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Overview of contents
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Title pages

Part one Background
1 Introduction
2 The Inquiry
3 Victoria's story

Part two Social Services
4 Ealing Social Services
5 Brent Social Services
6 Haringey Social Services
7 Tottenham Child and Family Centre
8 Enfield Social Services

Part three Health
9 Central Middlesex Hospital
10 North Middlesex Hospital
11 Health analysis
12 general Practice and liaison health visiting

Part four The police
13 brent Child Protection Team
14 Haringey Child Protection Team
15 Child protection policing in north west London

Part five Working with diversity
16 Working with diversity

Part five Learning from experience
17 The seminars

Part six Recommendations
Recommendations
General
Social care
Healthcare
Police
Annexes
Annexes Crown Copyright

18 Recommendations

Recommendations: 18 - 35 | 36 - 45 | 46 - 55 | 56 - 63

This section brings together the recommendations that are to be found in the Report. The way in which local authorities name committees and officers can vary. For ease of reference, the recommendations are expressed in the terms of the Local Authorities Personal Social Services Act 1970. To the left of each recommendation is an indication of the timescale for action:

1 means the recommendation should be implemented within three months.

2 means the recommendation should be implemented within six months.

3 means the recommendation should be implemented within two years.

Of the 108 recommendations in this Report, 46 are under '1' and a further 36 are under '2'. This means that some 82 of the recommendations could be acted upon within six months.

The paragraph numbers that follow the recommendations are cross-references to the paragraphs in this Report in which they can be found.

Recommendations: 18 - 35 | 36 - 45 | 46 - 55 | 56 - 63

Social care recommendations

 

Recommendation 18 When communication with a child is necessary for the purposes of safeguarding and promoting that child's welfare, and the first language of that child is not English, an interpreter must be used. In cases where the use of an interpreter is dispensed with, the reasons for so doing must be recorded in the child's notes/case file. (paragraph 6.25)
Timescale for action 1 See table at top of page
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Recommendation 19 Managers of duty teams must devise and operate a system which enables them immediately to establish how many children have been referred to their team, what action is required to be taken for each child, who is responsible for taking that action, and when that action must be completed. (paragraph 4.4)
Timescale for action 1 See table at top of page
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Recommendation 20 Directors of social services must ensure that staff in their children and families' intake teams are experienced in working with children and families, and that they have received appropriate training. (paragraph 4.16)
Timescale for action 2 See table at top of page
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Recommendation 21 When a professional makes a referral to social services concerning the well-being of a child, the fact of that referral must be confirmed in writing by the referrer within 48 hours. (paragraph 4.59)
Timescale for action 1 See table at top of page
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Recommendation 22 If social services place a child in temporary accommodation, an assessment must be made of the suitability of that accommodation and the results of that assessment must be recorded on the child's case file. If the accommodation is unsuitable, this should be reported to a senior officer. (paragraph 4.77)
Timescale for action 1 See table at top of page
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Recommendation 23 If social services place a child in accommodation in another local authority area, they must notify that local authority's social services department of the placement. Unless specifically agreed in writing at team manager level by both authorities or above, the placing authority must retain responsibility for the child concerned. (paragraph 4.82)
Timescale for action 1 See table at top of page
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Recommendation 24 Where, during the course of an assessment, social services establish that a child of school age is not attending school, they must alert the education authorities and satisfy themselves that, in the interim, the child is subject to adequate daycare arrangements. (paragraph 4.43)
Timescale for action 1 See table at top of page
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Recommendation 25 All social services assessments of children and families, and any action plans drawn up as a result, must be approved in writing by a manager. Before giving such approval, the manager must ensure that the child and the child's carer have been seen and spoken to. (paragraph 4.52)
Timescale for action 1 See table at top of page
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Recommendation 26 Directors of social services must ensure that no case involving a vulnerable child is closed until the child and the child's carer have been seen and spoken to, and a plan for the ongoing promotion and safeguarding of the child's welfare has been agreed. (paragraph 4.83)
Timescale for action 1 See table at top of page
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Recommendation 27 Chief executives and lead members of local authorities with social services responsibilities must ensure that children's services are explicitly included in their authority's list of priorities and operational plans. (paragraph 5.4)
Timescale for action 2 See table at top of page
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Recommendation 28 The Department of Health should require chief executives of local authorities with social services responsibilities to prepare a position statement on the true picture of the current strengths and weaknesses of their 'front door' duty systems for children and families. This must be accompanied by an action plan setting out the timescales for remedying any weaknesses identified. (paragraph 5.9)
Timescale for action 2 See table at top of page
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Recommendation 29 Directors of social services must devise and implement a system which provides them with the following information about the work of the duty teams for which they are responsible:
Timescale for action 2 See table at top of page
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• number of children referred to the teams;

• number of those children who have been assessed as requiring a service;

• number of those children who have been provided with the service that they require;

• number of children referred who have identified needs which have yet to be met. (paragraph 5.24)

 

Recommendation 30 Directors of social services must ensure that senior managers inspect, at least once every three months, a random selection of case files and supervision notes. (paragraph 5.27)
Timescale for action 1 See table at top of page
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Recommendation 31 Directors of social services must ensure that all staff who work with children have received appropriate vocational training, receive a thorough induction in local procedures and are obliged to participate in regular continuing training so as to ensure that their practice is kept up to date. (paragraph 5.30)
Timescale for action 2 See table at top of page
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Recommendation 32 Local authority chief executives must ensure that only one electronic database system is used by all those working in children and families' services for the recording of information. This should be the same system in use across the council, or at least compatible with it, so as to facilitate the sharing of information, as appropriate. (paragraph 5.46)
Timescale for action 3 See table at top of page
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Recommendation 33 Local authorities with responsibility for safeguarding children should establish and advertise a 24-hour free telephone referral number for use by members of the public who wish to report concerns about a child. A pilot study should be undertaken to evaluate the feasibility of electronically recording calls to such a number. (paragraph 5.71)
Timescale for action 3 See table at top of page
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Recommendation 34 Social workers must not undertake home visits without being clear about the purpose of the visit, the information to be gathered during the course of it, and the steps to be taken if no one is at home. No visits should be undertaken without the social worker concerned checking the information known about the child by other child protection agencies. All visits must be written up on the case file. (paragraphs 5.108 and 6.606)
Timescale for action 2 See table at top of page
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Recommendation 35 Directors of social services must ensure that children who are the subject of allegations of deliberate harm are seen and spoken to within 24 hours of the allegation being communicated to social services. If this timescale is not met, the reason for the failure must be recorded on the case file. (paragraph 5.27)
Timescale for action 1 See table at top of page
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Recommendations: 18 - 35 | 36 - 45 | 46 - 55 | 56 - 63

 

Recommendation 36 No emergency action on a case concerning an allegation of deliberate harm to a child should be taken without first obtaining legal advice. Local authorities must ensure that such legal advice is available 24 hours a day. (paragraph 5.128)
Timescale for action 1 See table at top of page
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Recommendation 37 The training of social workers must equip them with the confidence to question the opinion of professionals in other agencies when conducting their own assessment of the needs of the child. (paragraph 5.138)
Timescale for action 2 See table at top of page
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Recommendation 38 Directors of social services must ensure that the transfer of responsibility of a case between local authority social services departments is always recorded on the case file of each authority, and is confirmed in writing by the authority to which responsibility for the case has been transferred. (paragraph 5.52)
Timescale for action 1 See table at top of page
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Recommendation 39 All front-line staff within local authorities must be trained to pass all calls about the safety of children through to the appropriate duty team without delay, having first recorded the name of the child, his or her address, and the nature of the concern. If the call cannot be put through immediately, further details from the referrer must be sought (including their name, address and contact number). The information must then be passed verbally and in writing to the duty team within the hour. (paragraph 5.69)
Timescale for action 1 See table at top of page
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Recommendation 40 Directors of social services must ensure that no case that has been opened in response to allegations of deliberate harm to a child is closed until the following steps have been taken:
Timescale for action 1 See table at top of page
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• The child has been spoken to alone.

• The child's carers have been seen and spoken to.

• The accommodation in which the child is to live has been visited.

• The views of all the professionals involved have been sought and considered.

• A plan for the promotion and safeguarding of the child's welfare has been agreed. (paragraph 5.187)

Recommendation 41 Chief executives of local authorities with social services responsibilities must make arrangements for senior managers and councillors to regularly visit intake teams in their children's services department, and to report their findings to the chief executive and social services committee. (paragraph 5.193)
Timescale for action 2 See table at top of page
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Recommendation 42 Directors of social services must ensure that where the procedures of a social services department stipulate requirements for the transfer of a case between teams within the department, systems are in place to detect when such a transfer does not take place as required. (paragraph 6.7)
Timescale for action 1 See table at top of page
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Recommendation 43 No social worker shall undertake section 47 inquiries unless he or she has been trained to do so. Directors of social services must undertake an audit of staff currently carrying out section 47 inquiries to identify gaps in training and experience. These must be addressed immediately. (paragraph 6.1)
Timescale for action 2 See table at top of page
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Recommendation 44 When staff are temporarily promoted to fill vacancies, directors of social services must subject such arrangements to six- monthly reviews and record the outcome. (paragraph 6.29)
Timescale for action 1 See table at top of page
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Recommendation 45 Directors of social services must ensure that the work of staff working directly with children is regularly supervised. This must include the supervisor reading, reviewing and signing the case file at regular intervals. (paragraph 6.59)
Timescale for action 1 See table at top of page
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Recommendations: 18 - 35 | 36 - 45 | 46 - 55 | 56 - 63

Recommendation 46 Directors of social services must ensure that the roles and responsibilities of child protection advisers (and those employed in similar posts) are clearly understood by all those working within children's services. (paragraph 6.7)
Timescale for action 1 See table at top of page
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Recommendation 47 The chief executive of each local authority with social services responsibilities must ensure that specialist services are available to respond to the needs of children and families 24 hours a day, seven days a week. The safeguarding of children should not be part of the responsibilities of general out- of- office-hours teams. (paragraph 6.181)
Timescale for action 3 See table at top of page
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Recommendation 48 Directors of social services must ensure that when children and families are referred to other agencies for additional services, that referral is only made with the agreement of the allocated social worker and/or their manager. The purpose of the referral must be recorded contemporaneously on the case file. (paragraph 6.263)
Timescale for action 1 See table at top of page
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Recommendation 49 When a professional from another agency expresses concern to social services about their handling of a particular case, the file must be read and reviewed, the professional concerned must be met and spoken to, and the outcome of this discussion must be recorded on the case file. (paragraph 6.289)
Timescale for action 1 See table at top of page
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Recommendation 50 Directors of social services must ensure that when staff are absent from work, systems are in place to ensure that post, emails and telephone contacts are checked and actioned as necessary. (paragraph 6.318)
Timescale for action 1 See table at top of page
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Recommendation 51 Directors of social services must ensure that all strategy meetings and discussions involve the following three basic steps:
Timescale for action 1 See table at top of page
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• A list of action points must be drawn up, each with an agreed timescale and the identity of the person responsible for carrying it out.

• A clear record of the discussion or meeting must be circulated to all those present and all those with responsibility for an action point.

• A mechanism for reviewing completion of the agreed actions must be specified. The date upon which the first such review is to take place is to be agreed and documented. (paragraph 6.575)

 

Recommendation 52 Directors of social services must ensure that no case is allocated to a social worker unless and until his or her manager ensures that he or she has the necessary training, experience and time to deal with it properly. (paragraph 6.581)
Timescale for action 2 See table at top of page
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Recommendation 53 When allocating a case to a social worker, the manager must ensure that the social worker is clear as to what has been allocated, what action is required and how that action will be reviewed and supervised. (paragraph 6.586)
Timescale for action 1 See table at top of page
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Recommendation 54 Directors of social services must ensure that all cases of children assessed as needing a service have an allocated social worker. In cases where this proves to be impossible, arrangements must be made to maintain contact with the child. The number, nature and reasons for such unallocated cases must be reported to the social services committee on a monthly basis. (paragraph 6.589)
Timescale for action 2 See table at top of page
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Recommendation 55 Directors of social services must ensure that only those cases in which a social worker is actively engaged in work with a child and the child's family are deemed to be 'allocated'. (paragraph 6.590)
Timescale for action 1 See table at top of page
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Recommendations: 18 - 35 | 36 - 45 | 46 - 55 | 56 - 63

Recommendation 56 Directors of social services must ensure that no child known to social services who is an inpatient in a hospital and about whom there are child protection concerns is allowed to be taken home until it has been established by social services that the home environment is safe, the concerns of the medical staff have been fully addressed, and there is a social work plan in place for the ongoing promotion and safeguarding of that child's welfare. (paragraph 6.594)
Timescale for action 1 See table at top of page
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Recommendation 57 Directors of social services must ensure that social work staff are made aware of how to access effectively information concerning vulnerable children which may be held in other countries. (paragraph 6.619)
Timescale for action 2 See table at top of page
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Recommendation 58 Directors of social services must ensure that every child's case file includes, on the inside of the front cover, a properly maintained chronology. (paragraph 6.629)
Timescale for action 1 See table at top of page
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Recommendation 59 Directors of social services must ensure that staff working with vulnerable children and families are provided with up-to-date procedures, protocols and guidance. Such practice guidance must be located in a single-source document. The work should be monitored so as to ensure procedures are followed. (paragraph 8.7)
Timescale for action 2 See table at top of page
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Recommendation 60 Directors of social services must ensure that hospital social workers working with children and families are line managed by the children and families' section of their social services department. (paragraph 8.19)
Timescale for action 2 See table at top of page
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Recommendation 61 Directors of social services must ensure that hospital social workers participate in all hospital meetings concerned with the safeguarding of children. (paragraph 8.27)
Timescale for action 1 See table at top of page
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Recommendation 62 Where hospital-based social work staff come into contact with children from other local authority areas, the directors of social services of their employing authorities must ensure that they work to a single set of guidance agreed by all the authorities concerned. (paragraph 8.53)
Timescale for action 2 See table at top of page
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Recommendation 63 Hospital social workers must always respond promptly to any referral of suspected deliberate harm to a child. They must see and talk to the child, to the child's carer and to those responsible for the care of the child in hospital, while avoiding the risk of appearing to coach the child. (paragraph 8.100)
Timescale for action 1 See table at top of page
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