Learning and Improvement Framework

In line with the principles in Chapter 4 of Working Together to Safeguard Children 2013 Luton LSCB has developed a Learning and Improvement Framework. Its purpose is to enable member organisations and the LSCB as a whole to be able to learn from experience and achieve sustainable improvements in services and outcomes for children. This involves learning from the full range of work with children and their families - examples of good practice, cases with good outcomes and ‘typical’ cases as well as cases with poor outcomes or where there have been shortcomings in practice.

Routine activities such as supervision, case reflection and discussion provide important opportunities for improvement and learning, supplemented by single and multi-agency audit. Member agencies will be expected to identify and learn from ‘near misses’ and cases that cause front line staff disquiet. Open reporting of concerns about practice is a foundation of developing safer practice and service improvement. All member agencies are expect to support staff who bringing cases and practice that concern them to the attention of senior professionals or managers so that they can be reviewed.

When conducting Serious Case Reviews and other reviews of serious incidents the LSCB will seek to identify all of the factors that may have contributed to shortcomings in services. Reviews will address the wider organisational factors implicated in an incident as well as the decisions and actions of front line staff, in order to understand ‘why’ events happened. This means that reviews will touch on the work and decisions of managers, commissioners of services and other decision makers and will not focus exclusively on the involvement of front line staff and managers who were close to the event.

The Learning and Improvement Framework recognises the complexity of work to safeguard children, the difficulty of many of the decisions that have to be made and the importance of both personal and organisational accountability. It recognises that in a complex system dealing with risk and behaviour that is sometimes outside of professional control, errors will sometimes occur. In keeping with the principles set out in Working Together to Safeguard Children 2013 SCRs and other case reviews will be conducted in a way which:

  • recognises the complex circumstances in which professionals work together to safeguard children
  • seeks to understand precisely who did what and the underlying reasons that led individuals and organisations to act as they did
  • seeks to understand practice from the viewpoint of the individuals and organisations involved at the time as well as using hindsight
  • is transparent about the way data is collected and analysed
  • makes use of relevant research and case evidence to inform the findings

The steps taken to conduct reviews will be proportionate to the scale and level of complexity of the issues being examined. Reviews of serious cases will be led by individuals who are independent. Professionals will be fully involved. Families will be involved and helped to understand the process and their expectations will be managed sensitively.

Final reports of SCRs will be written in plain English so that all interested parties can read and understand them. They will be published on the LSCB website, unless there are legal reasons why this should not happen. When the LSCB publishes the findings of a review into a serious case it will set out the response of the LSCB and member agencies to the review findings and the progress that has been made in implementing any recommendations made.

The LSCB will undertake regular monitoring and follow up of the action taken to implement the learning from reviews in order to demonstrate that reviews lead to sustained improvements in services and better outcomes for children. Progress reports on the LSCB website will be regularly updated.

As well as publishing the findings of individual Serious Case Reviews the wider work undertaken within the Learning and Improvement Framework will be described in the LSCB’s Annual Report and on the website.