Developing a culture of reflective safeguarding:

from compliance to learning and adapting

Eileen Munro November 24th 2011

Outline

• A systems approach

• Analysis of previous reforms

• Improving the work environment to support good practice

• The role of LSCBs

Drivers of the system in recent years

The child protection system in recent times has been shaped by five key driving forces:

• social pressure to keep children safe

• a belief held by many that uncertainty in child protection work can be eradicated

• a tendency in inquiries to focus on professional error without examining the causes of any error

• the undue weight given to proceduralization, performance information, and targets

• a belief in simple, linear causality

A simple, predictable world

Workers create the problems ….

The person-centred approach

• We analyze the causal sequence until we get to a satisfactory explanation.

• Human error provides a satisfactory explanation.

• Human error is blamed in 70-80% of all major accidents, including child abuse deaths.

To Reduce Human Error, We

1. Put psychological pressure on workers to perform better.

2. Reduce human factor as much as possible.

formalize/mechanize/proceduralize.

3. Increase surveillance to ensure compliance with instructions etc.

Reforms

“The technocratic view is faulty, not because it is incorrect, but because it is incomplete”

Tinker A. & Lowe A. (1984) ‘One-dimensional Management Science: The making of a technocratic consciousness’, Interfaces, 14(2) 40-49

What is overlooked/undervalued?

• Uncertainty

• Requisite variety

• Child’s journey

• Emotion

• Relationships

• Influence of tools on practice

Creating the learning environment • Valuing expertise

• Feedback

• Regulation

• Inspection

• Management

Skilled workers

We need smart people who use tools

NOT

Smart tools used by unskilled people

Re-designing practice

• Individuals are not totally free to choose between good and problematic practice because the standard of performance is connected to features of the tasks, tools and operating environment.

• Improving practice involves maximising the factors that contribute to good performance and minimising the factors that contribute to problematic practice

• Aim is to make it easier for practitioners to work well and harder to make mistakes.

The implications

Relationship skills are needed to engage other humans – using intuitive knowledge and emotions

Cognitive skills are needed to make sense of information and plan, using both intuitive and analytic thinking, and drawing on research

Critical reasoning is needed to check accuracy of fallible processes – supervision is essential

Feedback

• Essential to know whether decisions and actions were good

• From families – have we helped?

• From all levels in organisation

Regulation

• Working Together: – Rules are good for working together– Professional guidance should be owned by

professions– Adopt police risk principles

• Assessment Framework:– reduce to core principles

Inspection

• Child’s journey

• Evidence of helping

• Evidence of learning

our collective challenge

A responsible culture not a A responsible culture not a blame cultureblame culture

Serious case reviews

• Adopt the systems approach of health and other high risk work

• Recognise individual is neither autonomous or a puppet on strings

• Seek to understand why poor practice happened

• Improve national learning

Management

• Identify local needs• Design how to help• Performance management data as

information not indicators• Feedback from front line and users

Sharing responsibility for the provision of ‘early help’

New duty for local authorities and statutory partners to secure provision New duty for local authorities and statutory partners to secure provision of early helpof early help:

- specify against local profile of need

- set out access to social work expertise for those in other services

- have clear arrangements in place to make an ‘offer of early help’ ‘offer of early help’

Sharing responsibility for early help: Recommendations

Developing expertise at individual level

Intuitive learning from experience, also needs feedback and reflection

Formal learning, also needs to be embedded in use

Emotional awareness, sensing and discussing

Developing expertise at organisational level

• Users’ feedback

• Front line feedback

• Single loop and double loop learning

• Peer review and inspection

Developing expertise at multi-agency level

• Case reviews

• Shared training

• Shared review of effectiveness

What to aim for a system that learns whether children are being helped, and how they have

experienced the help, innovating in response to feedback

a system free from all but essential central prescription over professional practice but with clear rules about where and how to co-ordinate to protect children and young people

a system where professional practice is informed by research and evidence, competent judgement informing action when the work is too varied for rules

a system that expects errors and so tries to catch them quickly

a system that is ‘risk sensible’.