Death of a baby, a few months old, in July 2011. Child W was found dead by his/her mother, after the child had been brought to bed by the mother's partner and placed between the couple as they slept. Prior to Child W's birth, mother and older siblings had been assisted by the Police Public Protection Unit to relocate to Coventry, from Birmingham, following incidents of domestic abuse. Older siblings of Child W had been subject to child protection plans in the past when the family had been living in Birmingham. Child W and his/her siblings had been removed from the family home following an incident of suspected violent assault against the mother by her new partner, however there was insufficient evidence of concern to progress to child protection plans. Makes recommendations covering: the provision of residential accommodation to those fleeing domestic violence; patterns of multi-agency working; and, risk assessment processes and tools used by professionals.
      
 Title:  Serious case review: Child W. LSCB: Coventry Safeguarding Children Board Author: Coventry Safeguarding Children Board Date of publication: 2012  This case review report was deposited by the publishing LSCB(s) with the national SCR repository, a partnership between the Association of Independent LSCB Chairs and the NSPCC.  This report is available online via the NSPCC Library Catalogue. Copyright of this report remains with the publishing LSCB(s) listed above.                           Coventry Safeguarding Children Board Serious Case Review Child W May 2012     This is the report of the Serious Case Review concerning the death of Child W, which was commissioned by Coventry Safeguarding Children Board. It was conducted using the Learning Together / Social Care Institute of Excellence systems learning methodology.     2        Coventry Safeguarding Children Board  Learning Together Systems Review  Child W   May 2012        3 Report of the Learning Together Review of Child W  Contents Page Introduction / Background to the review 4 Succinct summary of case 4 Process and structure of the review 5 Scope and terms of reference 5 Sources of data 6 The Findings 8 Appraisal of professional practice in the case – a synopsis 8 Management system 14 Patterns of multi-agency working 16 Processes and tools used by practitioners 20 Summary of the seven findings 26 Bibliography  27 CSCB response to the seven findings 28              4  1.  Introduction   Background to the Review 1.1  Child W was a few months old when he/she died in July 2011. The death of Child W was referred to the Coventry LSCB and the Chair of the LSCB decided that the case met the criteria for holding a Serious Case Review. The Chair commissioned this review. Ofsted was notified of the decision and following correspondence and discussion with the Department for Education (DfE) permission was granted for the case to be reviewed using the Social Care Institute for Excellence (SCIE) „Learning Together‟ methodology.    Summary of the case  1.2  Child W was found dead by his/her mother in July 2011. The child had been brought to bed by the mother‟s partner and placed between the couple as they slept.  1.3  In early 2011, following concerns expressed by the local family support and universal services‟ professionals and following anonymous allegations that the three older siblings of Child W were witnessing domestic abuse; Coventry Children‟s Services undertook a Core Assessment of the family and judged that continued support from the Common Assessment Framework (CAF) team was sufficient to support the children. 1.4  Child W was born in late May 2011 following a normal pregnancy and birth. Four weeks after the birth of Child W, a serious incident took place. Both the mother and her partner were intoxicated with alcohol and the partner was suspected of a violent assault on the mother. Children‟s Services and the police became involved and judged that neither parent was capable of looking after the children at that time.  1.5  A strategy meeting was held. Those professionals present decided that there was insufficient evidence of concern about the care of the children to proceed to case conference and child protection plans. The decision reached by members of the meeting was that a further six week period of assessment was required. A week following the strategy meeting Child W was found dead by his/her mother, the child having been brought to bed by her partner and placed between the couple as they slept.  1.6  The inquest was held on 16th December 2011 and the Coroner recorded an open verdict 1.7  The family had previously lived in Birmingham. In 2009, the mother of Child W was seriously assaulted by her then partner and she, and her children, fled to Coventry with the support of local police. The family initially lived in hostel accommodation in Coventry and some months later the family was given a tenancy in Coventry. Support was provided to the family by a local Domestic Violence Support Project and the local family support and universal services professionals.   5 1.8  While she was in the hostel the mother met Child W‟s father with whom she had a transient relationship resulting in the pregnancy. Later, when she was in her own independent tenancy, the mother became involved with a new partner who had a history of alcohol and drug abuse and domestic violence. She was living with this man at the time of Child W‟s death.   Process of the Review 1.9  The scope of the review was agreed by the Review Team as being from 1 December 2009 to 15 July 2011. This covers the period when the family moved to Coventry from Birmingham and the date of the death of Child W in July 2011.  1.10 The mother of Child W and her partner were informed both verbally and in writing that a Serious Case Review was to be undertaken and their involvement through taking part in individual conversations was requested. Both declined the invitation to be involved.   Review team - Who was involved? 1.11  The Review Team was led by an Independent Professional from a voluntary agency and an Independent Safeguarding Consultant who has undergone training on the SCIE „learning together‟ methodology. These two reviewers were assisted by a review team of representatives from relevant local agencies.    Structure of the review process - What was done?  1.12   The Review Team met on six occasions on the following dates: 7 November 2011, 28 November 2011, 12 December 2011, 9 January 2012, 30 January 2012 and 2 April 2012. 1.13 The Review Team met with the Case Group (the professionals who had worked directly with the family) on two occasions on the following dates: 20 January and 16 March 2012. 1.14  In addition members of the Review Team held individual conversations with members of the case group on 14 November 2011, 18 November 2011 and 5 January 2012.   Scope and terms of reference 1.15   In line with qualitative research principles, reviewers endeavour to start with an open mind in order that the focus is led by what they actually discover through the review process. This replaces terms of reference that have a specific focus of analysis before the review process has begun.  1.16   The use of Individual Management Reviews is not part of the SCIE „Learning Together‟ methodology. However prior to gaining the permission from the Department for Education to depart from some of the requirements of Working Together (2010) in respect of Serious Case Reviews, the Coventry LSCB had commissioned Individual Management Reviews from the following agencies:  6  University Hospitals Coventry and Warwickshire  Coventry City Council ,Children, Learning and Young Peoples Directorate   Children's Social Care Services   Children's Multidisciplinary Team  School and Education Service   West Midlands Police  The Supported Accommodation Provider  Specific information was also provided by Birmingham City Social Care Services in the form of a summary report. 1.17  When approval was gained from the Department of Education to use the SCIE methodology a decision was taken to draw upon the Individual Management Reviews as an additional source of data to supplement the content of the individual conversations with key staff that were subsequently conducted.   Sources of data:   Data from practitioners 1.18 Information was provided by members of the Case Group who were directly involved with the family through a process of individual conversations. A total of sixteen conversations were held with individual practitioners.     Individual management Reviews (IMRs)   1.19 Information was also obtained from the Individual Management Reviews together with various agency records. The Review Team has considered Individual Management Reviews from the agencies listed above at 1.11     Documentation  1.20 The following documents were reviewed by the review team:  Minutes from relevant Multi-agency Risk Assessment Conference for domestic abuse (MARAC) meetings  Core Assessment - March 2011  E mail information provided by hostel  E mail information from the Police  Information provided by local nursery  Signs of Safety Assessment  7  Background information from the local domestic abuse project    Data from family, friends and community 1.21  The mother of Child W and her partner were informed both verbally and in writing that a Serious Case Review was to be undertaken and their involvement through taking part in individual conversations was requested. Both declined the invitation to be involved during the course of the review.  In November 2012, the mother of Child W met with one of the lead reviewers following the completion of the review to discuss the findings and was invited to contribute any comments she may have. She was informed of the publication arrangements for the report on the LSCB website. She was able to endorse the concerns expressed in the report about some of the unregulated accommodation she was placed in; saying she felt unsafe and unsupported there. She also recognised that from her own experience women in violent relationships need longer term support than she had received in order to avoid falling back into pre-existing patterns of behaviour, particularly when moving into a new area. She was thanked for her contribution which will be fed into the action plan for further consideration.   Data from Birmingham  1.22 Birmingham Children‟s Services did not complete an IMR in accordance with the terms of reference as the timescale of the case review commenced after the family had left Birmingham.  Nonetheless, it became apparent that agencies in Birmingham would have valuable information that shaped how the family were received into Coventry and initially influenced the provision of services.  The Birmingham LSCB provided a summary report which has been considered during the review process. It has not been possible to hold individual conversations with the staff in Birmingham who were involved with the family at the time. This has left the review team with some unanswered questions about how the case was managed and what information was transferred to Coventry services in late 2009.  Methodological comment and limitations 1.23 Attendance at the first meeting of the review team and case group was excellent and the results provided a good level of information. Unfortunately, some agencies were unable to attend the second of these meetings due to competing operational priorities and leave commitments. The review team has therefore significantly relied on information gained from those staff in those agencies provided in the individual conversations.  1.24 The underlying patterns in the safeguarding system discussed in the findings have been identified by members of the case group during the review process. These are based on their views and experience. In order to determine the frequency of these patterns and the extent to which they are applicable across all the local services, the LSCB may want to undertake action or further investigative work.   8  The ways in which this case provides a useful window on the systems in Coventry 1.25 A number of systems were influential in the way that the case unfolded; the way in which cases are considered by the Children‟s Services, the relationships between professional groups involved in the Common Assessment Framework, the way cases are assessed and the thresholds for subsequent intervention are all key features of the case under review. The examination of these systems and the way they interact with each other has provided an opportunity to gain insight into the strengths and areas for development in those systems and forms the content of the findings below. 2.  The findings 2.1 A key feature of the systems model is the endeavour to make the particular case being reviewed act as „a window on the system‟. This involves moving from the analysis of intricate details of the case (via the key practice episodes and their contributory factors), to a deeper level of analysis. The nature of a systems review process is to seek to answer questions about actions and events, which seemed reasonable to those involved at the time but with hindsight now seem questionable based on all the information available.  2.2 This deeper level is about what can be learnt from this particular case, which may be relevant to professional practice more broadly. In terms of service improvement the Review Team is seeking to identify patterns in the way that workers interact with and are influenced by different aspects of single and multi-agency systems, as opposed to issues unique to this case. While these influences on practice may manifest slightly differently in different cases, the underlying factors are the same. SCIE call these the „underlying patterns of systemic factors‟. As stated above, the LSCB may want to undertake action or further investigative work to determine the frequency of these patterns and the extent to which they are applicable across all the local services.  2.3 The systems model that SCIE has developed includes six broad categories of underlying issues. In this review, three of these have been particularly relevant to the analysis of the information and data considered: –   management system,   patterns of multi-agency working, and   processes and tools used by practitioners. 2.4 Each pattern features interactions between people and aspects of the system, including other people. Each category may have many different subcategories and it is hoped these will be developed and expanded as more case reviews using this model are developed. There is, of course, overlap between categories.  2.5   A critical final step in the case review process is to both identify and prioritise the main underlying patterns. This has drawn from discussions both among review team members and with contributions from the case group  9   Appraisal of professional practice in this case – a synopsis  2.6 The family of Child W moved to Coventry from Birmingham fleeing domestic violence and were assisted in doing so by the Police Public Protection Unit (PPU) staff in Birmingham and Coventry. The children of the family had been subject to child protection plans in the past in Birmingham. An initial assessment was completed at the time the family were placed in hostel accommodation in Coventry.  2.7 The police public protection arrangements across the two local authority areas worked well and the prompt intervention by domestic violence officers evidenced that domestic abuse and a speedy response to it is a priority in the two areas. However, Children‟s Social Care Services in Birmingham and Coventry were not involved in the move and were therefore unable to assess the situation in respect of the children and this was potentially compromising to their safety. 2.8 Birmingham Children‟s Social Care Services tried on two occasions to transfer this open case to Coventry Children‟s Services for help. The Referral and Assessment Service (RAS) in Coventry refused to take the case on the basis that it was early days into their move and the family did not have a permanent address in the Coventry area. The high volume of workload also precluded their involvement. There were clearly child protection concerns at the time of the move to Coventry as it has emerged that Birmingham Children‟s Social Care Services were considering removing the children if the mother had refused to move due to the dangers presented by her ex-partner, although it appears that the children were not subject to child protection plans as might have been expected. The case was transferred to Coventry after a short delay but the Review Team was particularly interested to understand why the Coventry service had not immediately taken over responsibility for the case.  2.9 Finding suitable refuge accommodation for the family proved difficult for PPU officers. The hostel where the family were initially placed may have contained residents who were a danger to the children and no comprehensive checks were carried out regarding the background of those people resident at the hostel. This raised questions for the review team about how local commissioning of appropriate provision occurred and how compliance with quality and safety standards was achieved. 2.10 The case was referred promptly to the Multi Agency Risk Assessment Conference (MARAC), which is part of the Multi Agency Public Protection Arrangements (MAPPA) in Coventry. Members of the conference initiated an immediate move of the family to another DVA supported accommodation provider, which is commissioned by the local community safety partnership arrangements in Coventry. This was good practice particularly as this hostel provided the family with appropriate security and support including psychological assistance for one of the children who, in the past had witnessed domestic abuse taking place.  2.11 From the safety of the DVA supported accommodation, the mother felt able to disclose to the Coventry Police that during the incident of abuse which had necessitated her move to Coventry, one of her children had also been assaulted by her ex-partner, something she had previously denied. The police reviewed the  10 information in the case and referred it back to the Birmingham area as there is a police protocol that offences are investigated in the area where they happened.  The case was allocated to inexperienced officers and administrative mistakes were made in both the Birmingham and the Coventry Police areas and as a result the case was dealt with inappropriately. This had the effect of concealing the mother‟s inability to prioritise the needs of the children over her own, potentially exposing them to future risk. 2.12 Six months after becoming resident at the DVA supported accommodation the mother met a new partner; staff become aware of this new relationship in May 2012. In September 2010 the mother notified staff that she was five weeks pregnant with Child W by which time the relationship had ended.  2.13 While resident in the DVA supported accommodation, the staff there were concerned about the mother‟s ability to prioritise her children‟s needs and tried to persuade her to stay resident there allowing the time for her to develop life and parenting skills. A Common Assessment Framework (CAF) procedure was put in place providing a simple structure for local professionals involved with the family to meet and access appropriate services for the family. Unfortunately, the mother chose to find her own independent tenancy and left the hostel after nine months, in October 2010. Before doing so she split up with Child W‟s father and began to see someone else. 2.14 After leaving the DVA supported accommodation, the service allocated a worker from the Teenage Parents floating support in November 2010, to support Child W‟s mother in her new home, alongside active input from a Children‟s Centre family support worker. The Common Assessment Framework arrangements remained in place which was helpful to the mother and allowed for a level of monitoring.  However, this type of support was voluntary which meant that the mother did not have to access it if she chose not to. The type of support offered by them seemed appropriate at the time, but in hindsight it was insufficient to ensure the safeguarding of the children, as its function was to focus on the needs of young parents. 2.15 It became evident that the mother‟s new partner had a history of alcohol abuse and drug abuse and had been physically abusive to a previous partner. The adolescent child of this man was also subject to a CAF. However, the professionals involved made no attempt to undertake a formal assessment of the partner‟s possible risk to the children, or to co-ordinate the interventions between the CAF‟s 2.16 Over time and on a number of occasions the professionals involved in the CAF had suspicions that domestic abuse was being perpetrated against the mother and challenged her to disclose which she refused to do. The voluntary nature of the support she was receiving through the CAF process did not support the workers to be assertive and to challenge the mother. Professionals found it difficult to find supporting evidence of actual abuse in the face of the mother‟s denial that there was a problem. 2.17 The local family support and universal services professionals involved in the CAF attempted to escalate the priority of the case by trying to engage Children‟s Social Care Services with their concerns about the probability that mother‟s new partner was perpetrating domestic violence against her. The requests by the local family  11 support and universal services professionals for more formal intervention by those in the Children‟s Social Care Service were not initially accepted. The workers in Children‟s Social Care Services believed there was a lack of clear evidence of risk to the children on which to take further action. This raised questions for the review as to why the concerns of local family support and universal services professionals were not fully understood or acted upon immediately. 2.18 However, shortly afterwards, following an anonymous referral from a neighbour, the Children‟s Social Care Service did intervene and escalate the case to Child in Need status and undertook a core assessment of the family over a three month period. The assessment was completed during a period of stability in the family. The assessment recommended no further action except for continued support from the local family support and universal services professionals. However, the basis of the assessment was unclear, gave a poor analysis of the risk factors contained in the family situation and did not consider the effect that the mother‟s current pregnancy may have on the situation at the time or after the birth of the baby. The Review Team wished to discover why the assessment process had produced that result. 2.19 Child W was born normally in May 2011 and suitable advice was given, both verbally and in writing to the mother by both hospital and health support staff in respect of the safe care of the newborn child which included safe sleeping arrangements. Subsequent to Child W‟s death Child W‟s mother confided in a member of the Review Team that she had remembered being given advice about safe sleeping and not taking Child W to bed and had understood the advice. However, she acknowledged that she and her partner had ignored the advice on a number of occasions. 2.20 A month after Child W‟s birth the police and Children‟s Social Care Services were called to the family home. Both of the parents had consumed large amounts of alcohol and they had had a violent argument in which the mother had sustained an injury. They were both judged to be incapable of looking after the children at that time. Temporary arrangements for looking after the children were agreed jointly by the police and Children‟s Social Care Services but were unsatisfactory in that they did not ensure that the violent partner would not return to the house therefore this insufficiently safeguarded the children. 2.21 Following this incident Children‟s Social Care Services intensified visits to the family and all those local family support and universal services professionals involved in the CAF were asked to provide information and attend a professionals meeting. This provided a good opportunity for information sharing. A few days later a strategy meeting was held to consider the case going forward to a child protection case conference. 2.22 A suitably experienced senior social worker in the absence of the team manager took the chair. The meeting considered the case and used a risk assessment tool to guide members of the meeting in their decision making in respect of the next steps in the case. The results from using the tool were inconclusive. 2.23 The chair of the meeting was unconvinced that the risk factors outlined by the professionals in the meeting were based on hard evidence and believed that the  12 family were being co-operative in working with the services involved. The chair, mistakenly with hindsight, believed there to be a consensus for the decision to „defer a move to case conference for six weeks pending further assessment and support of the family‟. The decision not to take immediate formal safeguarding action was agreed by those at the meeting and no dissenting views were recorded at the time. Again with the benefit of hindsight it is arguable that there was sufficient evidence at the time to move more directly into more formal child protection processes. Given the available information the Review Team were keen to understand why such a result had occurred. 2.24 At the strategy meeting arrangements were made for a child in need meeting to be held with the family as it was thought important to ensure that the family were clear about the level of concern held by local professionals. The family arrived very late for this meeting saying they could not stay as they had another appointment. The meeting was cancelled and a further meeting set for two weeks after that. The couple had attended but this situation should perhaps have raised more concerns about whether the couple were taking the professionals' concerns about their children sufficiently seriously. 2.25 One week after the strategy meeting, the mother and her partner had been consuming alcohol and Child W was taken into bed with them by the partner. The mother awoke in the morning to discover that Child W was lying in between them and was not breathing. An ambulance was immediately called but the child was subsequently pronounced dead. It is the view of the Review Team that while the potential for some form of harm to Child W may have been predictable, the death was not preventable.  Systemic Issues 2.26 The „Learning Together‟ methodology has allowed the Review Team, working with the Case Group to identify and explore the issues raised above where they manifest themselves not only in this case but perhaps more widely in other instances across the safeguarding system. In accordance with the „Learning Together‟ methodology these wider „systemic‟ issues seek to provide a „window‟ into the safeguarding system and allowed the review team the opportunity to analyse a number of underlying patterns in the system.  2.27 It should be stressed that the issues that the review examined which were felt to be peculiar only to this individual case under review were not included as part of the findings as they were not felt by the Review Team to be manifest in the wider safeguarding system. This approach is a feature of the SCIE systems methodology.  An example of an issue believed to be peculiar to this individual case was safe sleeping arrangements. Following a thorough examination and discussion of the issue, the Review Team were confident that the matter had been dealt with properly by the agencies involved in the safeguarding system. Those involved in the case were found to have appropriately used written information, verbal prompts and suitable advice and support to the mother of Child W and her partner in respect of safe sleeping. The Review Team concluded that because the mother of Child W and her partner had chosen to ignore the advice that they were given that this issue was  13 an individual aspect of this particular case alone, albeit that it led to the circumstances of Child W‟s death. 2.28 The likely underlying patterns in this case are listed below and then discussed:  a) Management System i) High levels of demand and limited capacity may lead to difficulties in prioritising all cases accurately, particularly those transferring in from another adjacent local authority.   ii) Workflow through the children‟s social care teams may not always occur within agreed timescales because of the overall competing high levels of demand in the City.   b)  Patterns of multi- agency working  i) There is a perception that the timing and appropriateness of transfer of cases from and to the local multi-disciplinary family support teams who use the Common Assessment Framework (CAF), a system known as „stepping up‟ or „stepping down‟ cases needs to be further refined to clarify expectations.    ii) Consistent and comprehensive quality assurance standards for the provision of residential accommodation to those fleeing domestic violence are not in place. iii) The role of the agencies providing accommodation, support and counselling for domestic abuse cases is not sufficiently clear and potentially concentrates attention on adult victims with insufficient focus on safeguarding vulnerable children.   c)     Processes and Tools used by practitioners  i) Does the current system for identifying the levels of need and support to families, along with the expectations of the role and responsibilities of professionals and agencies, require reconsideration by Children‟s Social care?   ii) Considering risk using any tool including the „Signs of Safety‟ model may lead to ambiguous judgements and decision making. The implications of this need to be considered to ensure there is a standardised implementation of the use of the tool. There should be sufficient knowledge of the tool to allow professionals to challenge decisions which flow from the use of the tool.    iii) Assessments of need, particularly core assessments, are potentially insufficiently multi agency in production and may lead to gaps in the information required to complete a comprehensive assessment.   a) Management System  i) High levels of demand and limited capacity may lead to difficulties in prioritising all cases accurately, particularly those transferring in from another adjacent local authority.     14 2.29 When Birmingham Children‟s Social Care Service made requests to Coventry Children‟s Social Care Service for transfer of the case between areas this was not immediately agreed. The refusal by Coventry on both occasions was justified by a different rationale. On the first occasion Birmingham were told that evidence of the family being permanently resident in Coventry was required and that hostel accommodation did not indicate that the family were permanently housed locally. On the second occasion Birmingham were informed that excessive workload precluded the service taking on responsibility for the case at that time. This transfer difficulty was regrettable but the case was accepted shortly afterwards.  2.30 Participants in the Case Group described that there was a general expectation that neighbouring authorities within reasonable driving distance, wishing to transfer complex cases to Coventry would be asked to hold and to continue to work with those cases for a period. The rationale for this being that the other authority would be able to continue to visit the family, and experience had shown that families frequently move back to their original home town. There was a lack of clarity about whether this understanding was explicitly stated in regional procedures.  2.31 The Review Team discussed the issue of cross border transfers and noted that, while regional procedures in the West Midlands had existed in respect of case transfer arrangements these were no longer current and required revision to take into account changing legislation and organisational structures. 2.32 In Northamptonshire County Council v Islington LBC (1999) and C (a child) v Plymouth City Council (2000), the Court of Appeal gave authoritative guidance on the test to be applied when determining which local authority is to be designated under Section 31(8) of the Children Act 1989. It was held in these cases that a child is ordinarily resident where the parent of a child with parental responsibility resides. Further to these legal provisions the Children Act 2004(S11) (1)/ (2) lay duties on authorities to safeguard children and co-operate together to do so. Therefore in this case, the mother and her children who were resident at a hostel in Coventry should have perhaps been provided immediately and without any delay with a social care service, if the appropriate level of need was reached.  2.33 In many respects the exact legal position is a moot point, what is of relevance and concern is the need for a focus on the welfare of children moving over the boundary into the Coventry LSCB area.   FOR CONSIDERATION BY THE LSCB High levels of demand and limited capacity may lead to difficulties in prioritising all cases accurately, particularly those transferring in from another adjacent local authority. This case review illustrates that on some occasions cases moving into the Coventry LSCB area that would be eligible for transfer into the Coventry Children‟s Service may not be given immediate priority.   15 While it is a reasonable stance that children and their families „in transit‟ should remained connected to staff in the local area that has been working with them, a change of address, albeit temporary does change the situation. Professional staff from another area working across a boundary will probably not know or have access to local resources once a family has moved, thus potentially  causing operational and communication difficulties when working in that different area.  The Review Team is aware that the lack of current protocols, understood and supported by Children‟s Services staff in Coventry and published more widely within the region is a barrier to efficient case transfer. It is a challenge to the LSCB to ensure the safe and timely acceptance of children‟s cases from external authorities into the Coventry area.  It is a challenge to the LSCB to ensure protocols are developed which apply to local and regional transfers of cases into Coventry and when in place, that the procedures are publicised and supported by management action.     ii) Workflow through the children’s social care teams may not always occur within agreed timescales because of the overall competing high levels of demand in the City.  2.34 The high level of demand on the Coventry Children‟s Social Care Services, Referral and Assessment Service (RAS) was given to Birmingham Children‟s Social Care Service as a reason why the service was unable to respond to the request for immediate transfer in respect of the family in this case review.  2.35 The Review Team was told that a large numbers of cases were being handled by the RAS in mid 2011 and a commonly held view in the case group was that there was a resource versus demand mismatch at that time. The RAS staffing comprises of twenty five social workers, five senior practitioners, five team managers and one integrated service manager (ISM). The average caseload within the service is twenty five cases per full time equivalent social worker. Some cases remained in the service longer than the agreed six weeks duration due to problems with transfer to longer term teams. Many cases reached second child protection and looked after children reviews before it was possible to transfer them into other teams. In 2010-2011 the service dealt with:  Contacts        13,478  Referrals           3655  Initial assessments            3100  Core Assessments               1097  Section 47 enquiries           567  Initial child protection conferences             384  FOR CONSIDERATION BY THE LSCB Workflow through the children’s social care teams may not always occur  16 within agreed timescales because of the overall competing high levels of demand in the City. The RAS plays a crucial role as an initial access point to children and families requiring service and represents the „front door‟ of the children‟s service. Decisions about whether or not to grant access to services take place in the service as do initial and core assessment s of children and their families. Clear operational protocols are in place to govern the throughput of cases ensuring that the team holds cases for a maximum of six weeks before cases are moved on to longer term or specialist teams. However, there is a wide acknowledgement that those protocols have not always been adhered to because of the high number of cases the RAS is dealing with caused by a backlog of cases which should move on to other specialist teams. The nature of the work is such that the demand for referral or re referral cannot be estimated or the ebb and flow of cases being presented accurately calculated. In these circumstances of a demand versus resource mismatch in this service there is a potential for staff to become stressed and their abilities of assessment and decision making to become impaired. The LSCB will want to consider whether workflow through the system is still a difficulty and what can be done to alleviate any difficulties. It is a challenge to the LSCB to satisfy itself that contingency plans are in place to ensure that those children who require services from the RAS receive them.  It may be advantageous to consider the issues in respect of RAS in the context of the whole of the Children‟s Services.       b) Patterns of multi-agency working  i) There is a perception that the timing and appropriateness of transfer of cases from and to the local multi-disciplinary family support professionals who use the Common Assessment Framework, (CAF), a system known as ‘stepping up’ or ‘stepping down’ cases needs to be further refined to clarify expectations.   2.36 A number of the local multi-disciplinary family support professionals were involved in giving support to and monitoring the progress of the family in the case being reviewed. It is clear from the evidence gained during both the individual conversations and the Case Group meetings that those operating the CAF arrangements encountered difficulties in escalating the case under review for the involvement of Children‟s Services. The rationale given for this by Children‟s Services was that there was still insufficient evidence to warrant further action.  2.37 Those local family support and universal services professionals involved in this case felt that there was what they perceived to be a more general reluctance on the part of Children‟s Social Care Services to become involved directly in a case unless there was a clearly identified significant worsening of the situation or a crisis. This may  17 also reflect a lack of clarity on the part of these professionals about their roles in managing the CAF plan and helping the family. 2.38 Those involved in the review from Children‟s Services pointed out that the CAF process was nationally designed to provide early intervention and involves „everyone whose job involves working with children and families to keep an eye out for their well being and be prepared to help if something goes wrong‟ The Common Assessment Framework for children and young people: a Practitioners guide 2006. Using this ethos the expectation of Children‟s Services staff is that cases will be effectively contained and worked with at a CAF level unless there was a clear crisis or rationale for their intervention. These differing viewpoints did not seem to be aided by current procedural guidance and management arrangements and potentially left a gap where CAF professionals needed support with their concerns and easier access to children‟s professionals with a greater level of expertise. 2.39 Case Group members from Children‟s Social Care Services were keen to point out that they had limited resources and were often not in the best position to intervene as to do so would have the unintended consequence of elevating a case beyond the levels of intervention that were warranted or beneficial to the children. FOR CONSIDERATION BY THE LSCB There is a perception that the timing and appropriateness of transfer of cases from and to the local multi-disciplinary family support who use the Common Assessment Framework (CAF)  a system known as ‘stepping up’ and ‘stepping down’ cases needs to be further refined to clarify expectations.   The CAF system is a valuable method of accessing early intervention for a large number of children and families. However, those involved in the CAF process need clarity of role and the confidence to carry out that support role effectively.  There is a misperception by some of the professional staff using the CAF that it is in some way a method of diverting cases that otherwise would or should receive attention from the Children‟s Services. This misperception is reinforced by case examples, such as the one under review, where CAF professionals experience a difficulty in „stepping up‟ cases where they feel there is genuine concern and where the expertise of a social worker is required. While it is difficult to quantify these perceptions they do exist and potentially may prevent the smooth operation of the CAF system which in turn potentially frustrates the aim of the CAF system to provide coordinated early support and intervention to families.  It is a challenge to the LSCB to ensure that professionals in all agencies are fully equipped and confident to perform their roles within the CAF process and that assistance and support for more complex case situations is available to staff who require it.   18  ii) Consistent and comprehensive quality assurance standards for the provision of residential accommodation to those fleeing domestic violence are not in place.   2.40 Domestic violence was a significant feature in the case under review. Child W‟s mother‟s attempts to flee domestic violence brought her into contact with residential accommodation which provided temporary sanctuary from the violence she was subject to. The Case Group members described to the Review Team variability in the quality and safety of the establishments she took refuge in. In the first hostel in which the mother of Child W stayed she received threats from other residents. This is an independent non-commissioned hostel. The second DVA Accommodation  provider is a properly commissioned DVA service subject to contractual monitoring by their commissioner, Coventry City Council.   2.41  The Review Team were concerned about the lack of comprehensive arrangements for the regulation and monitoring of independent non-commissioned establishments both locally and nationally. The Review Team remained unconvinced that the needs of the children who accompany women fleeing domestic violence, as in this case, were fully considered and safeguarded.   2.42 The Review Team discovered that in the absence of national regulations and quality standards applicable to the operation of residential hostel accommodation dealing with domestic violence that effectively anyone can set up such accommodation as a private landlord. The implication of this situation is that it is not possible for those agencies assisting in placing women and children in such accommodation to be reassured that it complies with general children‟s safeguarding principles. It can also be difficult to know with certainty if staff working in the establishments have the professional expertise to provide services such as counselling and support to vulnerable women and children. The Review Team believe that this is an issue of national significance and should be noted for potential action by the relevant government departments such as the Department for Education and the Home Office.  2.43 At a local level the Review Team believe it is essential that those professional staff and police personnel involved in responding to and assisting those subject to domestic violence should satisfy themselves that the residential accommodation in which they place vulnerable women and children is safe and provides the level of expertise required to respond to the needs of its residents, both adults and children.   iii) The role and expertise of agencies providing accommodation, support and counselling for domestic abuse cases is insufficiently clear and potentially concentrates attention on adult victims with an insufficient focus on safeguarding vulnerable children.   2.44 Members of the Case Group described how difficult it can be to work with adult women who are often in denial about the abusive relationships they are in. The case under review highlighted the need for staff in both supported accommodation and family support services, dealing with domestic violence and abuse, to be confident in  19 identifying, challenging and responding appropriately to signs of domestic abuse and to be mindful that small children who are present in the household can be potentially vulnerable.   2.45 The Review Team were struck by the paradox that certain types of work such as statutory child protection interventions usually attract a mandatory response from well qualified and experienced professionals, whereas domestic violence and abuse  situations which also demand high levels of skill and investigative abilities tend to be dealt with by less experienced and qualified staff. The Review Team were further struck by the tendency in agencies for whom child safeguarding was not a primary focus, when responding to the needs of adult victims, sometimes allowing themselves to be distracted from the needs of potentially vulnerable children.  FOR CONSIDERATION BY THE LSCB Consistent and comprehensive quality assurance standards for the provision of residential accommodation to those fleeing domestic violence are not in place. The role and expertise of agencies providing accommodation, support and counselling for domestic abuse cases is insufficiently clear and potentially concentrates attention on adult victims with an insufficient focus on safeguarding vulnerable children. In the absence of prescribed national standards for the quality and safety of residential accommodation dealing with victims of domestic violence, it is a challenge to the LSCB, working in partnership, to ensure the safety of children in these facilities. The LSCB will want to consider how best it can do this both through direct commissioning and through individual agency practice. In respect of direct commissioning, the LSCB activity is likely to overlap with that of the local Community Safety Partnership in order to ensure that contracts reflect the needs of both adult victims and their children. It will be a challenge to both of these partnership bodies to ensure that contracts not only reflect quality and safety standards but also, as part of ongoing contract monitoring, that those standards are maintained. With respect to individual agency practice, it will be a challenge to both the LSCB and the Community Safety Partnership to ensure that individual professionals making referrals to residential accommodation are aware of the safeguarding needs of children and ensure that they are not compromised when placing their adult carers.      c) Processes and Tools used by Practitioners  i) Does the current system for identifying the levels of need and support to families, along with the expectations of the role and responsibilities of  20 professionals and agencies, require reconsideration to take into account the Munro recommendations?    2.45 The circumstances in which professionals become involved with children and their families and the level of that involvement is often referred to as a threshold of intervention. On a number of occasions in the case being reviewed the local family support and universal services professionals identified instances where they believed that domestic abuse was being perpetrated within the family and that this was likely to be affecting the wellbeing of the children. When they made attempts to escalate their concerns to colleagues in Children‟s Social Care Services they were told that they had insufficient evidence on which to take further action. The effect of this was that on some occasions the case was inappropriately maintained by the CAF professionals outside of the formal safeguarding system in local family support and universal services. The Review Team believes that this links into the issues described above in relation the timing and appropriateness of transfer of cases from and to the local multi-disciplinary family support professionals.   2.46 Some members of the Case Group felt that the application of thresholds may not always be as consistent as they would like to see. Coventry Local Safeguarding Children Board (CLSCB) have developed and published procedures and processes in respect of how thresholds of intervention should operate taking into account the skill mix of the workforce involved, available resources and the need to promote the welfare of children and ensure their safety. 2.47 The tool used to govern this is known as the „Promoting Children and Young People‟s Welfare Model‟. The model works on the principle of four levels, level one being access to universal services usually characterised as those which are normally available to all children such as playgroups or nurseries, through to level four where specialist intervention such as situations requiring action to prevent significant harm or the need to provide alternative care. Within the model the CAF process is located between levels two (life chances may be impaired without services) and three (life chances will be impaired without services). 2.48 The Review Team agreed that the formulation of thresholds and their publication is a helpful aid to multi agency understanding of child safeguarding but the existence of written tools will not in themselves ensure that levels of need will be correctly identified. Munro (2011) notes „procedures are always incomplete and require skills and the use of judgement to implement them.... When the organisation does not pay enough attention to these skills, then procedures may be followed in a way that is technically correct but is so inexpert that the desired result is not achieved‟. 2.49 Despite the existence of the agreed thresholds contained in the „Promoting Children and Young People‟s Welfare Model‟ there may remain a lack of understanding about what referral information would elicit a particular response from Children‟s Social Care Services. This led to some staff becoming frustrated when they did not get the response they expected. On occasions this led to referrers over emphasising the importance of certain pieces of referral information in order to gain the required response and trigger intervention.   21 2.50 This phenomenon has been observed in other places, White et al (2008) note that “Often referrers 'talk up' referrals to avoid the threat of being blamed for inaction. The introduction of the Common Assessment Framework (CAF), a standard process designed to support early intervention and encourage other professionals to continue working with families rather than refer to children's social care, may be sometimes having its own unintended impact. In a high blame, high risk environment, rather than encouraging other agencies to work with families for longer CAF has sometimes increased referral rates to children's social care”. 2.51 Children‟s Social Care Services staff were innately aware of this tendency for referrals “to be talked up” and believed that they sometimes under-reacted in order to compensate for what they believed was information bias. However, that situation has the potential effect of undermining and altering the agreed threshold levels from all perspectives with potentially unsafe consequences.   FOR CONSIDERATION BY THE LSCB Does the current system for identifying the levels of need and support to families, along with the expectations of the role and responsibilities of professionals and agencies, require consideration to take into account the Munro recommendations? The consistent and safe application of thresholds of intervention is crucial in maintaining the safety of children and young people and ensuring that services are provided at the appropriate level according to assessed need.  The Promoting Children and Young People‟s Welfare Model provides an agreed multi agency approach to thresholds of intervention. The review discovered some issues of concern in the consistent and appropriate application of thresholds for intervention. While the review team acknowledge that considerable efforts have been made to illustrate, raise awareness and train professionals about the agreed threshold levels there remains a degree of inconsistency which is problematic. It is particularly essential to ensure that those referring into Children‟s Services are clear, accurate and open about their concerns and that those receiving referrals respond appropriately as required by the levels of the agreed model of thresholds. It is a challenge to the LSCB to ensure that children are dealt with at the most appropriate level of the service in order that they can access the part or parts of the children‟s service that effectively promotes their welfare and safety.  In order to meet this challenge staff in the children‟s service, particularly those who interface with CAF professionals require support and supervision facilities to provide checks and balances in the decision making process.    ii) Considering risk using any risk assessment tool such as the ‘Signs of Safety’ model may lead to ambiguous judgements and decision-making. The implications of this need to be considered to ensure there is a standardised  22 implementation of the use of the tool. There should be sufficient general knowledge of the tool to allow professionals to challenge decisions which flow from the use of the tool.  2.52 The „signs of safety‟ tool was used in the review case at a key juncture, the strategy meeting in July 2011, when determining the risks present in the family. It produced a variable result showing signs that on the numerical scale used by the tool risks were between three and five on a scale of zero to ten where zero represents an unsafe situation and ten a safe one. The interpretation of this result, while acknowledged at the time as uncertain, was insufficient to trigger the case being referred on for discussion at a child protection conference. 2.53 The „signs of safety‟ tool is in widespread use within services for children in Coventry and elsewhere in the country and has recently been introduced for use by CAF professionals such as those within the multi-disciplinary team. Those teams of professionals using the tool have received training on how to operate it. 2.54 The tool depends on the use of questions around a number of domains and the answers to those questions lead on to the numerical score previously described. In the case under review there was a wide variation in the results the tool provided which case group members, attending the strategy meeting found confusing. 2.55 The tool is based on research, Turnell (1997) and was first introduced in Coventry around 2006 and “uses the ethos of solution-focused work, building on strengths and enabling families to find their own solutions. It encourages the use of solution-focused techniques, including scaling questions and goal-setting as the vehicle for obtaining good quality assessments.”  The tool is well thought of and features in The Munro Review of Child Protection (2011) as a practice exemplar. 2.56 Members of the Case Group indicated that it gave confidence to those using it when a clear result at either end of the scale is obtained but it is less effective when mid-range more ambiguous scores are indicated.  2.57 Clearly the use of the tool can be extremely beneficial by focusing on what works well within a family rather than what does not. Chapman and Field (2007) describe the tool as „assisting with moving from „conveyor belt‟ practice characterised by getting cases through the system to more reflective practice characterised by critical reflection of the issues‟. 2.58 The Review Team concluded that problems resulting from the use of the tool were likely to be due to its application when the scoring is not clear-cut rather than a fundamental problem with the tool itself.  FOR CONSIDERATION BY THE LSCB Considering risk using any tool including the ‘Signs of Safety’ model may lead to ambiguous judgements and decision making. The implications of this need to be considered to ensure there is a standardised implementation of the use of the tool. There should be sufficient general knowledge of the tool  23 to allow professionals to challenge decisions which flow from the tool. The „signs of safety‟ tool has much to commend it and is now in widespread use in Coventry and elsewhere. The case under review revealed the possibility of ambiguous interpretation of its findings and a lack of confidence in some staff regarding results in the mid range of its scale where there was an indefinite indication of risk. It is a challenge to the LSCB to ensure that those staff using the tool have had adequate training and possess the skills to operate it correctly through the use of appropriate questioning and a critical appraisal of the answers received. It is also a challenge to the LSCB to ensure that appropriate management oversight, support and supervision is in place to provide failsafe checks to the results obtained from tools such as the „signs of safety‟.   iii) Assessments of need, particularly core assessments, are potentially insufficiently multi agency in production and may lead to gaps in the information required to complete a comprehensive assessment.     2.59 The core assessment undertaken and completed in March 2011 appears to have been too optimistic in its conclusions with respect to the family‟s functioning. It insufficiently considered the likely effects of the birth of Child W and while acknowledging a number of risk factors, discounted their importance in respect of the safety of the children. 2.60 Members of the Case Group were of the view that, in respect of assessments there was a formal link to thresholds of intervention. The formal system of applying thresholds is discussed above.  However, the application of those thresholds is a matter for professional assessment and judgement and is ultimately a subjective activity. 2.61 Core assessments in Coventry Children‟s Social Care Service use the National Framework for the Assessment of Children in Need and their Families and are carried out by social workers from Children‟s Social Care Services. Part of the emphasis of this type of assessment is the notion that assessments take a multi disciplinary approach to both the assessment and provision of services. This approach can manifest itself in a number of forms. However, one of the strengths of a collaborative approach to assessment is that different agencies not only contribute information to an assessment but also a level of analysis and a different perspective on the functioning of a particular family. This approach can lead to a more balanced assessment of risk with the fullest information possible and which is less likely to be skewed by the priorities, bias or resources of one particular agency or professional.  2.62 The view of the Case Group was that joint assessments were not being regularly undertaken in this way and general practice was more, as in most authorities nationally, about the act of gaining information from participating agencies or professionals. This method had the effect of isolating some professionals from the decision making process contained in the assessment. Munro (2011) notes that   24 „Different social workers often undertake each assessment and a second one frequently starts the whole process again rather than building on a common assessment submitted by another agency or the initial assessment‟.  2.63 The review team were unable to access the CAF assessment completed by the local family support and universal services professionals for the case under review. The Review Team have been subsequently reassured that the initial CAF undertaken by the DVA accommodation provider was completed in March 2010 and placed on the shared electronic database then in use (and therefore assessable to most agencies). Regular Family Support meetings were held in March, May, July and November 2010.  2.64 Children‟s Social Care Services staff need assessments from those involved in the CAF about what plan has been implemented and with what outcome. That information can then form the beginning of a specialist “core” assessment. The reviewers questioned whether those processes were satisfactorily in place and, if not, whether this was a major barrier to closer working with Children‟s Social Care Services, illustrated by Children‟s Social Care Services staff feeling CAF professionals relied too much on „gut‟ instinct rather than clearly articulated, written evidence. 2.65    Adding to the above issues, the current restricted timescales for the production of assessments does not aid multi-agency assessment. Indeed in the case under review the social worker was keen to finish the assessment quickly as it had already stretched beyond the statutory timescale for completion. This pressure to complete assessments within tight prescribed timescales was highlighted by Munro (2010) in part one of her review. She notes „a significant concern among social workers, non-social work professionals working with children, and leaders of Children‟s Services about what is said to be over-prescribed guidance on assessment, the restrictions placed upon practitioners by the associated timescales, and the perceived ambiguities concerning the purposes of the Common Assessment Framework (CAF)‟. The acceptance by the government of a relaxation of timescales for assessments may assist this problem in the future. FOR CONSIDERATION BY THE LSCB Assessments of need, particularly core assessments, are potentially insufficiently multi agency in production and may lead to gaps in the information required.    The assessment function, particularly in respect of core assessments, is a key piece of activity when safeguarding children as such assessments are a major building block in decision making.  In order that a wide range of information can be gathered, debated and analysed the best assessments are completed on a multi agency basis and should include the views and analysis from a range of professionals involved with the family. Due to time constraints and practicalities it can often be difficult for professionals to meet in person to carry out joint assessments. However, the sharing of written  25 information needs to be supplemented by contact in other ways to facilitate debate, analysis and to form joint recommendations. It is a challenge to the LSCB to promote the use of joint assessment techniques allowing for debate and conflict resolution within the process where necessary.                        26 Summary List of the Findings of the Review   Finding 1 Lack of clarity about responsibilities in relation to transfer of cases between neighbouring authorities. Finding 2 High levels of demand and limited capacity may lead to difficulties in prioritising all cases accurately, particularly those transferring in from another adjacent local authority.  Finding 3 Workflow through the children‟s social care teams may not always occur within agreed timescales because of the overall competing high levels of demand in the City.  Finding 4   The mechanism for the timing and appropriateness of transfer of cases between the local multi-disciplinary family support teams who use the Common Assessment Framework (CAF) and Children‟s Social Care; a system known as „stepping up‟ or „stepping down‟ cases needs to be further developed to ensure all agencies understand how to use this system effectively to protect children.   Finding 5 Consistent and comprehensive quality assurance standards for the provision of all residential accommodation used by those fleeing domestic violence are not in place. Finding 6 The role of the agencies providing accommodation, support and counselling for domestic abuse cases is not sufficiently understood by partner agencies and potentially concentrate attention on adult victims with insufficient focus on safeguarding vulnerable children.  Finding 7 The current system for identifying the levels of need and support to families, along with the expectations of the role and responsibilities of professionals and agencies, need to take into account the Munro recommendations. Finding 8 Considering risk using any assessment tool including the „Signs of Safety‟ model may lead to ambiguous judgements and decision making. The implications of this need to be considered to ensure there is a standardised implementation of the use of the tool. There should be sufficient knowledge of the tool to allow professionals to challenge decisions which flow from the use of the tool.   Finding 9 Assessments of need, particularly core assessments, are potentially insufficiently multi agency in production and may lead to gaps in the information required to complete a comprehensive assessment.     27 Bibliography  Munro, E. (2011) The Munro Review of Child Protection: Final Report A child-centered system. London: The Stationary Office.  Munro, E. (2010) The Munro Review of Child Protection: Part One: A systems analysis. London. The Stationary Office 2010. Turnell, A. and Edwards, S. Aspiring to Partnership: the signs of safety approach to child protection: Child Abuse Review Vol 6 1997. Pages 19-190. Department for Education and Skills (2006) The Common Assessment Framework for Children and Young People: Practitioners Guide. London: The Stationary Office.   Children‟s Workforce Development Council (2010).  Present position and future action:  Children‟s Workforce Development Council. White, S., Hemming, J and Norman, A. (2011) „Social workers cannot be out seeing families when they are inputting data‟: Comment Section, Family Law Week 15 November 2011.  Chapman. M and Field, J. (December 2007) Strengthening our engagement with families and increasing practice depth: Social Work Now Volume 38                 28 Coventry Safeguarding Children Board  Response to the Findings of the Review concerning Child W  Coventry Safeguarding Children Board met on 5 April, 24 May and 8 October 2012 to consider and discuss the implications of this review for current and future practice with families and children in the City.  The Coventry Safeguarding Children Board    has accepted the findings of the report in principle and committed at its meeting on 5th April 2012 to progress actions against each finding.   has continued to consider the extent to which the findings are applicable across all the local services and it will be undertaking further investigative work in relation to all the findings.  is determined to respond promptly and effectively to the findings of the review. It wants to improve practice and will use the findings to do so. Some immediate responses have already been put in place. A clear focus on action from learning is being adopted to ensure that the required changes happen following this case review.  The findings of the Review have and are being taken forward using the Learning Together system. A.  Issues with clear cut solutions that can be addressed locally and by all relevant agencies. Finding 1 Lack of clarity about responsibilities in relation to transfer of cases between local areas. Action 1 The West Midlands Regional Protocol for the transfer of cases – child protection and children in need - to be reconsidered and developed by LSCB Chairs and DCSs. This has already been discussed regionally and will be taken forward. To be completed by March 2013  29 B. Issues where solutions cannot be so clearly described because they are complex issues where there may be competing priorities and inevitable resource constraints and there are no easy answers. Finding 2 High levels of demand and limited capacity may lead to difficulties in prioritising all cases accurately, particularly those transferring in from another adjacent local authority.  Action 2 Coventry Children‟s Services have recently undertaken a fundamental service review to ensure that needs and demands can be more appropriately provided for.  As a result there has been an increase in social work capacity in Neighbourhood teams in order to strengthen services at the front door of the service.  The LSCB has been kept appraised by the DCS of these developments. The LSCB has requested an additional report concerning activity and response during 2011/12 to identify what progress and improvements have been made.   More frequent monthly monitoring of the demand of CAF activity across all agencies and on children‟s social care will now be required by the LSCB. Finding 3    Workflow through the children‟s social care teams may not always occur within agreed timescales because of the overall competing high levels of demand in the City.  Action 3 As above, the Coventry Children‟s Services fundamental service review was set up to consider the increases in demand on children‟s services and how best these might be addressed.  The LSCB has recently received a baseline report about staffing and caseload sizes in children‟s social care. It has also sought a baseline report concerning the efficiency of transfer of cases between the RAS and the longer term teams in Coventry. This information is part of regular performance updates to the Board.  The LSCB will be monitoring more regularly the size of caseloads across children‟s social care against the staffing establishment as part of its performance framework.  30  The LSCB Chair carried out a visit to the RAS service in mid-2011, this visit will be repeated again with other LSCB members every 6 months. Framework to be agreed by September 2012  Reporting schedule to be in place by January 2013  C. Issues that require further research and development in order to find solutions, including those that would need to be addressed at a national level. Finding 4 and Finding 7 There is a perception that the timing and appropriateness of transfer of cases from and to local multi-disciplinary family support services who use the Common Assessment Framework (CAF), a system known as „stepping up‟ or „stepping down‟ cases needs to be further refined to clarify expectations.   And Does the current system for identifying levels of need and expectations of the role and responsibilities of levels of support to families and children need to be reconsidered taking account of the Munro recommendations? Action 4 and 7  The CSCB has reviewed its subcommittee structure and this finding will be taken into account.  The LSCB will refocus the work and role of the current Promoting Children‟s and Young People‟s Welfare sub-group to provide a means of more effectively monitoring the effectiveness and capacity of all early intervention services as required by the Munro Review.  The LSCB will carry out an independent review of the current mechanisms for the management of the interfaces between different levels of service and intervention.  The LSCB will take forward the recommendations and outcomes of this review with partner agencies. To be completed by March 2013   31 Finding 5 and 6 Consistent and comprehensive quality assurance standards for the provision of residential accommodation to those fleeing domestic violence are not in place. Role of Agencies providing accommodation, support and counselling for domestic abuse cases is not sufficiently clear.    Action 5 and 6. Coventry City Council and Community Safety Partnership is undertaking a review of all aspects of service delivery for domestic violence and abuse. The LSCB will refer this issue to that review and will monitor progress. To be referred immediately and progress monitored 3 monthly. Finding 8 Considering risk using any tool including the „Signs of Safety‟ model may lead to ambiguous judgements and decision-making. The implications of this need to be considered to ensure there is a standardised implementation of the use of the tool. There should be sufficient knowledge to allow professionals to challenge decisions which they do not agree with. Action 8 The LSCB will review the current multi-disciplinary arrangements for risk assessment including the use of the signs of safety tool and for recommendations, if required, for improving practice. To be completed by September 2013. Finding 9 Assessments of need, particularly core assessments are potentially insufficiently multi-agency in production potentially and may lead to gaps in the information required to complete a comprehensive assessment. Action 9  The arrangements for assessment are currently subject to national review and update as the National Assessment Framework is being reframed. There are pilots of different ways  32 of conducting assessments across the country. Some of these are achieving better inter-professional engagement with and contribution to core assessments in particular.  The LSCB will be holding workshops for partner agencies to consider the implications the national pilots and of the new framework when this is issued by Government.    The LSCB will ask for an update from Board members on the current arrangements and systems for ensuring that all assessments undertaken from CAF to Core Assessment are sufficiently inter-professional and shared with all relevant partners. To be completed by March 2013.                