Background

Keeping vulnerable children and young people safe and free from harm is a very emotive subject and a challenging part of the work of the public health services. Multi agency working is essential to co-ordinate an effective response once an “at risk” child is identified. If a school nurse is concerned that a child is looking neglected and becoming more withdrawn, then she needs to promptly involve social workers & GPs. A young teenager who is found rough sleeping by police will need a safe place to stay, a health check and a social worker to investigate the family situation.

Ensuring these agencies are providing the support at the necessary standard is monitored by the government and one of the ways of assuring the quality of the collaboration and of driving standards up, is what is called the Joint Targeted Area Inspection (JTAI). External scrutiny of joint working is an uncomfortable but very necessary way to shine a light on good and poor practice. Boroughs are given just two weeks’ notice, and there are enormous demands placed on the agencies to be inspected in a short space of time. It means senior managers need to identify and free up resources to respond to the inspectors’ requests and authorise access to all the medial and social care records of cases required. It also requires an active approach to communication and liaison with all of the layers of people in the hierarchies in the system. To achieve the necessary depth of insight, the JTAI use a “deep dive” approach to examine the areas’ handling of a number of cases, and within the health system, that will involve examining hospital notes, school nurse records and GP practice notes. Retrieving these from offsite storage can be problematic and it can feel like individual health professional’s work is open to criticism even though it is the area’s joint working processes that are being assessed.

Acute hospitals have become very used to be inspected by the UK’s Care Quality Commission (CQC) and the significant Board level interest will help in the management of these wide ranging inspections of quality and safety. Similarly, schools give a great deal of focus to OFSTED inspections as the outcome is crucial to their standing in the school league tables. However, the JTAI does not attract the same attention except within the Clinical Commissioning Group (CCG), whose role it is to commission the services for children within its boundaries and specify the quality of the liaison between agencies within its contracts.

An After Action Review was called 3 months after a JTAI by Alex*, The Chief Operating Officer (COO) of one such CCG as the participants involved in an inspection were still bruised by their experiences during it and he wanted them to learn for themselves how they might do it differently next time.

No one came to the AAR without some scars from their interactions with each other during the inspection. Excessively long hours had been worked, roles had been confused and responsibilities had not been fulfilled. Under such stressful circumstances, the tendency to find fault with others had flourished. The inspection report had been uncomfortable for them and their teams to read and only served to increase the tension across the child safeguarding system. Seeing them at work as individuals you would be incredibly impressed by their complete dedication to the most vulnerable children in their borough, but the report revealed some significant problems in how they operated together as a health system. The decision by Alex to call an AAR was a good one. An action plan had been created and the inspectors were due to return at the end of the year so positive energy needed to be released for a more collaborative approach.

Present in the AAR was Catherine, the Responsible Officer for Safeguarding in the borough who shows all the best characteristics of her type: a fearless approach to getting things done and a comprehensive knowledge of the people and services in the borough. But she is also typical of the nurse-turned-manager, in that she believes that if you just work harder, then all problems can be fixed. The NHS relies far too much on such heroic efforts, rather than on effective processes to make things work.

Also present was Nicky, the Named Doctor for safeguarding, David and Anna, the safeguarding nurses from two of the acute hospital trusts in the borough, Hazel, the lead for the school nursing service, Petra, the commissioner of children’s services, Shirley the CCG Director of nursing quality, Paul, the Chief Nurse from one of the Acute Trusts and Mike, the Public Health commissioner as well as Alex, the Chief Operating Officer who called the AAR.

The specific purpose of the AAR was to focus on how they worked together before and during the inspection and the AAR questioning about individual expectations revealed that participants had a range of experience of inspections previously and this affected how they behaved and felt. Those with previous experience had formed quite clear ideas of how the inspection would be managed and those with none, expected to be fully guided. The initial “kick off” meeting didn’t address such different starting places, but it was what happened after that had caused the most problems. Communication to those on the front line was fragmented and meant that staff became either very disengaged or very demanding of Catherine’s time. Management of the process was hampered by not having any administration staff allocated and Nicky as the Named Consultant tried to be helpful by responding to all the queries herself rather than referring them to Catherine and the central team so there was further fragmentation. However, the most significant impediment emerged during the AAR discussions: access to medical records was not authorised promptly and staff on the front line were not able to prioritise the inspector’s requirements as they still had their day job to do.

When the question was asked “So why weren’t you able to do what you expected to do?”, there was a pivotal moment when Paul, the Chief Nurse said “I hold my hands up. We failed to give this the right level of attention at the Board level”. Paul had been quite quiet during the first half of the AAR, listening to all the first-person accounts of what had actually been going on for others in the system, and had learnt for himself what his Trust had failed to do. The energy level in the AAR changed after Paul spoke and there were further admissions of gaps in what was done which provided fertile ground for the learning to be captured and actions to be discussed.