Proven practice research: improving safeguarding

The Social Care Institute for Excellence’s weekly analysis of research findings behind specific social work practices.

Children’s safety and welfare are ­global concerns and efforts are made continually to improve children’s services. How senior managers learn from frontline practice – and identify problems and solutions – is central to this. To date our most public way of learning has been through the investigation of the death of a child from child abuse or neglect.

In the UK, as in many countries, these serious case reviews or public inquiries have been a major influence on the way services have developed. However, their value has been increasingly questioned, as it has become apparent that they regularly identify the same problems in frontline practice and make similar recommendations.

In its new report Learning Together to Safeguard Children: Developing a multi-agency systems approach for case reviews, Scie presents a systems model of organisational learning that can be used by safeguarding and child protection agencies. It has been adapted from accident investigation methods used in aviation, engineering and, more recently, in health. Scie has also launched a resource guide to help practitioners put the model into practice.

Similar difficulties in engineering, and other high-risk industries led to the development of the systems approach. It was taken up in the field of health, including by the National Patient Safety Agency. This looks for causal explanations in all parts of the system. Rather than stopping after faults in professional practice have been identified, the approach explores the interaction of the individual with the wider context to understand why things developed the way they did and allows for more effective solutions. Consequently, Scie adapted the model of safeguarding and child protection work.

Taking an approach from radically different professional fields requires detailed developmental work to adapt it to children’s services. The model builds on Managing Risk and Minimising Mistakes (Scie, Bostock et al, 2005). It is underpinned by a review of the safety management literature (Munro, 2008). Two pilot case reviews were conducted using the systems approach, working closely with two local safeguarding children’s boards in England. Valuable feedback was provided by staff at all stages to adapt the model.

The goal of a systems case review is to act “as a ‘window’ on the system” (Vincent, 2004). It provides the opportunity to study the whole system, learning about what worked well as well as problems, near misses and mistakes.

The cornerstone of the approach is that individuals are not totally free to choose between good and problematic practice. The standard of their performance is influenced by the nature of:

● The tasks they perform.

● The tools to support them.

● The environment in which they operate.

The approach, therefore, looks at why particular thoughts and actions take root in multi-agency professional practice. It does this by taking account of the many factors that interact and influence an individual worker’s practice.

Ideas can then be generated about how to re-design the system at all levels to make it safer. The aim is to “make it harder for people to do something wrong and easier for them to do it right” (Institute of Medicine, 1999).

Good or problematic practice may, on the surface, look different in different cases, but the sets of underlying causes may be the same. Reviewers need to identify these patterns of systemic factors that contribute towards good or poor quality work. They can be either constructive patterns of influence or create unsafe conditions in which poor practice is more likely.

Scie’s model includes a six-part typology of such patterns for child welfare. As more systems reviews are carried out, recurrent issues within each pattern will be identified.

● Human-tool operation: for example, the influence of assessment forms including initial and core assessment and common assessment framework form, and databases such as the Integrated Children’s System.

● Human-management system operation: for example, resource-demand mismatch, including performance management indicators.

● Communication and collaboration in multi-agency working in response to incidents/crises: for example, referral procedures and cultures of feedback.

● Communication and collaboration in multi-agency working in assessment and longer-term work: for example, understanding the nature of the task assessment and planning as one-off event or ongoing process.

● Family-professional interactions: for example, how child welfare professionals and parents interact.

● Human judgement/reasoning: for example, failure to review judgements and plans.

The systems model can be applied to serious case reviews. It can help to improve the quality and rigour of analysis and effectiveness of recommendations. It can also ensure that the process is a learning exercise in itself.

It can also be used to review routine case work. This has particular value in times of major change in services delivery, when it can be used to understand progress on the implementation of new working practices and accompanying tools such as the common assessment framework. It helps identify what is working well, where there are problematic areas and, crucially, why, so that solutions can be found to improve effectiveness.

The approach can help to ensure that cases are reviewed in a consistent manner and help the drawing of wider lessons from similar findings locally, regionally and nationally.

The title of Scie’s resources, Learning together echoes Working together (HM Government, 2006), the key guidance in England and Wales on multi-agency working to safeguard and promote the welfare of children. If safeguarding is everyone’s business, learning should be too and the systems model for case reviews facilitates this.

First, the model is a collaborative one. Those involved directly in the case under review are centrally and actively involved in the analysis. Consequently, staff participating can learn with and from each other and gain more understanding of the similarities and differences between their patterns of thought and action.

Second, the systems model provides a practice-led view to help highlight for senior managers how new policies and guidance, strategic and operational decisions affect direct work with children, young people and their carers and families. Consequently, a sense of common purpose can be generated between those at the sharp and blunt ends of the system, facilitating joint ownership of the case review process, findings and recommendations throughout all layers of the system.

Practitioners’ messages

● Developments in engineering and health indicate the potential benefits of using a systems approach to understanding front-line practice to improve quality and safety of service provision.

● The adapted systems model for multi-agency safeguarding and child protection work requires a respectful approach towards the practice experience of street-level workers and their managers.

● The model involves moving beyond the basic facts of a case chronology and appreciating the differing views that workers had at the time.

● The aim is to identify underlying patterns of factors in the work environment that support good practice or create unsafe conditions in which poor practice is more likely.

● This kind of organisational learning is vital to improving the quality of services provision and needs to be applied to ordinary work, not just to tragedies


Further information

● Resource Guide 13 and Report 9: Learning together to safeguard children: developing a multi-agency systems approach for case reviews 

● Report 6: Managing risks and minimising mistakes in services to children and families

Working Together to Safeguard Children

This article is published in the 23 October issue of Community Care magazine under the heading A systems approach to improving safeguarding


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