An Ofsted inspection of a special educational needs school carried out in January 2022 raised a number of serious safeguarding matters. Ofsted concluded that pupils were not being kept safe and were at risk of immediate and imminent harm. Learning includes: a need for the Department for Education (DfE) to strengthen processes for matching academy sponsors to special schools; there was sufficient information for Ofsted to decide to undertake a no notice inspection of the academy earlier; the need to put in place a process to address the multiple safeguarding concerns about the care of children in the academy; and a need for agencies to recognise that regardless of what Ofsted would do they have a responsibility to take action to safeguard the children. Recommendations include: the DfE to revise its process for identifying academy sponsors for special schools; professionals should always consider what other routes they should explore when a referral about a child or about the behaviour of an adult does not meet the safeguarding criteria they use; and the partnership should agree a document for parents and carers that outlines how to raise concerns in relation to children with disabilities and what to do if these concerns are not responded to.
      
 Title:  Review of safeguarding practice in response to events at Harlow Academy. LSCB: Nottinghamshire Safeguarding Children Partnership Author: Nottinghamshire Safeguarding Children Partnership Date of publication: 2023  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.                                   Review of Safeguarding Practice in Response to Events at Harlow Academy  Report to Nottinghamshire Safeguarding Children Partnership (NSCP)  June 2023      Contents          1. Executive summary.  1 2. Why this review was undertaken.  8 3. The needs of the children who attended Fountaindale School and Harlow Academy.  9 4. Abbreviated terms of reference for the review. Full terms of reference are in Appendix 2.  11 5. Work undertaken for the review.  12 6. Outline of the regulation and oversight system for schools.  13 7. Inspection outcomes, changes of school status and changes of leadership at Fountaindale School and Harlow Academy.  19 8. Parent and carer experience and views.  22 9. Fountaindale School Key events -2017 to 31st March 2021.  28 10. Harlow Academy key events- 1st April 2021 to 25th January 2022.  31 11. Analysis of events.  41 12. Responses to the key lines of enquiry set out in the terms of reference.  47 13. Recommendations.  52  Appendix 1. Integrated Chronology  55  Appendix 2. Full terms of reference for the review.  Appendix 3 Acronyms  76  82     1 | P a g e   1. Executive summary.  1.1. An out of schedule Ofsted inspection of Harlow Academy, part of the Evolve Trust, was undertaken on 18th January 2022.1  A number of serious safeguarding matters were raised by Ofsted. Ofsted concluded that Pupils were not being kept safe and were at risk of immediate and imminent harm.   1.2. Given the seriousness of the issues raised by the findings of the Ofsted inspection NSCP Strategic Leadership Group determined that there would likely be learning for all partnership agencies, and that an umbrella review should be commissioned to ensure the learning from the reports and learning exercises already completed and from health and police partners was consolidated. Ofsted and the Department for Education (DfE) were also invited to contribute to this review considering their significant involvement over the period of concern.   1.3. The review focuses on the safeguarding response provided for the children by the NSCP agencies. The period for the review was March 2017 to January 2022. The review drew on work completed, such that overall learning could be identified for the future.   In addition, the review author met with some parents and carers and reviewed Evolve Trust governance documents.  1.4. The chronologies and reports from Nottinghamshire County Council (NCC) and Nottinghamshire Healthcare Foundation Trust (NHFT) present a shocking picture of the decline of the quality of care of children at Harlow Academy in the months prior to the Ofsted inspection of January 2022. The decline was to a point where the school was not safe for the children.  Almost certainly the quality of their education also declined but that is not the focus of this review.  There is considerable hurt and anger in the parent and carer community about what has happened.    1 Where Harlow Academy is named in full the formal title Harlow Academy will be used. The term school will be used otherwise for the sake of simplicity as an accurate description of what Fountaindale School and Harlow Academy were.  2 | P a g e   1.5. In considering the multi-agency response to the safeguarding concerns about children at Harlow Academy an understanding of the system of regulation and oversight of schools is helpful.  This is not a straightforward topic, and the report sets out a simplified version.  Very few of those working in the system fully understood how systems of accountability worked and who was ultimately responsible for what.  1.6. Harlow Academy, called Fountaindale School prior to 1st April 2021, was a special educational needs school. The school provided specialist educational facilities on a day basis for pupils aged 3 to 18yrs. The school met the needs of children who have severe or profound learning difficulties, as well as additional difficulties that may include physical disabilities, complex medical needs, life limiting conditions, speech and language difficulties, sensory impairments, and under-developed social skills.   All the children have Education Health and Care Plans (EHCPs). At the time of the inspection in January 2022 there were 79 children on roll.  1.7. Fountaindale School was judged Outstanding in an Ofsted inspection in March 2017.  The inspection of February 2020 found the school Inadequate for leadership and management and for overall effectiveness. Arrangements for safeguarding were judged ineffective. In March 2021 a monitoring inspection, some of which was conducted remotely, found that “Leaders and those responsible for governance are taking effective action to provide education in the current circumstances.”  The judgement that the school was inadequate in February 2020 led the DfE to make an academy order and find an academy sponsor, the Evolve Trust, for the school which became Harlow Academy as part of the Evolve Trust on 1st April 2021.  1.8. The process of conversion to an academy did not involve any consultation with parents and carers. The DfE followed their usual process which they considered provided them with sufficient information to make an informed decision about the suitability of Evolve Trust to take responsibility for Harlow Academy.      3 | P a g e   1.9. It is evident that there had been serious difficulties at Fountaindale School prior to it being judged inadequate by Ofsted in February 2020.  These difficulties led to NCC issuing a very detailed and lengthy warning notice with 15 items in July 2019. While improvements were made the deeper difficulties at the school had not been addressed by the time Fountaindale School became Harlow Academy on 1st April 2021. No new permanent head teacher was appointed either before or after academy conversion leaving the school without a permanent head teacher between July 2019 and January 2022.  1.10. Once the school became Harlow Academy parents and carers noticed a change in the running of the school which suggested the Evolve Trust was not sensitive to the needs of their children. In the Autumn term 2021 there were a series of serious incidents of concern, almost all reported by NHFT staff based at the school. These included inappropriate use of restraint, failure to provide equipment required to support children's mobility or being able to sit in the correct posture, children not spending the correct time in specialist seating or in standing frames, orthotics being left on for too long, poor management of behaviour and inappropriate exclusions.  During the Autumn 2021 term there were 20 incidents of concern reported by NHFT staff.  Other incidents of concern were raised by parents and carers and staff.  1.11. By the end of September 2021 there were extensive discussions between NHFT and NCC about how to address the concerns.  NHFT had written to Ofsted setting out the safeguarding incidents they had recorded. There were discussions between NCC and Ofsted and the Regional Schools Commissioner (RSC). These discussions included whether Ofsted should undertake a no notice inspection of Harlow Academy.  These discussions did not lead to any action. The relationship between NHFT staff and Harlow Academy and Evolve Trust leadership had further deteriorated reflecting the growing concern of NHFT staff for the safety and welfare of the children at the school.   1.12. Further concerns raised in October and November 2021 led to further consideration of what to do including a plan to undertake a safeguarding  4 | P a g e   review of the school. This did not proceed because the NCC officer leading the review realised it could not address the concerns being raised as its focus was on policy and procedures and not care practice at the school. However, Ofsted understood this review would be addressing the areas of concern and this influenced their view of whether a no notice inspection was needed during the Autumn term.  1.13. Referrals were made to the Local Authority Designated Officer (LADO), the Multi-Agency Safeguarding Hub (MASH) and to the Integrated Children’s Disability Service (ICDS) but each referral on its own was considered not to be appropriate for that service to investigate.  1.14. There was a sense that other agencies were waiting for Ofsted to inspect and did not initiate their own programme of action to address the multiple areas of concern about the care of the children at Harlow Academy.  While leaders in NCC and NHFT met the leaders of the Evolve Trust, including the CEO, no initiative was taken by the most senior leaders to meet the Evolve Trust CEO or the Evolve Trust Trustees.  1.15. There were further complaints and issues of concern raised in December and early January including a growing number by concerned parents and carers. These further complaints, combined with the history and that the planned safeguarding review did not proceed, led to the Ofsted no notice inspection in January 2022.  1.16. The review has concluded that:  1. In retrospect the process and decision to identify the Evolve Trust as the sponsor for Harlow Academy was flawed as it did not adequately identify whether the Evolve Trust had the capacity and skills to successfully lead and manage Harlow Academy and ensure the needs of the children at the school were safely and effectively met. The DfE have recognised that they need to strengthen their process for matching academy sponsors to special schools.  5 | P a g e    2. There was sufficient information for Ofsted to decide to undertake a no notice inspection of Harlow Academy in early October 2021.   3. NCC, NHFT and Nottinghamshire CCG did not put in place a process to address the multiple safeguarding concerns about the care of children at Harlow Academy at the end of September 2021.  There was no process within their existing policies and procedures that fitted this set of circumstances, but this should not have prevented one being developed to deal with the circumstances raised by what was happening at Harlow Academy.    4. It appeared agencies were waiting for Ofsted to act rather than recognising that regardless of what Ofsted would do they had a responsibility to take action to safeguard the children at Harlow Academy.  5. Where referrals were made to services that could have acted such as LADO, MASH and ICDS there was no recognition that, even if the referral was not appropriate for that service, action was needed and that those in the service should be raising this with senior leaders and finding a way to ensure action was taken. 1.17 The review and individual agencies involved in the review have made  recommendations which include: 1. The DfE is revising its process for identifying academy sponsors for special schools.  2. NSCP will develop a process for responding to concerns about the quality of care in children's settings and consider when a formal multi-agency group needs to be put in place to lead such a complex enquiry.  3. NSCP staff with safeguarding responsibilities such as those working in MASH, LADO, named safeguarding professionals within NHS services  6 | P a g e   and Police working within public protection teams should always consider what other routes they should explore when a referral about a child or about the behaviour of an adult does not meet the safeguarding criteria they use.   4. The NSCP should agree a document for parents and carers that outlines how to raise concerns in relation to children with disabilities and what to do if these concerns are not responded to. This should include concerns about a child’s school.    5. Ofsted are conducting a learning review and intend to use this review to inform their thinking.   Conclusion 1.18 The decline of standards of care and education at Fountaindale and Harlow Academy were a consequence of a lengthy sequence of events.  There were many opportunities where a different course could have been taken that would have made a difference e.g. appointment of a capable permanent headteacher, a more enquiring approach to the review of the warning notice, more careful selection of an academy sponsor, Evolve appointing a capable headteacher, Ofsted inspecting in October 2021, NCC and NHFT working with other partners putting in place a formal process to deal with and address the many incidents and concerns raised about care of children at Harlow Academy, an active approach to engaging parents and carers and seeking their views and experience of the school.  1.19 Parents and carers have found what occurred painful and distressing. They have said they felt guilty because they sent their children to school knowing it might not be safe.  They feel their children have regressed in some cases or not made the progress they should have in others. Parents and carers are concerned that their children may never be able to recover the ground lost in their development due to the poor education and care they received at Harlow  7 | P a g e   Academy.  Parents and carers also recognised how much better the school is now and that their children are now happy in (the renamed) Fountaindale School.                               8 | P a g e    2. Why this review was undertaken.   2.1. An out of schedule Ofsted inspection of Harlow Academy was undertaken on 18th January 2022.  A number of serious safeguarding matters were raised by Ofsted. Ofsted concluded that Pupils were not being kept safe and were at risk of immediate and imminent harm.  The inspection identified that: • The children’s care needs were not being met and they were therefore not able to learn. The classrooms were unsafe, and the trustees were not fulfilling their duties, not just at an operational level, but at a strategic trustee level.  • The quality of the relationships within the school had contributed to the break down and removal of health staff who had been based at the school historically.    • Staff found it was difficult to work at the school and they felt they would be blamed when something went wrong.  They felt intimidated in these circumstances. • Staff said they did not feel free to speak out and that there was a culture of fear and a lack of openness. Staff essentially were saying they were too afraid to whistle blow.   2.2. No serious incident notification was submitted by the Local Authority to the National Safeguarding Panel as no specific serious child safeguarding case was identified. It was determined this was a concern of institutional failure which would be dealt with under the Nottinghamshire Safeguarding Children Partnership’s organised and complex abuse procedure.  The Local Authority commissioned an independent review in March 2022. The outcomes of this have been considered within this review.  2.3. NSCP Strategic Leadership Group determined that there would likely be learning for all partnership agencies, and that an umbrella review should be commissioned to ensure the learning from the reports and learning exercises already completed and from health and police partners was consolidated.  9 | P a g e   Ofsted was also invited to contribute to this review in light of their significant involvement over the period of concern.      3. The needs of the children who attended Fountaindale School and Harlow Academy.  3.1. Harlow Academy, called Fountaindale School prior to 1st April 2021, was a special educational needs school. The school provided specialist educational facilities on a day basis for pupils aged 3 to 18yrs. The school met the needs of children who have severe or profound learning difficulties, as well as additional difficulties that may include physical disabilities, complex medical needs, life limiting conditions, speech and language difficulties, sensory impairments, and under-developed social skills.   All the children have EHCPs. At the time of the inspection in January 2022 there were 79 children on roll.  3.2. The description of the children’s needs in paragraph 3.1 uses professional language and while accurate does not fully convey the lived complexity of the children’s needs, the quantity of care needed, the level of skill required and their vulnerability to the impact of not having their needs met to the timetable required or care delivered with the necessary skill.  Examples of needs that require timely and skilled intervention included: • The feeding of children through a gastric tube • The need to position children correctly and for the prescribed periods of time either in standing frames or in specialist seating to help improve or maintain posture or mobility. • The management of behaviour for children whose method of communication is through their behaviour requiring skilled observation and response to understand what needs the child is expressing and what is a helpful response.  10 | P a g e   • Monitoring of vagal nerve stimulation used to help reduce children’s epileptic seizures.2 • The administration of medication regimes.  3.3. A significant proportion of the children required regular medical interventions or spent periods in hospital for treatment including surgery to help improve posture or the flexibility of their limbs. There were children at the school who had life limiting conditions.  Their parents and carers were living with the reality that their child could become quite suddenly very unwell.  3.4. Finally, it is worth noting that caring for children with the range of needs the children at Harlow places huge demands on their parents and carers. It has an impact on the children’s siblings and wider families.  The experience of parents and carers is typically of having to “battle” for the needs of their children to be met across a range of needs and agencies. They need a complex web of services which reflect the complexity of their children’s needs, but which are not easy to navigate or coordinate.  All these factors mean it is especially important that the children can attend a school in which the parents and carers can have confidence the children’s needs are met, the children are happy, there is excellent communication between the school and parents and carers and the children are safeguarded from harm.       2 Vagal Nerve Stimulation (VNS) is an implanted electrical device that provides a timed electrical impulse to the vagal nerve to reduce the regularity of absence seizures. When seizures are occurring despite the device, in addition to the planned impulses, further impulses may be provided. If there is no awareness of increased seizures or side-effects of over stimulation then the medical team managing the device cannot make changes to care potentially leading to secondary complications.  Additionally, carers having no awareness of the regularity of seizure events is a potential signifier of wider neglect.   11 | P a g e   4. Terms of reference of the review.  4.1. The full terms of reference are set out in Appendix 2.    4.2. The key lines of enquiry for the review are: “It is important for any reader, but perhaps especially those unfamiliar with reviews of this sort, to understand the ambit and purpose of this ‘umbrella review’. It is not about the school or the leadership of the school or written for the families. It does not seek to tell the children’s story or provide a narrative understanding of their lives. The review is rather about the safeguarding response provided for the children by the NSCP agencies, once they were aware of the problem.  The review will draw together work already completed or in process, such that overall learning may be identified for the future”.    1. When concerns about the care of the children were raised what was the quality of response from safeguarding partners? Identify what escalation was undertaken by each agency, how effectively these escalations were responded to and any lessons for the partnership about the escalation procedures or practice. Include exploration of the circumstances of the health team no longer being on site.      2. Did the children’s disabilities impact on how partners understood their experiences at Harlow? Were they sufficiently considered in the response of agencies to the concerns being raised? Did those responding to the concerns have the correct expertise or draw on support from those who did?    3. What discussions took place by either individual practitioners or their agencies with senior staff at the school and Evolve, as the responsible Trust, about their safeguarding or other concerns? This could have been about specific incidents or more broadly about the culture, practice or staffing at the school?”   12 | P a g e    5. Work undertaken for the review.  5.1. Review of reports and chronologies received from NCC, NHFT, and Ofsted.  5.2. Review of reports from Nottinghamshire Police and DfE which included information about the role of the RSC and the Education and Skills Funding Agency (ESFA).   5.3. Meetings with thirteen parents and carers, nine in person and four online.  5.4. Review of parent and carer complaints which related to sixteen children.  5.5. Review of Harlow disciplinary and grievance documents.  5.6. Review of Evolve Trust records of Trust Board, AGM and other committee meetings.  5.7. Review of Ofsted reports, NCC warning notice of 18th July 2019, warning notice review of 2nd December 2020 and notice lifting the warning notice of 14th December 2020.  5.8. Online meeting with Care Quality Commission (CQC) representative to explore their role.  5.9. Completion of a single chronology of key events and commentary on those events primarily drawing on the chronologies provided by NCC, NHFT, Ofsted, Evolve Trust records and the DfE report.  5.10. Conversations with NCC, NHFT and DfE report authors.      13 | P a g e   6. Outline of the regulation and oversight system for schools.  6.1. In considering the multi-agency response to the safeguarding concerns about children at Harlow Academy an understanding of the system of regulation and oversight of schools is helpful.  This is not a straightforward topic, and this report sets out a simplified version.   6.2. Ofsted inspects schools but does not regulate them. Ofsted inspects and regulates children’s social care settings.  It has no direct role in school improvement.   6.3. The Care Quality Commission registers, monitors and inspects anyone or any service carrying out regulated activity under the health and care act. This includes the NHS service provided by NHFT to Harlow Academy and any other regulated activities provided to children at the school.  In respect of Harlow Academy, the CQC’s only role was as the regulator and inspector of the NHS services delivered by NHFT and other parts of the NHS to children at the school.  6.4. Fountaindale school was a local authority-maintained school.  This means the local authority was responsible for the overall running and performance of the school.  The local authority was involved in setting the budgets for maintained schools and provided a range of services directly to the school which the school purchased such as human resources, health and safety, school improvement, information and communication technology and building maintenance functions.  Maintained schools are often described as local authority controlled but this suggests a much greater degree of control than is the case in practice. For example, the local authority does not appoint the head teacher or other staff, it does not determine the allocation of the budget within the school and the school is free to purchase services e.g., HR, ICT, maintenance etc. from providers other than the local authority. How this works in practice is illustrated by the local authority having to issue an improvement notice to the governing body of Fountaindale School in July 2019 as the means to try to ensure the school improved or it could have  14 | P a g e   appointed an interim executive board to replace the school governors.  These are complex and clumsy mechanisms compared to being able to directly tell the head teacher and governing body what to do if there was a direct line management arrangement between the local authority and the school.  6.5. Fountaindale School was judged inadequate in the Ofsted inspection of February 2020.  This judgement required the DfE to issue an academy order for the conversion of Fountaindale School to an academy with an academy trust chosen by the RSC3. The conversion to academy status does not require any consultation with parents, children or the wider school community. Once Fountaindale School became Harlow Academy the local authority no longer had any role in the oversight, management or running of the school.  It had no formal mechanisms to intervene in the school.   6.6. Once an academy and operating as Harlow Academy responsibility for the school passed to the Evolve Trust.  The Evolve Trust like all academy trusts is regulated by the ESFA which is an arm of the DfE.  The intention of the policy of developing academies and multi-academy trusts is to have a self-improving school system regulated and overseen by the DfE and outside local authority ‘control’.   6.7. As its name suggests the ESFA is primarily concerned with ensuring good financial management and governance.  However, the funding agreement between the ESFA and an academy trust does require the academy trust and their schools to have the required policies and procedures in place, including to ensure that children are safeguarded within the school.  The ESFA had a role to investigate complaints about academy schools and multi-academy trusts. This role is now undertaken by Regions Group and overseen by Regional Directors (formerly RSCs). In the time period of this review the ESFA worked with the RSC who had oversight of the academy schools within their region.  Local authorities and Regional Directors have specific responsibilities in relation to school and academy performance. These  3 Now called Regional Directors  15 | P a g e   responsibilities and the related powers of intervention are set out in the published Schools Causing Concern Guidance. There is no informal mechanism for Regional Directors to ask Ofsted to inspect a school. Ministers can direct Ofsted to inspect but in practice this power is rarely used.   6.8. The ESFA, RSC and Ofsted can all receive complaints from parents and carers and others about a school or about individual children.  The ESFA can ask the school or academy trust to respond to the complaint as it did in relation to complaints about Harlow and in relation to other schools run by the Evolve Trust.  Ofsted uses complaints as part of its consideration of the performance of a school and whether or not to bring forward the date of an inspection.  Where Ofsted receive complaints relating to safeguarding, they will typically ask the local authority to review the complaint and provide assurance or not for academy as well as local authority maintained schools. The RSC considered complaints as part of their oversight of the academy schools in their region.  6.9. The local authority had responsibility to work with partners to assess the needs of children attending Fountaindale School and Harlow Academy and also to work with partners including parents and carers to determine how those needs would be met which would be set out in an EHCP. The Council, Nottinghamshire County Council (NCC) in this case, had the lead responsibility for ensuring the aims of the EHCP were met and the services set out in the EHCP delivered. The oversight within the council of the EHCP assessment and review processes was with the ICDS.   6.10. It is the Council’s role working with partners to commission the services needed to meet the needs in EHCPs either from maintained schools, academies or independent schools. All the children at Fountaindale School and Harlow Academy had an EHCP which was subject to annual review. The detail of how the needs set out in an EHCP of an individual child would be met are delegated to schools and they are funded to provide those services to the children attending.  Whether a child’s needs as set out in their EHCP are being effectively met was one of the areas of complaint by parents and carers  16 | P a g e   at Fountaindale School and Harlow Academy.  This is a common occurrence as parents and carers will challenge whether their child is receiving what they believe has been specified in an EHCP.  An example of a common area of dispute is where an EHCP says a child needs one to one support and whether this means that throughout a school day the child has a dedicated member of staff to help meet their needs or whether it means that at any time there is access to one-to-one support from staff members who may support a number of children.  The latter is how such support is commonly provided.  6.11. NCC also has the wider role of safeguarding and promoting the health and wellbeing of all children within its boundaries working with partners under section 11 of the Children Act 2004.  This broad duty enables the Council to provide or promote the provision of a wide range of services that benefit children.  It also encompasses the Council’s duty to safeguard children.  This is a broadly framed role which is not supported by the kind of specific regulation and guidance that is in place to safeguard individual children where they have been identified as children in need or as children in need of protection under s17 and s47 respectively of the 1989 Children Act.  This guidance is in Working Together to Safeguard Children 2018.  As all the children at Fountaindale School and Harlow Academy would be considered to have a disability they would all be considered children in need within the definition set out in s17 of the Children Act 1989.   6.12. The NHS bodies share the same broad responsibilities for all children as the local authority. The responsibilities to be discharged include working with partners including the local authority.  6.13. The roles of the inspectorates, the NHS bodies, the local authority and the DfE through the RSC (now Regional Director) and the ESFA have been set out to show the complexity of the system for oversight of schools and for meeting the needs of the very vulnerable group of children attending Fountaindale School and Harlow Academy.  It is fair to say that very few of those working within the system will have understood all the components and what their roles were. Once Fountaindale School became Harlow Academy  17 | P a g e   the only bodies external to the Evolve Trust with the authority to intervene in the running of Harlow Academy were the DfE through either the ESFA or the RSC. Neither body had any day-to-day oversight of the school. The day-to-day oversight was with the Evolve Trust Board of Trustees who could intervene. They were responsible for Harlow Academy.  Neither the ESFA nor the RSC had a clear mechanism to gather disparate intelligence about Harlow Academy and how the children were educated and cared for. This intelligence existed across the different parts of the local authority working with the children attending the school, the NHS practitioners working in the school, with Ofsted and with parents and carers.  6.14. The DfE recently published the outcome of a review of academy regulation and of the ESFA as one of its arm’s length bodies.  The review reflects the widely held concern that the current system of academy school and academy trust regulation is not satisfactory, not least for its complexity and lack of clarity of the roles of key parties, including local authorities.4 The review includes provisions for improving regulatory oversight of academy trusts and clarifying the process for parental complaints. There is also a specific commitment to introduce by Autumn 2023 a revised data sharing agreement between DfE and Ofsted, to support better information sharing around safeguarding and complaints, alongside continued work to reduce duplication.   6.15. The Chair of the Association of Directors of Children’s Services (ADCS) Educational Achievement Policy Committee, Heather Sandy, comment on the consultation is pertinent to this review. She said: “The school accountability system has long been confused and incoherent with a lack of clarity around roles and responsibilities. ADCS welcomes the commitment from government to create a more coherent system, in collaboration with local authorities, schools and parents, where there is a greater focus on inclusivity. However, it remains unclear how the current plans as set out will help achieve the ambitions within the SEND and Alternative Provision Improvement plan.  4 https://www.gov.uk/government/publications/academies-regulatory-and-commissioning-review  18 | P a g e   Local authorities play a key role in education with regard to school standards, special educational needs, safeguarding, and children in care whilst being democratically accountable to our local communities. Despite this, we lack many of the powers to effect change in our local school system. The recently dropped Schools Bill would have provided local authorities with some of the levers we need to help ensure the system works for all children and young people, including those with special educational needs. Without these powers, it is not clear how meaningful change will be achieved.”                    19 | P a g e   7. Inspection outcomes, changes of school status and changes of school leadership at Fountaindale School and Harlow Academy.  7.1. Ofsted Inspection Outcomes: • March 2017 – Outstanding. • February 2020 – Inadequate for leadership and management and for overall effectiveness. Arrangements for safeguarding were judged ineffective. Quality of education, early years provision and sixth form judged required improvement and behaviour and attitudes and personal development judged good. • March 2021 remote monitoring inspection. The inspection said: “Leaders and those responsible for governance are taking effective action to provide education in the current circumstances.”  Because of Covid restrictions the range of evidence available to inspectors was narrower than would normally be the case. The inspectors noted that this meant their letter of findings provided more limited assurance than the usual process.  • January 2022. This out of schedule inspection raised a number of serious safeguarding matters leading Ofsted to conclude that children were not being kept safe and were at risk of immediate and imminent harm.  7.2. Change of school status: • Fountaindale School ceased to exist as a maintained local authority school on 31st March 2021 and became Harlow Academy on 1st April 2021, an academy, and part of the Evolve Trust. Harlow became the fourth school within the Evolve Trust. The other schools in this multi-academy trust were a primary school, a secondary school and a special school for children with communication and interaction needs, many of whom will have an autistic spectrum condition.      20 | P a g e   7.3. Changes of school leadership at Fountaindale School and Harlow Academy: Headteacher or Executive Head Comment Dates Headteacher 1 In post when Fountaindale judged outstanding in March 2017 Left end of 2017/18 school year Headteacher 2 Emerging difficulties during this period. September 2018 to July 2019 Acting Headteacher 3 Described as acting headteacher in the March 2021 monitoring visit. Continues as acting headteacher throughout the transition from Fountaindale School to Harlow Academy and is in this role in January 2022. July 2019 to January 2022 Executive Headteacher 1 Appointed by the Local Authority following the issuing of the Warning Notice in July 2019. Appears to have had some continuing role in the school following the transition to Harlow Academy for the summer term 2021. Worked 3 days a week. July 2019 to March 2021 and some role to July 2021. Executive headteacher 2 There was a plan by Evolve Trust to appoint an executive head to Harlow Academy and it appeared that the principal of another Evolve Trust Academy was identified for this role, but they were never appointed to the role.  However, this person did work in Harlow Academy on some occasions and is referred   21 | P a g e   to in the chronology as executive headteacher as that is who those meeting this member of staff thought they were dealing with.  Executive Headteacher 3 This was the Chief Executive Officer of the Evolve Trust.   September 2021 to January 2022                           22 | P a g e   8. Parent and carer experience and views.   8.1. The views of parents and carers are from the notes taken in a face-to-face meeting with nine parents and carers and online meetings with four parents and carers. They reflect parent and carer views and opinions and not the views of the report author.   8.2. Parents and carers were clear that there were issues about the quality of care and education prior to 1st Aril 2021 when Fountaindale School became Harlow Academy and part of the Evolve Trust.  The view expressed by some parents and carers was that Fountaindale was never outstanding.  Their experience was that staff were allowed to do things whether in respect of care or educational provision that were outside the school policies.  There were significant staffing issues while the school was a local authority maintained school and not just when it became Harlow Academy and the responsibility of the Evolve Trust.  Some parents and carers thought the school had been well run by the Head who led the school up to 2018.  8.3. Parents and carers said that there were examples of parents and carers and staff whistle blowing at Fountaindale School.  Parents and carers said there was a history of a lack of sufficient staff to provide care at Fountaindale School.  Parents and carers felt that Fountaindale being a Beacon School led to a reluctance to recognise problems in the school and that Beacon activities took staff away from their main task of caring and educating the children at Fountaindale School.  Beacon Schools were identified as having good practice and to take a lead in sharing this with other schools  8.4. Staffing at Fountaindale School had been very stable with little change in the management team until 6/7 years ago. That was when the turnover of staff started.  The level of turnover since was illustrated by a parent noting that their child had had 10 teachers over 4/5 years.  There was a long history of not enough staff at the school.     23 | P a g e   Discussion of transfer of Fountaindale School to the Evolve Trust.  8.5. Parents and carers were told about the plan for Fountaindale School to become an Academy in January 2021. There was no consultation on academisation. There was no consultation on the change of name or on the change of uniform.    8.6. At a Teams meeting in February 2021 parents and carers were told nothing would change and that the uniform change would be implemented gradually by the Evolve Trust.  Parents and carers then found that from 1st April children must have the new uniform. They were also surprised that all children were given homework and that if it was not done children would not be entered into the incentives scheme.  Given the needs of many of the children this meant parents did the homework so their child would not be left out of the incentives scheme.  There were exhibitions of homework which for many children had no meaning. The work was done by parents. The new Harlow Academy handbook said that medical appointments would be treated as unauthorised absences.  Given the medical needs of many of the children this seemed inappropriate for the school and the children it serves.    8.7. Parents and carers thought the Fountaindale curriculum was good and the changes to curriculum introduced by Evolve did not make sense to parents and carers or in their view help meet their children’s needs.  Parents and carers felt the school was run like a mainstream primary and secondary school and was not reflecting their children’s needs. Parents and carers said they felt intimidated by the school. School staff presented themselves as “the experts” but then did not deliver an expert experience for their children.   8.8. In the period after the school was judged inadequate in 2020 and before Evolve took over parents and carers described the executive head, who was brought in by the local authority as executive head, as unapproachable5.   5 It is worth noting that much of this was during the most intense and difficult period of the Covid emergency when face to face communication was disrupted by Covid restrictions. This may explain why parents and carers experienced the executive head as unapproachable.  24 | P a g e   They felt she did not put things right but applied a sticking plaster. Parents and carers thought things got worse in the period leading up to 1st April 2021.  There was evidence of high staff turnover in this period.  Evolve Trust responsible for the school which was renamed Harlow Academy.  8.9. Parents and carers said that by September 2021 staffing levels were very poor as more staff had left.  The personal assistants who came into school with one child, employed by that child’s carers, were reporting how bad the staffing was.  Parents and carers expressed their concerns by filling out Ofsted questionnaires (the parent comments forms available on the Ofsted website) but there was no response to the concerns recorded in the questionnaires. Parents and carers used the Ofsted process but with no effect. Parents and carers said they experienced a closed culture at the school.  8.10. A number of parents and carers said they were lied to by senior members of the Harlow Academy management.  The response to the carers whose child was restrained by their coat being attached to their chair was that nothing of concern had happened. The carers said they were seen as too demanding in the standards they wanted for their child. Parents and carers were not aware of the issues between NHFT staff and the school.  The NHFT staff moving out of the school meant parents and carers had to take more time in attending appointments.  This made their already very demanding lives more difficult.  8.11. A parent did note the loss of Speech and Language Therapy (SALT) from the school in Autumn 2021 and put in a complaint to the SALT service about them not seeing her child. This parent believed SALT were told not to be honest with parents about what was happening and why they were no longer in school. Parents and carers felt that none of their concerns were properly dealt with. Harlow Academy leaders denied concerns.  The way a child was sent home, which the parent saw as an exclusion and the school said was not, was a good example of this.   One parent described how there were no protocols in place on use of restraint for her child. It was how the school managed her child’s behaviour, using a lap belt to keep her in her wheelchair.   25 | P a g e   When the parent asked about the use of physical restraint, the parent got woolly answers.  The school had no plan for her child to manage her behaviour and no protocols to use or training for staff caring for her child. Parents and carers gave examples of how their children’s distressed behaviour reflected their unhappiness about how they were cared for at school. Parents and carers gave an example of how the school did not properly monitor their child for seizures and mistook absences due to seizures for sleeping. The school did not recognise changes in children including their unhappiness and distress at how they were cared for. Raising concerns outside Harlow Academy.  8.12. Parents and carers spoke to the MASH or LADO or ICDS or the head of the virtual school for looked after children about their concerns, but they went round in circles. No action was taken. It seemed each issue was treated at an individual level rather than an overview being taken or the information from parents and carers pulled together. They were trying to get some structure to their complaints and concerns, but no one was listening to them as parents or carers or to the children.  Parents and carers said it was very difficult to find someone to complain to. They were not advised to go to the trustees of the Evolve Trust. They found it hard to find who was the Chair of the Evolve Trust. It was hard to see who to go to. They felt on their own but in time parents and carers did get together and realised many parents and carers had issues with the care and education of their children at Harlow Academy. Covid had kept people out of the school and was used as an excuse by the school to keep people out.  Parents formed a WhatsApp group on 9th November 2021.  The parent and carer Facebook group was infiltrated by Harlow Academy and parents and carers were told the school did not want any communication or comment about the school by parents on a Facebook group. Parents and carers had to be secretive about meeting up. It appears clear that leaders of the Evolve Trust and the Harlow Academy did not want parents and carers to meet each other. The regular coffee mornings that there had been stopped.    26 | P a g e   8.13. Parents and carers did complete questionnaires sent by Harlow Academy.  The response from the school to critical comments was the school leaders meeting the parents or carers making those comments and suggesting they move their child to another school or to home educate. This felt almost like a threat.    8.14. Parents and carers thought other agencies did know what was happening in Harlow Academy.  The agencies knew things were bad in September/October 2021. The children were ignored. Some of the children were clearly showing their unhappiness in their behaviour. A senior paediatrician told one parent that they used to go into the school and were then not allowed to go into the school. The specialist splint fitting company were also not allowed into the school.    8.15. Parents and carers experience was that the process to review EHCPs did not work well or help raise issues.  A carer gave an example of the school rewriting an EHCP to say the carer would not provide a personal assistant (PA) to give care to the child in school. The EHCP had said the carer would provide a PA to provide care for the child in school which was what the carer had agreed.  The carer believed that the school did not want the PA coming into school and seeing what was happening.6    8.16. Parents and carers saw an impact from so many social workers being part time and of staff movement so that the staff were not asking the right ‘why’ questions about what was happening for the children at school. Parents and carers felt that no one picked up on the issues at school whereas if the same issues had come up in their care of a child at home they would have been investigated as a safeguarding matter.     Regional Schools Commissioner  8.17. Parents and carers had had two meetings with the RSC after the January 2022 Ofsted inspection.  Parents and carers reported that the RSC had  6 A school can only propose changes to an EHCP. This change must be agreed or otherwise by the responsible local authority.  What parents described was outside the process for amendment of EHCPs.  27 | P a g e   apologised to them for what had happened when Fountaindale School became Harlow Academy and part of the Evolve Trust.  The RSC said that the correct process had been followed and information provided on Evolve Trust as requested but when considered in retrospect this had not provided the information the RSC needed. The RSC considered an informed judgement had been made based on the information gathered at the time.  In retrospect the RSC acknowledged that the matching process could have included more information about the special needs expertise a trust would require to meet the needs of the children at Fountaindale. The RSC assured parents and carers that the process has been improved following the experience of the transfer of Fountaindale School to Evolve Trust.  What needs to be different for the future?  8.18. Parents, carers and children need to be listened to. Parents, carers and children need to know where to go to raise complaints. The behavioural communication of children needs to be attended to and given the same weight as their verbal communication.  Parents need to be seen as the experts in their child and not experience, as they did at Harlow, the sense that any problem is their fault or that the school opinion is always deferred to, or the attitude is “we are the professionals so we know best”. There needs to be a linked system that can put all the pieces together when there are issues and concerns.   Final comments  8.19. Parents and carers said what a painful and distressing time this has been for them.  They feel guilty because they sent their children to school knowing it might not be safe.  They feel their children have regressed in some cases or not made the progress they should have in others. Parents and carers are concerned that their children may never be able to recover the ground lost in their development due to the poor education and care they received at Harlow Academy.  Parents and carers also recognised how much better the school is now and that their children are now happy in (the renamed) Fountaindale School.   28 | P a g e   9. Fountaindale school key events – 2017 to 31st March 2021.  9.1. The NCC report and information from parents show that Fountaindale School was in serious difficulties from 2018.  There were concerns about the relationships between the school and the NHFT services based at the school, issues about continuing care funding for individual children and expressions of safeguarding concerns for one child due to lack of supervision in school. In March 2019 NCC Governor services identified that the Fountaindale governing body was ineffective. In early July 2019 NCC instigated a leadership and management review which confirmed the serious concerns about the leadership and management of the school.  Following completion of this review NCC issued a warning notice on 18th July 2019. The warning notice had fifteen detailed recommendations. The areas of concern included lack of adequate supervision and safeguarding incidents not investigated or actioned in a timely or robust manner.  The warning notice was indicative of the depth of difficulties at the school.  NCC helped the school appoint an experienced executive head who worked in the school three days a week.   9.2. In January 2020 an educational psychologist raised concerns about the school’s engagement with termly monitoring visits and there was a growing shared concern about the effectiveness of the school including the care of individual children.  This suggests limited progress in improving the school.  9.3. Ofsted inspected the school in February 2020 and judged it inadequate for leadership and overall effectiveness as inadequate. Arrangements for safeguarding were not effective.   This led directly to the DfE making an academy order for the school to be converted to an academy with a sponsor identified by the RSC.  The DfE review notes that the RSC followed their usual process for identifying and vetting a potential academy sponsor in this case. It is normal for local authorities to be asked their views about trusts when the DfE is intervening, and in this case NCC were asked for their views. However, NCC had no formal role in the decision making.  There was no consultation with the school community including parents and carers.   29 | P a g e     9.4. Covid lockdown started in March 2020 which had a major impact on the school, the children attending and their parents and carers. The school remained open, but one impact was much reduced levels of contact with outside agencies.  9.5. By Autumn 2020 the Evolve Trust was actively being considered as the academy sponsor for the conversion of Fountaindale to an academy.  The Evolve Trust due diligence report of November 2020 noted that there were safeguarding issues, but these could be easily rectified using CPOMS and INVNTRY (recording systems for safeguarding incidents used by schools). The Evolve Trust due diligence report made no comment on the children’s needs and the match between their needs and the Evolve Trust’s capabilities except in respect of the curriculum Evolve could offer.  Evolve planned to offer a similar curriculum to that offered at their Beech Academy, a school for children with autistic spectrum conditions and other communication difficulties.   9.6. Extensive work was undertaken by NCC to improve the governance of the school and the safeguarding arrangements in the school. The review of the warning notice of 02/12/2020 showed a focus on policies, procedures and governance. These are all important, but the review did not look at the education and care practice within the school.   There does not appear to have been an exploration of why a school judged Outstanding in 2017 could decline so rapidly on the departure of the headteacher or the impact of a high turnover of staff after the Ofsted inspection of February 2020. The appointment of an experienced interim executive head when the headteacher appointed in 2018 left was helpful but there appeared to be no other changes made in the leadership team. There was no input from parents or carers to the warning notice review.  By the time of the review of the warning notice the decision had been made by the DfE that Fountaindale would become an academy.  This may have affected the local authority commitment to delving more deeply into the problems at the school and meant the local authority did not proceed to ensure the appointment of a permanent head teacher.  30 | P a g e    9.7. The CEO of Evolve Trust told the Evolve Trust AGM in January 2021 that Fountaindale School was outstanding 2 years before.  The CEO reported that the last inspection judged the school inadequate for safeguarding and leadership and management. All other judgements were reported as good, which was untrue.  The CEO said these issues could be quickly addressed with new systems and processes, a robust Single Central Record and new leadership. The CEO said governance issues could be resolved. These seem at best naïve statements. It suggests little careful evaluation, understanding and consideration of the needs of Fountaindale School and its pupils.    9.8. On 2nd March 2021 there was a virtual Ofsted monitoring visit which noted improved leadership and management in relation to safeguarding.  Ofsted recorded that between the March 2020 inspection and this visit 25 members of staff had left the school and a new assistant head, and 18 other members of staff joined.  The school had about 70 staff.               31 | P a g e   10. Harlow Academy key events – 1st April 2021 to 18th January 2022.  10.1. While there were clearly serious difficulties at Fountaindale school prior to its transfer to the Evolve Trust on 1st April 2021 these were not such that they led to partners or carers or NHFT staff or others working in and with the school raising serious concerns about the care and education of children at the school.  The tensions between the NHS staff based at the school and school leaders were present prior to the Evolve Trust taking responsibility for the school. Parents and carers were clear that there was a steep change in the quality of care and education at the school when the Evolve Trust took over- it declined.   10.2. From the review of Evolve Trust documents seen it is hard to see any focus on the very special needs of the children who attended Fountaindale School prior to the Evolve Trust taking over the school.  10.3. Parents’ experience of the change of responsibility for the school was of no consultation.  They were told little would change initially but rapidly in the summer term 2021 significant changes were made including to uniform and the curriculum.   The approach to uniform exemplifies what the parents and carers experienced as a lack of understanding of their children's needs e.g., the requirement for white shirts/blouses every day, rigid approach to footwear. After representations by parents and carers some changes were made but the impression the parents and carers had was that the needs of their children were not well understood.    10.4. Parents and carers also experienced the school as unwelcoming. To parents and carers, it appeared the school used Covid as a way to keep them out of the school.  10.5. The transfer to Evolve Trust did not lead to the appointment of a new head of school. An interim head of school was appointed who was an existing senior leader in the school.  Subsequently an executive head was appointed who was head of another Evolve School but who never took up the role. They  32 | P a g e   acted as a consultant to the school while continuing as principal of another Evolve School for children with special needs.  The executive head appointed by Fountaindale School and NCC when the warning notice was issued was to continue in role for the Summer Term 2021 to help with handover, but it is not clear whether this person was able to play any meaningful role in the running of the school after 1st April 2021.  Evolve Trust did not bring fresh day to day leadership to the school.  The leadership arrangements for Harlow Academy were confusing for parents and carers and partners.  10.6. In July 2021 the ESFA opened a concern case about the Evolve Trust. This was about governance and compliance at the trust following whistle blower allegations referred to the ESFA by Ofsted. The DfE review says that neither the Regional DfE Director nor ESFA were satisfied with the information provided about the culture of the Evolve Trust and questions remained around the behaviour of the CEO.  This information does not appear to have been shared with NCC or NHFT or Ofsted when serious concerns were being considered about Harlow Academy in September and October 2021.  10.7. By the summer of 2021 there were serious difficulties between the school leadership and NHFT staff based in the school e.g., NHFT staff accommodation in the school being changed without consultation or consideration of the ICT and other needs of NHFT staff.  Within the first four weeks of the start of the Autumn term there were a series of serious incidents.  These are described in the integrated chronology.  The integrated chronology which draws together the key events from the NCC and NHFT chronologies and those from the DfE and Ofsted shows the level of activity throughout September as these serious problems are reported and efforts made to deal with them. NCC and NHFT leaders met on 1st October 2021 and discussed concerns which included the safety of staffing levels, lack of supervision in class, closed school culture, NHFT staff feeling reprimanded for escalating safeguarding concerns, permission for entry denied due to DBS issues and education staff directed not to talk to NHFT staff on site. There is an intense level of activity between NCC and NHFT in early October in response to the mounting concerns. NHFT wrote to Ofsted to raise multiple  33 | P a g e   concerns.   The NCC service director spoke to a senior HMI at Ofsted.  Ofsted received a qualifying complaint through their complaint about a school (CAS) system from NHFT.  Ofsted considered this as a possible section 11a investigation. Ofsted’s powers under section 11a of the Education Act are to investigate concerns to determine the timing of the next inspection.  Ofsted’s response is that they were assessing concerns.   10.8. It is also evident that there were difficulties in other parts of the Evolve Trust including an inspection at the Evolve Trust’s primary school which the Evolve Trust challenged and the resignation of a newly appointed headteacher at the Trust’s secondary school.  Ofsted would have been aware of the inspection of another Evolve school where the outcome was being disputed. The outcome was Requires Improvement and unchanged by the challenge from Evolve Trust. This challenge delayed the publication of the report, but the intelligence of the issues found in this inspection was known to Ofsted.  The issues raised with the ESFA over the summer about the secondary school within the Evolve Trust were considered by the Evolve Board in October 2021. The Board were informed that the headteacher appointed to this school in summer 2021 resigned within four weeks of taking up post. This was a further indication of issues in the overall leadership and management capacity of the Evolve Trust.  10.9. On 14th October 2021 there was a strategic conversation between the RSC, and the CEO and Chair of the Evolve Trust.   There is no evidence from the DfE review document that issues about the conduct of the Trust were raised. The Trust provided assurances that performance at Harlow was improving and that the Trust would like an outstanding judgement or at least good with outstanding features at the next inspection.  It appears the RSC was unaware of the serious issues already raised with Ofsted, the concerns of the ESFA and the detailed knowledge of serious problems at Harlow held by NCC and NHFT.  It does not appear the RSC made any enquiries about how Harlow was functioning after becoming an academy apart from Evolve Trust staff and a Trustee.   34 | P a g e   10.10. During October there were more incidents and contact between the various parties seeking to progress the issues. There was no response from Ofsted other than to acknowledge the concerns and say they were dealing with them – Ofsted were undertaking a section 11a investigation but there was no clear timescale for this.  Ofsted received another CAS on 15th October about quality of leadership and management. This complaint was from a member of staff. Ofsted understood that the safeguarding concerns in this complaint were passed to the local authority by the complainant via the MASH. This was added to the existing section11a investigation but without any timescale given to decide on when the next inspection would be.   10.11. The escalation within NHFT and NCC led to the discussion with Ofsted and NHFT discussing the school with CQC.  As NHFT were in discussion with NCC and had escalated their concerns to Ofsted there was no role for CQC. Their role was to ensure NHFT were addressing the concerns which they were. NHFT also escalated their concerns to the Nottinghamshire Clinical Commissioning Group (CCG)7 who were their commissioners and had ultimate responsibility for the services delivered by NHFT. When these escalations did not lead to action such as an Ofsted inspection there was no additional action. This action could have included: • ensuring a chronology of incidents and reports of concern was developed • agreeing to approach the Evolve Trustees • making a formal complaint about the school to the ESFA and the RSC  • making direct approaches to the school from the most senior levels of NCC and NHFT • directing either MASH or LADO to undertake an investigation of concerns regardless of whether they thought the issues were strictly within their remit.   10.12. The concerns about the school were known at the most senior levels in NCC, NHFT and within Ofsted to senior regional staff. Essentially agencies were waiting for Ofsted to respond against a background of further incidents and  7 CCGs have now been replaced by Integrated Care Boards (ICBs)  35 | P a g e   expressions of concern.  Ofsted correctly identified in their review that the weeks they took to gather information which led to the inspection in January should not have prevented partners working to safeguard the children at the school during the Autumn 2021 term.  10.13. On 3rd November the ESFA received its first safeguarding case in respect of Harlow. An anonymous whistle blower alleges staff shortages, rapid departures of staff and pupils consequently left at risk of harm.  The complaint was received from Ofsted. ESFA did a desk review and Evolve Trust responded saying reduced staff would not impact on the health and safety of children as the school was over staffed.  It is worth noting that Fountaindale transferred a surplus to Evolve Trust of £445K which suggests there were ample resources to employ the staff needed. The case was closed.  The DfE chronology does not indicate that the ESFA made any cross checks with Ofsted, the RSC, NCC or NHFT in respect of the complaint or the response from the Evolve Trust.   10.14. In November there was an intense period of communication at the start of the month between agencies and the school. There was further communication with Ofsted including an updating call on 4th November, which communicated the continuing concerns of NHFT staff about Harlow Academy. Ofsted added this information to their existing section 11a investigation.  The termly meeting between the RSC, Director of Children’s Services for NCC and the NCC service director for education was held on 4th November 2021. Harlow was discussed.  The RSC was not aware of further concerns from Ofsted but was aware of what were held to be vexatious complaints about Evolve Trust.   10.15. On 5th November the NCC service director for education after meeting senior NCC staff recommended a no notice inspection to Ofsted.   10.16. In November there were more incidents and relationships between NHFT staff and school leaders deteriorate further.    The ICDS service manager, and NCC group manager for education, access and inclusion did meet with the school to discuss the separate cases of the children where concerns  36 | P a g e   were raised by the NHFT colleagues. On an individual level the CEO and the acting Headteacher were always able to provide updates about the actions they had taken. The school were however always aware that the ICDS manager and NCC education access manager were visiting, and class groups visited were therefore prepared for their arrival. When the NCC education access manager met with the acting Head and CEO on 10th November they agreed to commission a full safeguarding Audit to be led jointly by the Safeguarding Children in Education Officer (SCIEO) and the Occupational Therapy Service Manager who had a health background.   10.17. This planned safeguarding review did not address the issues of concern as it was essentially about policies and procedures not about care practice.   This review did not proceed as the SCIEO realised as they started to prepare for the review that it would not address the serious issues raised about the safeguarding and care of children at the school. This information was shared with Ofsted at the annual Ofsted and NCC engagement meeting on 10th December 2021. Senior NCC staff identified that the separate safeguarding procedures of the NHFT and the school were not allowing concerns to be followed up in a timely way.  When they were followed up within school, the health colleagues had no way of knowing if concerns had actually been addressed.  10.18. As an academy school the CEO of the Evolve Trust had to agree the terms of reference of the review.  The chronologies show there was a lack of clarity in early November between NCC and NHFT about what exactly the review would focus on.  The chronologies reflect different understandings of what the review would cover and who would undertake the review.  10.19. In order to ensure that the children were safe and educated both the NHFT and the education staff needed to find a way to effectively work together and to align their ways of working. The NCC group manager for education, access and inclusion working with a Senior Educational Psychologist worked to try to align safeguarding process and practice. To achieve this, they put the NHFT Leaders who had brought the complaints to the Council into a  37 | P a g e   meeting with the CEO and Headteacher on 2nd December 2021.  This meeting set out in some detail what the working relationship between health and education colleagues at Harlow Academy would look like if it was working well. The meeting agreed: • Leaders to meet again to discuss a Charter/Memorandum of Understanding on 20th January at 1pm – NCC and OT in ICDS to facilitate this. • Following this, leaders to have similar discussions with their staff.  • Explore joint safeguarding training in the future e.g., case studies, CPOMS linking to IR3 systems, to share NHFT Think Family Level 3 Safeguarding information. This work is indicative of the disparate efforts of NCC staff to try to address the issues of concern but without an overall plan or inter-agency leadership of how the serious issues at the school would be best addressed. 10.20. The planned safeguarding review also appears, from the Ofsted chronology, to be seen as something that might help resolve the issues between NHFT and Evolve Trust staff when its scope could never have done this.  The planned review was never focused on care practice and the safeguarding concerns raised about individual children. There was no indication that Ofsted asked for any clarity about what the review would cover, who it would be conducted by and whether it was focused on the issues of most concern.  Ofsted believe they did have a clear picture of the scope of the review. They had confidence in the LA’s ability to undertake such a review.  Ofsted thought that the CEO of the Evolve Trust welcomed the review. This was not the perception of the staff who engaged with the Evolve Trust CEO.  Ofsted’s view was that the local authority and the leadership of the school should have the opportunity to audit the safeguarding arrangements and to address the concerns raised before taking the ultimate step of initiating an inspection.  10.21. Ofsted had further intelligence about Harlow Academy from a parent when they conducted an area SEND inspection in Nottingham City in early November and on 10th November received complaints from three parents which covered staffing issues, use of staff from other Evolve schools,  38 | P a g e   concerns about leadership and management, wellbeing of pupils, school not sharing risk assessment and students sent home with soiled pads.  There was no evidence that Ofsted shared these complaints with NCC.  10.22. There was evidence that NHFT staff were getting increasingly distressed by what they observed and experienced in the school, for example making a referral to the NSPCC helpline which was not an appropriate action for NHFT staff. There were efforts to mediate between the school leadership and NHFT staff but there was no indication the school leaders grasped the NHFT staff viewpoint or recognised the experiences they or parents and carers were describing.  This mediation led to a sense for some agencies, notably Ofsted, that some of the issues were primarily concerned with inter-professional relationships and not quality of care and education. NHFT staff withdrew from the school in November and worked from another base.  The mediation effort and how it was portrayed within the Ofsted chronology seemed to obscure the issues as it moved the focus onto the relationships between NHFT and school staff rather than the care of the children.  10.23. Incidents of poor care at the school were being referred into MASH, LADO and ICDS but mostly these were seen as not appropriate for the service to deal with or outside their remit. For example, the LADO did not see there were examples of staff harming children which would fit their remit. MASH did not see the threshold of significant harm had been met for a s47 child protection enquiry.  ICDS has a focus on whether the children’s educational needs as set out in their EHCPs are being met. The ICDS workers have caseloads of 100s which means it is not equipped to offer a depth of response to individual child concerns.  10.24. People with concerns about the school, whether parents or partner agencies, were unclear as to the process they should follow. There was no clarity about how to respond to standards of care concerns in an education setting. The incidents were not brought together to provide a single view of children's experiences at the school.  By the end of November nothing had changed. There was no indication Ofsted were going to inspect though the school  39 | P a g e   thought they might be inspected. No other agency seemed to feel empowered to act for example by NCC using its broader powers to safeguard children or through its responsibilities for commissioning services for children with EHCPs or the ESFA and DfE regional team as the regulator for academies.  10.25. On 19th November there was a further discussion between NCC and Ofsted. Information was shared that NHFT staff were moving out of the school.  The initial recommendation from Ofsted’s 11a investigation was for a section 8 no formal designation inspection which means one outside the normal cycle of inspection.  The discussion appears to have been about whether an inspection was warranted in what appeared to be a dispute between members of staff at the school and the NHFT staff. Ofsted was considering whether the matter was best left to NCC and decided to keep in touch with NCC.  The focus of the issues seemed to have been lost in this conversation, with Ofsted appearing not to give weight to the findings of its own investigation. Following this discussion Ofsted gave weight to the safeguarding review which Ofsted understood would consider all aspects of the culture and statutory compliance of the school with safeguarding requirements. Ofsted seems to have had a different understanding of the review and of its limitations. Ofsted also understood the Trust were enthusiastic to engage with the review which was not the perception of those dealing with the Trust day-to-day.  There was a view that an important component of the issues was about the breakdown of relationships between NHFT staff and Harlow staff.  This approach was reflected in the Ofsted record of further conversations between NCC and Ofsted in late November and early December. Reassurance was taken from the safeguarding review being planned which was not warranted.   10.26. On 1st December the SCIEO and LADO discussed calling a complex strategy meeting in relation to concerns about individual children. The LADO thought the criteria were not met.  This discussion reflected a search for a process to manage the complaints and concerns about care of children but without either finding a process or at least agreeing to collate all the information  40 | P a g e   together to ensure there was an overview of all the issues and then considering what might be a process to deal with what is found.   10.27. In December the volume of parent and carer complaints was growing including complaints to Ofsted and parents and carers were beginning to organise to raise their concerns and express the view that their children were not safe at the school. Some parents and carers were complaining to anyone they thought might listen e.g., Ofsted, MP, local councillor, NHFT staff.  10.28. On 10th December 2021 there was the annual Ofsted and NCC engagement meeting.  Harlow was discussed NCC reported that they were not able to get to the root and branch causes of the issues due to the limited remit of the safeguarding review permitted by the Evolve CEO. NCC and Ofsted agreed to discuss the school after Christmas.  It does not appear that discussing the concerns with the RSC or ESFA who were accountable for the school and academy trust was considered. NCC had no authority over the school or academy trust. The Evolve Trust Board meeting in December makes no reference to any of the difficulties at Harlow other than there is no drive to improve from within the school despite  the fact the CEO had commissioned a Safeguarding Review, a  surprising omission.  10.29. In January there were more serious incidents about poor care of children at the school and further complaints to Ofsted.  On 10th January 2022 Ofsted spoke to NCC and agreed there were further concerns about the school.  NCC records suggest Ofsted agreed the school would be inspected. Harlow would be inspected the following week.  On 18th January 2022 Ofsted inspected finding extensive safeguarding failures and the school was temporarily closed. The Evolve Trust Board met on 25th January 2022 and reported they had no indication that special measures was a possible outcome of an inspection at Harlow Academy.     41 | P a g e   11. Analysis  11.1. The chronologies and reports from NCC and NHFT present a shocking picture of the decline of the quality of care of children at Harlow Academy to a point where the school was not safe for the children.  Almost certainly the quality of their education also declined but that is not the main focus of this review.   11.2. There is considerable hurt and anger in the parent and carer community about what has happened. Parents and carers feel guilt that they sent their children into a school which was unsafe.  Parents and carers have reported serious impacts on their children’s health and development some of which may be remediated but for others they may never catch up what they have lost through poor care and education at Harlow Academy.  Examples of what has been lost include loss of communication skills, loss of movement and flexibility of limbs, deterioration in children’s behaviour which is now much harder to change and loss of confidence in being in a school environment. Parents and carers do not feel there has been sufficient accountability.  11.3. Fountaindale school was in substantial difficulties from 2018.  The warning notice issued in July 2019 was extensive and covered many critical aspects of the running of the school including the management of safeguarding and the overall governance of the school.  The local authority appointed an executive head to take charge of the school, working three days a week. In February 2020 the Ofsted inspection judged the school inadequate.  The primary issues were safeguarding and leadership and management. This led to the DfE issuing an academy order.  While work continued to improve the school and address the many issues set out in the warning notice it meant NCC did not proceed to appoint permanent new leadership for the school.  11.4. The warning notice was reviewed in December 2020 and lifted because of the progress made.  The Ofsted monitoring visit of February 2021 reflected the progress made under the warning notice. However, the review of the  42 | P a g e   warning notice did not appear to look at care practice in the school in any depth.   11.5. The conversion to academy status as part of the Evolve Trust did not require any consultation with NCC or parents and carers or staff. The Evolve Trust was assessed as a suitable academy sponsor by the RSC.  The RSC followed their usual procedure, but this was not sufficiently rigorous nor did it have sufficient focus on what was required to provide the leadership and management for a school providing care and education for children with profound and multiple disabilities which had serious difficulties.  11.6. The DfE review notes that the regional schools team adhered to established processes for sponsor matching and subsequent actions to enable conversion.  The DfE report says there is scope to further refine the matching process including seeking views from SEND advisers in the case of special schools.   11.7. Parents and carers reported that when they met the RSC, she apologised for the way the transfer had proceeded and acknowledged that the process had been flawed and that there were ways in which the process could be improved.  11.8. A review of the Evolve Trust consideration of the decision to take on Fountaindale suggests very limited consideration of what was required to ensure the future success of the school. Most of the discussion was of financial and property matters.  The evidence suggests very limited understanding or thought about the children’s needs or of consideration of why this school was in difficulties.  There was a naïve or possibly arrogant view that the Evolve Trust had the skills and capacity to provide a high standard of care and education to the children at Harlow Academy.  11.9. On conversion to an academy and now named Harlow Academy the Evolve Trust made a number of significant changes to curriculum and uniform without effort to explain the changes to the parent and carer school  43 | P a g e   community.  The Evolve Trust did not appoint new leadership for the school. The intention was for the executive head in place at the point of conversion to continue to help with the handover, but it is evident this person was not able to fulfil this important role following the conversion of Fountaindale to Harlow Academy.    A senior member of the existing leadership team became acting head and in September 2021 the principal of another Evolve Special School was appointed executive head.  This executive head never took up the role and was not the named head at the time of the January 2022 inspection.  This meant that from the departure of the headteacher in 2018 Fountaindale and then Harlow Academy had no permanent headteacher but a succession of executive heads and a senior school leader in an acting head role.  This was fundamentally unsatisfactory for a school requiring a sustained period of good leadership to improve standards of care and education and develop relationships of trust and confidence with parents, carers, children and partners.  11.10. It is understandable why NCC and the Fountaindale Governing body did not proceed with a permanent head teacher appointment given the school was becoming an academy. It was a serious weakness that the Evolve Trust failed to make a headteacher appointment and provide the school with the leadership it needed.  11.11. Once the school was Harlow Academy there was further decline in the standards of care and education at the school as reported by parents and carers and NHFT staff.  The relationships between NHFT staff based in the school and the Evolve Trust leadership deteriorated further over the summer of 2021. In September 2021 there were a number of serious incidents of poor care of children including unauthorised and unsafe use of restraints.  By the beginning of October 2021, the multiple concerns about the school had been escalated to senior levels in NCC, NHFT, Ofsted and the DfE RSC. There was discussion of a no notice Ofsted inspection.  However, no action was taken and without the Ofsted inspection there seemed to be no alternative approach developed to address the wide range of issues of concern about the care of children at the school and the management of the school.   44 | P a g e   Looking at the evidence available to Ofsted or that could easily have been available in early October 2021 it is hard to understand why an inspection did not take place then.  It is also clear that the other agencies led by NCC should have initiated their own safeguarding actions at this time regardless of what Ofsted was going to do.  11.12. Concerns about children were brought to the attention of Ofsted and the LADO, MASH and ICDS within NCC.   Within NCC there seemed no clear route as to how to deal with the individual issues which did not fit the criteria used for either a s47 child protection enquiry or an enquiry about the conduct of staff.  If the LADO had taken a broader view of their remit they could have acted. Unlike for adult services there was no established process for considering institutional poor care.  That none of the senior managers developed such a process to deal with the situation at Harlow Academy whether as a whole school or a process to systematically address the numerous individual child concerns in early October 2021 was a significant gap.  11.13. The process could have been to mirror the adult concern process about institutional care or to treat what was happening as a critical incident and put in place a process to deal with the particular set of circumstances presented at Harlow Academy.    11.14. The pattern of serious concerns, intense communication between NCC and NHFT primarily, but with communication with Ofsted and the RSC continued through October and November 2021.  Efforts were made to intervene including through communication with the CEO of the Evolve Trust, a planned safeguarding review and mediation between NHFT staff and the school.  None of this made any difference or addressed the wide range of concerns about care of children at the school raised by NHFT staff and parents and carers.  Indeed, in October and November the proposed safeguarding review became a diversion and appeared to be given far more weight as a reason to delay inspection than it warranted. Ofsted report they were clear about the scope of the review and the ability of the local authority  45 | P a g e   to conduct the review. Ofsted’s understanding of the review and its potential was much more positive than that of NCC. Ofsted’s understanding, they saw as a positive reason not to undertake an inspection at this point.   11.15. There was no attempt made to bring the concerns to the attention of the Evolve Trustees. It is evident from review of the minutes of Evolve Trust meetings after the Ofsted inspection in January 2022 that the Evolve Trustees had no idea of the difficulties in the school.  This reflects both their lack of probing as to what was happening in the school they had recently taken responsibility for, and that no one sought to speak to them as the accountable body about the many concerns about the care of children at the school.  11.16. The accountability framework for schools is complex as outlined in section 6. It is designed so that Academy Trusts have a great deal of autonomy and that local authorities have no authority in respect of academy schools. However local authorities do have other powers and responsibilities as outlined in section 6.  These responsibilities are substantial for children with disabilities and special educational needs. In this case NCC did not seem to consider how it could use the power it has both formal and informal to intervene more vigorously on behalf of the children attending Harlow Academy all of whom had EHCPs and all of whom were children in need within the meaning of that term in the Children Act 1989.  11.17. One route would have been for NCC to act explicitly as an advocate for the children attending Harlow Academy and their parents and carers. No one talked to the parents, carers and children to gather their perspectives and experience.  11.18. Ofsted could have inspected in October 2021, and it is unclear why they waited. They seem to have been hoping that matters would improve given Ofsted knew NCC and NHFT were aware of the various issues and trying to address them.   46 | P a g e   11.19. The RSC and ESFA as parts of the DfE were responsible for regulating the Evolve Trust as the body responsible for Harlow Academy.  The ESFA is remote and as its name suggests primarily concerned with financial matters and whether an academy trust has the required policies and procedures in place. The ESFA responded to complaints by seeking assurance from the organisation complained about that they have addressed the issues raised.  It worked with the RSC, the LA and Ofsted to gain assurances that suitable processes and procedures were in place at the Evolve Trust. It is hard to see how the ESFA was equipped to respond to the variety of concerns raised about Harlow unless they had been presented to the ESFA in a very clear and organised way, for example through a chronology of the incidents presented jointly by NCC and NHFT.  11.20. The RSC chose the Evolve Trust as a suitable multi-academy Trust to take on Fountaindale and improve it. In retrospect it is clear that the RSC’s enquiries about the Evolve Trust’s suitability were inadequate and the RSC has acknowledged this and has stated that they have strengthened their assurance reprocesses for special schools converting to academies and the choice of academy sponsor.  11.21. The decline of standards of care and education at Fountaindale and Harlow Academy were a consequence of a lengthy sequence of events.  There were many opportunities where a different course could have been taken that would have made a difference e.g. appointment of a capable permanent headteacher, a more enquiring approach to the review of the warning notice, more careful selection of an academy sponsor, Evolve appointing a capable headteacher, Ofsted inspecting in October 2021, NCC and NHFT working with other partners putting in place a formal process to deal with and address the many incidents and concerns raised about care of children at Harlow Academy, an active approach to engaging parents and carers and seeking their views and experience of the school.    47 | P a g e   12. Responses to key lines of enquiry form the terms of reference.  12.1. When concerns about the care of the children were raised what was the quality of response from safeguarding partners? Identify what escalation was undertaken by each agency, how effectively these escalations were responded to and any lessons for the partnership about the escalation procedures or practice. Include exploration of the circumstances of the health team no longer being on site.     12.2. Given the outcome from the Ofsted inspection in January 2022 the quality of the safeguarding response from partners was inadequate because it was ineffective. The response did not achieve any change or intervention at an earlier point for example early October 2021.   Individual concerns were referred to MASH, LADO and ICDS but all struggled to fit the concerns into a policy and procedural framework they felt enabled them to act.  In a narrow sense some of their judgements but not all were correct in relation to the normal criteria they would use for accepting safeguarding referrals.  The information sharing was inconsistent which was a key point that MASH identified during this time. MASH needed more clarity as to the interface with LADO.  12.3. The chronology shows there was escalation from July/August 2021 from NHFT services and by the end of October significant escalation within NHFT and NCC to the highest levels, to the Nottinghamshire CCG8 and from both organisations to Ofsted.  The issue was not about escalation, but that escalation failed to lead to effective action. The only gap in escalation was that there seemed no consideration of escalating concerns to the Evolve Trustees. There was no effective response from Ofsted given the variety of information available to Ofsted from early October. Its own section11a investigation took some time and its conclusion that a section 8 inspection should be initiated was not followed. The lesson for the partnership is to  8 The responsibilities of Nottinghamshire CCG are now undertaken by the Nottinghamshire Integrated Care Board (ICB)  48 | P a g e   consider how to deal with safeguarding and quality of care issues which do not “fit” standard policy and procedures which are mostly designed for abuse or neglect of children by their carers or professionals which did not fit this situation.  The position is much clearer for adults where there is a clear process to deal with concerns about quality-of-care issues.  12.4. In this case once the serious concerns were escalated to senior leaders at the end of September and early October 2021 it was for them to establish a process to deal with the multiple concerns which were known.  No such process was established.  No one was identified to provide leadership to the partnership on the multiplicity of issues being raised about the care of children and the functioning of an academy school over which the local authority had no direct authority or influence. The Governance arrangements for academy schools were not well understood including the roles that their trustees and the ESFA and the RSC play as parts of the DfE, in governance by those working with Harlow Academy on a day-to-day basis. The concerns raised about Harlow Academy and the care of the children at the academy needed the kind of approach taken to a critical incident e.g., setting up a command and information structure to take action. This was a critical incident.  This would have led to a better understanding and overview of the information available. The information about the various incidents was not collated alongside other intelligence.  No one considered gathering parent and carer views or how the children's experience might be captured. There was no consideration of escalating the issues to the Nottinghamshire Safeguarding Children Partnership as a means to provide leadership and oversight. There was no formal consideration of how NCC could discharge their safeguarding and child in need responsibilities to the children attending Harlow Academy through acting on behalf of the children and their parents and carers.  12.5. There was no robust engagement with Evolve by the most senior leaders in NCC or NHFT either at CEO or Trust Director level.  Clearer leadership might have enabled someone to take on this role.   49 | P a g e   12.6. Either NHFT or NCC could have led such a process but given the responsibilities for all children held by NCC it would have been appropriate for the DCS to take the leadership role.  It is possible NCC felt disempowered to take such a role by the school being an academy, and therefore the local authority no longer having a role in the school.   However, NCC had other statutory responsibilities for the children at Harlow that could have enabled action.  12.7. The NHFT team no longer being on site came late in the Autumn 2021 term and was significant for what it said about the complete breakdown of relationships between the school and NHFT staff.  The chronology shows the NHFT team as one of the primary sources of concerns about children's care at the school.  They were in an impossible position.  The absence of a structure to manage the multiple concerns meant the experience of NHFT staff was not well captured in a way that might inform intervention.  12.8. Did the children’s disabilities impact on how partners understood their experiences at Harlow? Were they sufficiently considered in the response of agencies to the concerns being raised? Did those responding to the concerns have the correct expertise or draw on support from those who did?   12.9. The NHFT Teams and ICDS had a very good view of the children's needs. The experience of the children was not sufficiently considered and neither their parents and carers nor the children were asked. The ICDS responded to information about the experience of children and the parents' views but on a child specific basis e.g., convening reviews, supporting changes of school. They did not seem to think systemically and take all opportunities to gather information about the school.  Some of the parents’ and carers’ information was not known to ICDS as is clear from the local authority chronology. It is evident in retrospect from issues raised by parents and carers and when all the incidents of concern about care are read together that numbers of the children were very directly affected by the poor care they received.  This included clear behavioural signals of their distress which parents and carers picked up on but the agencies did not.   50 | P a g e    12.10. It is worth considering whether part of the difficulty was that the referrals about the children at Harlow Academy were responded to in the same way as concerns raised in a mainstream academy. However, the responsibilities of NCC and NHFT to these children were different given the nature of their needs and therefore a different and much more proactive approach should have been considered e.g., all the children were Children in Need as defined by section 17 of the Children Act 1989.  12.11. The correct expertise was available but was not used well enough.  It does not seem that anyone sought to gather parent and carer and children's views or communication about experience together.  Key partnership learning is that there is always a need to gather parent, carer, and children's views when concerns about care are raised.  In this case many of the children had been at Fountaindale School and then Harlow Academy for many years. They and their parents and carers were experts in their experience of the school over the years.  Parents and carers are also experts in their children’s needs and their voices raised about needs not being met seemed not to be heard.  12.12. What discussions took place by either individual practitioners or their agencies with senior staff at the school and Evolve, as the responsible Trust, about their safeguarding or other concerns? This could have been about specific incidents or more broadly about the culture, practice or staffing at the school?  12.13. The chronology shows there were many discussions by NHFT practitioners and their line managers with Harlow Academy leaders.  The response to these discussions was nearly always defensive on the part of the school.  The discussions were primarily about specific incidents. There was little if any wider discussion about school culture. There was a focus on the quality of the relationships between the professionals at some of these meetings and how these could improve, and that detracted from focussing on the experiences of the children and that standards of care needed to improve. This would have been very difficult for individual practitioners to discuss. It would have needed  51 | P a g e   a systematic approach to gathering all the information and collating it in a form that could have been used for discussion with senior school staff.  12.14. There were also discussions between the NCC group manager for education, access and inclusion and ICDS service manager and Harlow senior staff.  These were directed at trying to find ways forward and improve relationships between NHFT staff and Harlow staff. These discussions could have been more effective if they had been placed within a plan of action developed on a multiagency basis to address the concerns at Harlow Academy and led by NCC and NHFT.  12.15. The school framed much of the discussion as the NHFT staff being over critical or stirring things with school staff. This made any more measured discussion very difficult.  12.16. There were no discussions with the Evolve Trust Directors. There were no more structured discussions between senior leaders of NHFT and NCC and the Evolve CEO. It is surprising the Evolve CEO was not called in to meet the DCS, Service Director for education and NHFT Head of Nursing. This was a gap.            52 | P a g e   13. Recommendations  13.1. The recommendations have been developed with the review panel to ensure they reflect a consensus of views from a variety of agencies who have been closely involved in the review.    13.2. There are a number of recommendations from the DfE review which reflect learning from this review and have been implemented or are under consideration. These are: • Responsibility for oversight and monitoring of safeguarding within academy schools has moved from the ESFA to the Regional Directors in Regions Group of the DfE. • The DfE review identified there is scope to further refine the sponsor matching process including considering additional views form SEND advisers in the case of special schools and promoting Trust Boards awareness of the department’s due diligence guidance to inform their decision making. • The DfE review identified that it may be appropriate to require an external safeguarding review following conversion of schools that become inadequate due to safeguarding issues.  • The transfer for safeguarding function within the DfE from ESFA to Regions Group and a subsequent review of the safeguarding function which is currently underway will consider how best to ensure improved communication between relevant agencies. • The recommendations are reflected in the Academies Regulatory and Commissioning Review.  13.3. Suggested recommendations for NSCP: • The NSCP should develop a policy and procedure for situations of concerns about quality in settings where care is being provided to children.  This might helpfully mirror as far as is appropriate the adult procedure for concerns about quality of care in an adult care setting.  53 | P a g e   • NSCP to consider the circumstances where concerns about children’s care requires a structured multi-agency response led by senior staff in the partnership and which can give direction and authority to the work of the services working with individual children.  One option is that the NSCP should develop a procedure akin to the existing organised and complex abuse procedure, which puts the same clear framework around responding to institutional abuse and specifically requires the formation of a strategic management group following a multi-agency strategy meeting. • The NSC partnership should look at how intelligence could be routinely gathered and analysed across agencies from enquiries, complaints and referrals that might give early warning of concerns about organisations failing to effectively safeguard children. This should form part of any new safeguarding procedure on investigating potentially failing organisations. • All NSC partnership staff working with children should be aware of how to raise concerns about the quality of children’s care including how they can use their own or other agencies whistle blowing process. • The NSC Partnership should agree a document for parents and carers that outlines how to raise concerns in relation to children with disabilities and what to do if these concerns are not responded to. This should include concerns about a child’s school. • NSC Partnership staff with particular safeguarding responsibilities such as those working in MASH, LADO, named safeguarding professionals within NHS services, Police working within public protection teams should always consider what other routes they should explore when a referral about a child or about the behaviour of an adult does not meet the particular safeguarding criteria they use i.e. if there is not significant harm is there institutional harm, if not significant harm is this still a matter that requires action and a route needs to be found to act. 13.4 Ofsted are conducting a learning review and intend to use this review to      inform their thinking. This review will: 13.4.1  Consider how Ofsted works with partners to identify systemic   weaknesses quickly.  54 | P a g e   13.4.2  Use learning to inform our response to the DfEs consultation on    Trust regulation. 13.4.3  Consider the impact of Covid restrictions on our decision making    – would Ofsted have known more now, and would others have    been better able to advise us with systems running in more     normal times? 13.5 Given the findings of this review the NSCP should write to Ofsted highlighting  the findings from this review and suggesting Ofsted consider whether there is  any need to change how they respond to concerns about a school outside the  normal inspection cycle.    55 | P a g e   Appendix 1 Integrated Chronology Summary Chronology for Fountaindale School and Harlow Academy March 2017 to January 2022 Date Event Comment March 2017 Ofsted Inspection. School judged outstanding. Head retired not long after this inspection. At the reviewer’s meeting with parents and carers some said that in their view the school was never “outstanding”. October 2018 Partnership focus group.  Concerns of partners about the school. Relationship to health services of HR and finance at the school. Continuing care funding issues. Head’s view was that the school needed more resources.   November 2018 Mediation meeting.  ICDS mediating on whether child’s needs met at school.  December 2018 Family assessment for a child says there are safeguarding concerns within the school including lack of supervision Social care made recommendations as to how these could be addressed – staffing levels and improved practice. 09/01/19  Further concerns about a child’s care at school raised by parents Governors investigate complaint. 20/02/19 Parents complain to Ofsted. Concerns about leadership and management and wellbeing of pupil. Specific concerns about care of this child. Early indications of issues in quality of care in the school. 16/03/2019 Professionals meeting about the complaints and how handled.  Health staff identified two other children who were at risk and were considering referral to LADO.  The SCIE officer thought there should be a strategy meeting or special circumstances meeting.  Service manager disagreed. Deemed threshold not met for complex strategy meeting. Opportunity missed for wider discussion of concerns about care at the school.  First example of ‘confusion’ over how to proceed and of the complexity of thresholds for action between concerns about care standards and significant harm the threshold for as47 enquiry. 19/03/2019 Partnership focus group.  Concerns raised regarding working relationships between health staff working in the school and school staff.  Concerns about school cancelling meetings and budgetary concerns. Evidence that there were problems in relationships between health and school staff long before Evolve became responsible for the school. Reviewer’s meeting with parents and carers evidenced their view that there  56 | P a g e   were problems in the school before Evolve became responsible for the school. 26/03/2019 Governor services identify that the governing body is ineffective, and progress not being made with improvement areas Suggest systemic issues identified by the local authority in the school April 2019 onwards Partnership between the LA and school not effective. Head talking about leaving. Concerns about head and staff absences e.g., Governors supporting staff with feeding children. Difficulties are serious. 07/05/2019 Planning Alternative Tomorrows with Hope (PATH) event.  Staff feeling under pressure, low morale, not feeling valued or listened to. While the issues identified at this event contributed to the warning notice being given the opportunity to delve further into what was happening was not taken. 10/05/2019 Concerns raised in partnership forum discussed with Chair of Governors, head teacher, support to schools service and HR. These issues led to the warning notice. What else could have been done? 05/06/2019 TM for ICDS wrote to chair of governors about safeguarding concerns and heads response to them.   12/06/2019 Head sent home.    21/06/2019 Trust broken down between governors and LA May and June show depth of issues in the leadership and management of the school including how safeguarding concerns were addressed. 04 to 07/072019  NCC instigate a leadership and management review. Confirms serious concerns  18/07/2019 NCC issues warning notice to the school. Includes lack of adequate adult supervision, safeguarding incidents not investigated or actioned in a timely or robust manner. Notice has fifteen recommendations. It is detailed and extensive Evidence of the depth of difficulties in the school by July 2019 including poor relationships with health services that were impacting on the schools.  Executive Head named. Governing body strengthened by appointment of LA governors.  57 | P a g e   27/09/2019 Number of practice concerns investigated by the school including a child sustaining a fracture when hoisted into a bathroom.  06/12/2019 Staff member dismissed in their probationary period because of concerns about practice.  Failing to use postural support equipment correctly, failure to follow correct moving and handling techniques, leaving a student unsupervised on a plinth, using unnecessary force to reposition a child’s leg. The concerns are similar to those raised from Autumn 2021. Suggests there were wider systemic issues than suggested by dismissal of one staff member e.g., recruitment, induction, training of new staff.   21/01/20 Parents withdraw child from school as not getting the right level of support.  Lack of 1 to 1 support, left in soiled pads, TAs not skilled in using suctions.  School said there was insufficient funding for 1 to 1 support throughout the day. Similar concerns to those raised in Autumn 2021 about children at Harlow. 29/01/20 Educational psychologist raises concerns about school's engagement with termly monitoring visits.   Growing shared concern about the effectiveness of the school including care of individual children. This is over a term after the warning notice was issued.  Suggests issues are deep seated and not shifting under new leadership. 4 & 5/02/2020 Ofsted inspection. School found inadequate for leadership and overall effectiveness is inadequate. Arrangements for safeguarding not effective. Staff not appropriately trained to meet pupils needs. The school was rated good for behaviour and attitudes and personal development, requires improvement for quality of education, sixth form provision and early years provision. The report contains positive sections about the school and the tone is not overly critical.  The areas for improvement focus on safeguarding, staff training and paperwork to meet pupils care needs, governance, curriculum and careers advice and guidance. March 2020 Covid lockdown.   School remains open but level of contact with outside agencies very significantly reduced.  There is very little in the chronology during the first lockdown.   25/09/2020 Parental concerns about supervision were brought to the attention of the LADO.   Not clear any effective response from school or LADO. The school seemed to be placing responsibility on individual staff members and it is unclear if they are considering the full picture of the impact  58 | P a g e   of their staffing levels. The LADO could have shared this information with education colleagues/SCIEO. There was no apparent change in school capacity to respond to parental concerns.  17/11/2020 LADO referral – lack of supervision and use of the wrong chair leading to child having a head injury. Delays in internal follow up. Education colleagues not informed. The LADO should have shared this information with education colleagues/SCIEO given 2 similar referrals in 2 months 17/11/2020 Annual self-audit – report provides evidence of improvement in processes and understanding of responsibilities. Was there any evidence that standards of care had improved and were adequate? Nov 2020 Evolve Trust due diligence for taking over Fountaindale.  Notes that there are safeguarding issues to be rectified which can be done using CPOMs and INVNTRY suggesting recording is the main issue rather than practice. No comment on the children’s needs and the match between the children’s needs and Evolve Trust’s capability except in respect of the curriculum Evolve can offer. Evolve offer a new curriculum similar to that offered at the Beech Academy a special school for children with autistic spectrum conditions and other communication difficulties.   Evolve’s due diligence seemed very limited in terms of understanding what would be involved in meeting the needs for care and education of the children at Fountaindale School. 02/12/2020 Warning notice review – Evidence that the Governing body had fully addressed the concerns and was on track for requires improvement. Did this review look at care standards and practice? Were there any conversations with parents and children or observation of children? 14/12/2020 Warning notice lifted as school had addressed all the issues in the warning notice.   The focus appears to be on documentation and policies and not on the quality of the care and education in the school. Not clear the review looked at this at all. 19/01/2021 Evolve AGM. Note on Evolve taking on Fountaindale.  CEO reported school outstanding 2 years before.  Last inspection judged inadequate for safeguarding and leadership and management. All other judgements This seems an extraordinarily naive view of Fountaindale School and what would  59 | P a g e   reported as good.  This was untrue, Behaviour and attitudes and personal development were judged good.  The quality of education, early years provision and sixth form provision were judged requires improvement.  The Evolve CEO said these issues could be quickly addressed with new systems and processes, a robust single Central Record and new leadership. Governance issues could be resolved. be required from Evolve. Did they make any inquiries about the school? 02/03/2021 Virtual and in person Ofsted visit. Noted improved leadership and management in relation to safeguarding.  Between the Ofsted inspection of 4 & 5 March 2020 25 members of staff had left the school. New assistant headteacher and 18 new members of staff join. The range of evidence available to inspectors was narrower because of Covid restrictions. The lead inspector did visit the school, but aspects of the visit were carried out remotely.? Level of staff turnover very high. Staff group about 70 in total. 28/03/21 CEO of Evolve Trust reports shortlisting for head at Fountaindale/Harlow to start in September 2021.  The principal of Beech Academy was appointed executive head but never took up the post.  Harlow staff costs described as high compared to national benchmarks. Harlow had a surplus of £445K which transferred to the Evolve Trust. The leadership roles across all Evolve Trust schools seem to be in flux throughout the period April 2021 to January 2022. No permanent head appointment was made for Harlow, A newly appointed, in September 2021 head of Brunts Academy left after four weeks, there were issues with the leadership of the Brambles academy. 01/04/2021 Evolve take responsibility for the school. CEO Evolve Trust. Interim head – was senior leader at Fountaindale.  Former executive head continues as executive head for the summer term 2020/21 to help with the handover. No permanent new leadership at Harlow.   29/04/21 School handle safeguarding report of bruise on child outside guidance.  Passing responsibility to NHS colleagues for judgment on sending the child home. Suggests weak safeguarding practice. 09/06/21 Termly monitoring meeting by EPS.  Still virtual. Impact of contacts with the school being online and not on site and in person.  60 | P a g e   14/07/2021 Evolve Board. CEO reports she is based at Harlow and that improvements are moving at pace. The changes made to the curriculum and uniform were not well received by parents and carers. 22/07/21 Parent allegations about lack of support for a child at Brunts academy.  The NCC LADO had worked with CAMHS and confirmed they were not satisfied with the action and assurances received from the Evolve Trust. ESFA contacted the RDD to discuss the case and sought additional assurances from the Evolve Trust in line with usual ESFA procedures.  LADO’s view that the parent as unhappy about the support offered by the school and a lack of sensitivity to the pupil’s needs.  The LADO confirmed Evolve Trust had addressed social care concerns and that no further action was required form the LA. This case takes on more significance in the light of further complaints about Evolve Trust and the complaints made about the care of children at Harlow Academy.  27/07/2021 ESFA opened a concern case about Evolve Trust. This was about governance and compliance at the rust following whistle blower allegations referred to ESFA by Ofsted.  The Trust provided assurances against each allegation. However, neither RDD or ESFA were satisfied with the information provided about culture of the Evolve Trust and questions remained around the behaviour of the CEO.  The Trust was recommended to carry out an external review of governance in October 2021. This review did not take place. This was very significant information know to ESFA, RDD and Ofsted which was not known to NCC or NHFT.  It does not appear that this information was taken account of when there were discussions between NCC, Ofsted and RDD in early October 2021. 07 & 08 2021 Proposed office move for NHFT staff. Issues about servicing of chairs and ordering of equipment. Evolve upset that health staff appear to be questioning their understanding of children's needs. Issue about chairs and equipment ordering will have raised questions for NHFT staff about Evolve’s understanding of the children's needs. 05/08/21 Interim General Manager C & YP Specialist Services NHFT speaks to NCC Service Director.  Concerns about deteriorating relationships at Harlow since the change of leadership.  Health staff accommodation being changed. General safeguarding concerns raised with the head who appeared intimidated by the CEO. Call to CEO experienced as threatening though decision on accommodation changed.  Why did this complaint/raising of issues not lead to any action?  Should the LA have taken any other action such as a formal engagement with the Evolve Trust at CEO or Chair of Trustees level?   61 | P a g e   01/09/2021 Executive Head appointed but never takes up the role.  He does act as a consultant to the school and is referred to as Executive Head in interactions with NCC and NHFT staff. He is Principal of Beech Academy. This is part of the confusing picture of the leadership of Harlow and of the Evolve Trust Academies 02/09/21 NHFT staff see insufficient staff to meet needs. Staff unsure how to manage behaviour. Not enough staff to supervise students. Clear there are significant difficulties early in the term. 08/09/21 Email between health partners copied to Director of Education NCC – focus is health school relationships and accommodation issue, access to school and staffing levels.  Health staff refused full access as no DBS evidence This is very early in the Autumn term. Indicates significant issues at the school against a background of serious problems at the school. 09/09/21 Head of Nursing NHFT to Exec Head wishing to discuss urgent issues. Is a prompt response and they meet 10/09/21 This will have looked promising. 09/09/21 OT and physio met head of school and CEO of Evolve.  Tone described as aggressive.  Information shared on six incidents. This is incident 6 in the NHFT chronology. No joint problem solving and NHFT staff seen as problematic by school. 10/09/2021 Evolve Board extraordinary meeting. The focus is on Brunts Academy and complaints related to that school. Some are focused on the CEO and are on social media.  New headteacher had resigned after four weeks in post. Board agreed a cultural restructure at Brunts.  This led to proposals for staff restructuring at Brunts. Indicative of the wider problems within the Evolve Trust. Brunts academy had been subject to a restructure in the 2020/2021 school year. 10/09/21 Referral from Exec Head  and Head  to LADO about restraint of two children in chairs.  This was observed by health staff.   Relied on internal school investigation.  School upset NHFT staff reported without coming to school leaders first. Class teacher resigned. NHFT manager and head of nursing NHFT, Head of school and Exec Head met. Agreed to meet in four weeks. Critical incident which was never satisfactorily resolved. View of the school that concerns were exaggerated not effectively challenged.  Uncertainty over what is the route for such issues. 13/09/21 Head of Nursing to Group Manager requesting a meeting. The NHFT chronology records no response to this request. Missed opportunity to get a grip on this early in the term. 15/09/21 School considering referring OT to LADO for not informing school until next day about an incident.  This OT had raised a number of concerns. Appears a very hostile act by school. 15/09/21 Exec Head of school in conversation with Head of Nursing – attempting local resolution of the difficulties.   Exec Head of School appears interested in improving relationships  62 | P a g e   15/09/21 Head of School in conversation to Team Leader Paediatric Physiotherapy says CEO wants NHFT teams out of the school.  Examples in September of very problematic relationship with health staff. 23/09/21 Incident 8 Failure to order seating system for pupil. Assessment undertaken in May 2021. Significant impact on child’s care and wellbeing.  27/09/21 Incident 9. Seating related. Child fell off unsuitable seating in the absence of correct equipment.  Good example of why NHS staff so concerned. 27/09/21 Carer upset about child’s injury which carer believes occurred at school. MASH referral by East Midlands Ambulance Service.  Contact with LADO as well as MASH but though the incident was discussed there was no robust response.  Critical incident which went nowhere. 27/09/21 TL Paediatric Physio escalates to Head of Nursing NHFT. Poor communication, meetings cancelled, lack of equipment, safety, staff not safe on site. Significant escalation within NHFT. 01/10/21 Head of Nursing escalates to Exec Director Nursing, AHPs and Quality for NHFT.  Seeks advice about notifying Ofsted and CQC. Exec Director advises negotiation and being honest to provider before going to regulators. Reasonable advice but what is the timetable and threshold if the provider is unresponsive to concerns?  01/10/21 Meeting NCC and NHFT leaders following NHFT leaders e-mail of 08/09/21.  Concerns included safety of staffing levels, lack of supervision in class, closed culture, NHFT staff felt reprimanded for escalating safeguarding concerns, permission for entry denied due to DBS issues, education staff directed not to talk to NHFT staff on site. Outcome NCC service director had spoken to Senior HMI at Ofsted who said he would escalate the issues.  Serious concerns expressed. Discussion of escalation within Ofsted but appears nothing happened.  What else could NHFT and NCC have done at this point?  LA view that a no notice safeguarding inspection by Ofsted was the most robust action that could be taken. There was enough by this date to suggest serious problems in the care of children at the school.  No indication anyone planned to talk to parents and carers or the Evolve Trust 01/10/21 Ofsted record the NCC contact about Harlow. It reflects the concerns of NHFT staff noted in the meeting of NCC and NHFT leaders on 01/10/21. NCC said NHFT staff likely to raise their concerns through the complaints Ofsted is given a very clear picture of the issues and is aware of the wider issues  63 | P a g e   about a school (CAS) process. NCC raised that there were wider concerns about Evolve Trust in relation to high levels of staff turnover.  Ofsted note that the message from NCC chimed with findings from the inspection of the Bramble Academy that week.  A key issue was high staff turnover and support for school leaders from the academy trust. being raised about the Evolve Trust’s ability to lead and manage its schools. 01/10/21 Divisional General Manager NHFT to Service Director and Group Manager with an attached document of concerns.   NHFT escalation to NCC.   01/10/21 Head of Nursing and Divisional Manager NHFT speak to Service Director and Group manager NCC and agree this will progress to notifying Ofsted and the CQC asap. Later Service Director informs Head of Nursing Interim Divisional General Manager that she has spoken to Senior HMI at Ofsted. Also says NHFT will formally raise their concerns with Ofsted.  Urgent call to CEO of Evolve. The NCC Service Director spoke to Ofsted and followed this up in an email. Ofsted have reported they were kept informed by NCC. 05/10/21 Ofsted qualifying complaint raised by NHFT. Seven areas of concern raised including the incidents of restraint on 10/09/21.  Health aware of other significant incidents which were not included in the Ofsted complaint – time in foot orthosis, incorrect positioning/seating for feeding. What did Ofsted do with this complaint? There is evidence of extensive concern about the conduct of the school by this date.  Clear senior managers concerned about the care and wellbeing of the children. Why did this level of concern not lead to further action in the coming weeks given Ofsted did not inspect? 05/10/21 Senior EP and Group Manager met school and health leaders. New school leaders told them the staffing numbers and training issues had been addressed.   School leaders not new. The school leaders had been Fountaindale staff.  Was any detail sought on staffing levels? Did the EP and Group Manager feel able to challenge the school leadership and ask for detail given they had no formal authority in respect of the governance of the school?  64 | P a g e   07/10/21 Incident 10 Graphic description of the impact of low staffing levels observed by NHFT staff in the school This comes immediately after actions on 05/10/21 but does not seem to add to the escalation. 07/10/21 NHFT and NCC leadership communicate – no update from Ofsted following referral to them. Does Ofsted have timescales to respond to such complaints? 07/10/21 Ofsted received the CAS complaint from NHFT staff.  This raised concerns about behaviour management, managing restraint, medication practices, and generally meeting the needs of pupils with special educational needs and or disabilities.  Ofsted starts an 11a investigation. Why was this clear information together with what was already known about Harlow and the Evolve  Trust not enough to trigger a no notice inspection? 08/10/21 NHFT leadership and school leaders meet.  NHFT staff told they are guests in the school and school interim head believes NHFT staff are encouraging school staff to stir things up.  This is a serious allegation given the context and suggest little motivation or scope to repair relationships from school leaders. 08/10/21 CQC referral made by NHFT Cannot see there was ever any response to this referral to CQC 12/10/21 Evolve Board considers complaint to ESFA made over the summer about Brunts Academy.  The outcome of the inspection of Bramble Academy on28th September 2021 was not recorded in the minutes.  The leadership of the Trust challenged the outcome of the inspection which ultimately was RI, The challenge delayed the publication of the inspection until January 2022.   In Autumn 2021 there are developing issues with Brunts, Bramble and Beech Academies at the same time as the Evolve Trust is taking on Harlow Academy. 14/10/21 Head of Nursing calls Ofsted to follow up on complaint. Advised at login stage – email same day saying they are assessing concerns. This seems a slow and inadequate response from Ofsted. 14/10/21 Head of Nursing in NHFT raised the concerns held by NHFT with the Designated Clinical Officer for Special Education Needs and Disabilities at the CCG. [CCG roles now part of the responsibilities of the Integrated Care Board (ICB)]  14/10/21 Strategic conversation between RSC, CEO and Chair of Evolve Trust. It appears that no issues about the conduct of the Trust were raised. The Trust did not share the issues from the unpublished Bramble Inspection.  The Trust provided assurances that performance at Harlow was Given the history of complaints about Brunts and what was already known about Harlow it is surprising that the RSC was not more probing of the Evolve  65 | P a g e   improving and said it would like an outstanding judgement or at least good with outstanding features. Trust. This seems to have been a very unchallenging conversation. 15/10/21 Ofsted received a second CAS. This was about the quality of leadership and management resulting in high staff turnover and a lack of members of staff on the school site. This complain was from a member of staff. This was considered with the first CAS. There seems a lack of urgency from Ofsted given the weight of evidence of issues at Harlow and in Evolve Trust they were aware of. 15/10/21 Care agency to ICDS raising concerns about staffing ratios and their impact on care.  This seems to not have been registered with the other concerns raised by this date.  ICDS should have escalated this concern. 18/10/21 Team Leader Paediatric Physio email Head of Nursing concerned about sharing incidents. School seeing anything negatively. Indicative of problematic culture and relationships within the school 26/10/21 NHFT leadership to Director of Education about whether there had been any update from Ofsted.  Group Manager to NHFT leadership that they have been assured by Ofsted and DfE that the concerns are being looked into. No sense of urgency from Ofsted. It was unclear what being looked into meant in practice given that they had not instigated a No Notice Safeguarding Inspection October From 8th October to 26th October 3 further incidents recorded by NHFT staff of poor care. 11,12 and 13 in NHFT chronology. Significant incidents of problems in care of the children regularly recorded by NHFT staff. 01/11/21 Director of Education to NHFT senior staff. Confirmed escalation to Ofsted but no further feedback and need to decide on how to respond to that. It is now a month since the concerns were raised with Ofsted and nearly four weeks since put in writing. Why is there no response from Ofsted?  Is momentum lost waiting for Ofsted?  Was consideration given to developing a parallel plan if Ofsted did not act? 01/11/21 Care agency to ICDS – school not appreciating seriousness of child’s condition. Same child as email of 15/10/21. Also not seen and connected to other concerns.  02/11/2021 ESFA writes to the Chair of Evolve Trust saying they are satisfied with the assurances Evolve Trust has given to the issue raised in the letter sent on 13/09/21 by the ESFA in response to a complaint to the ESFA about This information about issues at Brunts Academy and the correspondence with ESFA was not known to NCC or NHFT  66 | P a g e   safeguarding, leadership and management and financial irregularities. These complaints were about the Brunts Academy. as they raised concerns about the management of Harlow Academy. 03/11/2021 ESFA’s first safeguarding case in respect of Harlow.  An anonymous whistle-blower alleged staff shortages and the rapid departures of staff had left pupils at risk of harm through insufficient support. ESFA did a desk review of policies and procedures which were up to date and the compliant.  The Evolve Trust responded to allegations by stating that the reduced staffing would not impact the health and safety of pupils as the school was over-staffed.  The case was closed as requiring no further action.  As the complaint was anonymous there was no route back to the complainant. The ESFA enquiry seems inadequate given the previous complaints about the Evolve Trust which were very recent. It appears no cross checks were made with Ofsted or the RSC or NCC.   The ESFA received further safeguarding complaints about Harlow but after the January 2022 Ofsted inspection.  The DfE acknowledge that information sharing between parts of the DfE, ESFA, and RDD, Ofsted and LAs regarding schools and academy trusts needs to be improved. 03/11/21 Incident 14 from the health chronology. Poor care of child. Seems to lead to a more considered discussion between health staff and the interim head of school who acknowledges there are staffing issues and issues about morale in the school.   04/11/21 Termly meeting of RSC, DCS and service director.  Harlow discussed including complaints from NHFT staff.  RSC not aware of further concerns from Ofsted and aware of vexatious complaints about another Evolve special school. Queries if the complaints are vexatious. Risks of assuming allegations are malicious.  Lack of curiosity about the number and pattern of incidents in a school with a history of serious difficulties. Why is RSC not aware of complaints to Ofsted? 04/11/21 NCC contacted Ofsted senior HMI. This was to update Ofsted about the continuing concerns of NHFT staff about Harlow Academy NHFT staff reported feeling intimidated by school leaders.  Ofsted informed NHFT considering withdrawing staff from the school site and delivering services from a local hospital site.  Ofsted adds this information to the information already held. Appears Ofsted and RSC are not communicating as no reference to RSC.   67 | P a g e   04/11/21 NHFT Head of Nursing emails Ofsted to ask for an update. Response is to apologise for the delay and that Ofsted are still progressing the concerns. Requested details of further incidents which were sent the same day. Slow response from Ofsted. 04/11/21 School leadership meet Service Manager Paediatric Therapies about Ofsted referral. School leadership deny any safeguarding concerns. This was an unplanned meeting.   Should there have been a meeting of school and senior managers from NCC and NHFT following this meeting? 04/11/21 NHFT manager and NCC service director discuss school and NHFT staff concerns. NHFT staff wish to relocate to a children's centre. Lack of response to the restraint incidents. Staffing levels a serious concern – medical team 2 instead do 4 from 08/11/21. Manual handling team reduces from 4 to 1. Further serious concerns. The Service Director went back to Ofsted and also met with the NCC Director of Children’s Services and updated the DofE. Why was it so difficult to mobilise any intervention or other actions considered? 04/11/21 Service Director emails to NHFT Divisional General Manager saying voicemail left for HMI at Ofsted saying aware NHFT colleagues made further referral to Ofsted. Service Director feels Ofsted are taking this seriously. Refers to meeting on 05/11/21 with LADO, DCS and Group Manager. Where is evidence that Ofsted have a grip of this?  04/11/21 NHFT manager to MASH – incident on 03/11/21 when   child left in vomit/soiled cloths for 2 hours.  Not changed until NHFT manager brought to attention of head. NHFT manager concerned about head’s response. Referred to LADO by MASH and referrer to speaks to ICDS.  LADO advised health to undertake a joint investigation with education staff. Report of this child being inappropriately punished on 21/10/21.  Concern referred to Ofsted on 17/11/21 The MASH response reflects a lack of clarity about how to respond to concerns about standards of care in education settings. The LADO advice was a joint investigation by health and education staff.  It is unclear why this advice was not followed. Nothing else was done.  Further example of concerns that do not lead to action and are not collated with other concerns.  04/11/21 Parental referral to MASH about care of their child at school. Time in toilet to complete suction procedure. Parent had been told by MASH to go to LADO who advised go back to MASH. LADO contacted ICDS so they were aware.  School unhappy ICDS dealing rather than MASH. School Another example of difficulty for a parent of getting a concern to the right place.  Response to parent behaviour by the school unreflective.  68 | P a g e   saying parent had been intimidating.  Parent has lost confidence in the school. 05/11/21 NCC service director, DCS, Group Manager and LADO meet.  Outcome group manager meets NHS professionals and school leadership at the school. After this meeting Service Director contacted Senior HMI at Ofsted to recommend a section 8, no notice inspection.   Professionals unclear about where to raise concerns.  Unclear what Ofsted response was. Informal notes were kept by the LA and this was agreed to be a confidential conversation. 05/11/21 NHFT Divisional general manager to Harlow NHFT Team setting out what has been done to raise the concerns and responses. This includes that there will be an independent review of incidents in the school by 2 investigators one senior NHFT and one LA.  This to be discussed with Harlow CEO that day.  The agreement for this joint review of incidents does not appear in the NCC chronology.  There is a lack of clarity from the chronologies about what was agreed.  This investigation never happened.  It seemed to change into the safeguarding review noted on 10/11/21 which was of policies, not looking at care practice or particular incidents. No consideration of seeking parent and carer views of what is happening in the school. Extraordinary level of activity during this week after the October half term but it does not lead to action. 08/11/21 Meeting health and education managers. Agreed plan for mediation between health and school. School CEO says she wants health staff to remain working from the school.  NHFT staff feel unable to be based at school due to concerns and feeling unsafe. Is this going anywhere?  Not clear if any chronology or other account of all the issues has been pulled together. 09/11/21 Divisional General Manger NHFT to Service Director to update on the NHFT staff position. Staff feeling vulnerable and anxious. NHFT managers met Exec Head to discuss referral to Ofsted. Exec Head had been contacted by Ofsted on 04/11/21 School expecting Ofsted that week. Interesting meeting is with Exec Head who seems consistently to take a more problem-solving approach but does not lead to change. 10/11/21 Ofsted undertaking an area SEND inspection. Information from a parent about high staff turnover and that the academy as falling short in providing appropriate provision for their two children. Ofsted notes the common feature with findings from the Bramble inspection.  10/11/21 Three Ofsted qualifying complaints from parents.  These cover staffing levels, use of staff from other Evolve schools, concerns about leadership Complaint in the Ofsted chronology. Was NCC aware of these at the time?  Further  69 | P a g e   and management, wellbeing of pupils, school not sharing risk assessments, students sent home with soiled pads. 2 of 3 pupils withdrawn from school.  evidence of how bad children's experience is at the school. 10/11/21 Group manager and CEO meet and agree safeguarding review. Focus is QA of policies and procedures.   This exercise seems to miss the point. Does not address the nature of the complaints and concerns raised since August. Multiple meetings and communication with different school leaders. Inherently confusing as to who will do what. 15/11/21 Carer complaint asking if child can move schools and needs not met due to current issues in school.  Email forwarded to ICDS.  ICDS worker met carer. Concerns escalated to senior manager in ICDS and group manager. Further example of concerns not being addressed and parent/carer concerns not leading to any action. 16/11/21 Incident 17 Health professionals and parents to LADO over CEO shouting at a child. Incident investigated by school staff and safeguarding governor. Deemed no role for LADO. Information shared with group manager.  Parent saying relationship with school irreparable. Another example of inappropriate care at the school but leads to no action. 17/11/21 Ofsted received further information about Harlow from the original complainant that the situation had not improved.  The information was added to the existing 11a investigation. There seems to be no timescale for the 11a investigation and no indication of Ofsted actively gathering information to triangulate the concerns that had been raised with them. 17/11/21   Incident 18 NHFT staff raise concerns about staff pupil ratios an example of inadequate care.  Incident form escalated to Ofsted, but incidents not shared with ICDS, CSC or the EHCP service. Incident 19 Feeding of child in wrong position. Risk to child’s airways. Continuing serious incidents of poor care of children. 17/11/21 Head of Nursing NHFT emails Ofsted about latest incidents 17, 18 & 19. Informs Service Director and Group Manager in NCC. Further alert to Ofsted 17/11/21 Executive Head  to Service Manager Paediatric Therapies about incident 17.  Questions health staff’s actions. Request staff be removed from the Relationships are awful.  No trust and serious antagonism from school leaders to NHFT staff.    70 | P a g e   school.  Prompt response from Service Manager Paediatric service on why staff responded as they did.  18/11/21 Incident 20 Staff ratios issues. Frequent incidents of serious concern. 19/11/21 Further conversation between NCC and Ofsted. Information shared that NHFT staff are moving out of the school.  Initial recommendation of 11a investigation is for a section 8 no formal designation inspection which means one outside the normal cycle of inspection.  The discussion appears to have been about whether an inspection was warranted in what appeared to be a dispute between members of staff at the school and the NHFT staff. Ofsted considering whether the matter is best left to NCC and decided to keep in touch with NCC. In retrospect this seems a very poor judgement given the volume of concerns from multiple sources. It also suggests the NHFT staff are just not getting along with school staff rather than professionally reporting their serious concerns about the care of the children. 19/11/21 NHFT staff out of the school.  Breakdown in relationship between school and NHFT staff complete.  22/11/21 Ofsted understands from NCC that the CEO of the Evolve Trust had agreed to NCC undertaking a review of the school’s safeguarding arrangements. Ofsted took some reassurance from this. The Ofsted Regional Director and Senior HMI agreed that there would not be an inspection while the safeguarding review was underway on the basis that another statutory authority was working with the school and focusing on the issues of complaint This is a further dimension of the muddle created by this review including its focus and scope.  It was rapidly clear this review was not going to address the concerns about care practice at the school.  Ofsted was too easily assured and did not have a clear enough view of what the review as intended to do to make the judgment made that an inspection was not needed. 23/11/21 NSPCC alerted. Four children mentioned. Incidents are described above. Not new information.  NSPCC contacted by Paediatric OT.   This was outside any recognised procedure within NHFT or the partnership safeguarding procedures for raising a safeguarding concern. Indicative of how desperate NHFT staff were getting to try to have some action to improve care at the school. 24/11/21 through Ofsted liaised closely with NCC. Ofsted reported NCC as saying the Evolve Trust appeared willing to engage positively in the agreed This is a mischaracterisation of what had happened and what was happening. The  71 | P a g e   to 10/12/21 safeguarding review process and that the work had uncovered a breakdown in relationships with health professionals.  focus is shifted to interprofessional relationships rather than the substance of the complaints about care and education of the children in the school. 30/11/21 Professionals meeting with foster carers about one child. Extensive concerns discussed about care at school. Outcome is supporting the foster cares to make a formal complaint to the school. Leads to meetings on 05/01/21 and 07/01/21 with the foster carers and the school and others. Carers reported as feeling heard.  Head of school denied this child was restrained by their jacket or strapped into her wheelchair. SW had observed this on 24/11/21 Where is LA role as advocate/parent of the child?  Why is SW so disempowered to not call the head out on what the SW had directly observed.  30/11/21 Paediatrician referral asking for support for a child whose behaviour is deteriorating. School described as not supportive but comment not explored.  Further incident in school reflecting dreadful relationship of school and NHFT staff. NHFT staff challenged about why they were discussing children in school.   Further evidence to another professional of problems at school.  1/12/21 SCIE officer and LADO discuss calling a complex strategy meeting in relation to the concerns about individual children.  LADO said criteria not met. Search for a process to put this into rather than addressing the issue directly 02/12/21 NCC Group Manager chaired a meeting of Evolve staff and NHFT staff to discuss issues.  This meeting set out in some detail what the working relationship between health and education colleagues at Harlow Academy would look like if it was working well. The meeting agreed: 1. Leaders to meet again to discuss a Charter/Memorandum of Understanding on 20th January at 1pm – NCC and OT in ICDS to facilitate this. 2. Following this, leaders to have similar discussions with their staff.  3. Explore joint safeguarding training in the future e.g., case studies, CPOMS linking to IR3 systems, to share NHFT Think Family Level 3 Safeguarding information. Not directly addressing the concerns about practice in the school but reflected the considerable efforts made by NCC and NHFT staff to try to make progress in a situation where they had no authority over the school but had to work through influence and goodwill.   72 | P a g e   09/12/21 Meeting about safeguarding review. Pre-work school needed to do had not been done e.g., self-assessment. School struggling to do the basics. 10/12/21 Annual Ofsted and NCC engagement meeting. Harlow was discussed.  NCC reported that they were not able to get to the root and branch issues due to the limited remit of the safeguarding review permitted by the Evolve CEO.  NCC and Ofsted agreed to discuss after Christmas.  The safeguarding review is not accurately portrayed. By this date it is clear the review is not going to cover the correct issues as it will be confined to policies and procedures and will not provide the information needed to address the concerns about care and education of children at the school. 15/12/21 Evolve Trust Board. Report that there are issues at Beech Academy and the CEO is putting in place a rapid recovery plan. The Board is concerned that the CEO is leading schools.  There is no reference to any of the difficulties at Harlow other than that there is no drive to improve from within the school despite the fact the CEO had commissioned a Safeguarding Review, a surprising omission. Further evidence that there are problems across the Evolve Trust of which the Harlow issues are one element. Ten Trust lacks capacity to lead and improve the schools. 15/12/21 Parent raises concerns to NHFT staff about child not being placed in his standing frame.  ICDS not aware of non-compliance with care plan. No one having the full picture or thinking they need the full picture of what is happening at the school. 30/12/21 Parents go to MASH about staffing ratios. No role for LADO.  Information shared with NCC. Were parents going to MASH not seen as another red flag? 03/01/22 Child has blister on foot. Children's A & E contact EDT. Caused by being left in his wheelchair all morning. Further example of poor care at school. 05/01/22 Ofsted received another CAS which was about the CEO of the Evolve Trust. It was about the CEO’s ways of behaving and operating.  It alleged impact of this on leadership and morale of staff and children across the Evolve Trust.    05/01/22 Incident 22. Parent contacted therapy team.  Staff member unaware of child’s needs. Further example of child’s needs not met lack of liaison with NHFT teams on child's needs and how to meet them. 07/01/22 Child removed from school as school could not or was unwilling to do catheterisation in school, seizures missed, concerns about staffing levels, This child is in school now. Catheterisation is a procedure within the  73 | P a g e   not stood often enough. Letter copied to Ofsted and MP. This was followed up by meeting with parents where it was agreed school would carry out catheterisation.   expectations for a school meeting the range of needs Fountaindale/Harlow was designed to meet. 07/01/22 Incident 21. Parents raise concerns to ICDS about child being in postural chair for most of the day. School says this is for behaviour management.  Completely inappropriate approach of school.  Why was this not strongly challenged at the time?   Further example of not joining up what was known from the numerous parental complaints.  10/01/22 Ofsted spoke to NCC and agreed Harlow would be inspected the following week. The further complaint, an MP’s letter following parents approaching him about safeguarding concerns and the lack of progress of the safeguarding review meant an inspection was now warranted.  10/01/22 Incident 23 Poor care of child reflecting inadequate staffing There is no improvement in pupil care. 12/01/22. T/C Senior HMI of Ofsted and Service Director. Senior HMI had asked for an update. Service Director said she remained concerned. NCC aware a letter from 24 parents had gone to the school. Why is this dealt with so informally? 14/01/22 Ofsted received two further CASs. They were initially sent on 17/12/21, the final day of the Autumn term. The complaints chimed with the information already gathered from the earlier complaints.  16/01/22 MDT meeting of child therapists who raise serious concerns about Head of school making statements that are untrue. Hard to believe what therapists say about a senior member of school staff.  Is this why it was so hard to move this on?  Parents had similar experience. They say they were lied to. 17/01/22 Ofsted received three further complaints about the three other schools in the Evolve Trust.  17/01/22 Previous school head, Senior HMI, to service director. Previous head has been informed there are only 4.5 fte teachers in the school. Alleges bullying and dishonesty of CEO. Why is this conversation so late in the timeline? 17/01/22 Incident 24. Mother reports child’s behaviour shows the child is frightened at school. How could parent and children's experience have been captured much  74 | P a g e   Incident 25. Similar to Incident 24. Child’s behaviour adversely affected by experience at school.  earlier in this account of the deterioration of the school? 17/01/22 Evolve Trust AGM Reported Bramble School was judged RI at the inspection in last week of September 2021, with part of the report highly critical. Second RI judgement for the school.  CEO said the school is good and moving in the right direction.  18/01/21 Unannounced Ofsted inspection and Harlow Academy is temporarily closed. CEO in call to Group Manager shifts blame to Interim head.  18/01/22 Referral to MASH by paediatric OT abut one child's bad experience in school. Parent says child scared to go to school. Further example of NHFT staff raising concerns but without being clear where to focus those concerns. 19/01/22 Ofsted received a further CAS about Harlow which alleged one child had hit another child and pupils were sat down for lengthy periods in the day. The complaint also said there was high staff turnover and poor communication with parents about children’s education programmes and use of communication aids. All very similar issues to those raised early in the term by NHFT staff.  25/01/2022 Extraordinary meeting of Evolve Trustees. Trustees report they had no indication that special measures was a possible outcome of an inspection at Harlow Academy. Suggests Trustees were not diligent in their probing of the CEO about what was happening at Harlow and that the CEO provided them with very limited if any information on the issues NCC and NHFT were raising with the CEO and other senior school staff.     75 | P a g e     76 | P a g e   Appendix 2 Terms of Reference for the review. Review of safeguarding practice in response to events at Harlow Academy - Scope and Terms of Reference  Background The school subject to this review of safeguarding practice was called Fountaindale School until April 2021 when, following the making of an Academy Order due to an inadequate inspection outcome and sponsorship by the Evolve Trust, the name was changed to Harlow Academy. The  was closed for a short period following an Ofsted inspection in January 2022. In February 2022 the Evolve Trust CEO was replaced with an interim, who was seconded from Greenwood Academies Trust, and a new Board of Trustees and Members were appointed. Nexus Multi Academy Trust was asked to provide improvement intervention and support for the school, whilst a plan was put in place by the Department for Education regarding the school and Evolve Trust’s long-term futures. Harlow is a special school making provision for some of the most vulnerable and disabled children, including children receiving end of life care and with severe physical disabilities. The school was built for this purpose and has around 80 children, aged 3-18, on roll. Until November 2020 the school had residential provision for pupils aged 14-18 years focused on promoting independence and improving social skills.   An Ofsted inspection in March 2017 graded the school as outstanding. The headteacher then retired and new leadership commenced with the Local Authority (LA) starting to note concerns in late 2018. A warning notice was issued to the school on 18th July 2019 because of the quality of governance and leadership.  Ofsted visited in February 2020 and placed the school in special measures.  At this point the Secretary of State issued an Academy Order and the Regional Schools Commissioner began to identify the sponsor for the school.  In the intervening period, the LA continued to be responsible for the school and put in interim leadership, the LA assessed that good progress was made in this period. The school transferred to Evolve Trust and re-opened as The Harlow Academy on 1st April 2021.  The Evolve CEO assumed Executive Headteacher responsibility for the Harlow Academy. A number of complaints were received by the Local Authority and Ofsted following this. These included a lack of qualified staff, children’s needs not being met, and professionals feeling intimidated by the leadership.  In the late summer months of 2021, health colleagues started to raise with the LA that staff were feeling intimidated and that they were observing unsafe practice across the school.  This was followed up and in the autumn term health professionals made an Ofsted qualifying complaint. A Section 11 virtual inspection by Ofsted was undertaken on 4th November 2021, followed by an out of schedule inspection on 18th January 2022.  A number of serious safeguarding matters were raised by Ofsted. Ofsted concluded that Pupils were not being kept safe and were at risk of immediate and imminent harm.    77 | P a g e   • The children’s care needs were not being met and they were therefore not able to learn. The classrooms were unsafe, and the trustees were not fulfilling their duties, not just at an operational level, but at a strategic trustee level. • The quality of the relationships within the school had contributed to the break down and removal of health staff who had been based at the school historically.   • Staff found it was difficult to work at the school and they felt they would be blamed when something went wrong.  They felt intimidated in these circumstances. • Staff said they did not feel free to speak out and that there was a culture of fear and a lack of openness. Staff essentially were saying they were too afraid to whistle blow.  Decision-making process No serious incident notification was submitted by the Local Authority to the National Safeguarding Panel as no specific serious child safeguarding case was identified. It was determined this was a concern of institutional failure which would be dealt with under the Nottinghamshire Safeguarding Children Partnership’s organised and complex abuse procedure.  Nottinghamshire Children’s Services have commissioned an independent review of Local Authority practice. The Department for Education has undertaken a ‘lessons learned exercise’ and are willing to share the recommendations developed from this. Evolve Trust has completed disciplinary investigations into the allegations raised. On further discussion on 16/08/22 the NSCP Strategic Leadership Group determined that there would likely be learning for all partnership agencies, and that an umbrella review should be commissioned to ensure the learning from the reports and learning exercises already completed and from health and police partners is consolidated. Ofsted will also be invited to contribute to this review in light of their significant involvement over the period of concern.     Period to be covered by the review The scope period will be from 14/03/2017 (when Fountaindale School received an outstanding Ofsted inspection grade) to 21/01/2022 (the date of the Ofsted inspection and resultant temporary closure of the school). It is acknowledged this is a wide scope, however the inclusion of 2017 onwards is for the author to review the context leading up to the issue of the 2019 warning notice for any themes or pertinent learning. The main focus of the review will be from the warning notice in July 2019 to the school’s temporary closure in January 2022.   Chronology and agency reports Nottinghamshire County Council has already commissioned a review with  a chronology that should be made available to the author.   78 | P a g e   Chronologies and reports will need to be provided by the Evolve Trust, health and police partners. These should detail events during the scoping period, with any additional significant events summarised with an analysis as to relevance/significance. The report should provide an analysis of involvement during the scoping period focussing on the key lines of enquiry set out in the following section.  Ofsted and the DfE will be asked if they are willing to provide chronologies. The DfE have already agreed to provide verbal feedback to the LA and will be asked to meet with the independent author. The same request is being made of Ofsted.  Reports may be subject to requests for disclosure by other parallel processes.  Key lines of enquiry for the review “It is important for any reader, but perhaps especially those unfamiliar with reviews of this sort, to understand the ambit and purpose of this ‘umbrella review’. It is not about the school or written for the families. It does not seek to tell the children’s story or provide a narrative understanding of their lives. The review is rather about the safeguarding response provided for the children by the NSCP agencies, once they were aware of the problem.  The review will draw together work already completed or in process, such that overall learning may be identified for the future”.  1. When concerns about the care of the children were raised what was the quality of response from safeguarding partners? Identify what escalation was undertaken by each agency, how effectively these escalations were responded to and any lessons for the partnership about the escalation procedures or practice. Include exploration of the circumstances of the health team no longer being on site.    2. Did the children’s disabilities impact on how partners understood their experiences at Harlow? Were they sufficiently considered in the response of agencies to the concerns being raised? Did those responding to the concerns have the correct expertise or draw on support from those who did?  3. What discussions took place by either individual practitioners or their agencies with senior staff at the school and Evolve, as the responsible Trust, about their safeguarding or other concerns? This could have been about specific incidents or more broadly about the culture, practice or staffing at the school?  Methodology for the review - The reviews commissioned by NCC and the Evolve Trust to be submitted to the author. - Reports and chronologies to be submitted by health and police using the templates provided.  79 | P a g e   - Chronologies to be requested from the DfE and Ofsted with verbal meetings requested with the independent author. - A briefing event to confirm the terms of reference and agree expectations to take place between the NCC report author, this report author and the health and police report authors.    - The author will determine in consultation with partners how best to engage with families but will ensure this is done as part of the review.  - Practitioner’s learning event. - An extraordinary meeting of the strategic leadership group (SLG) to sign off the report.  Interviewing of staff As this is an umbrella review, it is not anticipated that significant additional interviews will take place. However, partner agencies will ensure staff members are available and supported should they be interviewed.  Involvement of the families The report author, in consultation with the NSCP Service Manager and/or Independent Scrutineer, will determine how best to engage with the group of parents and carers to enable their contribution to the review.  Expert opinion The report author will have access to Dr James Fildes, a suitably qualified and experienced paediatrician and designated doctor for safeguarding, in order to ensure full understanding of the safeguarding response to the children’s particular medical needs.  Other relevant reviews The National Child Safeguarding Practice Review Panel are currently undertaking a national review into safeguarding children with disabilities and complex health needs in residential settings. This may report within the timescale of this review and this review will be submitted to the panel.  Organisations to be involved in the review Nottinghamshire County Council (Children’s Social Care, Commissioning and Education, Learning and Skills) Nottinghamshire Police Nottinghamshire Integrated Care Board and the Nottinghamshire Healthcare Trust The Evolve Trust Department for Education (specifically the regional schools commissioner) Nexus Multi Academy Trust Ofsted  80 | P a g e   Panel membership  Representative from Nottinghamshire County Council Representative from Nottinghamshire Police Representative from Nottinghamshire ICB and Notts Healthcare Trust Helen Bannister, author of the NCC review.   Representative from the Evolve Trust. The DfE and Ofsted will be invited to send a member should they agree to engage with the review.  Involvement of agencies in other LSCP areas 3 of the 79 children on roll at Harlow have Derbyshire postcodes. Should the author wish to explore the safeguarding response from Derbyshire’s agencies then this can be explored with the NSCP Service Manager providing the link as required.  Coroner’s inquiries/criminal investigations There is no coronial process and the criminal investigation has concluded with no further action being taken.  Media coverage The media have not been notified of the NSCP decision to initiate an umbrella review but there has been media interest in the events at Harlow in early 2022. Should agencies become aware of any media attention they should notify the NSCP Service Manager and direct the enquiries to the Nottinghamshire County Council Communications Department.  Legal advice There is no requirement for independent legal advice at this stage however should this become necessary then it will be provided by the NCC legal department.  Timescales The review timescale is 4 months. Reports and chronologies by health and police to be submitted within 4 weeks. Ofsted and DfE to submit chronologies within 4 weeks if they are in agreement and verbal meetings with both to be arranged with the report author by the NSCP service manager.  Commissioning of a lead reviewer Whilst this is not a Local Safeguarding Child Practice Review, the principles set out on p. 89 of Working Together 2018 are relevant and a suitably qualified and experienced person will be appointed to lead the umbrella review and author the report.     81 | P a g e   Review report The final report should be written in such a way that when it is published it avoids harming the welfare of any children or vulnerable adults involved.  Implementation of recommendations and feedback to staff A briefing document will be prepared by the NSCP Service Manager at the conclusion of the review for circulation amongst partners, along with the learning being incorporated into the Learning Framework. However, it is for involved agencies to ensure learning is disseminated rapidly once identified within the review process.  Liaison with national panel, Ofsted and DfE This will be the responsibility of the NSCP Service Manager in terms of distribution of the report. However, liaison with Ofsted and the DfE will be through the NCC Education, Skills and Learning service director in the first instance.                        82 | P a g e   Appendix 3 Acronyms  ADCS Association of Directors of Children’s Services AHP Allied Health Professions CAMHS Child and Adolescent Mental Health Services CAS Complaints about a School Process CCG Clinical Commissioning Group CQC Care Quality Commission DCS Director of Children’s Services DfE Department for Education EHCP Education Health and Care Plan EPS Education Psychology Service ESFA Education and Skills Funding Agency ICB Integrated Care Board ICDS Integrated Children’s Disability Service LA Local Authority LADO Local Authority Designated Officer MASH Multi-Agency Safeguarding Hub NCC Nottinghamshire County Council NHFT Nottinghamshire Healthcare Foundation Trust NSCP Nottinghamshire Safeguarding Children Partnership PA Personal assistant RDD Regional Department for Education Director RSC Regional Schools Commissioner SALT Speech and Language Therapy SCIEO Safeguarding Children in Education Officer SEND Special educational needs and disabilities SLG strategic leadership group  