Family Factors comprising � Social Factors, Mental/Psychological by yx0ASuy

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									                Cheshire West and Chester
       Local Safeguarding Children Board


  Procedure for Multi-Agency Practice and
             Learning Review




Version 6
1 August 2012
                                          Contents


   1. Introduction

   2. Criteria for Multi-Agency Practice & Learning Reviews

   3. Process for Undertaking Multi-Agency Practice & Learning Reviews

   4. Multi-Agency Practice & Learning Review Meeting

   5. Involvement of the Child(ren) and Family in the Process

   6. Reporting the Outcome of the Multi-Agency Practice & Learning Reviews and
      Learning Review Process

   7. Learning the Lessons from Multi-Agency Practice and Learning Reviews




Appendices:

Appendix A Multi-Agency Practice and Learning Review Flowchart
Appendix B Chronology Template
Appendix C Conversation Structure Summary
Appendix D Contributory Factors Classification Framework
Appendix E Agency report on the dissemination of learning and findings




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1. Introduction

1.1 Local Safeguarding Children Boards (LSCBs) are responsible for coordinating local work to safeguard
    and promote the welfare of children and for ensuring the effectiveness of work undertaken by the
    agencies working in their local area to safeguard children. In order to achieve these objectives, the
    LSCB is responsible for undertaking Serious Case Reviews under the criteria set out in chapter 8 of
    Working Together to Safeguard Children (2010).

1.2 LSCB Serious Case Review Procedures identify the process to be followed where cases are to be
    considered under the criteria set out in paragraph 8.4 of Working Together to Safeguard Children
    (2010).

1.3 The Serious Case Review Criteria Panel, having considered all the information available to it
    (including information for any review of the child's death), can make the following recommendations to
    the LSCB Chair:

   To convene a Serious Case Review Panel (SCRP) to undertake a SCR.
   To defer a decision until more information is available (e.g. Coroner’s report).
   To require agencies to undertake the Multi-Agency Practice and Learning Review process.
   To review the case via the Child Death Overview Panel process.
   To require agencies to undertake a sector or agency specific review.
   That the case does not meet the criteria for any review.

1.4 The procedures contained in this document should be followed in circumstances where the LSCB
    Chair has decided to undertake a Multi-Agency Practice and Learning Review.

1.5 In some instances it will be apparent from the outset that the criteria for initiating a SCR have not been
    met. The LSCB recognises that reviews of such cases may provide opportunity to identify learning to
    be disseminated to staff in a timely manner. Some agencies, such as Health Trusts, already have
    processes in place for identifying such cases and undertaking internal reviews to identify any lessons
    to be learnt. In order to enable all agencies to benefit from such, the LSCB has produced the Multi-
    Agency Practice Review and Learning process.

1.6 The Multi-Agency Practice and Learning Review process provides a timely approach which enables
    reflection upon a case by practitioners, and where appropriate, the child(ren) and family. The process
    aims to identify and disseminate learning in a timely manner. Therefore from the point of notification of
    a case to submission of the final report should take place within 3 months. In more complex cases this
    period may need to be extended. Any requests for extensions should be submitted to the LSCB
    Executive for approval, stating clearly the reasons for delay.

2. Criteria for Multi-Agency Practice Reviews

2.1 Cases can be considered for Multi-Agency Practice and Learning Review across a broad continuum.
This is from those which fall just below the threshold for undertaking Serious Case Review, down to those
deemed to demonstrate the capacity for practitioners to have acted in a more timely manner to safeguard
and promote the welfare of the child(ren).

2.2 This process is in addition to any single agency audits or reviews that may take place on individual
cases.

2.3 Cases will be considered in relation to a specific incident or a culmination of circumstances. Examples
of cases to consider include:

       Cases where something nearly went wrong – Eileen Munro refers to these as having the ‘PHEW
        factor’

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      Cases where the intervention of agencies was not; well co-ordinated, timely and effective, resulting
       in poor outcomes for the child and family.
      Cases which have featured good multi-agency practice, particularly where the cases were difficult to
       manage, but have had a positive outcome

It is envisaged that significant learning should be identified for every case referred.

2.4 The objectives of undertaking a Multi-Agency Practice and Learning Review are:

      To establish the facts ie, what happened, to whom, when, where, how and why
      To establish good and poor practice in assessment, planning and decision making processes
      To look for improvements rather than to apportion blame
      To establish how recurrence may be reduced or eliminated

In addition, specific objectives relating to the case may be identified.

3. Process for Undertaking Multi-Agency Practice and Learning Review

3.1 Any agency or practitioner can notify the LSCB Serious Case Review Group of cases to be considered
for Multi-Agency Practice and Learning Review, via the chair of the group, after appropriate consultation
with his/her line manager and/or agency designated safeguarding lead where it is believed that the criteria
may be met. In all such cases the agency should envisage that significant learning will be likely.

3.2 Details of cases for consideration should be sent to the Chair of the Serious Case Review Group of
the LSCB and the LSCB Business Manager. This should include:

      Names, dates of birth and addresses for the child(ren)
      Names, dates of birth and addresses of the parents/carers and key adults
      Schools attended
      GP Practice
      Brief circumstances of the case
      Reasons why the case should be considered for Review
      Suggested timeframe of case to be considered by Review
      Details of practitioners identified as working with the family during the timeframe to be reviewed

3.3 The Serious Case Review Group of the LSCB will make the decision as to whether the case meets the
criteria for Multi-Agency Practice and Learning Review, identifying the timeframe which the Review will
cover.

3.4 The LSCB Business Manager will write to the agencies involved to ensure the correct details of
practitioners and line managers involved in the case are made available. The agency representatives
contacted will normally be the agencies’ representatives of the LSCB. The information requested should be
sent to the LSCB Business Manager within 48 hours.

3.5 The LSCB Business Manager will then write to each of the practitioners involved, and their line
managers, requesting a chronology of the practitioner/team involvement with the child(ren) and/or family
during the timeframe identified to be covered by the Multi-Agency Practice and Learning Review.
Chronologies should be returned to the LSCB Business Manager within 15 working days. (See Appendix
B - Chronology Template.)

3.6 The LSCB Business Manager will then be responsible for ensuring that a composite chronology is
compiled to inform the subsequent professional discussion with practitioners and line managers involved in
the case. This is the Multi-Agency Practice and Learning Review meeting.

3.7 The Multi-Agency Practice and Learning Review meeting should take place no more than 10 days after
chronologies have been submitted.

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3.7 The Chair of the Serious Case review group will be responsible for nominating a person to facilitate
the Multi-Agency Practice and Learning Review meeting by managing the discussion and ensuring
accurate recording. This will be someone independent to the case. The LSCB Business Manager will
support in the facilitation.. The nominated PLR facilitator and the LSCB Business Manager should meet to
discuss and plan the PLR session(s).

4. Multi-Agency Practice and Learning Review Meeting

4.1 All practitioners and line managers involved in the case during the timeframe identified will be invited
to a Multi-Agency Practice and Learning Review meeting. The multi-agency chronology and other relevant
documents will be shared with attending practitioners in advance.

4.2 The purpose of the Multi-Agency Practice and Learning Review meeting is to:

         Establish what lessons are to be learned from the case about the way in which practitioners and
          organisations work individually and together to safeguard and promote the welfare of children. This
          includes evidence of good practice;
         Identify clearly what those lessons are both within and between agencies, how and within what
          timescales they will be acted on, and what is expected to change as a result;
         Improve intra- and inter-agency working and better safeguard and promote the welfare of children.

4.3 In preparation, staff involved in the Review should meet with the designated safeguarding lead for
their agency. The purpose of this meeting will be to support staff in reviewing the decisions they made and
considering what influenced their reasoning. It will also provide an opportunity to identify good and poor
practice. It is important that practitioners prepare for the meeting and consider what actions organisations,
themselves and others can take to reduce the likelihood of problems happening again. A structure for this
discussion is available at Appendix C.

4.4 All participants will be encouraged to reflect upon their practice and the involvement of their
team/agency in the case at the Review meeting. They will be encouraged to question one another in order
to aid reflection and learning.

4.4 The Review meeting will cover the eight categories adapted from the Root Cause Analysis
Investigation model developed by the National Patient Safety Agency:

        Family Factors comprising – Social Factors, Mental/Psychological Factors and Interpersonal
         Relationships

        Staff Factors comprising – Physical, Psychological, Social Domestic and Personality Issues and
         Cognitive Factors.

        Task Factors comprising – Guidelines, Policies & Procedures, Decision Making Aids and Procedural
         or Task Design.




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    Communication comprising – Verbal, Written and Non-verbal Communication and Communication
     Management.

    Work Environment comprising – Administrative Factors, Environment, Staffing, Workload and Hours
     of Work and Time.

    Organisational comprising – Organisational Structure, Priorities, Externally Imported Risks and
     Safety Culture.

    Education and Training comprising – Competence, Supervision, Availability/Accessibility and
     Appropriateness.

    Team Factors comprising – Role Congruence, Leadership and Support & Cultural Factors.

 (See Appendix D for Contributory Factors Classification Framework)

4.5 The Multi-Agency Practice and Learning Review meeting will be completed within 3 ½ hours. Due to
the complexity of some cases, it may be necessary to hold more than one Multi-Agency Practice and
Learning Review meeting.

5. Involvement of the Child(ren) and Family in the Process

5.1 The LSCB recognises that it is good practice to involve the child(ren), where they are of an age and
understanding to be involved, in the Review and parents/carers, or other relevant members of the extended
family. The child(ren) and family will bring an important dimension to the Review.

5.2 Consideration will be given as to how to approach the family to explain the purpose of the Review and
to seek their participation. In most situations it may be appropriate for one of the facilitators of the Multi-
Agency Practice and Learning Review meeting to visit the child(ren) and family with a practitioner already
working with the family who has built up a professional relationship with them. The facilitator needs to
decide the best time for this to happen (i.e. before the case begins)

5.3 In complex cases requiring more than one Multi-Agency Practice and Learning Review meeting, the
child(ren) and family participation should take place before the final Review meeting in order to inform the
professional discussion.

5.4 Consideration should be given as to who should inform the child(ren) and family of the outcome of the
Multi-Agency Practice and Learning Review. In most situations it should be one of the facilitators of the
review. The family should also be provided with a copy of the Multi-Agency Practice and Learning Review
report.

5.5 Where the child(ren) and/or family have not been involved in the Multi-Agency Practice & Learning
Review, the reasons for this should be noted in the final report; for instance, the family may not wish to be
involved or court proceedings may be underway. Legal advice may be required in some circumstances.

6. Reporting the Outcome of the Multi-Agency Practice and Learning Review Process

6.1 The LSCB Business Manager will provide a report detailing the outcome and learning from the Multi-
Agency Practice and Learning Review case to the LSCB Executive Board. The report should be
submitted in draft to the SCR Group/Panel first for comment and agreement.

6.2 Once the Executive Board has approved the report, it will be presented to the Serious Case Review
Group, who will be responsible for ensuring that the recommendations are implemented and will report
progress to the Executive Board.

6.3 The Executive Board will inform the LSCB Board of all Multi-Agency Practice and Learning
Reviews undertaken on behalf of the Board, and keep the Board appraised of progress in implementing
the learning from such Reviews, via quarterly reporting.
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7. Learning the Lessons from Multi-Agency Practice and Learning Reviews

7.1 Learning pertinent to a single agency will be disseminated via the agency’s own training, development
and awareness raising pathways.

7.2 Multi-agency learning will be disseminated via the Learning and Development sub group of the LSCB.

7.3 LSCB will also use a range of appropriate awareness raising tools to disseminate learning across the
workforce, such as newsletters, briefings and practice guidance.

7.4 Subsequent Multi-Agency File Audits may focus upon specific learning from Multi-Agency Practice and
Learning Reviews to ensure that recommendations have been embedded in to practice.




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                                             APPENDIX A
                      Multi-Agency Practice & Learning Review Process Flowchart

                                                                         Practitioner identifies case for
                                                                            consideration for Multi-
                                                                          Agency Practice & Learning
                                                                                     Review


                                                                          Discuss with line manager
                                                                         and/or agency’s safeguarding
                                                                                     lead


                                Agency refers to
                               SCR group of LSCB                               Does the case
                                                              Yes
                                                                              meet the criteria?

                                                                                                   No
                                                                    No
                                 Does the case                                 Consider agency
                                meet the criteria?                            processes for case
                                                                                review or audit
 LSCB Chair or SCR Sub-                            Yes
   Group Chair agrees to
  undertake Multi-Agency            Facilitator identified
Practice & Learning Review          Practitioners & line
                                     managers identified
                                    Chronologies
                                    Conversation with
                                     practitioners & line
                                     managers



   Where appropriate,                Multi-Agency Practice &
 meeting with child(ren) &          Learning Review meeting
          family


                                Report identifying learning
 Feedback to child(ren) &       & recommendations
         family                 submitted to Executive
                                Group for quality assurance



                                  SCR group manages
                               implementation of learning &
                                    recommendations




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APPENDIX B
CHRONOLOGY TEMPLATE

COMPREHENSIVE CHRONOLOGY

GUIDANCE: Using the Chronology template on the following page construct a comprehensive
chronology of involvement by the agency and/or team in contact with the children and family over
the time period set. For the purpose of this Multi-Agency Practice and Learning Review the
time period set is insert timeframe.

You are expected to provide a detailed chronology of your team’s involvement including
information about when the child was seen and details of that contact. You should also include
contacts that were planned but did not take place, stating the reason for this. Also, please briefly
summarise decisions reached, the services offered and/or provided to the child(ren) and family
and other action taken. Note specifically each occasion the child was seen, whether the child was
seen alone, and whether the child’s wishes and feelings were sought, and expressed.




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   APPENDIX B - CHRONOLOGY TEMPLATE

   GUIDANCE: Using the Chronology template on the following page construct a comprehensive chronology of involvement by the
   agency and/or team in contact with the children and family over the time period set. For the purpose of this Multi-Agency
   Practice and Learning Review the time period set is insert timeframe.

   You are expected to provide a detailed chronology of your team’s involvement including information about when the child was seen
   and details of that contact. You should also include contacts that were planned but did not take place, stating the reason for this.
   Also, please briefly summarise decisions reached, the services offered and/or provided to the child(ren) and family and other action
   taken. Note specifically each occasion the child was seen, whether the child was seen alone, and whether the child’s wishes and
   feelings were sought, and expressed.

Date    Time           Source of   Subject of           Event description, actions and outcomes                           Expected        Relevant    Child
                       Information recording                                                                              Practice/St     Terms of    Seen
                                                                                                                          andards         Reference   (y/n)
Enter   Enter the      e.g. data          e.g. Family   Detail the event, any observations noted, reasons for decisions   Refer to your               Simply
the     time in 24     systems, hard      member        taken and action take/not taken with reasons                      own internal                state
date    hour           file, interview,                                                                                   policies and                 Y or N
dd/mm   format, e.g.   etc.                                                                                               standards and
/yy     17:56                                                                                                             what was/was
ONLY    ONLY. If no                                                                                                       not met
        time is
        available
        enter 00:00
        and note
        why in
        Event
        Description
APPENDIX C - Conversation structure summary

1.   Introduction        -   Purpose of the conversation
                         -   Confidentiality and ethics
                         -   Outline of the structure
2    Overview            -   a brief description of what happened in this case and
                             the part you played
3a ‘Turning points’ or   - What do you think were crucial moments in this
   ‘key practice             sequence, when key decisions or actions were taken
   episodes’                 that you think determined the direction the case took or
                             the way the case was handled?
3b ‘Mindset’ and         - What did you think was going on here?
   ‘local rationality’   - What was behind your thinking (reasons but also
                             emotions) and actions at the time?
                         - What information was at the front of your mind? What
                             was most significant to you at this point? What was
                             catching your attention?
                         - What other things were occupying you at the time?
                         - What were your main concerns? What were you
                             tossing up at the time? Did these concerns clash at all?
                             Were there any conflicts? Were some dismissed,
                             others prioritised?
                         - What were you hoping to achieve?
                         - What options did you think you had to influence the
                             course of events?
4    Contributory        What were the key factors that influenced how you
     factors             interpreted the situation and how you acted at the time? In
                         what ways? Prioritise aspects that were most significant.
                         - Aspects of the family
                         - Aspects of your role
                         - Conditions of work/work environment
                         - Personal aspects
                         - Your own team factors
                         - Inter-agency/inter-professional team factors
                         - Organisational culture and management
                         - Wider political context
                         - Other
5    Things that went    - What things relating to the case went well?
     well                - What do you think you or others did that was
                             helpful/useful? And what factors supported/enabled it?
6    Queries from the
     overview
     perspective
7    Suggested           Off the top of your head, having thought back on this case
     changes             and your role, are there are any small, practical changes
                         that you can think of, that would help you/staff do a better
                         job?
8    Summing up          - Have we got your view of the case?
9    Reflections         - How have you found this session? Do you have any
                             comments or questions?
                         - How do you feel now, about yourself and your role,
                             after this discussion?

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     APPENDIX D - Contributory Factors Classification Framework
Family
                     Components
Factors
Social Factors      Cultural / religious beliefs
                    Language
                    Lifestyle (smoking/ drinking/ drugs/diet)
                    Sub-standard living accommodation (e.g. dilapidated)
                    Life events
                    Lack of support networks / (social protective factors -Mental Health Services)
                    Engaging in high risk activity
Mental/             Motivation issue
                    Stress / Trauma
Psychological
                    Existing mental health disorder
Factors             Lack of intent (Mental Health Services)
                    Lack of mental capacity
                    Learning Disability
Interpersonal       Staff to family and family to staff
                    Family engagement with services
relationships
                    Staff to family and family to staff
                    Parents to children
                    Family to family (Siblings, parents, children)

Staff Factors          Components
Physical              Poor general health (e.g. nutrition, hydration, diet, exercise, fitness)
                      Disability (e.g. eyesight problems, dyslexia)
issues
                      Fatigue
Psychological         Stress (e.g. distraction / preoccupation)
                      Specific mental illness (e.g. depression)
Issues
                      Mental impairment (e.g. illness, drugs, alcohol, pain)
                      Lack of motivation (e.g. boredom, complacency, low job satisfaction)
Social                Domestic problems (e.g. family related issues)
                      Lifestyle problems (e.g. financial/housing issues)
Domestic
                      Cultural beliefs
                      Language
Personality           Low self confidence / over confidence (e.g. Gregarious, reclusive, interactive)
                      Risk averse / risk taker
Issues
                      Bogus Healthcare worker
Cognitive             Preoccupation / narrowed focus (Situational awareness problems)
                      Perception/viewpoint affected by info. or mindset (Expectation/Confirmation bias)
factors
                      Inadequate decision/action caused by Group influence
                      Distraction / Attention deficit
                      Overload
                      Boredom

Task Factors                       Components
Guidelines, Policies and          Not up-to-date
                                  Unavailable at appropriate location (e.g. Lost/missing/non-
Procedures
                                   existent/not accessible when needed)
                                  Unclear/not useable (Ambiguous; complex; irrelevant, incorrect)
                                  Not adhered to / not followed
                                  Not monitored / reviewed
                                  Inappropriately targeted/focused (i.e. not aimed at right audience)
                                  Inadequate task disaster plans and drills


Decision making aids              Aids not available (e.g. checklist; risk assessment tool; secure e
                                   mail)


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                                     Aids not working (e.g.risk assessment tool, neglect check list)
                                     Difficulties in accessing senior / specialist advice
                                     Lack of easy access to technical information, flow charts and
                                      diagrams (phone numbers)
                                     Lack of prioritisation of guidelines
                                     Incomplete information (family history)
 Procedural or Task                  Poorly designed (i.e. Too complex; too much info.; difficult to
 Design                               conceive or remember)
                                     Guidelines do not enable one to carry out the task in a timely
                                      manner
                                     Too many tasks to perform at the same time
                                     Contradicting tasks
                                     Staff do not agree with the ‘task/procedure design’
                                     Stages of the task not designed so that each step can realistically
                                      be carried out
                                     Lack of direct or understandable feedback from the task
                                     Misrepresentation of information
                                     Inappropriate transfer of processes from other situations
                                     Inadequate Audit, Quality control, Quality Assurance built into the
                                      task design
                                     Insufficient opportunity to influence task/outcome where necessary
                                     Appropriate automation not available


Communication               Components
Verbal                    Inappropriate tone of voice and style of delivery for situation
                          Ambiguous verbal commands / directions
communication
                          Incorrect use of language
                          Made to inappropriate person(s)
                          Incorrect communication channels used
Written                   Inadequate family identification
                          Records difficult to read
communication
                          All relevant records not stored together and accessible when required
                          Records incomplete or not contemporaneous (e.g. minutes of meetings,
                           actions from meetings etc.)
                          Written information not circulated to all team members
                          Communication not received
                          Communications directed to the wrong people
                          Lack of information to family
                          Lack of effective communication to staff of risks (Alerts systems etc)
Non verbal                Body Language issues (closed, open, body movement, gestures, facial
communication              expression)
Communication             Communication strategy and policy not defined / documented
                          Ineffective involvement of family in decisions making
Management
                          Lack of effective communication to family of risks
                          Lack of effective communication to family about incidents (being open)
                          Information from family disregarded
                          Ineffective communication flow to staff up, down and across
                          Ineffective interface for communicating with other agencies (partnership
                           working)
                          Lack of measures for monitoring communication

Work
                          Components
Environment
Administrative           Unreliable or ineffective general administrative systems (Please specify e.g.:
factors                   contacts, family details, requests referrals and appointments)
                         Unreliable or ineffective admin infrastructure (e.g. Phones, bleep systems etc)
                         Unreliable or ineffective administrative support
Environment              Facility not available (failure or lack of capacity)

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                            Fixture or fitting not available (failure or lack of capacity)
                            Distractions


 Staffing                   Inappropriate skill mix (e.g. Lack of senior staff; Trained staff; Approp. trained staff)
                            Low staff to client ratio
                            No / inaccurate workload / dependency assessment
                            Use of temporary staff
                            High staff turnover
 Work load and              Shift related fatigue
                            Excessive working hours
 hours of work
                            Lack of breaks during work hours
                            Excessive or extraneous tasks
                            Lack of social relaxation, rest and recuperation
 Time                       Delays caused by system failure or design
                            Time pressure

 Organisational Components
 Organisational   Hierarchical structure/Governance structure not conducive to discussion, problem
 structure         sharing, etc.
                           Tight boundaries for accountability and responsibility
                           Professional isolation
                           Lack of robust Service level agreements/contractual arrangements
                           Inadequate safety terms and conditions of contracts
 Priorities                Not safety driven (Risk management)
                           External assessment driven e.g. IA’s , Core Assessments – national indicators
                           Financial balance focused
 Externally                Unexpected adverse impact of national policy/guidance (from DCSF /DFE, DOH/
 imported risks                HO/ Professional colleges)
                           Locum / Agency policy and usage
                           Contractors related problem
                           Lack of service provision
 Safety culture            Inappropriate safety / efficiency balance
                           Poor rule compliance
                           Lack of risk management plans
                           Inadequate leadership example (e.g. visible evidence of commitment to
                               safeguarding)
                           Inadequately open culture to allow appropriate communication
                           Inadequate learning from past incidents
                           Incentives for 'at risk'/'risk taking' behaviors
                           Acceptance/toleration of inadequate adherence to current practice
                           Ignorance/poor awareness of inadequate adherence to current practice
                           Disempowerment of staff to escalate issues or take action

Education and      Components
Training
Competence                 Lack of knowledge
                           Lack of skills
                           Inexperience
                           Inappropriate experience or lack of quality experience
                           Unfamiliar task
                           Lack of testing and assessment
                    
Supervision                Inadequate supervision
                           Lack of / inadequate mentorship
                           Training results not monitored/acted upon
Availability /             Training needs analysis not conducted/acted upon
                           On the job training unavailable or inaccessible
accessibility

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                       Safeguarding Training unavailable or inaccessible
                       Team training unavailable or inaccessible
                       Core skills training unavailable or inaccessible
                       Refresher courses unavailable or inaccessible
Appropriateness        Inappropriate content
                       Inappropriate target audience
                       Inappropriate style of delivery
                       Time of day provided inappropriate

Team Factors                      Components
Role Congruence                 Lack of shared understanding
                                Role + responsibility definitions misunderstood/not clearly defined
Leadership                      Ineffective leadership – Safeguarding
                                Ineffective leadership – managerially
                                Lack of decision making
                                Inappropriate decision making
                                Untimely decision making (delayed)
                                Leader poorly respected
 Support and cultural           Lack of support networks for staff
                                Inappropriate level of assertiveness
factors
                                Negative team reaction(s) to adverse events
                                Negative team reaction to conflict
                                Negative team reaction to newcomers
                                Routine violation of rules/regulations
                                Lack of team openness/communication with colleagues
                                Inadequate inter-professional challenge
                                Failure to seek support
                                Failure to address/manage issues of competence (whistle blowing)




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Appendix E

 Agency report on the dissemination of learning and findings
    from Serious Case Reviews and other Case Reviews
Agencies are asked to provide a 6 monthly update on how they have
disseminated the findings from case reviews, within their organisations. This
has been agreed across the Pan Cheshire LSCB’s to enable the same report
from agencies with shared footprint across the authorities to present at
different LSCB meetings.

The timing of presentation of the reports to be agreed with the relevant group
in each LSCB receiving the reports.

Cases referred to
This does not need the details of the case, the reference to the review is sufficient




How disseminated
For example: sharing at team meetings; incorporating in to training; briefing notes (provide
clear details of the dissemination, which teams and when; where did the briefing go; training
to who etc)




What was the significant learning for your agency?
Include a case example to demonstrate the learning




What are you doing differently as a result?




Any other planned dissemination/ learning from case reviews?




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