Findings and lessons from Learning Reviews

To ensure lessons are learned following incidents or near misses, the CSCP has adopted a Learning Review Approach that allows us

a)    To understand the  cases from the perspective of those involved

b)    Agree areas of good practice and where lessons can be shared to improve future practice

Key to this reflective approach is a timely focus on learning and practice change.

The trigger can be a concern about a particular practice area or it could be the outcome of a particular case.

The learning reviews are aligned to and do not replace usual escalation procedures either within or across individual agencies

A Learning Review concentrates on key issues, decisions and actions that have impacted on the safety and welfare of the child involved. By identifying and concentrating on ‘key findings/lessons’ it enables us to direct efforts to understanding why certain things did or did not happen.

It considers key findings from the case insofar as they relate to current practice and where change is required to reduce the likelihood of poor practice being repeated in the future or ensure the sharing of good practice.

An example template report is included in Appendix A.this external link will open in a new window

In summary the review learns how practitioners saw things at the time and explores with them the ways in which aspects of their work context were influencing their practice. The review:

  • Involves staff and managers in a reflective review process by listening to their perception of events to help to understanding how and why processes fail

  •  Involves multi-agency practitioners in a reflective process to learn lessons.

  • Focuses on learning lessons as they relate to current practice

  • Focuses on a wider systems approach to understand key factors, examining not only what happened but also why.

  • Involves frontline staff and managers in the action planning /change process.

  • Provides independent challenge, oversight and involvement in the review process

The actual review process, whilst should be guided by this document, can be adapted for each case.

a)    Learning review lead agreed by the Case Review Subgroup of the CSCP

b)    Terms of reference or Key Lines of Enquiry (KLOE) written by the Lead Reviewer in conjunction with members of the Case Review Subgroup.

c)    Staff and managers to be involved in the learning review group established and notified of the review

d)    Each agency involved to provide chronology of significant events

e)    This document, an outline briefing and chronologies circulated to staff and managers involved in the learning review

f)     Date to be set for workshop and participants to be invited – this needs to be done in advance and should give sufficient warning to allow participants to prepare for the review and adjust diaries if necessary

g)    Participants are requested to prepare for discussions by reviewing their involvement with the case. The purpose of the discussions will be to understand the agency staff/manager perspective regarding the case.

    • Key intervention/opportunities for intervention
    • Actions/decision making

a)    Workshop chaired by the Learning Review Lead with those involved with the case or can speak about agency involvement

b)    The workshop examines all of the elements of the KLOE to examine actions that would improve practice

The focus will be reflection on why events occurred and what can be learned for future practice improvements

The outcome of the practice review may be one or all of the following

a)    Issues specific to the case which require escalation or urgent action

b)    The ‘key findings’ of the review process

c)    Agreed actions required in respect of practice change

a)    Issues specific to the case should follow the usual managerial/professional or escalation processes/procedures

b)    The ‘key findings’ are shared as recommendations to the CSCP Case Review Group and CSCP Business Group for reflection and action planning

c)    The Action Plan is owned by the relevant CSCP Subgroup through the CSCP Business Group

a)    The PMQAG Subgroup of the CSCP is responsible for monitoring changes to practice through the regular scrutinising of the performance indicators, or through quality assurance activity such as through multi-agency audit.

Recommendations, lessons and findings will be published in the CSCP Annual Report, with specific lessons communicated to practitioners and agencies through the most appropriate mechanisms – such as newsletters.

Practice changes will be reflected in Policies and procedures for the CSCP and training and learning opportunities – for example e-Learning.

Please click herethis external link will open in a new window to view the Findings and Lessons Learning Review Methodology document

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