Sexual abuse of two children by a carer whilst in a long-term kinship care placement. An older sibling living in the same placement witnessed Child A being sexually abused by the carer and informed Mother and then the Police. Carer received a custodial sentence for the sexual abuse of Child A and Child B. Prior to entering care, Child A, Child B and Sibling 1 witnessed extensive and serious domestic abuse between their Mother and Father. Initially, the children were placed with Mother under an Interim Care Order, and later placed with Carer 1 and Carer 2 as kinship carers. The carers were subsequently approved as foster carers, and the placement became permanent for the children for 12 years. Learning includes: importance of robust exploration during the approval process for kinship foster carers; placement reviews for looked after children in kinship care placements should identify when National Minimum Standards are not met to avoid children remaining long term in inadequate accommodation; without consistent, rigorous and child focussed oversight by supervising social workers, shortcomings in the parenting capacity of kinship foster carers may not be identified or challenged. Uses the Welsh Child Practice Review model. Recommendations include: ensure that social workers support children in kinship care to identify a trusted professional who will enable them to get their voice heard in the decisions which impact on their lives; ensure that social workers have access to regular supervision which provides opportunities for reflection and critical challenge with a specific focus on the effectiveness of care plans for looked after children.
      
    Serious Case Review No:  2020/C8452  Published by the NSPCC On behalf of an unnamed local safeguarding children board      This report was written by an independent author and is owned by the commissioning LSCB.  This report is published by the NSPCC with the agreement of the National Panel of Independent Experts.  Publication of this report by the NSPCC does not constitute endorsement of the contents. Copyright of this report remains with the commissioning LSCB.     1    Local Safeguarding Children Board Serious Case Review   Child A and Child B  Final Report            June 2020    2    Contents   Page  Introduction   3  Process   3  The Family and background information   3  Agency Involvement   4  Analysis   7  Organisational Context   23  Good Practice   23  Conclusion Learning and recommendations   23                 3  1       Introduction 1.1 In May 2019, the Local Safeguarding Children Board decided to undertake an SCR1 in relation to the serious harm suffered by two children, who were sexually abused by a carer whilst in a long-term kinship care placement.  An older sibling living in the same placement witnessed Child A being sexually abused by the carer and informed Mother and then the Police. The carer is currently serving a custodial sentence for the sexual abuse of Child A and Child B.   1.2 It was recognised that there was potential learning from this case in the way that agencies worked together to support children in kinship care. The National Panel was informed of the decision to undertake a review.  2 Process      2.1 This report has been written with the intention that it will be published, and only contains information about Child A, Child B and their family that is required to identify the learning from this case. The review2 was guided by the terms of reference agreed by the steering group and followed the Welsh Child Practice Review model.  2.2 An independent author worked alongside the SCR panel to complete the review. The review considered single agency timeline reports and chronologies. Practitioners involved at the time participated in a learning event to discuss the case and identify practice improvements. The panel contributed to the learning and recommendations resulting from this review. The review considered multi agency practice during the two years prior to the disclosure by Child A that she had been sexually abused by Carer 1. Relevant information beyond this timescale also contributed to practice learning.  2.3 The author and a representative from the LSCB met separately with Child A, Child B and Mother to obtain their views about the support and intervention provided by agencies. Their contributions are included within this report and informed the findings and recommendations. The final report will be shared with Child A, Child B and Mother prior to publication. The second carer who will be referred to as Carer 2 was informed about the review and did not participate. An older sibling (Sibling 1) who witnessed the abuse spoke about his experience when the outcomes of the review were shared and his comments have been included.  3 The Family and background information  3.1 Prior to entering care, Child A, Child B and Sibling 1 witnessed extensive and serious domestic abuse between their Mother and Father. Initially, the children were placed with Mother under an Interim Care Order. Following further violence between the parents and a deterioration in Mother’s mental health, they were placed with Carer 1 and Carer 2 as kinship carers. The carers were subsequently approved as foster carers.   1 SCR’s have been replaced by child safeguarding practice reviews which should be considered for serious child safeguarding cases where: abuse or neglect of a child is known or suspected, and a child has died or been seriously harmed. https://www.gov.uk/government/publications/working-together-to-safeguard-children--2 2 It was the aim of the review to be compliant with Working Together 2015 which states SCRs should be conducted in a way that; recognises the complex circumstances in which professionals work together; seeks to understand precisely who did what; considers the underlying reasons that led to actions; seeks to understand practice from those involved at the time rather than using hindsight; is transparent about the way data is collected and analysed; and makes use of relevant research and case evidence to inform the findings.     4  3.2 The children were very young when fostered by Carer 1 and Carer 2 (Child A was 18 months; Child B was 4 years and Sibling 1 was 5 years old). The kinship care foster placement became the permanent living arrangement for the children for 12 years until the disclosure by Child A of sexual abuse by Carer 1. Child A and Child B were subsequently placed in alternative foster placements and Sibling 1 moved into semi-independent living.  3.3 Health visitor (HV) records noted that there were concerns about the behaviour of Child B when initially placed in kinship care and Carer 2 attended a behaviour management course. Health records reflected ongoing concerns regarding the behaviour and emotional wellbeing of Child B throughout the time in foster care.  A Family Support Worker (FSW) provided support to Child B and Carer 2.   3.4 Records of the Looked After Children (LAC) nurse, dated 2013, detailed information shared by a social worker following a home visit to the carers. It was noted that the family home was chaotic, and there were concerns that the children were left alone at home during the day. Also, it was thought that another child may be sleeping over which may have an impact on the behaviour of the children. Child B was 12 years old at the time.   3.5 Carer 1 supported Child B to report an alleged sexual assault by a teenage male to the Police when Child B was 14 years. The carers did not inform Children’s Social Care (CSC) until two months after the incident3. There was no evidence that the Carers were challenged about the delay in information sharing.  4 Agency Involvement   The following agencies/services were involved with the family during the period considered by this review: Children’s Social Care, CSC School/College Health Visitor Service LAC Nurse School Nurse Police The table below details the involvement of professionals with the family during the period considered by this review. This is not an exhaustive list and includes activity relevant to multi agency learning.  2016 to 2018  Event Agency/Service  Statutory LAC review CSC   Review Health Assessment (was due in October)  LAC Nurse    3 Police informed the LAC service and Carer 2 confirmed the allegation.   5   Social worker (SW) completed one statutory visit during this period  Child A and Child B requested to have time with Mother alone at her home  Child B was involved in an alleged physical assault   LAC review  A management audit of Child B’s file concluded that improvements were required and noted some good SW practice. Independent oversight by the Independent Reviewing Office (IRO) was recommended. Stable and positive living arrangements were highlighted  Permanence Planning Meeting, minutes noted that the carers were considering an application for Special Guardianship Orders (SGO)  CSC   CSC   CSC  CSC  CSC   CSC    CSC     PEP review completed LAC review   SW visited on three occasions during this period, Child A and Child B were seen alone on one occasion   Placement with parents agreed. Child A and Child B to have individual time with their mother at her home as they requested  SW supervision record noted that carers do not wish to pursue the SGO application   Support was provided to improve Child B’s attendance at college  Education CSC  CSC    CSC    CSC   School/college    LAC review - IRO raised a concern due to the lack of statutory visits by the social worker  Pathway assessment concluded for Child B and Personal Advisor (PA) allocated. PA changed one month later   Education records noted that LAC health assessments and LAC reviews could be held in school to reduce absences  Parents evenings were attended by carers and concerns re. Child B were discussed. Child A was reported to be doing well in school. Concerns regarding Child B underachieving and having poor behaviour and attendance were raised at PEP and LAC meetings and with the carers  CSC   CSC      School/college          6   Child B attended the GP and disclosed self-harm   Child A informed school that she was going to Birmingham for the weekend with a friend and her mother. School shared information and concerns with CSC  Child B attended A & E with a minor head injury following an alleged assault by boys on a bus  GP  School/college     LAC Nurse    LAC review records indicated that the placement continued to be assessed as safe and appropriately meeting the needs of Child A and Child B .  Duty SW completed a statutory visit with Child A and Child B. New SW was allocated   Child B was allocated a new 16+ Personal Advisor   Supervising SW reported in supervision that that the carers were highly rated, self-sufficient, and provided a range of opportunities for the children with minimal support needs  The annual review of Foster Carers was overdue following a change in process. No significant concerns were raised and continued approval of Carer 1 and Carer 2 as kinship carers for Child A and Child B was agreed  SW supervision notes recorded a discussion between the SW and team manager regarding Child B having outgrown the placement with Carer 1 and Carer 2   Child A was not taken to ophthalmology outpatients’ appointments in July and Sept and was discharged from the clinic  Child B argued with some boys at school as Child A had been crying all night and said that she was going to kill herself due to bullying by the boys. Form tutor was informed and followed up with boys and Child A   Review Health Assessment- 10 months overdue   Pathway review for Child B, the IRO added an amber alert on the file to enable a closer oversight around unmet health and education needs  Child A LAC review - visits have not progressed as expected due to a change in the allocated SW CSC     CSC   CSC  CSC     CSC      CSC     NHS Trust    School/college       LAC Nurse  CSC    CSC   7  and the previous SW being absent from work due to illness  Report by Sibling 1 that Child A had been sexually assaulted by Carer 1   Child B attended the GP alone on three occasions and was referred to CAMHS for a triage assessment.       Police   GP CAMHS  5 Analysis  5.1 The context in which Child A, Child B and Sibling 1 came to be placed with the carers will have influenced the assessment and decision-making process of professionals at the time. Care proceedings were initiated due to the violent and volatile relationship between the parents, and a placement was required for the children. The Children Act 1989 placed a duty on local authorities to explore family and friends’ placements when a child could not be looked after by their own parents. The Carers expressed a willingness to commit to the children long term and were subsequently approved as foster carers. The placement with the Carers provided a viable opportunity to keep the children together, and within the family unit.   5.2 Guided by the Terms of Reference for this Review, specific themes emerged following analysis of the available information. Exploration of each theme enabled rigorous examination of practice and identification of opportunities to improve the systems to safeguard children in care in the local authority, specifically those living in kinship care placements.  5.3 The themes identified were:         (i) Kinship Foster Carers - Approval and annual review  - Accommodation - Supervision of the kinship foster carers   (ii) Statutory procedures to safeguard looked after children in kinship care placements  - Statutory social work visits - Personal Education Plan and Review Health Assessment - Looked After Child reviews   (iii) Voice of the child and professional understanding of the lived experience of the children  (iv) Multi-agency information sharing  5.4 Whilst the themes will be discussed separately, it is important to note that each theme had an impact on the others, and learning identified in one area has the potential to influence practice in all. For example, the frequent change in social worker impacted on the development of a trusting relationship with Child A and Child B and professional understanding of their lived experience. In addition, shortcomings in the review process   8  for the foster carers meant that there was limited understanding about the capacity of the Carers to meet the physical and emotional needs of Child A and Child B and enable them to reach their potential.  (i) Kinship Foster Carers 5.5 The carers were approved as foster carers prior to the period considered by this review. However, some concerns which emerged during the initial approval process remained unresolved and were evident during this review. Whilst practice has since changed, the SCR panel identified that there was an opportunity for learning regarding the approval, review, and supervision of kinship carers. Approval and annual review  5.6 Child A and Child B had been in the placement for 22 months before the carers were approved as long-term kinship foster carers.  The delay in obtaining approval was due to concerns about the suitability of the accommodation and the ability of the Carers to implement positive behaviour management strategies.   5.7 It was noted in the LAC review dated 2007 that; the long-term plans for the children were still not formulated as the couple were struggling to manage the demands placed by the children. The kinship SW was not able to recommend to the Panel a long-term matching between the children and the carers due to concerns regarding their responses and their limited ability to use consistent behaviour management strategies.  5.8 There were specific concerns about the strategies used by Carer 1 to manage the behaviour of the children, and these were discussed with the safeguarding unit at the time. It was decided to address the concerns as a practice issue and advice was provided about appropriate sanctions. It was recorded that the carers were to be offered additional support around parenting and Carer 2 attended a parenting course. It was noted by the SCR Panel that processes are now more robust, and similar concerns would be referred to the Local Authority Designated Officer (LADO).   5.9 It is highlighted within statutory guidance that family and friends foster carers must be able to meet the child’s assessed needs, bearing in mind that those needs will often be greater than for other non-looked after children of a similar age4. Central to the assessment of a relative or friend to be a foster carer, will be consideration of the carer’s capacity to provide a level of parenting to meet the child’s needs within the requirements of the care plan and placement plan.   5.10 The local authority’s information leaflet for foster kinship carers describes the assessment process, which includes: the availability of carers and capacity to understand and respond to the child’s needs; the ability to put the child’s needs at the centre and safeguard children; understanding of child protection and development; and home environment and space in the home. Information provided to this review evidenced that there were concerns in each of these areas during the period that Child A and Child B lived with the Carers.   5.11 A statutory review of the placement took place annually and no concerns were raised during the 12 years that Child A and Child B were placed with the Carers. Continued approval was granted, and a strong narrative emerged amongst professionals and within agency records which stated that the placement was stable and family relationships were good.    4 Family and Friends Care: Statutory Guidance for Local Authorities, DfE (2011) p39.   9  5.12 The stable and positive arrangements were also highlighted in an audit report of Child B’s file dated 2017. At the time of the audit, concerns about Child B’s behaviour, emotional wellbeing and lack of attainment were contained in agency records, although not addressed within the care plan. The audit process to quality assure practice did not identify the discrepancy between the positive view of the placement and recorded concerns, specifically with regard to Child B. Whilst the consistent view presented by the Carers, family and professionals was that the placement was stable and positive arrangements were in place, there was information available to support an alternative narrative. The audit process lacked rigour and there was limited interrogation of information within records that were available at the time.   5.13 There was an opportunity within the foster carer’s annual review (required under regulation 28 of the 2011 Regulations) to identify any support required to assist the carers to meet the child’s needs. Whilst some support was identified, this was mainly to assist with the behavioural management of Child B and focussed on the changes that she needed to make. There does not appear to have been any discussion with carers about whether they required support to change their approach or further exploration to understand what may have been influencing Child B’s behaviour.  5.14 The Carers initially said that they were keen to progress an application for a Special Guardianship Order (SGO) which would have given them parental responsibility and increased permanence for Child A and Child B, however, this was not progressed. The SSW and SW shared the view that whilst the behaviour of Child A and Child B was not particularly challenging, the parenting capacity of the carers was basic5. It was the view of professionals at the time that the carers would require on-going support to meet the needs of growing teenagers and it would not be in the best interests of the children to pursue an SGO. It was recorded that the Carers were reluctant to pursue the SGO because they required ongoing assistance from the local authority to help them manage the behaviour of Child B. This view was supported by practitioners at the Learning Event. Sibling 1 said that every week he had to pay loan sharks, the family were always in debt. He felt like an item and that he was only being looked after so the carers could get their money.  5.15 Sibling 1 informed the review that the carers were always talking about money and he felt that money was the key motivation for them becoming kinship carers. Sibling 1 said that the carers spoke about losing money if they had an SGO and that is why they didn't agree to it in the end. This view was supported by Mother who said that the carers were only looking after the children for the money they could gain.    5.16  It was acknowledged by professionals involved with this review that the limitations of the Carers and the support they required to enable them to meet the needs of Child A and Child B was not explored or reflected in the statutory reviews or care plans. In the majority of cases, kinship care provides children with a good home environment, although for some (5-17%) the experience is not positive. The 2020 triennial analysis of SCR’s6 highlighted a study by Hunt, Waterhouse & Lutman 20087 which identified the need for careful assessment of the parenting capacity of potential caring relatives and the support they may require to enable them to look after the children most effectively.  5 This was identified as a concern during the initial assessment to approve the carers as kinship foster carers. 6https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/869586/TRIENNIAL_SCR_REPORT_2014_to_2017.pdf P70 7 Hunt, J., Waterhouse, S. and Lutman, E. (2008) Keeping them in the family: outcomes for children         placed in kinship care through care proceedings. London: British Association for Adoption and Fostering.     10   5.17 Placement of the three siblings with the carers appeared to address safety issues, keep the children together and within the family. The SCR review group considered that the efforts by professionals to keep the children together and within the family was an influencing factor during the approval process and possibly contributed to a lowering of the expected standards with regard to the assessment and review of the Carers.   5.18 The statutory process to approve the carers appears to have taken place without reference to the needs of the children or the review of the placement and care plans.   5.19 Practitioners at the learning event noted that practice has since changed, and the assessment and reviews of foster carers are now more robust and thorough. This view was supported by the SCR Panel who advised that since 2019 a Fostering Independent Reviewing Officer has had independent oversight over the foster care assessment and approval process. It is important that assurance is sought that practice improvement has had a positive impact on the lived experience of children in kinship foster care and this will be addressed in the recommendations.  Accommodation         5.20 The carers were approved as Foster Carers in 2007 on the basis that more appropriate accommodation would be found. The Carers’ home was too small to accommodate Child A, Child B and Sibling 1 and it was acknowledged within the minutes of the fostering panel that the accommodation did not meet the National Minimum Standards (NMS) in place at the time8 specifically, Standard 6: • 6.2 The foster home can comfortably accommodate all who live there. It is inspected annually to make sure that it meets the needs of foster children. • 6.4 Each child placed has her/his own bed and accommodation arrangements reflect the child’s assessed need for privacy and space or for any specific need resulting from a disability.  5.21 It would have been acceptable for Child A and Child B to share a bedroom initially, however the girls shared a bedroom with Sibling 1 until they were teenagers and with the carers when the house was very overcrowded.  It was noted in the LAC Review in 2007 that: The pressure of the housing situation was high as the adults and children were sharing a bedroom.   5.22 It was reported that the housing situation became extreme when the son of Carer 1 and his family regularly visited and eventually moved into the house. At one time there were up to 10 people in a two-bedroom house including twin babies. At the learning event practitioners stated that the SSW and SW challenged the carers about the sleeping arrangements and concerns were escalated to service manager level. Support was provided to rehouse the son and his family however the Carers persistently refused to move into larger, more suitable accommodation. Practitioners acknowledged that the house must have been very chaotic with large numbers of people living there.   5.23 Records from the Fostering Service indicated that efforts were made over the years to support the Carers to obtain accommodation with adequate space for the children. It was evident that professionals consistently discussed concerns about housing with the Carers, however, there was limited challenge regarding the lack of commitment by the  8https://bettercarenetwork.org/sites/default/files/Fostering%20Services%20National%20Minimum%20Standards.pdf    11  Carers to move to larger accommodation. There was no evidence that the Carers accepted the concerns of professionals about the limited space for the children, or that they were actively committed to improving the situation. This remained an issue for the 12 years that Child A and Child B were in the placement and NMS 6 was not met.   5.24 In interview with the independent reviewer Mother stated, I was fine with Child A and Child B going to the carers. I knew that Carer 2 wouldn’t move to a bigger house. I didn’t like them sharing a bedroom with Sibling 1, but the social workers didn’t say anything about it.   5.25 The inadequate accommodation and lack of personal space had a significant impact on the quality of life and emotional wellbeing of Child A and Child B. In interview both spoke about the large number of people in the house, noise, lack of privacy and lack of a place to sleep.   Child A: The house was very small, there were always lots of people. I used to give up my bed for my cousins. There were two bunks, we used to top and tail. I just used to get on with it, I didn’t have a choice. There was too much noise and too many people in the house. Social workers never used to ask how we were or how we felt that the house was so busy. It would have been better if all the rest of the family – uncle, aunts, and children were not there. The social workers knew how many people were in the house, they knew where we were sleeping.  Child B: I felt I had no privacy and couldn’t tell anyone but at the same time I didn’t want to move from my family. There was no door on the bedroom, we had no privacy. We used to shove it in the frame. I had anger issues and barricaded myself in the room once. It was very crowded in the house, two bedrooms and there were baby twins as well. The house was chaos, I was fighting for attention. People should have looked further and asked; why is it so overcrowded, why are there an extra 8 people? Every time the uncle aunt and their children came round, I was asked to sleep out. I used to sleep in the park, drink, get high. There was a lack of supervision, I fought with Child A, used to throw things, photo frame, phone. I had a support worker for anger issues.  5.26 Overcrowding had a significant impact on both Child A and Child B. Child A spoke about having no choice but to put up with it. As a child in the placement it was evident that she felt powerless to do anything as she knew that adults were aware of the situation. Child B highlighted the lack of critical questioning by professionals and described feeling torn between telling someone about the overcrowding, and the fear of potential separation from their siblings. It appeared that the fear of separation from siblings and family was a significant factor which prevented Child B from speaking out.  5.27 The accommodation arrangements for Child A and Child B were inadequate throughout the placement. There was a lack of effective challenge by professionals involved with the family. Mother, Child A and Child B stated that SW’s were aware that the accommodation was too small and overcrowded and, in the words of Child A, nothing was done. As time progressed there was a general acceptance amongst professionals that the accommodation was crowded, there was no evidence that the impact of lack of space and privacy on the children was considered.    5.28 Child A or Child B were not asked directly how they felt about lack of privacy, limited space and overcrowding. Whilst it is not appropriate to speculate about what they may have said, it is evident that not asking for their views was a missed opportunity. From   12  their perspective they had no choice but to put up with the situation. Child A and Child B were old enough to express their views and may have done so if the housing situation had been explored with them in a respectful way by a professional whom they trusted.  5.29 The panel for this Review questioned whether standards may have been lower for the kinship carer placement and the value of keeping the children within the family was given priority even when there was clear evidence that statutory minimum standards were not met. Whilst some compromise may be necessary when children are placed with kinship carers, it is important that professionals remain focussed on the needs of the child and that the lived experience of the child is fully considered when statutory minimum standards are not met.    Supervision of the Kinship Foster Carers  5.30 National Minimum Standards were revised in 2011 and Regulation 21 focussed on the provision of supervision and support for Foster Carers:  The fostering service supports their foster carers to ensure they provide foster children with care that reasonably meets those children’s needs, takes the children’s wishes and feelings into account, actively promotes individual care and supports the children’s safety, health, enjoyment, education and preparation for the future9 p 42.   5.31 The report prepared by CSC for this review noted that the placement was not appropriately supervised or monitored by the Supervising SW in line with good practice and statutory regulations. Given the strong perception of professionals that this was a stable placement, the children were settled, and carers were managing well, there were limited visits to see the carers and children during the timeline considered by this review.  5.32 Alongside the statutory visits, Child A and Child B were involved with a local organisation, which delivered art activities to improve the emotional health, wellbeing, and self-efficacy of vulnerable young people. Sessions were supported by SW’s and Supervising SW’s. Practitioners at the Learning Event spoke about having observed Child A and Child B regularly during workshop sessions and in performances. It was acknowledged by Practitioners and within the SCR Panel that observation of Child A and Child B, often accompanied by the Carers within the community, would have reinforced the perception of a happy and settled placement and provided false reassurance to professionals that the needs of Child A and Child B were being met.   5.33 The CSC report prepared for this review noted that supervision records for the SSW were limited and mainly descriptive. Records which were available continued the positive narrative that the placement was established and noted that carers provided good guidance to Child A and Child B despite challenges. The visiting pattern of the SSW reflected this view.   5.34 There was absence of effective multi-agency action to improve the situation regarding the parenting capacity of the carers and overcrowded accommodation. Whilst support and oversight provided by the foster care service could have been more thorough and child focussed, it was acknowledged by professionals involved in this review that practitioners from all agencies contributed to and maintained the positive perspective of the placement.   9https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/192705/NMS_Fostering_Services.pdf   13   Learning Point 1 It is important that there is robust exploration during the approval process for kinship foster carers about whether they can meet the needs of all the children in their care and any concerns are fully addressed prior to obtaining approval.   Learning Point 2 Placement reviews for looked after children in kinship care placements should identify when National Minimum Standards are not met, whether changes are required and within what timescale to avoid children remaining long term in inadequate accommodation.   Learning Point 3 Without consistent, rigorous and child focussed oversight by supervising social workers, shortcomings in the parenting capacity of kinship foster carers may not be identified or challenged and children may remain in placements where their needs are not met.  Learning Point 4 It is important that audits of a child’s file evidence critical reflection and explore whether identified concerns for looked after children are reflected appropriately within the care plan.   (ii) Statutory procedures to safeguard looked after children in kinship care placements  5.35 Statutory visits by social workers and reviews for looked after children are central to practice for children in care. It is important that practice is meaningful, and all relevant plans have a positive impact on the lives of children in care to ensure that they are effectively safeguarded and reach their potential. Opportunities for multi-agency practice learning in these areas is discussed below.           Statutory social work visits  5.36 It was acknowledged in the report submitted by CSC to this review, that social work practice and management oversight was, at times, inadequate, and practice standards were not met. This appears to have been exacerbated by frequent change of allocated SWs. There were lengthy delays between visits and case records were brief and repetitive. In addition, supervision records were descriptive, task focussed and contained little evidence of discussion with Child A and Child B or consideration of their life experiences. There were at times lengthy gaps between supervision of social workers by the team manager.    5.37 The Care Planning, Placement and Case Review Regulations 2010 state that when a placement is intended to last until the child is 18 visiting intervals can be extended to 3 months.   Regulation 35(3) (b) requires that a record of each visit is made. The record must include the Social Workers full name, the date of the visit and the date the recording was made. A copy of the report must be sent to the Supervising Social Workers for the foster carers.    5.38 Whilst the SW and SSW attended LAC reviews for Child A and Child B every six months there was little evidence of additional communication between the social workers   14  regarding the suitability of the placement, or the capacity of the Carers to meet the needs of the children.   5.39 During the period considered by this review, the IRO formally escalated a concern due to a six-month delay between statutory visits by the social worker. Repetition of a similar significant delay shortly afterwards indicated that the escalation by the IRO had minimal impact and did not result in sustained improvements to practice.   5.40 The change in social workers and long gaps between visits impacted on Child A and Child B who described their experience as follows: Child A: there were too many social workers. Workers need to be more aware of children’s wishes and feelings.  Child B:  I didn’t feel the SW was relevant to me. I was asked the same questions and gave the same answers. Then they wouldn’t show up for another 6 months. After the abuse, my behaviour got worse. I was 13/14 used to climb out of the window onto the roof. There were too many social workers to know what was happening. One person may have noticed it and worked it out from my behaviour. It would have helped to be seen on my own, even go for a walk in the park. I think a social worker should get on my level, share themselves, not focus on the process stuff and don’t treat me like an item. 5.41 Child A and Child B were seen alone by a SW at times, however, it was frequently recorded in case notes that Child A and Child B refused to be seen alone. This appears to have been accepted by social workers with little reflection in supervision. Child A and Child B explained that it was difficult for them to agree to be seen alone, especially when asked in front of the carers.  Child A: We used to have to be so careful as the family were in the room. We never got offered to be seen alone – maybe we should just have been taken. Social workers could have taken us out, they just used to sit us down at home. I would have loved to have gone out without my siblings. Everything you said to the social worker got repeated back to the Carers anyway.  Child B: There was too much chaos, I refused to be seen on my own in case I slipped up and they (professionals) got the carers involved. The Carers used to make us tell them what was said if we were seen alone.   5.42 It is not possible to say whether Child A and Child B would have agreed to speak with the SW if the SW had been more directive about taking them out from the placement. Child A and Child B said that it was very difficult for them to see the social worker alone. In addition, they felt unable to speak privately without things being repeated back to the Carers.   5.43 The frequent change of social worker together with infrequent statutory visits will have impacted on the development of a trusting relationship, quality of discussion and the willingness of Child A and Child B to see the SW alone. It is important that social workers have the confidence to be pro-active and assertive in their work with children in care regarding seeing children alone and away from their Carers. Requests to see children alone should be made in a child focussed and creative way and case notes should include the reasons given if a child refuses to see a social worker away from their Carer.   5.44 It was evident that the frequent change of social worker, during the 12 year placement with the Carers, had a significant impact on the quality of social work with Child A and   15  Child B. Each newly allocated social worker was presented with a positive narrative regarding the placement. It would have taken time and confidence for social workers to adopt a critically questioning approach to the care plan and within the looked after children reviews. In the absence of robust supervision to support this approach the positive discourse about the placement continued. Personal Education Plan and Review Health Assessment Personal Education Plan (PEP)  5.45 The PEP forms an integral part of the care plan and provides essential information to ensure that appropriate support is in place to enable the child to achieve the targets set. The PEP is used in school to make sure the child’s progress towards education targets are monitored, with the Virtual School Head having a quality assurance role.  5.46 Prior to the timeline for this review, Child B was reported to be struggling with things emotionally and received support from the school counsellor. Child B spoke about wanting to see more of her Mother and this was shared with the Social Worker at the time. Child A and Child B spoke positively about the school mentor who provided support during the period considered by this review.  5.47 Communication between school and the carers was reported to be good with updates provided by telephone and at PEP or LAC review meetings. Carer 2 attended meetings at school for Child A and Child B whenever possible and LAC Reviews were held in the home. The education representative was asked by the social worker in an email not to attend the statutory reviews due to lack of space. It was unclear why the reviews did not take place in school as the lead mentor had suggested this as an option. It was acknowledged by professionals involved with the review that it was not acceptable or appropriate that the social worker requested the education representative not to attend the statutory review due to lack of space in the family home.   5.48 Whilst it may be appropriate for some professionals not to attend LAC reviews when permanent placements are stable with no issues this was not the case for Child A and Child B. Throughout the period considered by this review there were concerns about the emotional wellbeing and achievements of Child B at school. The report prepared for this review by the school designated safeguarding lead (DSL) noted that worries with regard to the behaviour and attendance of Child B were raised at the LAC and PEP meetings and recorded in minutes held by the virtual school team.   5.49 In discussion for this review Child B acknowledged that they did not achieve their potential at school;  I needed help to meet my potential, didn’t turn up at school, and was late every day. I waited until Carer 1 had left or was asleep, used not to eat or to eat in secret. It would have been better if they looked behind the smiles, no one noticed the struggles of Sibling 1.    5.50 It was a significant omission that a key professional who had substantial contact with Child A and Child B10 did not actively participate in the LAC reviews. There appeared to be acceptance of the request not to attend the LAC Reviews. There was lack of robust  10 which included oversight of the counselling and mentoring provided by school   16  multi-agency discussion to explore and address the issues which impacted on Child B reaching her potential whilst at school, this was a missed opportunity.  Annual Review Health Assessment  5.51 It is a statutory requirement that looked after children have a health plan that is updated once every 12 months after the child’s fifth birthday. Statutory guidance notes that: The child’s social worker and IRO have a role to play in monitoring the implementation of the health plan, as part of the child’s wider care plan11.  5.52 The annual Review Health Assessment (RHA) provides an opportunity to focus on emotional and mental well-being as well as physical health. The RHA should inform other aspects of care planning, such as the impact of a child’s physical, emotional, and mental health on their education. Local authorities are required to use the Strength and Difficulties Questionnaire (SDQ) to assess the emotional well-being of looked after children. The SDQ score should be recorded within the annual health assessment.  5.53 The SCR Panel group noted that action to address practice improvement regarding use of the SDQ is underway across the local authority.  5.54 A LAC health representative did not regularly attend the statutory Reviews, and this has been addressed in immediate single agency learning12. The RHAs provided limited information about SDQ and the emotional wellbeing of Child A and Child B was not explored in depth. The report prepared for this review by the trust highlighted missed opportunities to explore information provided by Child A and Child B who were forthcoming to health professionals with information that may have indicated early concerns.   5.55 The opportunity to see the LAC nurse in a confidential slot was not always taken and the views of Child A and Child B about seeing professionals alone are included at 5.38.  It was acknowledged in the report prepared by the trust for this review that there needs to be better documentation about why children are not utilising the confidential slot in the RHA with LAC nurses. Also, when children do not utilise the confidential slot in the RHA this information should be shared with CSC and this will be addressed in the recommendations for this Review.   5.56 There was an omission to record a physical health condition for Child A within one RHA and it was noted that recording was below expected standards. In addition, there was no RHA completed between 2016 and 2018 (after the incident which triggered this review).  5.57  Whilst there may have been some challenges within the system to request RHAs, it was agreed by all involved with this Review, that such a substantial delay when RHAs were previously attended within a reasonable time frame was unacceptable. In 2018, the RHA was ten months overdue and repeated attempts to contact Carer 2 were unsuccessful. There was an omission to escalate to the trust LAC team manager and limited consideration by professionals of potential safeguarding concerns. It was not known whether the family were deliberately avoiding the RHA and the voice of Child A and Child B were not heard. Since 2018 there is an RHA tracking list in use by the LAC team to identify outstanding RHAs.   11 Promoting the health and well-being of looked-after children. March 2015 DfE, DH, p18 12 Current practice is that LAC nurses are expected to arrange cover or send a report to all Reviews.   17  5.58 There is a clear expectation that foster carers meet the health needs of children in their care. In this case however, there appeared to be an acceptance by professionals that the Carers were busy people and there was lack of challenge regarding the importance of prioritising the health needs of Child A and Child B.  Whilst the delayed health assessment was noted at the statutory LAC review, there was no effective action to progress the assessment or to ensure that the health needs of Child A and Child B were met.  Child A stated: Carer 2 never sorted our appointments cos she never had time. She couldn’t take time off work as she was ill a lot.  Looked After Child reviews  5.59 A key purpose of the statutory review is to ensure that appropriate plans are in place to safeguard and promote the overall welfare of the child and to ensure all plans are progressed effectively, according to local safeguarding multiagency procedures. Key plans that should be considered at the Child Looked After review are the Care Plan; Health Care Plan; Pathway Plan if applicable and the Personal Education Plan (PEP). It is important that the plans are considered together and contribute to the care plan.  5.60 When a child has been placed in a designated long-term foster placement for more than a year, consideration should be given to whether it is necessary to hold a meeting as part of each review There was no evidence of a formal decision to reduce the frequency of the LAC reviews and these continued to be held every six months.  5.61 The Reviews were attended by the IRO, Child A, Child B, the carers, Mother, the SSW and the children’s SW. Information and updates regarding health and education were shared, although representatives from these agencies did not routinely attend the reviews which took place within the family home. As noted in paragraph 5.44, the representative from school did not attend the reviews following a request by the social worker. Consequently, the care plan was reviewed by a closed professional network with no evidence of challenge or multi agency scrutiny to address whether the care plans met the needs of Child A and Child B.  5.62 The Care Matters Green Paper consultation in 2006-07 identified the following concerns regarding reviews for looked after children13          Not every statutory review was being conducted in a way that encouraged a challenging analysis of the proposals for meeting the child’s needs.           Unless care plans are rigorously examined the review is no longer an opportunity for informed reflection on the child’s progress and planning for the child’s future;      These concerns were evident in the review process for Child A and Child B.  5.63  Review records reflected that Child A and Child B were happy with their placement and care plan and had a good relationship with the Carers and social worker. Practitioners at the learning event acknowledged that there was lack of critical questioning by all professionals involved at the time and lack of robust monitoring of the care plan and personal education plan. The LAC reviews were at times repetitive and tokenistic and  13Subsequently addressed in statutory guidance:  https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/326311/Care_Matters_-_Time_for_Change.pdf   18  served to progress the positive view of a settled placement. Whilst Child A and Child B chaired their own reviews, they had a clear view about the value of these meetings and Mother appeared unaware about the care plan. Child A: I knew about the care plan I understood what was said in the meetings.  The review booklets are all the same, I wrote the same thing every time whether I was happy or not. Holidays were good I had my own space then.  Child B: The care plan is all about what we can’t do – there’s nothing in it about nurturing us. Often, I didn’t have money on my food card, and I used to steal for food.  Mother: I didn’t know what the care plan was and can’t recall what was in them. 5.64 Child A and Child B noted that the care plan was more about restrictions and was not aspirational in a way that assisted them to reach their potential. The views of Child A and Child B indicated that from their perspective the reviews had little value and the care plan lacked relevance and was restrictive.    5.65 Given the lack of an up to date assessment it was not possible for professionals to have confidence that the care plan met the needs of Child A and Child B.  The assessments undertaken at the time the children were placed with the carers were not reviewed or updated for many years. The physical and emotional needs of the children would have changed over the years however the care plan was not amended to ensure that additional needs were identified and met. It was noted by the author of the CSC report that:  Updated assessments would have given the opportunity to gain additional understanding of the needs and circumstances of Child A and Child B and ensure that plans were relevant and potentially more aspirational.  5.66 There was limited evidence that the statutory reviews had a positive impact on the lives of Child A and Child B. The narrative that the placement was stable and the children settled persisted, although there was information available to suggest otherwise. There was lack of critical exploration by multi agency partners of key issues and incidents which will have impacted on the wellbeing of Child A and Child B, specifically:  • There was a significant difference in the way that Child A and Child B were treated by carers in the placement. The behaviour of Child B was described as challenging within agency reports and professionals expressed concerns about her emotional wellbeing. Child B did not fulfil their potential at school and generally had poorer outcomes than Child A. Child A and Child B were consistent when explaining that they were treated differently by the carers. Mother stated that:      Child B was treated differently and never really got on with Carer 2. Child B got blamed for everything that Child A did. I always felt that Child A got more. If Child B asked for anything, she was told we’ll see if we can afford it.  • There was a reference in each statutory LAC Review to Child B understanding why she was in kinship care and it was noted that the Carers were supporting her with this. Absence of life story work, specifically for Child B, was highlighted in the trust report for this Review. Given the limitations of the Carers it is likely that Child B would have benefitted from formal life story work. There was no   19  evidence that multi-agency partners considered this as a potential unmet need for Child B.  • Concerns regarding lack of supervision for the children were identified at the beginning of the placement. During the period considered by this review there was an incident which resulted in School reporting potential safeguarding concerns to CSC14.  There were unresolved concerns about the quality of supervision provided by the Carers.  5.67 Agency reports submitted for this review noted that there was lack of professional curiosity by practitioners involved with the family, the implication being that if professionals had been ‘more curious’ information may have emerged that would have prevented harm. Burton V and Revell L (2018) explored the organisational factors that may inhibit professional curiosity in practice and act as potential barriers to invoking curiosity. They argued that for a practitioner to exercise curiosity they require confidence that tension and uncertainty will be managed within reflective practice and supervisory processes.  Whilst it is appropriate that professionals take responsibility for their own practice it is important to note that there were organisational factors which impacted on the ability of practitioners at the time to demonstrate curiosity. Opportunities for critical reflection and rigorous supervision were limited during the timeline considered by this review.   5.68  In addition, frequent change of social worker impacted on the quality of support provided.  Child A and Child B lacked the opportunity to develop a relationship with a trusted professional whom they may have been able to talk with about their experiences in foster care. It is important to note that whilst there was consistency in the professional contacts at school and college it appeared that Child A and Child B wished to keep their home life separate from school. Anxiety and fear about possible separation from each other and sibling 1 was a powerful deterrent which contributed to the reluctance of Child A and Child B to share openly with any professional about their experience in foster care.  5.69 The statutory review process lacked rigour and focused on the immediate or short-term future. There was a lack of professional challenge, in part, due to the small group of practitioners alongside the family at the reviews. The quality of the care plan was poor and lacked clarity about actions required to improve the circumstances of Child A and Child B and there was little evidence of aspirational planning for longer term successful, happy, rewarding adult life experiences. Learning point 5 Supervision of social workers should include the critical appraisal of the care plan for looked after children particularly when the social worker is newly allocated. This should provide an opportunity to identify gaps, consider unmet needs and challenge incorrect assumptions.  Learning Point 6 Frequent change in social worker and lengthy gaps between visits to looked after children reduces the opportunity for children in care to develop a relationship with a trusted professional outside of their family whom they can talk to about their experiences in care.   Learning Point 7  14 Child A had said she was going away for the weekend with a friend and her mother. School had concerns regarding the family and the carers did not know who Child A was going away with.   20  It is important that all relevant professionals attend Reviews for looked after children and there is robust scrutiny of all plans to promote the wellbeing and development of children in care and support to assist them to achieve their potential.  Learning Point 8 There may be many reasons why children in care decline to meet with professionals without their carers present. If children are not seen alone it may be difficult for professionals to have an informed understanding of their lived experience.          (iii)    Voice of the child and professional understanding of the lived experience of the    children 5.70 There was a lack of direct work by any professional with Child A or Child B and their verbalised wishes and feelings were accepted without question. Child A and Child B were described by practitioners at the learning event as ‘vocal’ at their respective LAC reviews and there were examples of direct statements from Child A and Child B within LAC health review reports. Professionals from all agencies accepted their views, often expressed in front of the foster carers, without further exploration.    5.71 Both Child A and Child B consistently stated that they were happy in the placement and felt that they could talk to the Carers or a teacher if they had any concerns. Opportunities to understand the lived experience of the children were missed by practitioners in health, education and social care. It was acknowledged at the Learning Event that Child A and Child B were not as happy as they reported and professionals acknowledged that they could have adopted a more critical and child focussed approach in their support of Child A and Child B.   5.72 Child B was abused by Carer 1 prior to the allegation made by Child A and spoke to the independent reviewer about how her behaviour changed when the abuse started. Child B said that no one noticed that she was in distress or asked what was going on in her life:  Child B I felt I had no privacy and couldn’t tell anyone, but at the same time I didn’t want to move from my family. I used to put on a happy face to hide my problems. I didn’t want people to know. I told Mum about the sexual abuse, but I didn’t make it clear what had happened. I told Sibling 1, but he didn’t believe me cos I’d told so many lies.  I totally changed (after the abuse started), they never asked about the change in the way I dressed, changed in my eating, I started to self-harm. No one looked between the lines. No one took me away from the house, I had counselling for self-harm, and I kept myself to myself. 5.73 Mother said that at that time Child B had told her about the abuse the social worker whom she could trust had left. Mother said that she did not share this information with professionals as Child B did not explain fully what had happened and she thought Child B had made it up. Mother: Child B told me about the abuse on the phone, she was supposed to come around and talk about it – I thought it was inappropriate touching. She didn’t come round to talk; it never came up again. Child B had been caught shoplifting and I thought she’d made it up so she could come and live with me quicker.  Because I didn’t tell the SW at the time, I couldn’t talk to her. I could have told JM (previous SW) and asked her to explore it with Child B.    21  5.74 It was not possible to have confidence that that the initial disclosure by Child B would have been explored appropriately had the SW remained in post. Furthermore, it was not known that Mother had also been abused by Carer 1 until the police investigation following the disclosure by Child A.   However, the CSC report prepared for this review noted that the frequent changes in SW and light touch in professional practice may have impacted on the ability of Child A and Child B to form relationships with their SW’s and limited the opportunity for the children to share any worries or concerns with a trusted adult outside of their immediate family. Whilst it is important to avoid hindsight bias, the disclosure by Mother that she had been the victim of abuse by Carer 1 is significant. It is important that the experiences of adult children of prospective kinship foster carers are fully assessed prior to approval being granted and this will be addressed in the recommendations.   5.75 When describing life with the foster carers Child A and Child B stated: Child A: Most of the time I was in my room, they (carers) used to be on the play station or watching horror films downstairs. I’d go to sleep early, there was no TV in the room. Child B dropped off with her behaviour in year 7. I got love and attention from my siblings even though we argued. I was closest to Carer 2, had been home a lot and my behaviour was better than Child B’s.  The carers made us cook our own food from year 7 they couldn’t be bothered, they used to fight with Child B and Sibling 1 – we all had to share a room. Child B had bruises – 1 or 2 a month.  Child B: I used to cry for attention so they would have to ring the SW’s, sometimes I wasn’t reported as missing from home – once I was out until 4 am. I stole from Carer 2, I told them Carer 2 was hitting me, SW came up to the bedroom and I told them about the threats to throw me out – nothing got done. All the reports said we were settled.  5.76 Professionals did not have a clear understanding of Child B’s wishes and feelings and without an opportunity to understand the context of the behaviour at the time and external influencing factors it is not possible to state with confidence what Child B was attempting to communicate by her behaviour. Challenging behaviour is often the way a child tries to communicate their distress or process their emotions. It is important that consideration is given to what children may be trying to communicate by their behaviour as well as verbally.   5.77 It is known from research that children’s behaviour may be a signal of sexual abuse even when there is no verbal disclosure. Information provided by the Centre of Expertise on Child Sexual Abuse noted that many children do not ‘tell’ in a straightforward way; rather, their behaviour and demeanour or the characteristics or behaviour of caregivers indicates that something is wrong15. It is important that practitioners are enabled to prioritise listening to the voice of children in care in a meaningful way and are alert to what children may be communicating by their behaviours.   5.78 Listening to the voice of the child has emerged as key learning in SCR’s16 which have highlighted the importance of recognising behaviour as a means of communication and the implications of doing so for practice. (Ofsted 2011 p 18; Sidebotham P. Brandon M. 2016 p118). Understanding the lived experience of the child is a complex process and the importance of professionals having a child centred approach is well recognised.   15 https://www.csacentre.org.uk/resources/key-messages/intra-familial-csa/ 16 The voice of the child: learning lessons from serious case reviews. Ofsted 2010   22   5.79 Understanding the lived experience of the child was a key theme identified in audits. It was acknowledged that there is a need to improve on obtaining children’s views as well understanding their lived experience. The audits highlighted the importance of putting together what children say and fully understanding their circumstances. Learning and recommendations from this review will complement current action plans to improve professional understanding about and response to the lived experience of the child.  Learning Point 9 Understanding the lived experience of the child is central to protective safeguarding work. It is important that children are provided with different ways to get their voice heard, and that professionals critically reflect on what is said and what children may be trying to communicate by their behaviour.      (iv) Multi-agency communication and information sharing  5.80 This review has identified some gaps in communication between agencies which include: • GP records in 2013 indicated that the GP was unaware that Father was not supposed to have unsupervised contact with Child A. The potential risk of Child A having unsupervised contact with Father was not assessed and this information was not shared with the SW.  This episode was 7 years ago, and it is possible that systems for information sharing have improved, however assurance is required.  • Non-attendance of health and education professionals at the LAC review resulted in missed opportunities to share information effectively and contributed to the unmet needs of Child A and Child B not being recognised or addressed.  • Child B disclosed self-harm to the GP in 2018. There was no evidence that the GP shared information with the LAC nurse or the SW. There was a missed opportunity for the LAC nurse and/or SW to explore potential causes for the distress and self-harm with Child B.  • Child B attended three appointments with the same GP during the week that Child A disclosed sexual abuse by Carer 1 and a referral was made to CAMHS. There was no evidence of information sharing between the GP and the SW regarding this referral and no evidence of liaison between CAMHS and the SW. It was a significant omission that CAMHS were not aware of the disclosure by Child A and therefore unable to explore this with Child B.   • In early 2017 Child B was involved in an alleged physical assault of teenage girls and whilst Carer 2 informed the Duty SW there was no communication directly or indirectly by the Duty SW to explore this incident with Child B. Records indicated that the allocated SW may have been on leave at this time and the incident was discussed with Child A and Child B one month following the event. There was no evidence of follow up discussion with the Police or discussion about the incident at the LAC review.  5.81 Information sharing is central to effective safeguarding practice and particularly    important when working with looked after children who are likely to have additional vulnerabilities.  Omission to share information effectively during the period considered by this review was a contributory factor which impacted on missed opportunities to effectively safeguard Child A and Child B and ensure their needs were met.    23  Learning Point 10 It is important that practitioners use available systems and processes within and between agencies to share information about the wellbeing of looked after children. Missed opportunities to share information can impact on the ability of practitioners to safeguard looked after children  6   Context  6.1 During the period considered by this review, Children’s Social Care in the local authority experienced a period of significant change.   6.2 At the learning event practitioners acknowledged that practice at the time was process driven, non-compliance with agency procedures was an issue and practice standards were not always met. Implementation of a comprehensive improvement plan is in progress and the learning and recommendations from this review aim to strengthen and complement the improvement journey.   7     Good Practice • Professionals from CSC and School supported the work of the local organisation that Child A and Child B attended and had contact in the community with Child A and Child B.  • A consistent group of professionals at school provided mentoring to Child A and Child B. • In 2018, the LAC nurse was proactive and contacted Carer 2 to discuss an assault on Child A by boys at school.  • GP records reflected detailed child focussed consultations with Child B and clear exploration of potential risks and support.  8 Conclusion, learning and recommendations  8.1 This review was triggered following the disclosure by Child A that she had been sexually abused by Carer 1. The review has found that there whilst there was no obvious missed opportunity to identify the sexual abuse of Child A and also Child B, it is possible that the shortcomings in multi-agency systems and processes identified by this review contributed to conditions which allowed the abuse to progress undetected.   8.2 Carer 1 and Carer 2 did not fulfil the responsibilities expected of kinship carers, however there was lack of challenge and the Carers had minimal involvement with the local authority. The motivation of the carers for taking Child A, Child B and Sibling 1 into their home was not fully assessed. The limited capacity of the Carers to parent was acknowledged but not effectively addressed. The benefit of keeping the children within the family and together appeared to have prevented consideration about whether this was the best placement for the children. The powerful perception that this was a strong stable placement persisted over many years and was supported by Child A, Child B and Mother who shared anxieties and concerns that if they were not with the Carers they may be separated from their siblings. From information provided to this review it was evident that Child A and Child B did not have their needs met and agencies were aware of some of the issues highlighted in this Review when the placement started.  8.3 Learning from this review has highlighted practice shortcomings that in isolation may not present a significant problem. However, when combined, they resulted in serious weaknesses in the systems and processes to safeguard looked after children in a kinship care placement. Practice shortcomings were identified in regard to: assessment, monitoring and supervision of kinship carers; voice of the child; the review process for   24  looked after children; effectiveness of statutory plans for looked after children including the RHA and the PEP; professional challenge of carers; escalation of concerns and multi-agency information sharing.   8.4 When assessing whether professionals were overly optimistic in their practice and decision-making processes it is important to consider the structures and contexts within which practitioners worked. Practice which may be assessed as overly optimistic and unquestioning can flourish when there is limited supervision and support to promote reflection, challenge, and critical thinking. As was the case in this review.  8.5 The 2016 Triennial Review describes authoritative practice as the ability to negotiate the complexity and ambiguity of child protection work with confidence and competence. It enables ‘professionals to be curious and exercise their professional judgement in the light of the circumstances of particular cases (Sidebotham et al, 2016)17.  Professionals involved in this review accepted the necessity to improve multi agency authoritative practice.   8.6 Whilst it is not possible to change the past, senior managers involved with this review stated that there is a sincere commitment and enduring responsibility to provide ongoing support to Child A and Child B. It was acknowledged by the SCR panel that services for looked after children in kinship care have significantly improved since the time period considered by this review. In addition to systemic changes to improve multi-agency practice there is a bespoke kinship care service and an advocacy service for looked after children. It is important that these changes reduce the risk of repetition of practice shortcomings identified by this review and have a positive impact on the lived experience of looked after children.   8.7 This review has benefited from the generous participation and reflection of practitioners from all agencies. It was a challenge for professionals who had been involved with the family over many years to critically review their practice and identify opportunities for multi-agency practice learning. There was acknowledgement by practitioners who attended the learning event of the powerful personal learning from participation in this review, specifically with regard to exercising respectful uncertainty when working with families and maintaining focus on the needs of the child.   8.8 The review also benefitted from the views of Child A, Child B and Mother who shared their experiences with courage to inform the learning and influence change in practice. The review will be shared with the family prior to publication. In discussion with the independent author Child A and Child B said they would be willing to consider involvement in the development of resources for children in care to raise awareness about sexual abuse and available support.  Learning and Recommendations  Learning Point 1 It is important that there is robust exploration during the approval process for kinship foster carers about whether they can meet the needs of all the children in their care and any concerns are fully addressed prior to obtaining approval.  Recommendation 1  Safeguarding Partners seek assurance that the approval and review process for kinship foster carers requires:  17 Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014. Sidebotham, Peter et al. Department for Education, 2016 p201.   25  • Rigorous exploration of the parenting capacity of all carers • Identification of any support (practical, emotional, financial) required to the enable the carers meet the needs of children in their care • Monitor the capacity of carers to respond to changing needs of children as they age and develop • Consideration of specific exploration with adult children of potential kinship foster carers about whether they experienced abuse of any nature as children  Learning Point 2 Placement reviews for looked after children in kinship care placements should identify when National Minimum Standards are not met, whether changes are required and within what timescale, to avoid children remaining long term in inadequate accommodation.   Recommendation 2 When placements do not meet the National Minimum Standards, a referral is made to the Fostering Panel for further consideration  Learning Point 3 Without consistent, rigorous and child focussed oversight by supervising social workers, shortcomings in the parenting capacity of kinship foster carers may not be identified or challenged and children may remain in placements where their needs are not met.  Recommendation 3  Safeguarding Partners seek assurance that: • Supervising social workers support kinship foster carers to meet the needs of children in their care and provide effective challenge when required • Supervising social workers have access to regular supervision which provides opportunities for reflection and critical challenge  Learning Point 4 It is important that audits of a child’s file evidence critical reflection and explore whether identified concerns for looked after children are reflected appropriately within the care plan.  Recommendation 4 Safeguarding Partners seek assurance that: Audits for looked after children in kinship care (single and multi-agency) are       robust and have specific regard to: • Identification of unmet need • The effectiveness of multi-agency arrangements to implement the care     plan   Learning point 5 Supervision of social workers should include the critical appraisal of the care plan for looked after children, particularly when the social worker is newly allocated. This should provide an opportunity to identify gaps, consider unmet needs and challenge incorrect assumptions.  Recommendation 5 Safeguarding Partners seek assurance that:   26  • Social workers have access to regular supervision which provides opportunities for reflection and critical challenge with a specific focus on the effectiveness of care plans for looked after children  Learning Point 6 Frequent change in social worker and lengthy gaps between visits to looked after children reduces the opportunity for children in care to develop a relationship with a trusted professional outside of their family whom they can talk to about their experiences in care.   Recommendation 6 Safeguarding Partners seek assurance that: • Children in kinship care receive statutory visits from social worker within timescales • Social workers support children in kinship care to identify a trusted professional who will enable them to get their voice heard in the decisions which impact on their lives  Learning Point 7 It is important that all relevant professionals attend Reviews for looked after children and there is robust scrutiny of all plans to promote the wellbeing and development of children in care and support to assist them to achieve their potential.  Recommendation 7 Safeguarding Partners seek assurance that learning from this review informs the system and process for looked after child reviews regarding: • Proactive attendance of all relevant professionals at the LAC review • Robust monitoring of the quality of all care plans including the PEP and HRAs • Effective multi-agency challenge and escalation of concerns when the needs of the children are not met  Learning Point 8 There may be many reasons why children in care decline to meet with professionals without their carers present. If children are not seen alone it may be difficult for professionals to have an informed understanding of their lived experience.  Learning Point 9 Understanding the lived experience of the child is central to protective safeguarding work. It is important that children are provided with different ways to get their voice heard, and that professionals critically reflect on what is said and what children may be trying to communicate by their behaviour.    Recommendation 8 Learning from this review informs and contributes to the action plan currently in place to improve multi agency practice to understand the lived experience of the child, and assurance is provided that:  • Professionals are proactive when encouraging children in care to meet with them and provide appropriate assurance that what is said will not be reported back to the carers    27  • Professionals explore and record why children may refuse to meet with them 1-1 and this is monitored   • Consideration is given to what children may be trying to communicate by their behaviour and whether what may be described as challenging behaviour is an indication of unmet needs   • The voice of children in care is evidenced within care plans and informs the provision of services and support  • Learning Point 10 It is important that practitioners use available systems and processes within and between agencies to share information about the wellbeing of looked after children. Missed opportunities to share information can impact on the ability of practitioners to safeguard looked after children  Recommendation 9 Multi-agency safeguarding partners are reminded of:  • Their responsibilities to share information both between and within their organisations   • The potential impact of practitioners to safeguard looked after children when these opportunities are missed     