A local authority criticised in a BBC Panorama investigation has said a “culture of bullying” in its children’s services department is no longer being tolerated.

The half-hour film, broadcast on 16 May, focused on a series of court judgments from 2018 and 2021 that severely criticised practice and management at Herefordshire council, and included critical quotes from social workers who had recently left the authority.

One unnamed practitioner said in the documentary: “It’s a culture of bullying, it’s a culture of control […] it’s not safe for families and it’s not safe for social workers.”

In an interview with Community Care following the programme, Herefordshire’s director of children’s services, Darryl Freeman, said there “clearly was a culture of bullying” at the authority.

But he said that he and chief executive Paul Walker had now made it clear that “bullying will not be tolerated”.

“We’ve called it out, we’ve challenged it where we’ve experienced that and it is not tolerated, it won’t be tolerated, it is just unacceptable.”

Caseloads in high 30s ‘was not uncommon’

Another former Herefordshire council social worker who spoke to Panorama said they had a caseload of 36 when they left after being told the target was 20, which meant “cutting corners and ticking boxes”.

Freeman, who joined the council on an initially interim basis last autumn, said caseloads had been high and rose sharply in the autumn of last year “when there was a real spike in demand”.

“When I took on the interim DCS role at the end of September, it wasn’t uncommon to see some workers with caseloads in the late 30s and 40s,” he said.

Average caseloads down to 21 with target of 18

But he said average caseloads now stood at 21, with only five social workers responsible for more than 25 cases and no one with more than 30.

“Our goal is to get to an average caseload of 18 before the end of the summer and to keep driving down further,” he said.

“We are really clear that if you have a manageable caseload you can have a better relationship with families, you can have much more effective practice.”

Documentary given permission to name social workers

Last month, the High Court granted Louise Tickle – the journalist who made the documentary – permission to name social workers involved in one of the cases it covered, despite Herefordshire arguing this could impede its ability to recruit practitioners.

Freeman said it would have been okay for the documentary to have named himself and Walker “if necessary” but the authority had tried to maintain the anonymity of frontline workers working with current cases primarily to “protect the wellbeing of our staff”.

In the end, Tickle did not name any social workers in her film and Freeman said the production team had been “sensitive” to Herefordshire’s concerns over doing so.

Concern at Panorama’s effect on recruitment

Freeman said managers had been briefing social workers at the council prior to the programme about what they expected the Panorama programme to include and “put in place mental health first aiders and lots of welfare support”.

Nevertheless, Freeman said the response to the documentary had been “sombre” and that he was concerned of a possible negative effect on recruitment and retention.

“There’s always a concern it will have an impact on recruitment and retention in what is already a difficult and challenging recruitment environment,” he said.

Loss of most social workers in past year

As of September last year, Herefordshire had a full-time equivalent (FTE) children’s social work vacancy rate of 19%, above the national average (16.7%) but down from 24.8% the previous year. However, its FTE agency social worker rate had climbed from 19.2% to 32.5%, double the national average.

The documentary said that, in the past year, Herefordshire had lost most (50) of its permanent children and families social workers and that 75% of its child protection practitioners were either less than two years’ qualified or agency staff as of March this year.

Freeman said some of the social workers who left had either retired or took promotions or other jobs elsewhere. But he admitted that some practitioners did leave as a result of a damning court ruling last year that questioned the council’s children’s services’ “fitness for purpose”.

“It was 50% of the overall permanent workforce that existed in April last year and that was across the whole year. That is certainly a higher proportion than you’d like, anyway, but not everybody just left in one go,” he said.

However, the relatively high number of agency staff, Freeman said, was due to the council’s addition of seven extra social work teams last year “focused on reducing caseloads and improving practice”.

“Most of that additional capacity by its nature is locum and agency or project teams for periods of time,” he said. “We will see that reduce because we won’t need all that extra capacity in a year’s time.”

£11.5m focus on boosting permanent workforce

Herefordshire’s recruitment of agency social workers last year was partly funded by a grant from the Department for Education (DfE).

The council has now drawn £11.5m from its reserves to continue improvements to its children’s services and make some of the newly created agency roles permanent.

“That puts us in a very strong position to maintain the additional capacity we have put in place over the past six months or so for the rest of this year and to really push now on reducing our reliance on locum and agency workers as we go forward and increasing the proportion of the workforce that is permanent,” said Freeman.

According to council documents, the £11.5m should pay for 122.75 extra full-time staff in 2022-23 then reducing to an ongoing increase in staffing numbers of 82 from 2023-24, a combination of social workers, managers, business support staff and a few other roles. As of September 2021, the council had 103 FTE children’s social workers.

Freeman said Herefordshire had some agency social workers that it had worked with for up to 12 months and that they had developed good relationships with families, but said it was less expensive to employ permanent staff.

Disputed figure

One figure he disputed in the documentary was that the council had spent £133,000 on two interim senior managers in the first two months of the year.

Freeman said the number was “odd” but was likely due to “a clumsy response to a freedom of information request”.

“I can certainly say that amount of money wasn’t paid to two senior interim members of staff during that period of time,” he said.

“But employing interim social workers and managers is more expensive than employing permanent social workers and managers and that’s another reason why we want to increase the proportion of the workforce that’s permanent going forward. It’s good for families and it’s good for the public purse as well.”

Gearing up for next Ofsted inspection

Herefordshire was rated as ‘requires improvement’ in its last inspection in 2018 and is currently working with a DfE-appointed independent adviser, Gladys Rhodes White, and improvement partner Telford and Wrekin council.

Freeman said the council said he expected another inspection before the end of this year but would not say what grading he expected to achieve.

“They will find us as they find us, but it will comes as no surprise to anybody that there are still some challenges for us,” he said.

“We are doing the right things now to improve practice and to improve the support for our social workers but it is still going to see a bit of time before they see that consistently reflected in improved outcomes for children and young people.”

Frontline has a lower social work qualification rate than other fast-track programmes, according to data from the providers.

About 90% of Frontline candidates completed the first year of the programme – thereby earning a social work qualification – in the three most recent intakes: 2018-19 (91%), 2019-20 (88%) and 2020-21 (90%).

This was below the completion rates for Step Up to Social Work’s three most recent intakes, which were 95% in 2016-17 and 96% in each of 2018-19 and 2020-21. Like Frontline, Step Up is focused on training practitioners to work in children’s services.

For Think Ahead, which trains social workers to work in adult mental health services, primarily, 94% completed their first year, earning a post-graduate diploma in social work, in the most recent intake (2020-21), with 92% doing so in the two previous ones, 2018-19 and 2019-20.

While the three courses have differences, they are of similar lengths (around 14 months), involve similar levels of financial support for students (tax-free bursaries of between £17,000 and £20,000 with no tuition fees) and involve the trainee being placed in a host local authority or – in Think Ahead’s case – an NHS mental health trust. Both Frontline and Think Ahead have a second year in which trainees are expected to complete a master’s degree alongside their assessed and supported year in employment.

Lack of comparable figures for university courses

There are no comparable figures available for university undergraduate courses – which tend to be over three years if done full-time – or postgraduate schemes, which tend to be two years full-time.

Ninety-three per cent of those who left university social work courses in 2018-19 achieved a qualification (91% for undergraduate and 96% for postgraduate), according to Skills for Care’s most recent report on social work education. But it did not report figures for the proportions of degree starters who successfully completed their courses, which may be lower than Frontline’s figure.

However, university courses are not directly comparable to fast-track ones as they are longer and offer much less financial support; students pay tuition fees and are not guaranteed a bursary which, in any case, is of much lower value than those provided to fast-track students.

Differences in intake

An academic source suggested that Frontline’s lower completion rate than Step Up could be to do with differences in intake. Step Up trainees must have significant experience of working or volunteering with vulnerable children. The programme draws from people working in similar fields to children’s social care, who may be expected to have committed to social work and so be more likely to complete their course.

Frontline targets high-achieving graduates who may not otherwise have considered a career in social work and who, because of their academic records, could choose other career paths if they decided social work was not for them, the source suggested.

‘We want as many to complete as possible’

A spokesperson for Frontline said it wanted “as many participants as possible” to complete both years of the programme.

“Our aim is to develop excellent social workers ready for a career in child protection social work, and the Frontline programme has been designed to ensure participants are prepared and equipped with the skills and resilience they will need to do their best work for children and families,” the spokesperson said.

“We know this is a challenging career, which is why we have strong support systems in place. But, if after all the extra help and support someone decides the programme is not for them, then we support their decision to leave.”

A spokesperson for Think Ahead said: “We always look to increase the number of trainees who qualify and who complete the programme.

“We prioritise their wellbeing and support the trainees to give them the possible chance of success. Our aim is to recruit and train excellent, compassionate social workers that will make a difference to people with mental health problems, and we are always looking for ways to improve and achieve that goal.”

Completion gap ‘of concern’

The Joint University Council Social Work Education Committee (JUCSWEC), which represents university social work academics, said it was “of concern” that completion rates for Frontline and Think Ahead were lower than for Step Up during the same period.

The spokesperson said the data needed to be “treated with caution” because of the possible impact of Covid-19 on completion rates across all types of social work course, adding: “Further analysis of this is needed including once data for mainstream programmes are available for the same periods.”

The news comes after the Department for Education (DfE) extended Frontline’s contract to deliver fast-track training for another year, meaning it will offer a programme starting in 2023, at a cost of £22.6m.

In December of last year, the DfE started consulting with potential providers on a contract  for an £80m Frontline-style social work training scheme starting in 2024, but it has not yet issued the tender.

The contract would replace the provision currently offered by Frontline and run for four cohorts.

“Serious procedural failings” led a council to wrongly assess that a man presented a risk to his son, the Local Government and Social Care Ombudsman has found.

The watchdog found it unfairly excluded the man (“Mr F”) from the child protection process and unjustifiably decided that he misused alcohol, which led it to believe he was a risk to his son.

Gloucestershire council has apologised to Mr F and paid him £1,100 in compensation for injustice and the “serious harm and distress” its decision making caused him.

The authority has also agreed to amend its formal records in relation to the case and carry out an in-depth review into what went wrong, reporting by next month.

Alcohol misuse concerns

The council decided to carry out a child and family assessment of the family in October 2020, after Mr F’s son sustained an injury – which records showed was not caused by his father – and was also displaying challenging behaviours.

During the assessment, some of Mr F’s relatives raised concerns that he was a regular drinker and this resulted in arguments in the family home. The council did not contact Mr F for his views and input on this issue.

In mid-December that year, Gloucestershire held a strategy meeting and decided to initiate a section 47 child protection enquiry, for which it took into account a 2006 conviction Mr F incurred for driving under the influence of alcohol.

The council’s social worker also noted that Mr F’s son had reported seeing his father drinking while in the family home. The council decided Mr F was “drinking too much alcohol” and this could present a risk to his son’s emotional stability and wellbeing.

Father not involved in section 47

On the back of the enquiry, the council decided to convene an initial child protection conference (ICPC) – implying that concerns of significant harm had been substantiated – with the section 47 outcome document referencing Mr F’s 2006 conviction as evidence of alcohol misuse and domestic abuse.

However, Gloucestershire did not contact Mr F for his views or input during the section 47 enquiry. The council’s social worker only met Mr F in early January 2021, after it had decided to convene the ICPC.

During this meeting, the social worker expressed concern relating to Mr F’s drinking, which he denied, saying he was not currently drinking because of the Covid-19 restrictions in place at the time.

In preparation for the ICPC, the social worker prepared a conference report, which the ombudsman said was “unequivocal” that Mr F misused alcohol, his son witnessed it and he domestically abused his then partner.

It also said Mr F had admitted drinking too much alcohol, which Mr F denied to the ombudsman, saying drinking was something he only did socially.

Delay in sharing report

The conference report was not shared with Mr F until March 2021, however, the council’s social worker said that they read this, as well as the child and family assessment report, to him over the telephone four days before the ICPC.

In preparation for the ICPC, another social worker assessed the family. The resulting “families first” report also referred to alcohol misuse by Mr F, and said it was difficult to comment on Mr F’s views due to limited contact with him and that, when present, he had not expressed any views about the situation.

In mid-January 2021, the ICPC determined that the threshold for significant harm to Mr F’s son had not been met and that the case could continue to be managed under a child in need plan with supportive strategies being implemented for the family.

Mr F said in that meeting that he had not had a lot of involvement in the child protection process. He told the ombudsman that he did not receive the minutes of the ICPC until May 2021.

‘No reasonable excuse’ not to involve father

As specified by Working Together to Safeguard Children, the ombudsman said that parents and carers should be interviewed by social workers as part of a section 47 process.

However, though it had ample time and opportunity to include Mr F in the process within the 15-day timescale set by Working Together, the watchdog found that it excluded him.

“There was no reasonable excuse for this and so I find the council was at fault and that this had the effect of undermining the accuracy and rationality of the conference report and s47 enquiries more generally,” found the ombudsman.

While the social worker carrying out the families first assessment said it was difficult to comment on Mr F’s views because he did not express them, the watchdog agreed with the man that he felt unable to because he was “so estranged from the process”.

Acting contrary to Working Together

“I consider my assessment so far supports Mr F’s view that he was unable to provide sufficient input due to the exclusionary process undertaken by the council’s social worker,” said the ombudsman.

The report also found that the council acted contrary to Working Together in not making sure that Mr F understood the purpose of the ICPC, leaving him unprepared for the meeting.

While the social worker said that they had read him the report over the telephone a few days before, the ombudsman concluded that they did not read the full report because of its length (about 8,500 words). In addition, it was not good practice to run through the report over the telephone in any case, the ombudsman found.

‘Unjustifiable weight given to family view’

The report also said that it was “wholly unsatisfactory” that social workers formed a judgment that Mr F misused alcohol without discussing it with him.

This was based on the perception of family members – primarily that of his ex-partner – that he was a regular drinker and he argued with his ex-partner when he returned from the pub.

The ombudsman found the council “unfairly attached greater weight” to family perception without justifiable reason, when Mr F had firmly denied he misused alcohol. The ombudsman also said he “[failed] to see the merits and coherency in the council’s perception that regular drinking and arguments between partners amounts to a fully evidenced judgment of alcohol misuse”.

‘Manifestly unfair and improper’

In addition, the report found “no analysis or evidence by the council” that Mr F’s 14-year-old conviction for driving under the influence was a relevant factor in the child protection process.

“I therefore consider it was manifestly unfair and improper for the council to have regard to this conviction in its assessment of presenting Mr F as someone who misuses alcohol in present day,” it added.

The ombudsman also found there to be a “fundamentally inaccurate” reference to police information supporting a concern of domestic abuse by Mr F towards his ex-partner, in the child and family assessment report, as there was no such information on police records.

‘Serious harm and distress’

“I believe Mr F has suffered serious harm and distress by reason of the faults identified,” the report concluded. “He has suffered an injustice.”

The ombudsman said he could not direct the council to restart the child protection process with Mr F’s involvement, as it had already been completed. But the report said Mr F had the right to have the council’s failings acknowledged by having the authority’s records amended, which Gloucestershire has agreed to do.

It has also agreed to the watchdog’s recommendations to:

• Send Mr F a detailed written apology at a senior level which acknowledges each area of fault and injustice identified by the ombudsman.
• Pay Mr F £1,000 for the “serious distress and emotional difficulty” its failings have caused him, plus an extra £100 for his time and trouble pursuing the complaint.
• Carry out a detailed review into the failings, focusing on the reasons why Mr F was excluded from the child protection process and why a view of alcohol misuse was supported despite little engagement with him.
• Provide additional training to the lead social worker involved in the case related to each identified failing.
• Review its information sharing procedures to ensure all parties involved in the child protection process are given timely information to prepare and provide input at key milestones.

Council accepts findings

A spokesperson for Gloucestershire council said: “The council fully accepts the findings of the ombudsman in this matter and regret that our service fell below the standards we would normally provide.

“We have formally apologised to Mr F and put in place a number of remedies to improve our practice as agreed with the ombudsman, to prevent this happening again.”

Social workers who are “passionate and knowledgeable about children’s needs” have helped a council improve from ‘good’ to ‘outstanding’, despite “continuous workforce challenges”.

In a report last week, Ofsted praised Derby council’s successful implementation of a strengths-based practice model, against the backdrop of Covid-19, for enabling practitioners to support children well and improving supervision.

Senior leaders had taken “creative” action on social worker recruitment and retention to ensure practitioners’ caseloads remained “manageable” in a “challenging” workforce environment, it added.

‘Passionate and knowledgeable’

Ofsted found the council had made progress on all the recommendations from its previous inspection in 2017.

The biggest improvement was in Derby’s services for children in need of help and protection, which were ‘requires improvement’ in 2017, but ‘outstanding’ in the latest report, with inspectors finding children received a “consistently high-quality service”.

Ofsted said social workers were “passionate and knowledgeable about children’s needs”. “Comprehensive” assessments captured children’s views and wishes, used family history to identify risks and considered children’s culture and identity, while plans were also of “consistently good quality”.

This was supported by the practice model, which helped staff ask difficult questions to help parents and children understand why services were involved with them.

Ofsted said that staff had “embraced” the model and used it “consistently and effectively to support children”.

New practice model leading to improved supervision

In rating leadership as outstanding also, inspectors praised senior managers for successfully implementing and embedding the model during the pandemic.

It said the model had “shaped and improved the quality of supervision and management oversight” and provided clear evidence of the rationale for decision-making.

Overall, supervision was “regular and generally of a good standard, combining management direction with opportunities for reflection and individual support”, Ofsted added.

Inspectors also praised leaders for sustaining social work recruitment and retention “in a challenging environment”, to ensure that most social workers had manageable workloads.

Derby’s turnover rate for social workers almost doubled, from 8.8% to 15.2%, from 2019-20 to 2020-21, as did its agency worker rate, from 6.5% to 12.1%, according to Department for Education figures.

This brought turnover up to the national average though Derby’s agency worker rate remained significantly below the England-wide rate of 15.5%.

According to the DfE’s measure – which is controversial with practitioners – Derby’s average caseloads edged up, from 17.4 to 18.3, between 2020 and 2021, above the national average of 16.3.

Leaders ‘accessible and supportive’

Inspectors also said social workers consistently reported that senior leaders and managers were accessible, supportive and keen to hear their views about how services could be improved. Staff also appreciated the council’s continuing professional development offer, including a series of lunchtime learning events.

The one area not rated outstanding was provision for children in care and care leavers, which retained the good grade Derby obtained in 2017.

As with children in need of help and protection, inspectors said assessments were comprehensive, and praised the quality of care planning, as well as oversight by independent reviewing officers.

Social workers visited children regularly, helping to build trusting relationships, however, some children said they had too many changes of practitioner and had to repeat their stories.

While some children benefited from good-quality life story work, not all did, though the report pointed out that senior leaders had invested in this area, including by recruiting a practitioner to support social workers to carry it out.

Insufficient care placements

Ofsted found that children who needed permanent care lived with carers who met their needs and most made good progress.

However, it said there were not enough placement options for children who needed care, and that sufficiency was “a continuous challenge”.

“This means that some children live outside Derby, resulting in changes of school and more complex arrangements around family time,” its report said.

It said there continued to be an overall shortfall of foster carers in Derby but that their number was increasing following targeted recruitment campaigns.

In relation to care leavers, Ofsted praised “passionate” and “committed” personal advisers, who invested in building strong relationships that made young people feel valued.

Andy Smith, Derby’s strategic director of people services, said: “Our staff are dedicated to seeking the best outcomes for Derby’s children and work incredibly hard in what is a challenging, but ultimately rewarding job.

“To be rated outstanding is a real achievement and a testament to their passion and hard work. We’ve come a long way in five years but we know there is still work to be done to be even better, and we have plans in place for this.”

Story updated 17 May 2022

A BBC Panorama investigation has sought to highlight the “traumatic” effect on families when the state intervenes badly in their lives.

The half-hour film, broadcast on 16 May, focused on a series of court judgments that severely criticised practice and management at Herefordshire council, as well as two other cases of families who felt failed by the authority when it took their children into care.

Journalist Louise Tickle said her programme – for which she was given court approval to name individual social workers and families – focused on how the cases affected the children and their relatives.

“It absolutely does blight children’s lives.” she said. “Many of them will never recover from the intervention of the state into their families when it is done badly.”

She said she also wanted the programme – for which she spoke to social work experts and practitioners who used to work for Herefordshire – to shine a light on a severely overstretched family justice and child protection system and the extent to which it militates against good practice.

Damning judgments

A High Court ruling last year found social work teams at Herefordshire council ignored the concerns of a senior judge and the advice of a psychiatrist in pursuing a plan for special guardianship orders (SGOs) for four children who had made false allegations of sexual abuse against their parents.

The children did not see their parents for eight years, during which time one child died of a serious illness. Giving judgment, Mr Justice Keehan said the decision making in the case called into question the “fitness for purpose” of the council’s children’s services, prompting the Department for Education to issue an improvement notice on Herefordshire.

The local authority was previously criticised by the same judge in three court judgments in 2018. In one case, Mr Justice Keehan said that 14 children in Herefordshire had “wrongly and abusively” been in section 20 care arrangements for a “wholly inappropriate lengthy period of time”, and should have been the subject of legal planning meetings or care proceedings much earlier.

In a second judgment that year, he condemned social workers who had misrepresented and failed to disclose evidence during adoption proceedings that separated twins. This case was featured in the Panorama programme, for which Tickle interviewed the adoptive parents for each twin; their words were spoken by actors in the programme.

The programme also featured the other case from 2018, in which Mr Justice Keehan criticised Herefordshire’s “woeful” treatment of two half-sisters who suffered emotional and psychological harm as a result of chaotic care planning over a period of years. Tickle interviewed one of the sisters, whose words were also spoken by an actor.

Challenging reporting restrictions

Tickle first planned to investigate Herefordshire council’s children’s services in 2018 after the three damning judgments of that year, but she was prevented by legal restrictions designed to protect the identity of families involved. Specifically, section 12 of the Administration of Justice Act 1960 (s12) prevents the publication of information relating to proceedings under the Children Act 1989 or Adoption and Children Act 2002, where a court sits in private, as is invariably the case.

But after the High Court ruling last year, Tickle said she was “so aghast at what this local authority had seen fit to do”, she applied for permission to challenge the application of s12 in these cases, on public interest grounds.

Tickle obtained an order last year from Mr Justice Keehan enabling her to speak to and quote, with their consent, anyone involved in the four cases. She could also name and film them if they agreed, except in the one ongoing case.

“I have found out some pretty awful stuff,” she said. “[The 2021] case has very severely traumatised the children and the mother involved.”

Earlier this month, she also obtained court permission to name and film a mother in a separate case, who had three children placed in Herefordshire’s care in 2018 because of allegations of fabricated and induced illness before she successfully had the care order discharged in 2020. The woman, Angeline, was featured in the programme.

Permission to name social workers

In that judgment, the High Court also granted Tickle permission to name social workers involved in the case despite the local authority arguing that doing so could impede their ability to recruit practitioners.

Mrs Justice Lieven said was “extremely aware of the problems with the recruitment of social workers nationally and in the Midlands” and that the “role of a social worker is an enormously difficult one”.

But she said the provisions of s12 were to protect the “best interests of the children”, not the local authority.

She also said that social workers in the Herefordshire cases “[were] not being made subject to a campaign of harassment” and were therefore “no different to any individual who may be commented upon or criticised in a public broadcast”.

“Ms Tickle and the BBC are undertaking a documentary programme with all the journalistic standards that are applicable,” she said. “For those reasons I do not conclude that there is a justification for anonymity.”

Tickle said: “We fought against the idea that a local authority, an arm of the state, could prevent the press from naming people who were not currently involved with a family or had done something wrong, or indeed who were currently involved with the family but were senior members of the council.”

However, the programme did not name individual social workers or managers.

Arthur and Star review ‘may trigger more risk-averse practice’

Tickle’s programme comes ahead of the publication of the national review into Arthur Labinjo-Hughes and Star Hobson’s deaths.

Tickle said she expected the review to “make social workers feel absolutely as if they must be risk averse at all costs”, potentially leading to a spike in child protection investigations and children being taken into care, as followed the reviews in the wake of the Baby P case.

The number of children in care in England reached a record high of 80,850 in 2020-21, according to Department for Education figures, although the number of children entering care was at its lowest in nine years, the high care population being driven by fewer children leaving care.

According to figures from the annual children in need census, child protection enquiries in England under section 47 of the Children Act 1989 increased by 126.7% from 2009-10 levels to 198,790 in 2020-21, though this total was lower than for the previous two years.

Tickle said a culture of risk aversion was preventing good social work with children and families.

“Senior social workers have told me that that actually prevents them from doing good, targeted social work with families that need it because everybody is so incredibly petrified that they are busy doing investigations, of which many go nowhere,” said Tickle.

Tickle’s programme also highlighted staffing pressures in Herefordshire including high turnover, a lack of experience and high use of agency staff and interim managers. She also identified that there were 10 senior managers who had moved from one struggling authority to another, often in interim roles, over the past eight years.

Use of interim manaers ‘no way to build a service’

On the programme, she asked Ray Jones, emeritus professor of social work at Kingston University and St George’s, University of London, whether this was a good use of public money.

“No, not at all,” said Jones, who is currently leading a review into children’s services in Northern Ireland and has previously supported struggling authorities to improve. “Partly because you can’t do the job you’re here to do if you’re here today, gone tomorrow. I think people see them as a source of expertise, a source of holding things together at that point in time, and both of those points are right. But it’s not a way of building a service that will be strong for the future.”

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Tickle told Community Care that the family courts were also “completely overstretched” and that overall “the seams have gone” from the children’s social care system “and there are people just desperately trying to sew them up”.

“In the middle of this there are families who are deeply traumatised by the kinds of interventions that are not helpful. Meanwhile, families who need help and support are not getting it and children who desperately need to be removed, social workers don’t have time to make those assessments accurately. It is a horrible mess,” she said.

‘The state is doing harm’

Tickle’s programme also comes ahead of the publication of the government-commissioned children’s social care review’s final report.

She was unable to speak to review lead Josh MacAlister for the programme about his potential recommendations, but she said, “something has to change in the way children’s social care is both funded and in how they approach their work with families because whatever is happening now, it is not working”.

She said the practice of children in care “being sent from pillar to post around the country to different foster carers and residential children’s homes” was leading to them being “hugely traumatised”.

“Their links with their families and particularly with their siblings are being broken, and the state is doing harm,” she said.

Tickle said everyone was “understandably horrified” by child deaths but that there was a “less obvious trauma”, of social care intervening wrongly in people’s lives, that will “blight” children’s and families’ futures.

“I have seen the results of this by talking to the people involved in these cases. It is not as easy to understand and not as easy to talk about and not as easy to quantify,” she said.

BBC Panorama’s Protecting Our Children: A Balancing Act was screened on Monday 16 May 2022 and is now available on iPlayer

“Exceptional” direct work and strong leadership have helped a London council improve to ‘outstanding’, despite a spike in vacancies last year.

Ofsted upgraded Merton from the good rating it earned in 2017 after finding “skilled, experienced” professionals were making a positive difference to children’s lives, backed by “highly aspirational” leaders who had “strengthened and built on the impressive work at the time of the previous inspection”.

The improvement came despite government figures showing the council’s full-time equivalent social worker vacancy rate more than doubled, from 15.7% to 37%, from September 2020 to September 2021, with its agency worker rate rising from 18.2% to 33.4% over the same period. The turnover rate in the year to September 2021 was 30.6%, double the rate from 2017-18, since when it has increased year on year.

Ofsted noted that “an increase in staff turnover means that a small number of families experience too many changes of social workers”, but highlighted leaders’ efforts to recruit social workers and keep caseloads manageable amid fast-rising child protection demand.

‘Exceptional’ direct work

In a report this week, inspectors praised the quality of direct work with both children in need of help and protection and those in and leaving care.

Though rating the authority as good, rather than outstanding, for help and protection, Ofsted found “exceptional examples” of social workers using direct work tools to evaluate the impact of parental vulnerabilities while keeping a clear focus on children’s safety.

Inspectors said practitioners used these tools to help children with complex needs manage their behaviours and express their views, while for vulnerable teenagers, “skilful direct work” was helping them develop strategies to leave harmful situations.

Ofsted found social workers exhibited “trauma-informed therapeutic practice” and praised the care they took to understand family histories, cultural heritage and each child’s unique and diverse needs.

‘Highly skilled, well-trained social workers’

Ofsted said Merton’s services for children in care and young people leaving care were outstanding, having previously rated them as good. Inspectors found “highly skilled, well-trained” practitioners were using a wide range of direct work tools to understand children’s histories and identities and build trusting relationships with them.

Tailored mental health support, both from the co-located CAMHS service and skilled social workers, was helping build children’s resilience and preventing placement breakdown, said Ofsted.

The inspectorate said the council was “dedicated to pursuing timely permanence for all children if they cannot live safely with their birth families”. Most children in care and care leavers lived in “safe, stable, good-quality homes that meet their needs”, where appropriate, with siblings or extended family, found inspectors.

Ofsted praised the impact of an increase in the number of personal advisers, who it said advocated “tenaciously” for care leavers to ensure they received the best support to move safely into independence. This involved maintaining close contact, including when young people were out of area or in custody, providing support beyond the age of 25 where necessary and encouraging young people to attend regular health checks.

Leaders ‘listening to staff’

In rating leadership as outstanding, inspectors said senior managers had invested considerably in professional development, “leading to sophisticated and transformative direct work with children and families”.

Leaders also listened to staff, for example, by adapting and expanding Merton’s practice model when social workers said they found it too restrictive.

Management oversight supported robust practice in most teams working with children in need of help or protection, while quality assurance activity had “driven up standards across the service”.

‘Nimble’ response to Covid demand spike

The inspectorate also praised leaders for a “nimble” response in bringing in “much-needed” additional social work resource due to a substantial increase in the number of children on child protection plans during the pandemic.

Amid the authority’s staffing pressures, Ofsted said Merton had a “relentless focus” on recruitment and retention of frontline managers and social workers, which was increasing the number of permanent staff.

It said leaders were keeping caseloads manageable, “providing staff with the space and opportunity to get to know their children and families very well”.

Average caseloads at September 2021 were 14.4, in line with the average for London but down from 16.8 in September 2020, according to the Department for Education’s annual workforce statistics.

In terms of areas for improvement, Ofsted said some children who entered care in an emergency were not taken to foster carers by social care staff, and that the quality of work by out-of-hours staff in these situations needed to be better.

It also found that care leavers had to accept their first housing offer or risk losing priority status, and the authority needed to be more flexible, though inspectors pointed out that Merton was addressing this.

‘Ringing endorsement’

Eleanor Stringer, cabinet member for children and education at the time of the inspection, said the outstanding rating was “a ringing endorsement” of the work children’s services staff had done over the past five years.

“I’m particularly proud that Ofsted recognised how staff went above and beyond the call of duty during the pandemic to continue to provide excellent services despite the disruption involved and I’d like to thank everyone for their hard work over the past few years,” she said.

“The team are a credit to the borough, and I’m proud that as a council we have supported and protected our children’s services throughout a challenging period.”

Social workers’ quality of working life continued to decline following the end of Covid lockdown measures despite other frontline professionals reporting improvements, according to a new study.

Phase four of the Health and Social Care Workforce Study, covering November 2021 to February 2022, found social workers were more likely to feel burnt out than social care workers, nurses and allied health professionals.

Social workers reported an increase in burnout related to working with service users, while most other professionals were less burnt out on this measure than in phase three, which covered May to July 2021, as the country was reopening from the last lockdown.

But social workers’ overall wellbeing recovered from phase three to four, as it did for other professionals.

Quality of working life continues decline

Respondents’ quality of working life, assessed using the Work-Related Quality of Life (WRQOL) scale, increased on average across all professions in phase four of the study, from 72.45 to 75.42.

This is the first increase recorded by the study but still lower than the 77.59 recorded in phase one, which covered May to July 2020.

But researchers found social workers’ quality of working life continued to decline, with scores of 68.92 on average in phase four, compared with 69.92 in phase three, 73.67 in phase two and 80.63 in phase one.

All other professions’ quality of working life recovered from phase three to phase four, apart from midwives, who reported a decline from 64.35 to 63.76.

The WRQOL scale asks professionals to say to what extent they agree with a series of work-related statements on career satisfaction, stress at work, general wellbeing, home-work interface, control at work and working conditions.

Scores of 71 or under indicate a lower quality of working life.

Credit: Ulster University

Practitioners burnt out by work with service users

Social workers’ ‘client-related’ burnout – defined as the extent to which they feel “prolonged physical and psychological exhaustion” perceived as being related to work with clients – increased from phase three (32.56) to phase four (32.9), while it dropped in all other professions except midwifery.

The study found that a lower proportion of social workers were suffering from high or severe client-related burnout but more experienced moderate burnout between the phases.

However, a score of 49 or lower is considered low, according to the Copenhagen Burnout Inventory, which was used to assess participants.

Practitioners’ burnout levels were higher for the two other domains – ‘personal’ and ‘work-related’ – but both fell from phase three to four, from 67 to 65.08 and from 64.06 to 63.45, respectively. These are considered moderate.

However, burnout levels across all three domains were higher for social workers than in phase two of the study (November 2020 to February 2021), as was the case across professions.

“Burnout scores had decreased UK wide, suggesting that overall health and social care workers are under less stress in their jobs, despite several people mentioning burnout among themselves or colleagues in the focus groups and open-ended survey questions,” the study authors said.

“Client-related burnout, however, has continued to rise amongst social worker respondents, suggesting that interactions with service users are more challenging and higher caseloads may be increasing burnout.”

Credit: Ulster University

Overall wellbeing recovers

Overall wellbeing among all professions increased on average from phase three to four, the study found, with social workers’ increasing from 19.31 to 19.95. This was measured using the Short Warwick Edinburgh Mental Wellbeing Scale, which asks people how they have felt over the previous two weeks. Scores range from 7 to 35, with 18-20 indicating a possible case of anxiety or depression.

But all occupational groups showed a decrease in their overall mean wellbeing scores from phase one (May to July 2020) of the study to phase four, except nurses, with social workers’ score falling from 21.14.

Social workers and midwives’ overall wellbeing also remained lower than they were for phase two (November 2020 to February 2021) of the study, unlike for other professions.

Staff shortages over winter

Most respondents to the survey from all professions said their services were short-staffed due to Covid-related illnesses and shielding from the virus during a spike in infections in late 2021 and early 2022.

Social workers and other professionals also said recruitment and retention difficulties were exacerbating the pressures they were already facing from colleagues’ sickness absences.

One practitioner in England said they felt an increasing pressure as they had not been able to see and talk to colleagues face-to-face.

“Social work is innately problem solving, but not having a team base and continued uncertainty after so many months uncertainty takes its toll on us all. Morale is hard to keep up.”

Another in Northern Ireland said the pandemic continued to have a “significant” impact on social work education and the training of new staff due to much of the teaching being done online.

“There are limits to learning from direct work with service users. Many social workers are under so much pressure that they don’t have time for learning and development.”

Another survey respondent said that “there is a culture within social work of ‘just get on with it’”.

‘More recognition could help exhausted workers’

“The survey findings reveal that the health and social care workforce is continuing to struggle with the work changes from the Covid-19 pandemic,” the study authors said. These changes have increased work demands, increased staff burnout and stress, reduced staff morale and job satisfaction.”

“More recognition could help already exhausted workers with greater peer and management support. The changes to working conditions have been additionally frustrating inability with high vacancies and turnover and difficulties recruiting new staff.

“With increased workloads and changing working patterns, managers and human resource professionals have been dealing with the brunt of staff frustrations and backlash, this alongside a lack of recognition and understanding needs addressing as we progress through this next stage of the pandemic.”

SWU: ‘Social workers must feel valued’

John McGowan, general secretary of the Social Workers Union (SWU), said he was not surprised that practitioners were continuing suffer from burnout.

“Employers need to understand that to improve morale across their team, every member of staff needs to feel valued,” he said. “Some of the best protections from the impact of high turnover of staff are manageable caseloads and high quality, regular and reflective supervision, as well as improving administrative processes to enable for more direct and preventative. However, these protective measures are harder to achieve against a backdrop of funding cuts and an increasing number of children, families, adults and communities in need of help and support.

“Social work needs to be properly funded to retain the workforce and protect vulnerable children and adults. Funding for social work services has always been a major issue. One of the biggest crisis areas is local government budget cuts which have significantly increased financial pressures on the social care system.”

‘Inadequate’ authorities bore the brunt of a sharp rise in children’s social workers leaving their jobs last year, a Community Care analysis has found.

Turnover at English councils currently rated inadequate by Ofsted increased by 4.6 percentage points on average, from 2019-20 to 2020-21, more than double the 1.9-point rise nationally that took turnover to 15.4%, the highest in five years. Three of the 19 current ‘inadequate’ authorities acquired their ratings after September 2021, the end of the period covered by the turnover data.

The average turnover rate was relatively static at councils now rated requires improvement, while it rose by 2.1 points at ‘good’ authorities and by 1.7 points at those now graded outstanding, found our analysis of current Ofsted ratings and Department for Education workforce data.

Turnover now clearly linked to rating

Unlike last year, when we carried out a similar analysis, there is now a clear relationship between Ofsted grade and turnover rate: the higher the service’s inspection rating, the lower its social worker churn in 2020-21.

As was the case last year, the higher an authority’s Ofsted grade, the lower its agency worker, vacancy and sickness absence rates, and caseloads, as measured by the DfE.

Relationship between Ofsted ratings and workforce indicators

Separate DfE research has found social workers at ‘inadequate’ authorities were more likely to work longer hours and less likely to find their jobs fulfilling.

Calls for Ofsted overhaul

The findings prompted calls for Ofsted’s inspection regime to be reformed to ensure that it did not deepen the sector’s retention problems, ahead of the forthcoming report of the children’s social care review.

The review has implied it may recommend changes by highlighting the impact of negative Ofsted ratings on retention and by questioning the current inspection regime’s value in assessing what matters to children and families.

Ofsted has pledged to reassess its inspection regime in the light of the care review’s recommendations and, in response to our analysis, said that it recognised that workforce pressures were greater at ‘inadequate’ councils.

Sharp rise in social workers leaving ‘inadequate’ councils

The average full-time equivalent (FTE) staff turnover rate at currently ‘inadequate’ councils rose from 13.6% in 2019-20 – in line with the average for all authorities – to 18.2% in 2020-21, well above the national average (15.4%).

Turnover rates at ‘outstanding’, ‘good’ and ‘requires improvement’ councils were 13.8%, 16% and 16.3%, respectively, in 2020-21.

While the DfE data showed the national vacancy rate rising from 16.1% to 16.7% from September 2020 to September 2021, the gap between the best and worst-rated authorities grew.

Those now rated outstanding bucked the national trend by reducing their average vacancy rate by 1.5 point to 7.7%, while the average rate for currently ‘inadequate’ councils grew by 1.9 points to 26.3%.

However, a sharp rise in vacancies among authorities now classed as ‘good’, amid a fall among ‘requires improvement’ councils, saw the middle two groups coalesce around the national average: 16.6% for ‘good’ councils and 17% for those rated requires improvement.

Agency staff usage the biggest divide

Use of agency staff remained the biggest divide between ‘inadequate’ and ‘outstanding’ authorities, with the former (26.7%) having average rates that were almost four times the latter’s (6.9%).

Again, there was compression in the middle, with those currently rated requires improvement seeing their agency rate fall by 0.9 points to 16.4% on average, with currently ‘good’ councils using more locums on average (16.1%, up from 14.5%).

Sickness absence also increased by the most at currently ‘inadequate’ authorities, with 3.6% of working days lost on average per full-time equivalent social worker in 2020-21, up from 3.1% for the same authorities in 2019-20. Rates flatlined at ‘outstanding’ councils at 2.4%.

‘Outstanding’ local authorities had an average caseload of 15.5, for ‘good’ councils it was 16.2, for ‘requires improvement’ authorities 16.8, and ‘inadequate’ ones 17.4 as of September 2021, according to the DfE. However, practitioners have criticised its measure as an underestimate and the department has said the figure should be treated with caution.

Longer hours and less job satisfaction

The findings chime with other data on the experiences of practitioners at differently-rated authorities. Notably, the latest wave of the DfE’s longitudinal survey of children’s social workers, published last year, found that staff in ‘inadequate’ authorities were more likely to work more than 45 hours a week (36%) than those in ‘outstanding’ (24%), ‘good’ (22%) or ‘requires improvement’ (26%) councils.

It also found that those at ‘inadequate’ and ‘requires improvement’ councils (70%) were less likely to find their jobs satisfying than those at ‘good’ (72%) or ‘outstanding’ (79%) authorities.

Particular challenges for ‘inadequate’ authorities

In response to our findings, an Ofsted spokesperson said: “All local authorities face challenges in staff turnover, vacancies and the use of agency staff, and we recognise that these are particularly difficult for those judged to be inadequate.

“We also recognise that, when a local authority is rated inadequate, and subject to the Department for Education intervention, it can lead to a regional, or sub-regional, challenge as it seeks to draw in staff from stronger surrounding councils to enhance its improvement journey.

“The availability of a stable, skilled workforce is one the toughest challenges facing the sector, particularly as we come out of the pandemic when many staff have reassessed their work and career priorities.

“Government – both central and local – need to work together to meet the needs of the sector.”

Care review set to report

The figures come with the care review – led by Josh MacAlister – considering the future of Ofsted’s inspection regime for local authorities, ahead of its upcoming final report.

In the review’s ‘case for change’ last year, it said the sector was “over-reliant on Ofsted ratings as a metric of success” and questioned whether they “measure the things that matter to children and families”.

It also noted that turnover and levels of inexperienced staff were higher at local authorities rated ‘inadequate’, which it said created “a spiral of increasing workload pressures for the remaining staff”.

Since the case for change’s publication, social workers have made representations to the review on the need to reform the inspection regime, to tackle levels of paperwork, make practice less risk-averse and improve retention.

In its recently published five-year strategy, Ofsted pledged to review its social care inspection system in light of the recommendations of the care review, while our analysis prompted further calls for reform.

‘Social workers repelled by poor rating’

David Wilkins, senior lecturer in social work at Cardiff University, who has researched the factors driving Ofsted performance, said social workers did consider inspection ratings when choosing which council to work for, so ‘inadequate’ judgements could repel potential applicants.

“If you look at it from the perspective of an individual social worker, particularly if they are working in an area with lots of different local authorities, why wouldn’t you want to work for an authority that has been rated outstanding and has been officially recognised as providing good supervision?” he said.

Wilkins argued that this “knock-on effect” from Ofsted inspections meant the inspectorate’s current process should be reassessed.

“Ofsted’ ultimate purpose is to improve services, not just to inspect them,” he said. “So, I think you have to then ask, ‘is the current mechanism of inspection a good way of improving services?’ If it is leading to things like retention problems in councils that are already struggling, then maybe not.”

Directors: ‘Ofsted judgments tell partial story’

In its response, the Association of Directors of Children’s Services (ADCS) warned that “Ofsted’s use of a single word judgement for a complex set of services and differing local contexts tells at best a partial story and even risks weakening the very services the inspectorate seeks to improve”.

“We know that higher performing local authorities typically enjoy greater workforce stability, with on average lower sickness absence rates and caseloads, as this analysis shows,” said Rachael Wardell, chair of the ADCS’s workforce development policy committee.

“That said, some local authorities do succeed in maintaining or restoring stability, despite a negative inspection outcome and many staff will stay and play their part in bringing about positive change,” she added. “We should be learning from these successes to see what measures can be applied more widely.

“Local authority children’s services face significant recruitment and retention challenges and we need more support from government to improve workforce stability.”

Negative ratings can ‘demoralise’ workforce’

A spokesperson for the British Association of Social Workers (BASW) said performance ratings can “demoralise a workforce” and said more focus should be on “giving social workers quality time to do their job”.

“We know that environments where wellbeing and duty of care are paramount allow for good social work practice to thrive,” they said.

“For those that are struggling, we need to ensure they have extra support, funding and resources, mixed with strong leadership, to enable social workers to have manageable caseloads, good quality supervision and consistency within teams.”

Rick Hood, senior lecturer in social work at Kingston University, who has studied the impact of Ofsted inspections, said there tends to be a spike in child protection interventions at all councils following inspections, but this increase is prolonged at authorities rated ‘inadequate’.

He said authorities rated inadequate tended to have increased vacancies and use of agency social workers the year after their inspection, while those rated good and outstanding would see a fall.

Hood’s research has found that inadequate-rated authorities tended to have higher levels of deprivation and potentially more children in need per social worker. This resulted in practitioners having higher caseloads, in turn causing greater workforce instability, vacancies, and sickness.

A “significant variation” in the quality of social work has led inspectors to downgrade York council to ‘requires improvement’.

The authority lost its good rating – earned in 2016 – after inspectors found deficits in the quality of assessments, direct work, evidence to court and supervision, amid rising turnover of social workers, in a full inspection in March.

Inspectors said the authority had tried to reverse a decline in practice identified in a 2019 focused visit covering children in need and child protection services. But while the vast majority of teams had shown improvements, Ofsted said the “pace of change [had] been too slow”, in a report published this week.

Children left in neglectful situations

Inspectors said some children remained in neglectful situations for too long, as a result of assessments that did not analyse the effects of cumulative harm and lead to over-optimism about families’ progress.

More generally, some assessments of children in need of help and protection lacked evaluation, leading to plans that did not identify their needs or the risks they faced appropriately.

Direct work with children in need was also of variable quality, with insufficient effort made to communicate with children with additional communication needs, meaning plans were not sufficiently informed by their voice.

Ofsted said social workers’ analysis of information in return home interviews for children who had gone missing was “weak”, with each incident considered separately, and missed opportunities to explore the reasons why they went missing.

This echoed findings from a 2018 joint targeted area inspection of York on the multi-agency response to child sexual abuse, underlining Ofsted’s more general view that areas for improvement had not been fully addressed.

Inspectors said that while applications to court were generally appropriate and timely, social workers’ evidence was not consistently of high quality, leading to delays in securing permanence for some children.

Children in care were seen regularly by their social workers – and alone where appropriate – but not all benefited from direct work or were helped to understand their life histories.

While most records were written to the child, which would help them understand the rationale for decisions should they access them in future, others would not because they lacked a clear sense of the child’s experiences and views.

Ofsted said most looked-after children were in stable homes that met their needs. However, for a small number of children under 16  in unregistered children’s homes, a lack of timely care planning. had led to uncertainty about their living arrangements, a negative impact on their emotional wellbeing and further unregistered placement moves.

Better supervision needed

Ofsted linked the inconsistencies in practice to the council’s failure to effectively embed its systemic practice model, which was introduced in 2018 to address a decline in the quality of social work.

In an echo of the findings of the 2019 focused visit, the inspectorate said social workers needed to be better supervised to more effectively identify drift and delay for children and address practice shortfalls.

While caseloads were manageable, increasing turnover had led to some children experiencing a number of changes of social worker, something that had also left some workers feeling unsettled

Government figures show York’s turnover rate for children’s social workers leapt from 13.2% to 19.7%, from 2020-21, as its vacancy rate also rose, from 11.6% to 16.1%. And while most social workers were positive about working for York, some were unable to access learning opportunities because of service pressures, stifling their development.

Council: ‘Improvement work will continue’

Ian Cuthbertson, executive member for children, young people and education at York council, said he was pleased Ofsted noted some improvements since 2019, but said the authority recognised that consistency of practice and ensuring children and young people influenced decision making needed to improve.

“Work to address these challenges has been under way for some time and will continue, now we have completed the permanent appointments of chief officers within children’s services,” he said.

“I would like to thank our children’s social workers, social care staff, their managers and partners across the city, who continue to do such amazing work in what continues to be a challenging time for children’s social care services across the country.”

West Berkshire remains ‘good’

Ofsted also inspected West Berkshire in March, rating the authority as good across the board, an improvement on its last full inspection five years ago, when it was ‘good’ overall but ‘requires improvement’ for children in need of help and protection.

This improvement had been secured by investment in an early response hub, which had led to “extensive, timely and creative early help”, and more funding for social workers in family safeguarding teams, said inspectors.

Ofsted praised the quality of practice at the front door, which meant children and families were referred to the right agency at the right time. “Strong pre-proceedings work” ensured parents knew what was expected of them, meaning some families safely exited this stage, and Ofsted also found that Cafcass and family judges praised the quality of court practice.

In relation to children in care, the inspectorate highlighted effective practice with those at risk of harm, good support for unaccompanied children and the priority given to enabling children to live with wider family networks.

Ofsted also said senior leaders fostered social workers’ professional development, managers were “hands-on and present” and an experienced workforce, with strong relationships between staff, enabled healthy challenge.

However, inspectors said that some social workers faced high workloads, the quality of case recording needed to improve and some assessments of children in need lacked an explicit exploration of their ethnicity and culture.

Dominic Boeck, West Berkshire’s executive member for education, children and young people, said: “This report again shows how committed everyone at West Berkshire Council is to improving the lives of all of our children, no matter the challenges they may face. We’ve worked hard to maintain the rating we were given in our last inspection and we will look for ways to do even better.”

A lack of oversight caused by frequent changes of social worker led to a toddler suffering significant harm, a case review has found.

The safeguarding practice review found multiple failings by Northamptonshire health and social care professionals in relation to the girl (referred to as Child Au), who suffered chronic neglect and serious injuries during the 17 months she was in her parents’ care.

She had three social workers from September 2018 to January 2019, which meant an assessment took three months to complete and then had to be redone, and there was a lack of management oversight “which resulted in Child Au suffering significant harm”.

The review also heavily criticised the quality of decision-making by Northamptonshire County Council, saying it was “seriously concerning” that it did not initiate child protection procedures. It also heavily criticised a social worker’s decision not to conduct a home visit immediately when informed of an unexplained injury to Child Au.

Wider failings at ‘inadequate’ council

An inspection of the county council later in 2019, in which it was rated inadequate, suggested Child Au’s experience reflected wider practice failings. Ofsted found children were left for too long on child protection plans when experiencing chronic neglect, with social workers and team managers “over optimistic about change” and accepting self-reporting from carers too readily. Inspectors also criticised management oversight and found longstanding issues with turnover in the council’s “extremely fragile” workforce.

Northamptonshire Children’s Trust, which took control of children’s services from the council in November 2020, apologised for action not being taken sooner to safeguard the child and said there was inadequate support for social workers at the time.

Last year, the toddler’s parents, Sarah Elizabeth Cunnington and Ryan Eames, were both jailed for two years and seven months after pleading guilty to neglecting a child.

Child Au is now being cared for by foster parents and, while the review said she was making progress, it added that she needed specialist intervention to deal with the impact of her early experiences.

Failure to refer

During the first months of Child Au’s life, health visitors noted significant concerns, including in Cunnington’s lack of attachment to Child Au, found the review, commissioned by Northamptonshire Children’s Safeguarding Partnership.

Her eight-month check found she was underweight and developmentally delayed, while in a subsequent visit, in July 2018, a health visitor concluded she was “grossly under stimulated and subject to neglect”.

However, the health visitor did not make a referral to the multi-agency safeguarding hub (MASH), leaving Child Au “at risk of serious neglect and significant harm”, the review found.

When a referral by health visitors was made, at the end of September 2018, the review found that the MASH should have initiated a child protection enquiry as it “indicated that Child Au was being neglected, and that her care was compromised by her parents”.

‘Gravity of risk not recognised’

The team manager’s decision to undertake a single assessment instead “did not recognise the gravity of the risk of harm Child Au was facing”.

After visiting the family, the allocated social worker left the council in early October, meaning the case was passed to a second practitioner.

However, the second social worker did not visit the family until the end of October, did not complete the assessment until December 2018 and then concluded that Child Au should be referred to early help.

The review found this conclusion was “profoundly influenced” by a report from a consultant community paediatrician, who found that Child Au was “well cared for” though “developmentally behind”. The report said this was a “concerning” judgment, based on a single consultation that seemingly did not consider underlying reasons for her presentation, besides medical ones.

Assessment ‘abandoned’

The social care assessment was then effectively “abandoned” when the second social worker left in December 2018, leading the team manager to commission another assessment by a third practitioner.

Shortly before Christmas that year, a housing support officer informed the third social worker that Child Au had been found in her cot, with her arms taped on a bare mattress.

The review said the practitioner should have visited the home immediately instead of waiting until the following day.

The report found that the practitioner did not seemingly raise the issue of the girl’s arms being taped up with the parents on her visit, nor in supervision. The practitioner did find Child Au subdued, with no bedding on her cot, no food for her in the cupboards and no toys visible.

However, despite this, the team manager decided Child Au was in need and she was left with her parents over Christmas, a view challenged by the housing provider.

Lack of action ‘raises serious questions’

“In light of the stark evidence of neglect, the lack of immediate action by children’s social care to initiate child protection procedures raises serious questions of professional judgment,” the review said.

Leaving her in the care of her parents resulted in Child Au suffering injuries, the review found. In early January, the father told the social worker that Child Au had an unexplained swollen arm.

But instead of conducting a home visit and seeking medical advice immediately, she advised him to take the girl to the GP.

The parents did so, but they then waited several hours to take her to A&E, rather than doing so immediately as the doctor advised.

‘Inappropriate and dangerous’

The review found the doctor should have called the social worker to ensure the parents took the child to hospital, with the police summoned if they objected.

“To leave it to the parents to take Child Au, a non-mobile 17-month-old infant, to A&E with an unexplained injury was inappropriate and dangerous,” it found.

Child Au was found to have six fractures, including to her left arm, at different stages of healing and weighed 7.3kg.

The child was taken into police protection and a strategy discussion was held, after which the council applied for an emergency protection order to instigate care proceedings.

‘Not enough to observe and record neglect’

“If there is one important and resounding lesson to be learned from this review [it] is that it is not enough for professionals to observe and record signs of neglect and abuse,” said the report. “Action is required if children are to be protected from significant harm.”

“Concerns about the care provided by Child Au’s parents were documented within weeks of her birth. It took over a year for those concerns to be referred to children’s social care. It is seriously concerning that once the referral was received, two single assessments did not result in child protection procedures being initiated, nor was the action taken by children’s social care challenged, apart from the housing provider.”

It urged Northamptonshire Safeguarding Children’s Partnership to ensure its neglect strategy learns from the review and there is sufficient professional awareness and understanding of neglect.

‘Support for social workers was inadequate’ – trust

Julian Wooster, chair of Northamptonshire Children’s Trust, said: “This is an incredibly upsetting case, and we owe it to this child to ensure that the learnings from this report are put into practice.

“We apologise that action wasn’t taken earlier to safeguard this child and acknowledge the findings of the report. It is clear, that at the time there was inadequate support and guidance to social workers.

“Good progress has been made to address the recommendations of the report and we are working closely with our partners to ensure every child and young person is given the safest possible environment in which they can flourish. This child is now very settled in foster care and is thriving with support and care.”

The trust is commissioned to provide children’s services by West and North Northamptonshire councils, which replaced the county last year.

An Ofsted monitoring visit covering children in need and those on child protection plans last July found improvements in supervision and that most children received the right level of support. However, inspectors said there were some children for whom neglect was not recognised soon enough, and there was more to do stabilise the workforce.

“Recent Ofsted visits have identified improvements in our services,” said Wooster. “But of course, there is no room for any complacency, and we will continue to work relentlessly to make improvements to our services so that they are true examples of best practice to ensure we achieve the best possible outcomes for children and young people in Northamptonshire.”