Care Inspectorate Learning Reviews Alignment for Public Protection Landscape

OFFICIAL OFFICIAL CPC/ASPC Joint Meeting Care Inspectorate Learning Reviews alignment across the public protection landscape 17 April 2024 27/05/2025 1 OFFICIAL OFFICIAL

OFFICIAL OFFICIAL Background Children s The Care Inspectorate became the central collation point for all Significant Case Reviews in April 2012 and Initial Case reviews in June 2017. Role continued as we moved to learning reviews in September 2021. Code of practice to contribute to continuous improvement. National reporting: Significant Case Reviews in Scotland 2012 2015 Triennial Review of Initial Case Reviews and Significant Case Reviews (2018-2021) National overview report 1 April 2021 to 31 March 2022 Learning reviews for children in Scotland, Data report for 1 September 2021 31 March 2023 Learning review Liaison Group: Information sharing arrangements between the Care Inspectorate, Scottish Government and CPCScotland in relation to Learning Review activity. OFFICIAL OFFICIAL

OFFICIAL OFFICIAL Background Adults Care Inspectorate has acted as the central repository for both initial case reviews and significant case review since November 2020 following the 2019 Interim National Framework for Adult Protection Committees for Conducting a Significant Case Review, Continued following May 2022 publication of National Guidance for Adult Protection Committees: Undertaking Learning Reviews Code of practice mirrors children s code - support continuous improvement locally and disseminate common themes to support national learning. National reporting: Triennial review of initial case reviews and significant case reviews for adults (2019-2022): Learning from reviews Annual report on significant case reviews and learning reviews for adults 2022-2023 OFFICIAL OFFICIAL

OFFICIAL OFFICIAL Volume Children Children Year of notification (fiscal year) Total number of notificatio ns 27 ICRs NOT proceeding to SCR ICRs proceeding to SCR Learning review NOT proceeding 5 Learning review proceeding 11 2 9 2021/22 29 N/A N/A 12 17 2022/23 50 N/A N/A 27 23 2023/24 OFFICIAL OFFICIAL

OFFICIAL OFFICIAL Volume adults Adults Year of notification Total number of notificatio ns ICRs NOT proceeding to SCR/LR ICRs proceeding to SCR/LR reviews proceeding under a different process 15 Nov 2019 Sept 2022 (three years) 90 58 17 Oct 2022 Nov 23 31 17 10 4 OFFICIAL OFFICIAL

OFFICIAL OFFICIAL Themes - Children GIRFEC: including responding to wellbeing concerns, information sharing between children and adult services. The completion / quality of chronologies. Neglect: Identifying and responding to childhood neglect was a factor for four of the six children considered in SCR reports submitted. This included the identification, assessment and response to neglect in disabled children. Adolescent mental health and emotional wellbeing Pre-birth and post birth planning and assessment Transitions: including the transition from primary to secondary school and when a young person moves from children services to adult services. Thresholds for intervention: This includes the need for child protection processes to be strong enough to ensure children with disabilities have timely and holistic responses, informing the assessment of neglect and risk. OFFICIAL OFFICIAL

OFFICIAL OFFICIAL Themes - Adults Neglect and self-neglect were the most prominent categories of harm identified. While there was evidence some partnerships were responding to these issues, more needed to be done nationally. The circumstances of those affected by mental health and substance misuse were most frequently considered in reviews. Health and social care partnerships should carefully consider this to inform future trauma informed improvement activity. Ineffective communication and information sharing contributed to poor outcomes for adults at risk of harm. Poorly planned hospital discharges were a significant feature in some reviews. This requires close consideration and improvement across health and social care. Improved professional curiosity, understanding of responsibility, effective decision making, and a trauma-informed approach should strengthen risk assessment and risk management. (Triennial review of initial case reviews and significant case reviews for adults (2019-2022): learning from reviews) OFFICIAL OFFICIAL

OFFICIAL OFFICIAL Care Inspectorate Developments Align processes as far as we can: Notification Review Response Joint annual reporting from 2025 Continue to comment on the quality of reviews with reference to respective adult or children s learning review national guidance Develop a greater future focus: Use our engagement opportunities to consider what difference / improvement reviews have or will generate Support a revised, joint Learning Review Liaison Group : Broader terms of reference, overview of all learning from reports and consideration of impact and timely identification of themes and trends Possible maintenance role for national guidance Continue to work with the National Hub for reviewing and learning from the deaths of children and young people and SG with a view streamlining processes when a child or young person dies and meets the criteria for review under different requirements or processes. OFFICIAL OFFICIAL

OFFICIAL OFFICIAL Next steps We will keep you updated on our internal processes We plan to relaunch our Quality Assurance Reference Group and include adult services membership for comment and feedback on proposed changes Continue to work with Scottish Government on public protection agenda development, including revised LR liaison group Also, consider the implications for public protection / strategic scrutiny in light of recommendation 18 of the Independent Review of Inspection, Scrutiny and Regulation OFFICIAL OFFICIAL