To: <Chief Nurse>
CC: NHS England Chief Operating Officer for Area
NHS England Chief Nurse for Area
CQC Compliance Manager Lead
CQC Compliance Manager
CQC CSI Lead Inspector
Dear < >
Notification of review of services for looked after children and safeguarding in
<insert name> commencing <insert date> 2014.
The Care Quality Commission (CQC) is the independent regulator of health and
social care services in England. Our role is to make sure that health and social care
services provide people with safe, effective, compassionate and high-quality care,
and we encourage them to make improvements.
We are writing to inform you that we will conduct a review of safeguarding
children and services for looked after children in your area beginning on
<insert date> 2014 and ending on <insert date>. The reviews will focus on the
quality of health services for looked after children, and the effectiveness of
safeguarding arrangements for all children in the area. The review will be conducted
under section 48 of the Health and Social Care Act 2008 and will focus on evaluating
the experiences and outcomes for children, young people and their families who
receive health services within the boundaries of <insert name>.
The review will be led by <insert name> together with <insert name>, who are
inspectors from our Children’s Services Inspection team. The lines of enquiry for this
review programme are enclosed as Appendix A. Before we arrive on site, we will
review relevant child health performance reports and data relating to NHS
commissioning and provider activity. This will include information that we hold and
information in the public domain. We have listed the key documents that are not
generally available publically in Appendix F, and we would be grateful if you could
send them to us in readiness for our visit.
Before our site visit, we will also make contact with the Director of Nursing or other
appropriate senior manager in the NHS England Local Area Team and the local
Healthwatch team.
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Our on-site review will begin with an initial meeting with yourself as Chief Nurse and
the designated nurse/s, so that you can provide the overview and context for your
work.
Appendix B provides an indicative timetable of the suggested flow and timings of our
review activity. Please amend this as necessary to fit the work we need to do in your
area.
Appendix C provides more detail about our planning requirements. We would be
grateful if you would use the attached appendices to co-ordinate arrangements to
involve other health partners.
During our review, we will be case tracking arrangements for safeguarding and
health for looked after children, care leavers and those receiving early help.
Appendices D and E should help you to identify suitable cases for tracking that meet
our criteria and enable lead professionals to provide an overview of their work with
each individual child/young person and their family. Our case tracking activity will
involve visiting local services to talk to a range of health professionals and sitting
with them to review their work with individual children/young people. This includes
reviewing individual children’s health records. We will also ‘dip sample’ additional
records in areas where we require additional or further evidence of the range and
quality of work undertaken. We may on occasion also observe front-line practice.
The inspectors will follow the journeys through health services of a maximum of eight
children, using a case tracking approach. To do this, the lead health professional for
each case should provide a summary of their work and the outcomes achieved,
including a chronology of the case (please see Appendix E). Recognising the work
involved, we ask you to arrange for us to receive this while we are on site, by 4pm on
Monday. However, we would want to see the list of children (Appendix D), when we
arrive on Monday morning.
We appreciate that availability of medical and nursing staff may be restricted by
clinical commitments, so we recommend that you make arrangements for us to meet
with them as soon as possible. If they are not available, then please arrange for us to
meet with a peer or supervisor who is familiar with the case. Please do not cancel
critical work such as children’s appointments or attendance at safeguarding
meetings. If there are potential commitment clashes, please advise us, so that we
can agree how best to manage these situations.
When tracking a child’s journey through the services it is important that we meet with
and speak to children and their families. Once the cases are identified, we would like
you to contact them to ask if we can meet them once we are on site. Could you
please also advise us of the dates of any meetings with them that are scheduled to
take place while we are on site. We will ask you to let them know that we plan to
read their records and ask them to tell us if they do not want us to. There may be
other opportunities to meet children or their families, such as at a looked after
children group, and we will discuss with you the options and our capacity to attend
these before we arrive on site.
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Using information from the review
We will write a report about our key findings across the local health economy, and
where necessary, we will make recommendations for improvement. The draft report
will be sent to you no later than 10 working days from the end of the review to enable
you to make a factual accuracy check before returning it to us.
After every review, a copy of our report should be provided to all agencies involved
in the review. We expect one person in the area to take responsibility for circulating
the report, collating comments about its factual accuracy and responding to us. That
person would normally be the Chief Nurse for the CCG, but we are aware that in a
minority of cases it may be appropriate for someone else to take on the lead coordinating role. If this is the case, please advise us who the report should be sent to.
Otherwise we will automatically send to the Chief Nurse.
Information about each healthcare organisation will also contribute to CQC’s
inspection, regulation and monitoring of care services. If we identify any serious
concerns during a review, we will immediately notify you of these and we will ask that
you keep us informed of the outcomes. We will also share our concerns with other
organisations, where necessary, including regulatory bodies with accountabilities for
safeguarding and looked after children.
If you have any queries about the arrangements set out in this letter, please do not
hesitate to contact <insert name> or email the project team at Childrens-ServicesInspection@cqc.org.uk.
Quality assurance
All reviews are subject to a quality assurance process. If there are any issues that
the inspection team cannot resolve, you may wish to discuss these in the first
instance with Lynn Davinson, Children’s Services Inspection Manager. You can
contact her through the Children’s Services email box: Childrens-ServicesInspection@cqc.org.uk.
Yours sincerely,
Lead Inspector
Encs: Appendix A - lines of enquiry
Appendix B - indicative timetable
Appendix C - guidance to help plan the review
Appendix D - case tracking template
Appendix E - summary template for each child/young person case tracked
Appendix F - key documents list
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Appendix A: Lines of enquiry
Introduction
The Children’s Services Inspection team is undertaking a targeted review of how well
local health services identify, help, protect and provide child-centred care and to
ensure that children’s health needs are effectively met. Inspectors will evaluate the
quality and impact of local health arrangements for safeguarding children and
improving health outcomes for children who are looked after. This includes mapping
the child’s journey at all stages – from pre-birth through to their transition to
adulthood, and from the point of their entering to leaving care.
This paper contains lines of enquiry that relate to the responsibilities of health
professionals for keeping children safe and meeting the health care needs of
children who are looked after. While undertaking the review, inspectors may need to
include additional lines of enquiry or focus more on some lines of enquiry than others
in response to the findings from case tracking and discussions with children and their
families, relevant frontline and senior managers, specialist safeguarding or looked
after children (LAC) health staff.
These lines of enquiry have been informed by the new policy direction for vulnerable
children and CQC’s priorities, and they support a new framework and reporting
arrangements centred on:

The experiences and views of children and their families.

The quality and effectiveness of safeguarding arrangements in health
including:
o
Assessing need and providing early help.
o
Identifying and supporting children in need.
o
The quality and impact of child protection arrangements.

The quality of health services and outcomes for children who are looked
after and care leavers.

Health leadership and assurance of local safeguarding and looked after
children arrangements including:
o
Leadership and management.
o
Governance.
o
Training and supervision.
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Lines of enquiry
1. The experiences and views of children and their families
The role and impact of health services in safeguarding children

Children and their families or carers tell us about their good experiences of using
local health services with regard to safeguarding.

Children and their families tell us about how the support they receive with regard
to safeguarding is helping to improve their health and wellbeing.

Children and their families tell us what is not working well and what needs to
change with regard to safeguarding.

Children and their families tell us whether they have been given clear and timely
information about how local health services can help them about safeguarding
issues.

Children and their families tell us whether it is easy to get help from local health
services about safeguarding issues (universal, targeted or specialist); or whether
they have had to wait, and for how long.

Children and their families tell us about how they have been involved in planning,
agreeing and reviewing the help they need about safeguarding from local health
services.

Children and their families tell us whether they would recommend their local
health services to others with regard to safeguarding.
The role and impact of health services in supporting children who are looked
after and care leavers

Children and their families or carers tell us about their good experiences of using
local health services.

Children and their families tell us about how the support they receive is helping
to improve their health and wellbeing.

Children and their families tell us what is not working well and what needs to
change.

Children and their families tell us whether they have been given clear and timely
information about how local health services can help them.

Children and their families tell us whether it is easy to get help from local health
services (universal, targeted or specialist); or whether they have had to wait, and
for how long.

Children and their families tell us about how they have been involved in planning,
agreeing and reviewing the help they need from local health services.
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
Children and their families tell us whether they would recommend their local
health services to others.
2. The quality and effectiveness of safeguarding arrangements
within health
Assessing need and providing early help:

Health professionals (all sectors) have clear and effective systems to identify and
support children and families who would benefit from early help.

Assessments, care plans and child in need reviews are underpinned by effective
joint working between local health care services and partner agencies.

Health assessment, care planning and review arrangements are well targeted,
child-centred, and recognise the diversity of children’s needs and family
circumstances.

Barriers to the effective delivery of early help health services are recognised and
effectively addressed.
Identifying and supporting children in need

Health professionals (all sectors) have clear and effective systems to identify and
support children in need and their families.

Health professionals effectively involve children and their families in work to
address areas of concern.

Deterioration in the physical, emotional, mental health and behavioural needs of
children and young people (all ages) is effectively identified and addressed.

Professional accountabilities for managing risk are clearly identified, and actions
taken by health professionals to reduce risk are well targeted and effective.

Health professionals can evidence effective safeguarding arrangements that lead
to improved outcomes for children in need and their families.
The quality and impact of child protection arrangements

Health professionals are clear about thresholds and their professional
accountabilities for keeping children and young people safe.

Assessment of needs and risks to children are well documented in referrals
made by health professionals.

Health professionals effectively contribute to multi agency safeguarding hub
(MASH) arrangements (where they exist).
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o
There is timely and appropriate follow-up of risks to the health, safety,
development and wellbeing of children.
o
There are appropriate safeguards for managing confidentiality and consent.

Access to health professionals out of hours is good for those who require an
urgent response.

Assessment of children’s needs, their family circumstances and risks is
comprehensive and informs the development of individually tailored, outcome
focused health plans.

Health staff are appropriately engaged in all aspects of child protection activity.

The wishes and experiences of children, young people and their families are
clearly recorded and reviewed.

Systems for tracking children and their families who move between different
health teams or services are well managed.

Local health safeguarding arrangements give high priority to addressing risks to
the health and wellbeing of looked after children.

The health care and treatment of vulnerable children meets practice guidance
and standards (from NICE, Royal Colleges, including lessons from research).
3. The quality of health services and outcomes for children who are
looked after and care leavers

Health assessments, health plans and review arrangements are comprehensive
and child-centred.

Communication, information sharing and partnership working between health
commissioners, NHS providers, children and their carers is timely, effectively coordinated, and promotes improvement in the health and wellbeing of children
who are looked after and care leavers.
o
Confidentiality and consent is well managed.
o
Health staff are appropriately engaged in LAC assessment and review
arrangements.
o
Child health outcomes are closely monitored and risks are escalated.

The needs and risks to the health and development of children and young
people placed out of area are clearly identified and addressed.

Access to health professionals out of hours is good for those who require an
urgent response.

There is effective and targeted work with children at risk of sexual exploitation,
those with emotional, mental health and behavioural needs, and children with
disabilities and complex health needs.

Health support for teenage parents is well targeted and effective in driving
improved outcomes for young people and their unborn/new born babies.
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
Barriers to the effective delivery of health care for looked after children and care
leavers are recognised and effectively addressed.
4. Health leadership and assurance of local safeguarding and
looked after children arrangements
Leadership and management

Clinical Commissioning Groups (CCGs) and NHS Local Area Teams provide
good leadership in work to continuously improve health safeguarding and looked
after children arrangements.

Partnership working between NHS trusts, GPs, and child and adult health
services is well co-ordinated and supports effective use of organisational
capacity and expertise.

Management oversight and review supports effective tracking of risks to children
and improvements in child health outcomes.

Workforce planning is highly developed, is responsive to changes in demand
and gaps in organisational capacity are effectively managed.
Governance

Lines of accountability/governance arrangements for safeguarding children,
including support for children who are looked after, are clear and effectively
managed within the work of health commissioners and providers.

Trust performance reports provide a clear picture of the effectiveness of local
arrangements for safeguarding and improving the health and wellbeing of
children and young people.

Children and young people are encouraged to regularly share their views and
experiences in evaluating the quality and impact of local health services.
Training and supervision

Health staff are well trained in safeguarding and looked after children work, and
their competencies are checked to support compliance with Working Together
and inter-collegiate guidance.

Learning from serious case reviews and previous inspections is supporting
measurable improvements in practice.

Research is effectively used to inform practice and promote innovative work with
children and their families.
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Appendix B: Indicative timetable for children who are looked after and safeguarding (CLAS) review
(Please read alongside guidance notes)
Monday
9.00
Travel &
arrival on
site.
10.00
Introductions
Housekeeping
Review of
schedule
Tuesday
Review of key
documents and
case notes
Travel
Wednesday A&E/Urgent Care
Discussion
Case track
Dip Sample
11.00
12.00
Meet with
Lunch &
exec lead
write up
&
designated
Midwifery services – discussion
with named midwife
Case track
Dip sample
Travel
Lunch &
Write up
Travel
Thursday
CASH Services
Discussion
Case Track
Dip Sample
Travel
Substance Misuse
Discussion
Case Track
Dip Sample
Friday
Follow up outstanding lines of enquiry
Meet children and families
Write up
Travel,
lunch &
write up
1.00
2.00
3.00
4.00
Travel
Meet LAC health professionals
Dip sample initial & review assessments, to
include care leavers
Lunch
Write up
Travel
5.00
6.00
Write up
Collect
case
summaries
& key
documents
Write up
Health visitors & school nurses
Discussion
Case track
Dip sample
CAMHS
Travel
Adult MH
Write up
Discussion
Services
Case Track
Discussion
Dip Sample
Case Track
Dip Sample
Named GP
Meet children and families
+ GPs on case
Progress outstanding lines of enquiry
tracking or other
Write up
Travel
Feedback
Travel Home
This is only an indicative timetable and will vary according to the local area and the number of inspectors allocated. The definitive
timetable will be agreed between the lead inspector and the lead for the local area being inspected.
During dip sampling, we will be testing out lines of enquiry using case analysis tools.
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The healthcare of looked after children and care leavers, and the involvement of healthcare professionals in delivering that care,
will be tested in all settings using dip sampling.
The designated nurse/executive safeguarding lead will be asked on Monday morning to provide 8 cases for case tracking:
a) Cases where the health visitor made a referral to the local authority children’s services
b) Cases where Child and Adolescent Mental Health Services (CAMHS) made a referral to the local authority children’s
services
c) Cases where midwifery services have made a referral to the local children’s services.
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Appendix C. Guidance to help plan the review
Introduction
Given the short notice period, tight management and co-ordination of planning is
essential. This guidance aims to provide an outline of our requirements to ensure the
smooth running of the review. The indicative timetable (Appendix B) provides an
overview of the suggested flow and timings of the review activity. This will be
adapted following discussion with the lead inspector and considering:

the size and complexity of NHS commissioners and providers operating in the
area, and

the numbers of inspectors in the team.
The timetable should be completed in time for the first meeting with inspectors on
day 1 of the review. Although we recognise that changes to the schedule may be
required from time to time, we advise trying to keep to the suggested structure to
enable sufficient time for meeting young people and their families and for any
contingencies. Inspectors can be flexible in meeting or telephoning young people
and their families out of hours if required. Can you please provide:

the full address and postcode of locations we will be visiting

the name, role and contact number for the person who will take responsibility for
meeting us and showing us to the place where the interview/case tracking
activity will take place. This person should also ensure that we meet the relevant
staff and can access relevant child health records etc.
For all case tracking and dip sampling work, our meetings should take place
where there is easy access to the records of the core 8 children/young people
selected. In addition we will need to randomly sample a number of others to
fully reflect the age, gender and diversity of local children and their families.
Please ensure we have sufficient time for comfort breaks and for travel between
locations, including at peak times. It would be a great help if we were aware in
advance of parking facilities. The indicative timetable indicates time required for
inspection team meeting and writing up activity, wherever possible, no other
commitments should be made for these periods.
Day 1
After introductions and coverage of any security access and health and safety
issues, we would like to have a copy of the final timetable and the list of cases
(Appendix D) selected for case tracking. The inspection team will have a brief
meeting before meeting with:

The CCG executive lead and designated doctor/s and nurse/s for safeguarding
and looked after children. This interview will explore relevant lines of enquiry in
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relation to leadership and assurance and will draw on performance reports/data
submitted as part of the Key Document list (appendix F).

The afternoon of day 1 is focused on exploring the experiences and quality of
work undertaken with children who are looked after and care leavers. Inspectors
will check which lead professionals (or their peers/supervisors) are available to
undertake case tracking and dip sampling work and will need to have direct
access to children’s electronic and/or paper records, including for care leavers
and those placed out of area. Where there are two or more inspectors deployed,
one inspector will have a short meeting with the local manager/named nurse for
the looked after children (LAC) health team.

Completed case summaries per individual child/young person (Appendix E) to be
shared with inspectors at the end of day 1.
Day 2

Visit the local Accident &Emergency (A&E) or urgent care centre. The visit will
commence with a short meeting with the manager/named nurse for
safeguarding. Following this, inspectors will undertake a range of case tracking
and dip sampling work. It would be helpful to link with the paediatric liaison nurse
in undertaking this activity (where they exist).

Meetings with school nurses and health visitors. The format will include an initial
short meeting with the relevant operational manager/s and named nurse/s and
then sitting with the lead professional for each of the children we are case
tracking, supplemented by some dip sampling of the experiences of other
children/young people on their caseload.
Day 3

Meeting with midwifery staff. The format will include a short initial meeting with
the relevant operational manager/named midwife and then sitting with the lead
professional for each of the children we are case tracking, supplemented by
some dip sampling of the experiences of other children/young people on their
caseload.

Meeting with Child and Adolescent Mental Health Services (CAMHS) staff.
The format will include a short initial meeting with the relevant operational
manager/named safeguarding professional and then sitting with the lead
professional for each of the children we are case tracking, supplemented by
some dip sampling of the experiences of other children/young people on their
caseload.

Meeting with adult mental health staff. The format will include a short initial
meeting with the relevant operational manager/named safeguarding professional
and then sitting with the lead professional for each of the children we are case
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tracking, supplemented by some dip sampling of the experiences of other
children/young people on their caseload.

Leave space mid-week for the lead inspector to have a short inspection team
meeting and catch up with designated nurse/person co-ordinating the review.
Day 4

Meeting with contraception and sexual health services (CASH) staff. The format
will include a short initial meeting with the relevant operational manager/named
safeguarding professional and then sitting with the lead professional for each of
the children we are case tracking, supplemented by some dip sampling of the
experiences of other children/young people on their caseload.

Meeting specialist substance misuse staff. The format will include a short initial
meeting with the relevant operational manager/named safeguarding professional
and then sitting with the lead professional for each of the children we are case
tracking, supplemented by some dip sampling of the experiences of other
children/young people on their caseload.

Meeting named GP(s) and GP practice staff (practice(s) will be determined
following discussion with the lead inspector). The format will include a short initial
meeting with the relevant operational manager/named and lead GPs and then
sitting with the most appropriate member of practice staff in reviewing the
records of children we are case tracking registered with the practice. This will be
supplemented by some dip sampling of the experiences of other children/young
people involved in safeguarding activity or about whom GP practice staff have
raised concerns.

Dedicated time should be mapped out on day 4 (and other days, if feasible) for
telephone or face-to-face contact with children/young people and their families
who consent to meet with/talk to us.
Day 5

Complete face-to-face and telephone contact with young people and their
families.

Prepare feedback for sharing.

Provide headline feedback and overview of next steps.
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Appendix D: Case tracking template for case selection
Once completed, this document is to be retained and destroyed by NHS <insert
name> when the local report is published. For the purpose of case tracking, once the
cases have been identified and agreed, NHS <insert name> will allocate the initials
and unique identifier and share these with all health agencies involved in the case.
This will help the NHS provider organisations to locate the notes in preparation for
discussion and examination of the notes by the CQC inspector.
Parents’ NHS numbers should be included if they are currently open or have used
midwifery, mental health or specialist substance misuse services in last 12 months.
Case No., & type
Child’s NHS
No.
Child’s initials & Parent NHS No.
Unique Identifier & initials
(please indicate
if looked after)
Case 1 (health visitor,
midwifery & adult mental
health)
Case 2 (health visitor,
midwifery & adult mental
health
Case 3 (health visitor,
midwifery & substance misuse
staff)
Case 4 (school nurse,
CAMHS & CASH)
Case 5 (School nurse,
CAMHS & CASH)
Case 6 (School nurse,
CAMHs-child with a disability)
Case 7 (school nurse, CASH
& Midwifery)
Case 8 (School nurse, CASH
& Midwifery)
Contingency
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Appendix E: Summary template for each child/young person case
tracked
Please complete a case tracking template for each of the 8 core children and young
people. The case tracking sample should reflect the age range, diversity of needs
and family circumstances of children and young people you support.
TEAM AND LOCALITY
Case number:
Child’s NHS number, initials and
unique identifier
Brief pen picture of the child/young person (including if unborn baby):
Chronology of case
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Summary of work undertaken by child health professionals and view of its
impact
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Planned visits/meetings with respect to this child/family week commencing
Signed:
Role:
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Appendix F: Suggested list of key documents
Please provide the following documents to help us have the most up-to-date picture
of the leadership and assurance of local health arrangements for safeguarding and
meeting the health care needs of children who are looked after in the area. Please
provide the latest version within the time frame of the last 12 months. Please forward
by email to Childrens-Services-Inspection@cqc.org.uk by Friday <insert date> 2013.
Key documents:

Latest action plan and progress report/s to Trust Board/LSCB in relation to
recommendations for health made in previous SLAC inspection.

Action plan(s) of serious case review(s) and progress report(s) in relation to
recommendations for health.

Most recent annual report(s) from designated doctor/nurse for Looked After
Children.

Most recent Children’s Safeguarding Annual Report for each of health
organisations named in this letter.

Recent report(s) outlining GP performance in relation to safeguarding and looked
after children.

Recent audit(s) of safeguarding and looked after children arrangements and
management action plan(s).

Survey/evaluation and outcomes of recent work undertaken to listen to and learn
from the experience of young people and their families.

CCG/NHS England safeguarding and looked after children performance
management reports including relevant board/governance committee reports
since April 2013.

Latest safeguarding training figures expressed as a percentage of total
workforce across all sectors and levels.

Example(s) of innovative practice.
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