Presentation on theme: "Learning together to safeguard children London Safeguarding Board annual conference December 5 th 2011 Dr Sheila Fish, Senior Research Analyst."— Presentation transcript:
Learning together to safeguard children London Safeguarding Board annual conference December 5 th 2011 Dr Sheila Fish, Senior Research Analyst
Current context Munro Rec. 9: Govt. require LSCBs to use systems methodology. July 2012 Govt. agreed and plan transition First test SCR announced by Tim Loughton 8 th November
Brief history Early development work Pilot programme completed – NW & W Mids Training & accreditation programme & network of accredited reviewers Developing a tiered offer: Collaborative Condensed Focused Nb. deep and narrow not quick and dirty Supporting test SCRs
The methodological heart remains the same based on a theoretically- informed understanding of human performance adapted from aviation and NHS
Methodology hinges on how do we understand the human role in good or poor practice Do we treat people as the source of errors? Emphasis on fallibility and irrationality Requirement for procedural interventions and standardization Increase use of technical solutions Or assume to err is human and that people are also the source of safety Emphasis on flexibility and adaptability, recovery from error; spotting error inducing conditions Focus on redesigning systems to play to our strengths as human beings and support our predictable weaknesses
Fundamentals: Goal is to provide a window on the system An explicit last step moves beyond case-specific learning to identify & prioritise the generalisable An open enquiry is required with the focus of analysis led by the data The focus/findings not pre-set at the beginning Must be multi-agency from the outset Need to understand the interactions between agencies; Individual Management Reviews are not part of the process; And collaborative with people at all levels Necessary in order to explore what lay behind actions/decisions And to indicate whether or not issues are usual/common
So back to that heart involves three key aspects
1. Reconstructing how different professionals saw the case as it unfolded Remember at all times, what you are trying to do. In order to understand other peoples assessments and actions, you must try to attain the perspective of the people who were there at the time. Their decisions were based on what they saw on the inside of the tunnel – not on what you happen to know today (Dekker 2002: 79)
2a. Identifying Key Practice Episodes (KPEs) for detailed analysis Timeline spaces in between KPE KPE 3 KPE4
2b. Analysing KPEs: appraising practice & identifying the contributory factors Description of episode & time span covered Explanation of its significance to how the case developed and/or was handled Appraisal/Judgement of practice Contributory factors Rfajfoau fow o pwa kf aksdhf oiu reoi fi waop fail Aspects of the family: Fawefijow faio iooif0 dsndk e e9j we9u dp Multi-agency factors: aselfiu feuseoi Aefa wfo uwaop f wafaseui sdooie oioia rour Personal aspects: Asfaweu oif oawi raweior iu siiesa
3. Questioning what light the case has shed on current strengths and problematic areas? Identification and prioritisation of generic, underlying patterns (using consistent typology) Formulated as challenges or considerations for the Board and member agencies, leaving the Board to decide on appropriate action
The findings tend to be insights into how the multi-agency system is functioning More nuanced explanations of what lies behind problematic areas often issues themselves are not new, but the systems framework allows us to formulate what they are about in different ways helps Boards and member agencies think differently issues need consideration; to be grappled with with implications for action plans resonates with Marion Brandons latest research on SCR recommendations
Difference between the three tiers Who conducts the data collection & analysis Multi-agency review team vs. pair of reviewers Former more resource intensive but generates strong ownership of the findings How to collaborate with people at all levels Includes both data collection and opportunities for staff to correct, challenge and amplify the analysis Individual conversations and/or workshop or workshops Impacts on extent of the training effect of the process
CollaborativeCondensedFocused Time span4-6 months3-4 months1-2 weeks FocusPicture windowPortalLetter box Lead reviewers 20 days10-15 days5-10 days Senior managers days1-2 days Case workers2-3 days2 days1 day
But what about the impact? There are no studies in peer-reviewed literature on the effectiveness of RCA in reducing risk or improving safety, and there are no evaluations of the cost or cost- effectiveness of the procedures compared with other tools to mitigate hazards (Wu, et al. 2008: 686). If we focus on quality and consistency of application & requirement to monitor longer term outcomes, we may be in a better position in a decades time
So what of the process?
A SCIE Learning Together case review can help in the following scenarios: a particular practice theme or issue has been identified as of concern particular ways of working seem to be going well and need to be better understood a case that has been considered for an SCR but didnt meet the criteria where there is nonetheless learning to be pursued an serious untoward incident / SCR
Key players organised like this
Process is structured around key meetings The review team meet with the case group for an introductory meeting, individual conversations and two group follow on meetings The review team meet alone for initial planning meetings to review relevant documentation and for analysis meetings.
Exercise 1. LSCB and member agencies 2. Lead reviewers 3. Review team 4. Case Group 5. Family members In light of what you have heard so far, what might the perspectives be of people in your groups position? What might the biggest fears be for them about this process? What would they see as the biggest challenges and what most exciting?
Three known key barriers to take up of this approach have been identified 1. Knowing best ultimately the most total barrier to learning 2. Fear of loss of control assumption that control is their job 3. Not knowing how to change thinking lack of personal awareness and pressure of work Jake Chapman 2004 System failure: why governments must learn to think differently. 2 nd edition. London: Demos.
For further info Learning together publications & social care tv films available on Contact: