the abuse continues, the more extensive the abuse, and the older the child.  A number of features of sexual abuse have also been linked with severity of impact, including the relationship of the abuser to the child, the extent of premeditation, the degree of threat and coercion, sadism, and bizarre or unusual elements.  A child’s ability to cope with the experience of sexual abuse, once recognised or disclosed, is strengthened by the support of a non-abusive adult carer who believes the child, helps the child understand the abuse, and is able to offer help and protection.
The reactions of practitioners also have an impact on the child’s ability to cope with what has happened, and on his or her feelings of self-worth.
A proportion of adults and children and young people who sexually abuse children have themselves been sexually abused as children.  They may also have been exposed as children to domestic violence and discontinuity of care.  However, it would be quite wrong to suggest that most children who are sexually abused inevitably go on to become abusers themselves.

Child Sexual Exploitation
In Bolton we recognise that the sexual exploitation of children and young people happens and that it is a form of child sexual abuse.  It involves the use of power and control by perpetrators and is usually characterised by the exchange of sexual services for some form of payment, such as money, alcohol, drugs or consumer goods or even a bed or place to stay.
Children and young people at risk of sexual exploitation can be male or female, able-bodied or disabled and from a range of cultural, religious, and ethnic backgrounds.  Perpetrators of child sexual exploitation will also be male or female, able-bodied or disabled and from a range of cultural, religious, and ethnic backgrounds.  Child sexual exploitation does not discriminate.
Children and young people become involved in sexual exploitation for a variety of reasons.   It may be as a consequence of parental conflict, physical violence, relationship problems, sexual abuse, bullying, truancy, or substance misuse (either by the child or by a member of their family).  Children and young people can also be drawn into sexual exploitation via their friendships, the use of the internet, and other technology.

Description of young person with identifiable risk factors Levels 1 - 3

Sexually exploited children are rarely visible on the streets, and it is therefore difficult to gather consistent and meaningful data.  Moreover, street based sexual exploitation of children is only a small part of the bigger picture of sexual exploitation of children by adults and other children and young people.
The age range of children who are victimised through sexual exploitation has come down in recent years from the 16-18, to children under 16 years of age.  The evidence is that children across all cultures, and including a significant proportion of children in the care of local authorities, can be at risk of sexual exploitation.

Neglect
Severe neglect of young children has adverse effects on children’s ability to form attachments and is associated with major impairment of growth and intellectual development.  Persistent neglect can lead to serious impairment of health and development, and long-term difficulties with social functioning, relationships and educational progress.  Neglected children may also experience low self-esteem, and feelings of being unloved and isolated.  Neglect can also result, in extreme cases, in death.  The impact of neglect varies depending on how long children have been neglected, the children’s age, and the multiplicity of neglectful behaviours children have been experiencing.

Social Exclusion
Many of the families who seek help for their children, or about whom others raise concerns in respect of a child’s welfare, are multiply disadvantaged.  These families may face chronic poverty, social isolation, racism, and the problems associated with living in disadvantaged areas, such as high crime rates, poor housing, childcare, transport and education services, and limited employment opportunities.  Many lack a wage earner.  Poverty may mean that children live in crowded or unsuitable accommodation, have poor diets, health problems or disability, are vulnerable to accidents, and lack ready access to good educational and leisure opportunities.  When children themselves become parents this exacerbates disadvantage and the potential for social exclusion. Racism and racial harassment are an additional source of stress for some families and children, as is violence in the communities in which they live.  Social exclusion can also have an indirect effect on children, through its association with parental substance misuse, depression, learning disability, and long-term physical health problems.

Domestic Abuse
Most children and young people who live with domestic violence are likely to be affected by it in some way, although some children develop apparently successful ways of coping.  Many children experience fear and distress, as well as varying degrees of physical, psychological or emotional developmental problems, the causes of which may be misunderstood by a range of professionals, including doctors, teachers and social workers.  Recognising this, the Children Act 1989 afforded greater opportunities to hear the voice of the child, and the Adoption and Children Act 2002 acknowledged the significance of domestic violence for children by amending the definition of ‘harm’ to include ‘impairment suffered from seeing or hearing the ill-treatment of another’.  Despite this, it is not always appropriate to assume that the child is at direct risk from the violence and, therefore, in need of child protection measures.
The most recent focus on ‘safeguarding’ recognises the role of a range of professionals in promoting children’s welfare.  The relationship between domestic violence and safeguarding children is complex and requires respectful and sensitive handling .
Mental health of a parent  (see also chapter on maternal and infant mental health)
One in four adults will experience some kind of mental health problem in the course of a year.  This could include depression and anxiety, or psychotic illnesses such as schizophrenia or bipolar disorder.
Depression and anxiety are common.  Mental ill health in a parent or carer does not necessarily have an adverse impact on a child’s development.  Just as there is a range in severity of illness, so there is a range of potential impact on families.  The consequent likelihood of harm being suffered by a child will range from a minimal effect to significant one.
The potential impact of a parental mental illness and the child’s ability to cope with it is related to age, gender, and individual personality.  For babies and infants post natal depression may hamper the mother’s capacity to empathise with, and respond appropriately to, her baby’s needs.  A consistent lack of warmth and negative responses increases the likelihood that the infant will become insecurely attached.  Depression may also reduce the level of interaction and engagement between mother and child.  Parents in these circumstances may have greater difficulty in listening to their children and offering praise and encouragement.  Mothers who experience psychotic symptoms after giving birth, and those who continue to be depressed at six months after the birth, are more likely than other mothers to regard their babies negatively and ignore cries for warmth and comfort.
Parental substance misuse
Parental or carer drug or alcohol use can reduce the capacity for effective parenting.  In particular the children of parents or carers who are dependent on drugs or alcohol are more likely to develop behaviour problems, experience low educational attainment, and be vulnerable to developing substance misuse problems themselves.  Some children’s health or development may be impaired to the extent that they are suffering or likely to suffer significant harm.
Difficulty in organising day-to-day living means that important events such as birthdays or holidays are disrupted and family rituals and routines such as meal or bed times, which cement family relationships, can be difficult to sustain.
Problem drug misuse may cause parents to become detached from reality or lose consciousness.  When there is no other responsible adult in the home, children can be left to fend for themselves.  Some problem drug using parents may find it difficult to give priority to the needs of their children.  Finding money for drugs may reduce what is available to meet basic needs, or may draw families into criminal activities.  Poverty and a need to have easy access to drugs may lead families to live in unsafe communities where children are exposed to harmful anti-social behaviour and environmental dangers.  At its extreme, parental problem drug misuse can be implicated in the serious injury or death of a child.

The Level of Need in the Population

The proportion of people in Bolton aged 0-19 years is slightly higher than the average for Greater Manchester or for England and Wales.  In 2011, 25.8% of the population in Bolton were aged 0-19, with 6.8% of these being aged 0-4.  The population of dependent children is unevenly distributed across the borough, ranging from 26% in Rumworth to 18.6% in Little Lever & Darcy Lever.  Although overall the total number of dependent children has remained relatively stable since 2001, there has been a significant increase in the number of under-5s, with 2,000 extra children in this age group now living in Bolton, reflecting a general trend across the UK.  Population projections for Bolton suggest that the number of dependent children will increase by 17% between 2010 and 2035.
The rate of referrals to Children’s social care has increased over recent years and in 2011/12 was higher than national or statistical neighbour (SN) averages at 606 referrals per 10,000 children and young people compared to 533 and 585 respectively.  However, the proportion of children and young people who ultimately became subject to a Child Protection Plan during 2009/12 was significantly lower than national or Statistical Neighbour averages at 39 per 10,000 compared to 46 and 58 respectively.
Winter and Connolly  found a relationship between levels of deprivation in a community and the rate of referrals for child protection support.
Deprivation in Bolton is higher than the National average.  The Income Deprivation Affecting Children Index (IDACI) is used to identify the percentage of children aged under 16 in each LSOA that live in income-deprived households.  Bolton has a significant amount of LSOAs in the 15% most deprived in England.
The number of Bolton’s LSOAs in the most deprived 15% in the country fell slightly for the IDACI index between 2007 and 2010, with just below a fifth of the LSOAs in Bolton now falling into this range.  However, the number of LSOAs in the 5% most deprived in England has increased from 3 to 6, meaning that by measures affecting children, some of the most deprived areas in Bolton have become relatively more deprived compared to the rest of the country.

Current Services in Relation to Need

Lead responsibility for ensuring that work to keep children safe is embedded within the work of all agencies in Bolton rests with Bolton Safeguarding Children’s Board (BSCB).
The work it carries out includes:
• Developing policies and procedures to keep children safe in our area, including when and how to make child protection referrals, Serious Case Reviews etc.;
• Raising awareness with the community and with partner agencies about key safeguarding issues in Bolton;
• Quality assuring and evaluating how well our processes are being used and the impact they have;
• Understanding and responding to themes identified from Serious Case Review and Child Death Overview Panel;
• Working with partners to develop the safeguarding workforce, including the views of workers on safeguarding processes, developing and responding to safeguarding training needs, safe recruitment etc.
Council Social Care services manage a total of six Children’s Homes, including two Short-term Breaks facilities for Children with Disabilities and an Adolescent Support Unit.  Community-based children’s services are provided by three Referral and Assessment teams, three Safeguarding Teams and three Looked After Children’s teams, supported by three teams for family support (which manage 18 children’s centres between them) and borough wide teams for children with a disability, youth offending, adoption, fostering, sexual exploitation, young people’s substance misuse and young people leaving care.  There is an emergency out of hours service providing cover across the borough.
The Clinical Director for Clinical Governance and Safety will take the lead for Safeguarding within the new Bolton CCG, supported by designated and named professionals in accordance with the requirements of Working Together to Safeguard Children.
At 31 March 2012 there were 236 children who were the subject of a child protection plan.  This is a substantial decrease from 367 in March 2010.  Some 42 % of these children are aged under 5 years, 56% are aged 5-16, and 2% are 16 years or older.  The categories of child protection plans were neglect at 48% and emotional abuse at 34 %, physical abuse at 14 % and sexual abuse at 4%.  During the year to 31 March 2012, rates of children becoming subject to a child protection plan fell.
In October 2011 Children’s Safeguarding in Bolton was subject to a peer review facilitated by the Local Government Association.  This review identified many strengths of safeguarding in Bolton, but suggested that the Council and its partners would be able to improve service quality by clarifying further the difference between children at risk of significant harm (who will be subject to a Child Protection Plan) and those with a high level of need, who need support for the child and family even though the threshold for a CPP may not be met.  The Council has reviewed its procedures in light of this feedback and rates of children becoming subject to a full child protection plan fell during the year to March 2012 accordingly.

Projected Service Use and Outcomes

ONS projections based on the 2011 Census suggest that the number of children and young people aged 18 and under in Bolton will increase by just over 10 % over the next decade from 68,201 in 2011 to 75,124 in 2021.  In 2013 this population group numbers 69,338.
The proportion of people in Bolton aged 0-19 is slightly higher than the average for Greater Manchester or for England and Wales.  In 2011, 25.8% of the population of Bolton were aged 0-19, with 6.8% of these being 0-4.
The population of dependent children is unevenly distributed across the borough, ranging from 26% in Rumworth to 18.6% in Little Lever & Darcy Lever.  Although overall the total number of dependent children has remained relatively stable since 2001, there has been a significant increase in the number of under-5s, with 2,000 extra children in this age group now living in Bolton, reflecting a general trend across the UK. Population projections for Bolton suggest that the number of dependent children will increase by 17% between 2010 and 2035.
In the January 2012 School Census, 28.9% of the school population was classified as belonging to an ethnic group other than White British compared to 25.4% in England overall.   Analysis of the ethnicity of children referred to social care services conducted within the Children’s Services Department suggests that the pattern of referrals is now broadly representative of the ethnicity of children and young people within the borough.

Evidence of What Works

London Assistant Directors of Children’s Services submitted the following description of effective practice in child protection to the 2011 Munro Review:
Good social workers possess a range of knowledge, skills and abilities which they utilise to undertake purposeful intervention in the following way:
Assessment as the first stage in developing an understanding of what is happening in a family and the impact on the children within that family.  Relying on practice wisdom and underlying social work theory, the skilled practitioner uses interview and observation to acquire information in order to describe the social history of the family, the relationships between family members, and crucially, the needs of the child in a number of different dimensions (physical, emotional, social etc.) and how these needs are being met or not met.  Social workers work closely with children and parents, and talk to other professionals in order to understand a child and family’s needs, resources and resilience, showing understanding of patterns and dynamics within the family, as well as the impact of wider environmental factors.
Analysis i.e. the ability to break down the different elements within the family situation and the wider community, in order to understand the relationship between the various factors that are impacting on the child, the weight to give to each factor and how they might be changed or influenced.  Using information intelligently and constructing a narrative and hypotheses which can be tested and re-tested are a daily part of the competent social worker’s task.
Risk assessment and the ability to predict future behaviours of parents, weigh up protective and risk factors, and assess the potential for change in a family or with parents is an essential element of the continuing assessment of the family.  These are difficult judgments made in complex situations and demand a combination of reasoning skills and practice wisdom. This is a core skill of children’s social workers.
Working alongside families, understanding family dynamics and contributing environmental factors to help families gain insight, build on strengths and change established patterns of behaviour/relationships – use of systemic family therapy and family group conferences.  In this same context, social workers are able to use the legislative framework in an authoritative way when required.
Problem solving as a key part of social work intervention with families who have complex and difficult lives.  Competent social workers spend time with children and families looking for solutions to their difficulties as defined by the family, and use creativity to ensure the least intrusive intervention is provided.
Decision making and planning based on identified needs, set within the legal and policy framework and which rest firmly on the involvement and wishes and feelings of children – and families when their view is not contrary to the child’s needs.  Good plans are clear, relate closely to outcomes, are accessible to children and families, and able to make effective use of services.  Competent social workers are able (when permitted) to use their professional judgment in decision making and planning to promote positive outcomes for children.  Care planning for children subject to a child protection plan and looked after children is a fundamental aspect of the children’s social worker role and has to be based on a holistic view of the child not always available to other professionals.
Building strong relationships between the social worker and the child and his/her family.  Social workers build relationships with children, young people and parents in extraordinarily difficult circumstances, and within a context that would appear from the outset to be counter to any chance of creating a positive dialogue.  The situations in which social workers build positive relationships, and go on to use the relationship to create change, include those in which: children are being removed from their family; in adversarial legal processes; with parents who may be aggressive, intimidating or violent; with parents who are dishonest, but often plausible or at least where the evidence to prove their dishonesty doesn’t exist; with parents who have substance misuse difficulties and erratic behaviour; and in cases where the social work intervention is actively resisted.  Equally the children may display some or many of these features.  The children’s social worker is frequently required to work with both parent and child in an extremely complex mix of hostility and psychological disorder.
Partnership with other agencies in every area of work undertaken by children’s social workers, including effective safeguarding, information sharing, use of the lead professional role and coordination of multiple plans to keep children safe.  This usually requires the social worker to have at least a working knowledge of how systems operate in education (primary and secondary schools, SEN, inclusion), health (acute, community and CAMHS), housing (homelessness as well as a range of providers who will have different policies and procedures), adult services (mental health, substance misuse, adult social care, etc.) and the voluntary sector ranging from small local projects to large national charities.  Invariably the social worker has to work with a range of these other agencies to construct a care package for each child or family, which requires skills in negotiating, persuading and influencing as well as in monitoring and reviewing the care plan and actions of those partners.
Relationships with Looked After Children which sustain those children through periods of loss, transition and turmoil.  When the same social worker is able to work with a child over a long period, they assist in building resilience and developing positive outcomes for children as they grow up, providing emotional and practical support and helping young people move on to independence.  Social workers demonstrate a sophisticated understanding of the need to enable children to stay with their families in situations which are far from perfect, and to remove them if absolutely necessary and on the basis of good evidence.  Social workers engage in detailed planning to allow children to return safely home after periods in care, or permanency planning when they cannot return – recognising the urgency required for young children and securing permanent placements in the shortest time possible.
Underlying all the work that social workers do is a value base which incorporates an approach where empathy and warmth are central, where respectful scepticism is a priority and which is based on an holistic view of the child and family.  Social workers act as advocates and at the core is the preservation of human rights for children, and their families, when these are not in conflict.

Further key sources for information on effective interventions and evidence-based policy are highlighted on Bolton’s Health Matters by clicking here

Community Views and Priorities

A small scale study conducted by the Children’s Rights Director for England and available at this link points to the central importance of clear communication with children and young people who are, or who may become, the subject of child protection plans.  In particular, the Children’s Rights Director identifies a common fear among children who become subject to safeguarding proceedings that they will be removed from home.

A larger study of children’s views, available at this link was conducted as part of the Munro review.  This study also reinforced the central importance of clear and honest communication between children and their social workers, and emphasised the fact that children say that it is very important to them that they feel they can trust their social worker.  67% of the children taking part in this study said that they thought that their wishes and feelings had made “not much difference” or “no difference at all” to what happened to them.

Bolton Council has built mechanisms for obtaining feedback from children and young people and their families on the effectiveness of services into its procedures for case management.   This has led directly to changes in the way services are provided – for  example, consultation with children and families over their preferred venue for core groups and child action meetings led to changes in the way that these meetings are organised.

A project led by Action for Children in Bolton in 2011/12 particularly in relation to those on CPPs has enabled the voice of the child to be heard more effectively.  BSCB has now agreed to fund this work for a further year.  The format of the child protection plans have also been amended to give higher priority to the recording of child and family views.

Equality Impact Assessments

No proposed changes to Safeguarding policy requiring an Equality Impact Assessment have been brought forward since the previous safeguarding JSNA chapter was published.  The cohort of children subject to Child Protection Plans is regularly monitored on age and ethnicity to ensure that we can feel confident that all sectors of the population are able to access this provision should it be needed.  In the event that inequality of access is identified, strategies will be developed to address this.

Recommendations for Further Needs Assessment Work

• Child protection for children with disabilities.
• Developing our understanding of what it is like to be a child in a family where a parent has a mental health or substance misuse problem and whether there is more we can do to build parental condition into child protection assessments and plans.

Key Contacts

• Mike Tarver – Independent Chair, BSCB             
• John Daly – Assistant Director, Staying Safe
• Pam Jones,  - Designated Nurse, NHS Bolton

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