Joint inspection of services to protect children and
young people in the Moray Council area
February 2009
Contents
Page
Introduction
1
1.
Background
2
2.
Key strengths
3
3.
How effective is the help children get when they need it?
4
4.
How well do services promote public awareness of child protection?
7
5.
How good is the delivery of key processes?
8
6.
How good is operational management in protecting children and
meeting their needs?
13
7.
How good is individual and collective leadership?
15
8.
How well are children and young people protected and their needs
met?
18
9.
What happens next?
19
Appendix 1 Indicators of quality
20
How can you contact us?
21
Introduction
The Joint Inspection of Children‟s Services and Inspection of Social Work Services
(Scotland) Act 2006, together with the associated regulations and Code of Practice,
provide the legislative framework for the conduct of joint inspections of the provision
of services to children. Inspections are conducted within a published framework of
quality indicators, „How well are children and young people protected and their needs
met?‟. 1
Inspection teams include Associate Assessors who are members of staff from
services and agencies providing services to children and young people in other
Scottish local authority areas.
1
‘How well are children and young people protected and their needs met?’. Self-evaluation using quality
indicators, HM Inspectorate of Education 2005.
1
1. Background
The inspection of services to protect children2 in the Moray Council area took place
between June and September 2008. It covered the range of services and staff
working in the area who had a role in protecting children. These included services
provided by health, the police, the local authority and the Scottish Children’s
Reporter Administration (SCRA), as well as those provided by voluntary and
independent organisations.
As part of the inspection process, inspectors reviewed practice through reading a
sample of files held by services who work to protect children living in the area. Some
of the children and families in the sample met and talked to inspectors about the
services they had received.
Inspectors visited services that provided help to children and families, and met users
of these services. They talked to staff with responsibilities for protecting children
across all the key services. This included staff with leadership and operational
management responsibilities as well as those working directly with children and
families. Inspectors also sampled work that was being done in the area to protect
children, by attending meetings and reviews.
As the findings in this report are based on a sample of children and families,
inspectors cannot assure the quality of service received by every single child in the
area who might need help.
Moray covers an area of 2,238 square kilometres and is located in the north east of
Scotland. The population live mainly in small towns and rural settings. The centre of
administration is Elgin.
Moray has a population of 86,750 people. The percentage of children under 16
years is 18%, which is the same as the national average. Moray is the fourth least
deprived local authority area in Scotland. Twelve percent of families are headed up
by a single parent, compared to 21% in comparator authorities3 and 25% in Scotland
as a whole. In the year ending March 2007, 430 children were referred to the
Children’s Reporter on care and protection grounds. This was 2.7% of the child
population compared to the national average of 4.8%.
Throughout this document ‘children’ refers to persons under the age of 18 years as defined in the Joint
Inspection of Children’s Services and Inspection of Social Work Services (Scotland) Act 2006, Section 7(1).
3
Comparator authorities include Angus, Highland, Dumfries and Galloway, Falkirk and Scottish Borders.
2
2
2. Key strengths
Inspectors found the following key strengths in how well children were protected
and their needs met in the Moray Council area.

Children and families benefiting from supportive relationships with staff
who know them well.

Sure Start nursery nurses working with very young children and their
parents in the family home to promote positive parenting.

Improved risk assessment and decision-making by police attending
review child protection case conferences.

Strong vision and commitment to protecting children within Grampian
Police.

Effective partnership working with the voluntary sector improving the
well-being of vulnerable children and their families.
3
3. How effective is the help children get when they need it?
Staff from across services established positive relationships with many
children and families. Children’s views were not always sought and
considered when decisions were made about them. Effective support was
delivered to very young vulnerable children and their parents in their homes.
There was no community provision where children’s services staff could
routinely deliver parenting programmes and reduce identified risks to very
young children. Some children were unclear about their right to be safe or
how to get help. Appropriate action was not always taken to protect children
at immediate risk. Some children’s needs were not met well due to the limited
range and availability of services.
Being listened to and respected
Communication between children, their families and staff with whom they came into
contact was satisfactory. Staff across services established positive and supportive
relationships with many children and families. Health visitors and early years staff
were alert to changes in the behaviour of very young children which showed they
may need help. Vulnerable children and their families had supportive relationships
with workers from a range of voluntary services. Children with communication
difficulties were helped by staff working with them to express their views. A few
parents and children with learning disabilities did not get the support they needed to
be able to fully understand what was happening. The views of parents and relatives
were not always sought and considered. Social workers did not always spend
sufficient time with vulnerable children developing trusting relationships and helping
them to gain a better understanding of their circumstances. Children on the Child
Protection Register (CPR) did not meet regularly on their own with their social
worker.
Most children and parents who attended formal meetings such as Local Assessment
Planning (LAP) meetings, child protection and child care review case conferences
were listened to and their views taken into consideration. However, school-aged
children did not always attend meetings held about them. They did not usually
attend child protection case conferences. Some children looked after away from
home were helped by a children’s right’s officer to have their views considered at
decision-making meetings. This limited service was unable to meet the needs of
children on the CPR. Children were not supported well to complete Having Your Say
forms before attending Children’s Hearings. Their views, including the individual
views of brothers and sisters, were frequently not recorded in social worker’s reports.
Services did not ensure that interpreters were routinely arranged for meetings and
interviews with parents whose first language was not English, to help them
understand fully what was being discussed.
4
Being helped to keep safe
Strategies used to help keep children safe were satisfactory. Vulnerable families
with very young children were supported well by health visitors and Sure Start
nursery nurses working in their homes. Supporting Moray’s Families, Moray Youth
Action and Moray Carers provided effective support to children and their parents.
Family relationships and children’s well-being improved as a result. Children and
families benefited from advice and guidance provided by family support and home
school link workers. Council services were expanding to meet the support needs of
children with disabilities and their parents. Children at risk of being excluded from
school were helped to continue their education and become more confident through
HUT 9 at Forres Academy. There were plans for this successful multi-agency
approach to be adopted more widely. Women’s Aid provided good support for
children affected by domestic abuse. Health and council funded services to help
young people misusing substances and those affected by parental substance misuse
were underdeveloped. The Moray Parenting Strategy had not delivered parenting
programmes council-wide targeted at those with most need. There was a lack of
community based provision for very young vulnerable children where children’s
services staff could work alongside their parents. Family support services were not
readily available in the evenings and at weekends.
Most children could identify a trusted adult, usually a teacher, that they could confide
in if they had a problem. Secondary school-aged children experienced supportive
relationships with guidance teachers although they often lacked confidence in
teachers’ ability to deal with problems of bullying. When invited, police officers,
school nurses and the domestic abuse development worker participated well in
children’s personal and social education. Children’s awareness of how to keep
themselves safe through personal and social education programmes varied.
Arrangements for monitoring children educated at home were clear. Education staff
were alert to children missing from school. Education staff sometimes made
decisions about exclusions and part-time timetables for vulnerable children which
increased the risks in their lives. They did not always give sufficient consideration to
children’s home circumstances or work with other services to find alternative
arrangements.
The Moray Information Bus (MIB), Elgin Youth Café and sexual health drop-in centre
(SMS) successfully promoted safe and healthy lifestyles. The role of the North East
of Scotland Child Protection Committee (NESCPC) in protecting children was not
publicised in schools or made known to families by distributing information through
schools. There was no multi-agency strategy in place to raise children’s awareness
of keeping themselves safe. Some children were unfamiliar with local and national
help-lines and how to make contact with them. Police ran effective programmes
about safe use of the Internet. Children did not always access these before they
were going on-line independently. A few younger children were using social
networking sites without sufficient awareness of the possible dangers.
5
Some examples of what children said about keeping themselves safe.
“Bobbies come into this school.”
“We have peer mediation to sort out problems and I am
training to be a mediator.”
“I can find the ChildLine number in telephone boxes.”
“The MIB bus comes round every week and it‟s a great place
to go. You learn a lot and its good fun.”
Immediate response to concerns
The immediate response to concerns was unsatisfactory. There were
inconsistencies and delays in health and council staff reporting concerns about
children’s safety or welfare to social work or police. Information about immediate
risks to children was not always gathered and fully considered by social workers.
Effective use was made of foster care and residential placements to keep some
children safe. Social workers did not always carry out routine checks before placing
children with relatives. Some children were left in high risk situations or could have
been placed securely elsewhere through the use of appropriate legal measures.
Health and social work staff did not always take action quickly when children were
experiencing neglect. When there were high levels of risk or concern about children,
social workers often relied too much on working voluntarily with parents. There were
delays in decision-making processes to obtain compulsory measures of supervision.
When parents were cooperating with services, staff often assumed that the risks to
children were reduced.
Meeting needs
Overall, meeting children’s needs was weak. Children and their families benefited
from support services although these were sometimes withdrawn after too short a
period. Prompt actions reduced risks and met the needs of some children on the
CPR. Effective steps were not always taken to exclude offenders from households
so that children were safe from possible abuse within their own homes. Children
affected by substance misuse had access to a limited range of services to meet their
needs. Care arrangements for a few children were provided inappropriately in the
local hospital children’s ward. Children did not always receive the help they needed
to recover from abuse.
Voluntary sector staff helped inform decision-making about some children’s future
care through working with families in a residential setting and supervising contact
arrangements. Some homeless families and care leavers were placed in unsuitable
accommodation which did not meet their needs. A systematic approach was not
taken to ensure that children received treatment when their parents did not keep
medical appointments. Dental services were not always available to children who
6
needed treatment. Full health assessments were not routinely provided for children
on the CPR who needed them or for children starting to be looked after away from
home. While some vulnerable young people were helped to achieve qualifications
and life-skills, others needs were not so well met. Kinship carers did not always
receive the support or financial help they needed to meet the needs of children in
their care.
Health, education and social work services worked in partnership with parents of
pre-school aged children with complex needs to deliver well-coordinated support
plans. Mental health services were not widely available to children at school or in
their local community. There were lengthy waiting times for child and adolescent
mental health services (CAMHS). When children and families needed specific
treatment programmes these were not always provided. Children whose sexual
behaviour posed risks to themselves and others were helped through a well-planned
programme. Drug and alcohol services supported many parents but were often
withdrawn when appointments were missed, despite continuing concerns for their
children.
4. How well do services promote public awareness of child protection?
Services had not taken sufficient action to raise public awareness of child
protection services. Publicity materials about who to contact with concerns
had not been produced and distributed widely. The out-of-hours social work
service (OOSWS) had still to ensure an effective response to child protection
referrals.
Being aware of protecting children
The promotion of public awareness of child protection was weak. Some measures
were in place to publicise child protection and information about how to report
concerns. Services providing support to air force staff had distributed leaflets and
posters in local bases, increasing awareness amongst them and their families.
There was a recorded child protection message for members of the public waiting for
their call to be answered by the police. Posters and leaflets about protecting children
were seldom on display at public places throughout the Council area. Children had
not been consulted about raising public awareness of child protection. The Council
and Grampian Police websites included clear advice on how to make contact about
child protection concerns. The NESCPC website was not well-developed. Funding
had recently been agreed and work planned to re-design it. The NHS Grampian
website contained no information about child protection. None of the websites
provided pages which were easy for children to use.
A 2007 Citizen’s Panel Survey provided some useful information about current levels
of public awareness. The majority of respondents said that they would take action
to protect children if they suspected abuse. The Child Protection Helpline was not
well known. Police and social workers responded promptly to day-time phone calls
from the public raising concerns about children’s safety and welfare. Anonymous
calls were almost always taken seriously. Referrals from the public were increasing,
however, those who made referrals did not routinely receive feedback. The police
7
on-call system ensured that there was a specialist officer available at all times. The
out-of-hours social work service (OOSWS) had only one social worker on duty at any
time. They were not always trained in investigative interviewing of children. When
the social worker was responding to an emergency there was no one else available
to deal promptly with a child protection referral. Management information about the
demand for services to protect children out-of-hours was unavailable.
5. How good is the delivery of key processes?
Children and families involved in child protection processes did not always
fully understand what was happening. Their views were not routinely sought
and considered. Staff across services did not always share information about
children in need of protection. In some cases, there were significant delays in
the identification and investigation of suspected abuse. Initial referral
discussions involving health, police and social work did not take place to plan
an appropriate response to child protection concerns. Assessment and
planning processes resulted in some children remaining on the Child
Protection Register (CPR) for too long without any improvement in their
situation.
Involving children and their families
Involvement of children and their families in key processes was weak. Parents were
routinely invited to attend child protection case conferences. The NESCPC had
produced a leaflet for parents attending case conferences, but it did not encourage
their involvement. Children and families did not always receive explanatory leaflets
about child protection processes. Parents were not helped to provide their own
reports to meetings. Review child protection case conferences did not always take
place when children and their parents could attend and were often postponed.
Health visitors routinely discussed their reports with parents prior to meetings.
However, social workers’ reports were not always shared with children and families
in advance of meetings. Sometimes they were shared just before a meeting with
little time to read and fully understand them. Parents did not always receive copies
of minutes of meetings early enough. Some parents were unclear about what it
meant to have their children’s names on the CPR. There were no written agreement
with parents about the risks to their child, what they had to do to reduce these by
when and what help they would get. They were not always informed what would
happen if the risks remained the same or increased. Some children were not told by
their social worker that their name was being placed on the CPR and why. Brothers’
and sisters’ names were sometimes placed on the CPR without identifying the risks
to each of them. A helpful introductory pack and invitation to contact the children’s
rights officer had been produced and made available to staff, but was not
consistently given out to children. Some children’s views recorded by social workers
were not up-to-date or were the worker’s account of the child’s views. Parents with
learning disabilities or mental ill-health were not automatically provided with
advocacy services to support them. Parents were not always informed in writing of
their legal rights when children were looked after voluntarily or how to appeal against
the decision to put their child’s name on the CPR.
8
All services had good procedures in place for handling complaints. The Council had
recently been more responsive to people making complaints and had developed a
child friendly complaints leaflet in consultation with Dialogue Youth. Other services
had yet to develop easy to use complaints procedures for children. The Who Cares?
worker post had been vacant for some time leaving children looked after away from
home without an important source of support to raise any complaints. Views about
their experiences were not sought routinely from children and parents involved in
child protection processes. The NESCPC did not gather and analyse complaints
and feedback to inform and improve practice.
Sharing and recording information
The sharing of information within and between services was unsatisfactory. Health
and council staff were not always clear about their responsibility to share information
when there was a concern about the safety or welfare of children. When information
was shared there was often no clear understanding of which staff needed to know.
Information-sharing did not always result in appropriate action being taken. Practice
did not follow the pan-Grampian information-sharing agreement or Getting Our
Priorities Right (GOPR) guidance. Information-sharing often depended too much on
staff relationships.
Particular features of information-sharing included the following.








Effective information-sharing amongst police, midwives, health visitors, social
workers and Women’s Aid about children affected by domestic abuse.
Variable practice in sharing child protection concerns without parent’s
consent, particularly by health staff.
Paediatricians at Dr Gray’s Hospital were reluctant to share information with
police and social workers.
Health staff in doctor’s practices and school nurses did not routinely get
access to information on vulnerable children, including children on the CPR.
Limited information-sharing between paediatricians based in Dr Gray’s and
Aberdeen Children’s Hospital.
Inconsistent information-sharing about plans for mothers and babies returning
home from hospital between Aberdeen Maternity Hospital and local
community midwives and health visitors.
Variable practice in information-sharing between housing and social work
staff.
Feedback to staff who made child protection referrals to social work was not
provided routinely.
The quality of recording in children’s files was variable. Social work files were
generally well-structured and dated lists of key events and staff involved were
becoming more common. However, there was often poor quality recording of factual
information and significant gaps in electronically recorded case notes. The structure
of Family Health Records did not help health visitors plan their work effectively. Most
education files were not well structured. They did not consistently record
improvement in learning outcomes and achievements for children looked after or on
9
the CPR. Significant events in the lives of children on the CPR which were known to
individual services were not gathered together to give a full picture.
Some staff took time to explain to children and parents when information would be
shared, why and with whom. A form for seeking agreement to information-sharing
from parents had recently been introduced in social work. However, the social
worker obtaining consent did not inform relevant staff from other services that they
had done this. Staff working in mental health services for both adults and children
were reluctant to share information about child protection concerns with staff from
other services. The practice of seeking children’s consent had not yet been
developed.
Police and criminal justice social work staff shared information effectively about sex
offenders who may pose a risk to children. There was good sharing of information
with the local authority housing service through a single point of contact. However,
information-sharing about sex offenders with relevant staff across health services
was less robust. Criminal justice social work staff responsible for offenders who may
pose a risk to children usually attended and contributed information to child
protection case conferences and core group meetings. Children and families social
work staff attended Multi-Agency Public Protection Arrangement (MAPPA) meetings
when this was identified as relevant to a specific case.
Recognising and assessing risks and needs
The recognition and assessment of risks and needs was unsatisfactory. Most staff
across services were alert to signs that children may be in need of protection.
Paediatricians at Dr Gray’s hospital did not always follow inter-agency and NHS
Grampian child protection procedures or the agreement with Aberdeen Children’s
Hospital for managing suspected child abuse in very young children. There were
some significant delays in the medical assessment and reporting of possible abuse.
These resulted in delayed investigations of abuse to a few children who had serious
injuries. Discussions about child protection referrals took place between social
workers and police. These only happened when social work managers thought that a
joint investigation was necessary rather than automatically in response to all child
protection concerns. Health staff were not routinely involved in planning
investigations and decision-making about child protection medical examinations.
Decisions on holding initial child protection case conferences were made by
individual social work managers rather than jointly with other services.
Health visitors identified and assessed the risks and needs of vulnerable children
and families. Link social workers provided a valuable point of contact for schools to
assist in the early identification of concerns. Social workers’ assessments were too
dependent on information reported to them by support workers, rather than evidence
gathered from observing and working with children and families. Staff in education
and adult services did not always appreciate the importance of information known to
them to fully inform assessments. Many focused too heavily on the needs of
parents. Staff from different services did not contribute fully to the assessment
process. The quality of assessments was variable and specific risks and unmet
needs were not always identified. Reports did not always assist Children’s
Reporters in making decisions about the needs of children. The time from the end of
10
an investigation to an initial child protection case conference taking place varied, with
examples of long delays. A few children’s names were removed from the CPR
without further risk assessment being carried out. Insufficient importance was
placed on assessing the racial, religious, linguistic and cultural needs of a few
children. Kinship carer assessments were not always carried out.
Training had improved the way that police and social workers planned and carried
out joint investigations. Paediatricians were available at any time to carry out
medical examinations. There was no room equipped for child sexual abuse
medical examinations to take place locally. Forensic medical examiners were not
available. The response to young people needing child sexual abuse medical
examinations was variable. They were seen in Aberdeen, some in a police station
by a single doctor and others at the Aberdeen Children’s Hospital. Some young
people were distressed by these arrangements, including the lack of choice of a
male or female doctor to carry out examinations.
The NESCPC had produced an inter-agency procedure for working with substance
misusing pregnant mothers. A Moray ante-natal care procedure was being
developed to identify vulnerable unborn babies affected by parental substance
misuse at an early stage. Midwives were identifying and assessing high risk
pregnancies, but most were unaware of procedures to guide their practice. Drug and
alcohol staff were alert to child protection concerns when women using their service
became pregnant. They routinely identified and assessed substance misusing
parents with dependent children. Social workers were not using a risk assessment
checklist to help them assess the impact of parental substance misuse on children’s
lives.
Planning to meet needs
Overall, planning to meet the needs of children was weak. Services were improving
LAP meetings to help children and their families. The organisation of case
conferences had recently improved through the provision of good administrative
support. There were independent chairs of child protection case conferences and
child care reviews. Chairs did not have sufficient authority to monitor and report on
the effectiveness of plans and to challenge any lack of progress in carrying them out.
Many child protection plans were vague about what actions were necessary to
reduce or minimise risk by when.
There was generally good attendance at initial child protection case conferences for
very young children. However, general practitioners (GPs) and school nurses
seldom attended, often leaving school-aged children with no one present who had
responsibility for their health needs. All children on the CPR had an allocated social
worker and there was a high level of continuity of staff involved in children’s plans.
Child protection plans did not always link strongly enough to assessments of risks
and needs. Apart from social work staff, attendance at review child protection case
conferences varied. Police had deployed an additional officer to the Family
Protection Unit (FPU) and were now attending routinely. Arrangements for
attendance at child protection planning meetings by education staff during school
holidays were unclear. Plans to support children’s learning were not linked to child
protection plans. Decisions were made at review child protection case conferences
11
to remove some children’s names from the CPR without the involvement of health
staff.
Child protection concerns for unborn babies led to pre-birth case conferences.
These were not always held within agreed timescales. Plans to work with expectant
mothers and their partners to reduce the risks before babies were born were not
always made or implemented effectively by services. Some children remained on
the CPR too long with no sustained improvement in their circumstances or change to
their child protection plan. Child protection review case conferences did not agree
what the alternative plan would be if minimum changes were not achieved within
agreed timescales. Planning for children needing permanent family placements was
regularly monitored to prevent delays.
Parents were usually well involved in core group meetings. However, these did not
always take place regularly and attendance was variable. When multi-agency core
group meetings took place as planned these helped to improve some children’s
lives. Core groups were used well to share information and to monitor developments
in children and family’s circumstances. They did not focus sufficiently on evaluating
the progress of child protection plans. Chairing and minute taking arrangements
were inconsistent. Child protection chairs made appropriate decisions about the
membership of core groups and how often they should meet. They did not use the
minutes of core group meetings to monitor their effectiveness.
12
6. How good is operational management in protecting children and meeting
their needs?
The policies and procedure provided to support staff in joint-working had not
ensured consistent practice. The 2005-08 Integrated Children’s Services Plan
(ICSP) had limited impact on improving the lives of vulnerable children.
Management information to inform planning of services to protect children
was in the early stages of development. The North East of Scotland Child
Protection Committee (NESCPC) had identified the participation of vulnerable
children in their work as a priority. A start had been made to reviewing
staffing levels and skills to improve the delivery of services to protect children.
Single and inter-agency child protection training was not well matched to
identified needs.
Aspect
Comments
Policies and
procedures
Policies and procedures were weak. The NESCPC was
developing a range of policies to promote joint-working and a
system to monitor and review them. Recently revised and
improved inter-agency child protection guidelines were
available to staff on-line. Services did not always ensure that
staff knew about NESCPC policies and procedures and put
them into practice. The pan-Grampian information-sharing
agreement was unfamiliar to staff. The development of local
procedures in health and council services had led to
inconsistencies in practice. There were important gaps in
some key child protection procedures leaving some staff
unclear about their roles and responsibilities.
Operational
planning
Operational Planning was weak. Key partners had been
involved in developing the 2005-08 Integrated Children’s
Services Plan (ICSP). Partnership working had been
enhanced as a result. ICSP priorities were linked to local
action plans and service improvement plans. However,
limited progress had been made with actions aimed at
improving vulnerable children’s lives. Staff had limited
awareness of the ICSP and its relevance for their work.
Implementation of the 2005-08 ICSP had not been monitored
and evaluated. There had been no annual progress reports
over the period of the plan. The draft 2009-10 ICSP had the
potential to improve outcomes for children with more rigorous
implementation and monitoring of actions. Performance
management was improving but had yet to impact on
improving outcomes for children. Some management
information was collected but was not always used effectively
to improve service delivery. There was no systematic
approach to using management information to inform planning
or policy.
13
Aspect
Comments
Participation of
children, their
families and other
relevant people in
policy development
Participation of children and families in policy development
was weak. The NESCPC had recently involved Dialogue
Youth in producing a leaflet called We want to help you –
What to do if you don‟t feel safe. Children’s rights officers
were planning to involve children with experience of the child
protection system in the work of the NESCPC. However,
Moray children’s rights officer was no longer involved. Young
people participated well in the Elgin Youth Café and sexual
health drop-in centre (SMS). Consultation about
re-locating the SMS service to the local hospital had not taken
sufficient account of their views. Children had not been
involved in the development of the new ICSP.
Recruitment and
retention of staff
Staff recruitment and retention were satisfactory. Staffing of
the NESCPC office was jointly funded by health, police and
the Council. Additional social workers were being recruited to
establish a joint FPU. The role of an officer to manage the
FPUs across Grampian was developing effectively. Reviews
of staffing to improve services to protect children, including
school nurses, children’s mental health workers and children
and families social workers, were underway. There was no
social worker based in Dr Gray’s Hospital to promote more
effective communication about children at risk. Safe
recruitment practices were in place across all services.
Development of
staff
Development of staff was weak. The NESCPC delivered an
annual training programme. However, it did not reflect
identified priorities or take account of the numbers of staff
needing training. NESCPC training was not well-coordinated
through a Moray plan for single agency and inter-agency
training. Induction in child protection for new staff was
inconsistent in health and council services. The quality of
basic awareness training was variable and had yet to be
delivered to essential groups of staff. Health visitors and
social workers received regular consultation with their
supervisors on child protection cases. Health staff did not
have sufficient support locally from an experienced child
protection advisor.
14
7. How good is individual and collective leadership?
The vision to protect children in individual services was stronger than that
shared among partners. The contribution of Moray Community Health and
Social Care Partnership (MCHSCP) and the Council to resourcing the work of
the North East of Scotland Child Protection Committee (NESCPC) was
insufficient. Strong partnership working with the voluntary sector delivered
effective services. Partners took insufficient action to meet gaps in services
and tackle weaknesses in key processes. The NESCPC and Moray Chief
Officer’s Group (MCOG) had not developed self-evaluation to provide them
with sound evidence of how they were doing. Significant Case Review (SCR)
recommendations had not been met fully. Paediatric practice in response to
cases of suspected child abuse was not monitored adequately.
Vision, values and aims
Overall, vision, values and aims to protect children was satisfactory. The aims of
individual services clearly reflected a commitment to protecting children. The
NESCPC Chief Officers Group (COG) had not developed a shared vision and aims
for the NESCPC and communicated these to staff in Moray effectively. The MCOG
had developed a clear vision for protecting children but stronger emphasis was
required on promoting children’s rights.

Elected members saw protecting children as a priority to be achieved through
multi-agency working. The Chief Executive and senior managers from
Educational and Community Services had taken a lead role in raising staff
awareness of the Council’s vision. Staff who had not traditionally regarded
protecting children as being part of their role, were starting to become more
actively involved.

Most senior managers and staff in NHS Grampian and the Moray Community
Health and Social Care Partnership (MCHSCP) were clear about the priority
given to protecting children. Collective responsibilities for protecting children
through working with other services had not been communicated to all staff
effectively. Staff were generally unaware of the role of the NHS Protecting
Children Group.

The Chief Constable’s strong vision and values had been communicated
effectively to staff. Child protection was a key strategic priority for Grampian
police. Senior police officers ensured that protecting children influenced their
work. Staff at all levels were diligent in carrying out their responsibilities for
the safety and welfare of children.
The Council had developed a programme to successfully raise staff awareness of
social issues, including mental illness, domestic abuse and child protection.
Insufficient support had been given to staff to help them work with the increasing
range of people and cultures in Moray. Managers from across services were actively
involved in developing an ICSP with a greater focus on improving outcomes for
children.
15
Leadership and direction
Overall, leadership and direction were weak. The COG did not give enough direction
to services to protect children. The NESCPC was making slow progress in
progressing priority areas of work. There was a lack of commitment from partners,
with the exception of police, to provide sufficient staff time to deliver the NESCPC
business plan. The MCOG had strengthened structures to implement the plan
locally. They had produced a separate child protection business plan but it did not
clearly connect with the NESCPC business plan. NHS Grampian Protecting
Children Group had been slow to revise their child protection strategy and develop
an action plan.
The Chief Constable provided strong leadership to the NESCPC. The police
managed the NESCPC office effectively. Moray Council had two places on the
NESCPC, but was not represented by staff of sufficient seniority. The work of the
NESCPC was supported by sub-groups. The core membership of these did not
always have representatives from each of the key agencies, including the voluntary
sector, to complete tasks effectively. When members of the NESCPC were unable
to attend meetings they did not brief substitutes or give them authority to make
decisions.
The NESCPC’s finances were committed fully and managed openly. The
communications and training sub-groups did not have sufficient budgets to fulfil their
areas of responsibility, especially given the low baseline from which they were
starting to operate. The Police Superintendent and the Council’s Chief Executive
had made money available to build and staff a joint FPU. Health services had not
contributed to staffing or resources for this. Systems to enable a joint FPU to
provide more effective services had yet to be developed. A joint approach had not
been taken to providing suitable accommodation for child protection case
conferences.
Leadership of people and partnerships
Individual and collective leadership of people and partnerships were satisfactory.
Elected members, senior officers in the Council and the Police Superintendent gave
a strong lead to furthering partnership working. The MCHSCP had yet to become
fully involved as a partner in funding services jointly to protect children. Close
working relationships in Moray did not always result in effective partnership working
to deliver services jointly. SCRA’s contribution to partnership working was limited
and managers were not fully involved in developing the new integrated approach to
assessment.
Local multi-agency management teams were established and further investment was
planned to deliver locally based services to meet the needs of vulnerable children.
Housing services were not sufficiently involved in partnership working to protect
children. Legal services and social work did not always work together effectively to
serve the best interests of children.
16
The lack of multi-agency screening of domestic abuse referrals meant that full
information was not always available to support decision-making. Services for
children affected by substance misuse had not been developed through partnership
working between the Drug and Alcohol Action Teams (DAATs), the NESCPC and
MCOG.
The voluntary sector was a major partner in delivering services for vulnerable
children. National and local voluntary organisations provided a significant and
valued contribution to service delivery. They were represented in all the main
decision-making groups. A voluntary sector manager chaired a multi-agency
resource group, demonstrating trust and commitment by partners. There was a
voluntary services representative on the NESCPC reporting to a local forum.
Partnership working had not tackled some significant gaps and shortfalls in services
such as parenting programmes and children’s mental health services. Good
partnership working with the Soldiers, Sailors, Airmen and Families Association
(SSAFA) helped locally based Royal Air Force families.
Leadership of change and improvement
Leadership of change and improvement was weak. The NESCPC had started to
identify sources of key information about service effectiveness from which to assure
itself how well children were protected. A newly formed continuous improvement
sub-group had responsibility for quality assurance and self-evaluation. The MCOG
had made a start to self-evaluation. Members carried out single agency
self-evaluation and then collated their findings. This process had not provided strong
enough evidence from which to evaluate their overall performance. While the
NESCPC had completed some Significant Case Reviews (SCRs), these were not all
done within agreed timescales. Mechanisms were not in place for monitoring and
evaluating the implementation of recommendations from these reviews.
The NESCPC had completed a SCR in 2006 with important findings on practice in
the Moray Council area. The recommendations had not been implemented well and
significant weaknesses identified in systems and processes continued. Social work
case files and case conference minutes were audited by managers but they did not
look closely enough at practice. The NESCPC was developing methods of
assessing risk to strengthen practice. A helpful multi-agency audit of three child
protection cases had been completed. This had identified key areas for
improvement.
Current arrangements in Dr Gray’s Hospital did not ensure that the paediatric
response to suspected cases of child abuse met practice standards consistently.
Initial audits of child protection arrangements in GP practices had identified areas for
improvement. NHS Grampian had introduced performance measures to identify
areas for improvement. Grampian Police had effective systems in place for auditing
key processes which continued to lead to improved practice across the force.
Changes in structures for managing FPUs had resulted in improvements in child
protection investigations.
17
8. How well are children and young people protected and their needs met?
Summary
Inspectors were not confident that all children at risk of harm, abuse or neglect and
in need of protection were receiving the help and support they needed. The
immediate response to concerns did not always lead to rigorous assessment of risk
and the use of appropriate legal measures. Inspectors identified significant
weaknesses in sharing information about children in need of protection, particularly
by some staff in health services. There were delays and deficiencies in the
identification and investigation of suspected child abuse. Planning for children did
not always bring about a reduction of risk within acceptable timescales. Overall,
there were significant weaknesses in some critical areas.
The NESCPC, the MCOG and the individual services they represent, led by Chief
Officers should ensure that they make improvements to strengthen services to
protect children in Moray. In doing so they should take account of the need to:

Ensure that assessments of risk are rigorous and appropriate legal measures are
used, when necessary, for children in need of protection;

Fully implement agreements and guidance to ensure the effective sharing of
information;

Introduce inter-agency discussions to manage effectively the investigation of
suspected child abuse;

Improve assessment, planning and decision-making for children whose names
are on the CPR;

Increase the involvement children in decision-making about their lives and
consult them on the development of services to protect children; and

Improve the effectiveness of the NHS Protecting Children Group, the NESCPC
and the MCOG in protecting children and meeting their needs.
18
9. What happens next?
Chief Officers have been asked to prepare an action plan indicating how they will
address the main recommendations in this report, and to share that plan with
stakeholders. Within four months, Chief Officers should submit to HM inspectors a
report on the extent to which they have made progress in implementing the action
plan. Within one year of the publication of this report HM inspectors will re-visit the
authority area to assess and report on progress made in meeting the
recommendations.
Emma McWilliam
Inspector
February 2009
19
Appendix 1 Quality Indicators
The following quality indicators have been used in the inspection process to evaluate
the overall effectiveness of services to protect children and meet their needs.
How effective is the help children get when they need it?
Children are listened to, understood and
Satisfactory
respected
Children benefit from strategies to
Satisfactory
minimise harm
Children are helped by the actions taken
Unsatisfactory
in immediate response to concerns
Children’s needs are met
Weak
How well do services promote public awareness of child protection?
Public awareness of the safety and
Weak
protection of children
How good is the delivery of key processes?
Involving children and their families in
Weak
key processes
Information-sharing and recording
Unsatisfactory
Recognising and assessing risks and
Unsatisfactory
needs
Effectiveness of planning to meet needs
Weak
How good is operational management in protecting children and meeting
their needs?
Policies and procedures
Weak
Operational planning
Weak
Participation of children, families and
Weak
other relevant people in policy
development
Recruitment and retention of staff
Satisfactory
Development of staff
Weak
How good is individual and collective leadership?
Vision, values and aims
Satisfactory
Leadership and direction
Weak
Leadership of people and partnerships
Satisfactory
Leadership of change and improvement
Weak
This report uses the following word scale to make clear the evaluations made by
inspectors:
Excellent
Very Good
Good
Satisfactory
Weak
Unsatisfactory
20
Outstanding, sector leading
Major strengths
Important strengths with areas for improvement
Strengths just outweigh weaknesses
Important weaknesses
Major weaknesses
How can you contact us?
If you would like an additional copy of this report
Copies of this report have been sent to the Chief Executives of the local authority
and Health Board, Chief Constable, Authority and Principal Reporter, Members of
the Scottish Parliament, and other relevant individuals and agencies. Subject to
availability, further copies may be obtained free of charge from HM Inspectorate of
Education, First Floor, Denholm House, Almondvale Business Park, Almondvale
Way, Livingston EH54 6GA or by telephoning 01506 600262. Copies are also
available on our website www.hmie.gov.uk
If you wish to comment about this inspection
Should you wish to comment on any aspect of child protection inspections you
should write in the first instance to Neil McKechnie, HMCI, Directorate 6:
Services for Children at HM Inspectorate of Education, Denholm House,
Almondvale Business Park, Almondvale Way, Livingston EH54 6GA.
Our complaints procedure
If you wish to comment about any of our inspections, contact us at
HMIEenquiries@hmie.gsi.gov.uk or alternatively you should write to BMCT,
HM Inspectorate of Education, Denholm House, Almondvale Business Park,
Almondvale Way, Livingston, EH54 6GA.
If you are not satisfied with the action we have taken at the end of our complaints
procedure, you can raise your complaint with the Scottish Public Services
Ombudsman (SPSO). The SPSO is fully independent and has powers to investigate
complaints about Government departments and agencies. You should write to the
SPSO, Freepost EH641, Edinburgh, EH3 0BR. You can also telephone
0800 377 7330, fax 0800 377 7331 or e-mail: ask@spso.org.uk. More information
about the Ombudsman’s office can be obtained from the website: www.spso.org.uk.
Crown Copyright 2009
HM Inspectorate of Education
This report may be reproduced in whole or in part, except for commercial purposes
or in connection with a prospectus or advertisement, provided that the source and
date thereof are stated.
21