Serious Case Reviews: How much are we really learning?

I went to an event where they asked this question and my response is, we are good at learning lessons. I think the reviews themselves are quite good at pointing out where there need to be improvements. Where we go wrong is what we do with this information once we have it. I am not speaking, necessarily, of the local authority where the incident happened. It appears that, when it comes to local authority services, all the learning from others is very much externalized. Executives and senior management recognize the importance of the key themes but don’t really make internal changes based on the reports from the case reviews from other authorities. Most have internal quality assurance process and case audits but it isn’t until something tragic occurs in the particular local authority that systems/processes are checked and/or reviewed for failings.

We need to learn from the mistakes of others. I think serious case reviews should prompt internal mini reviews. Take the learning from the case reviews and do a mini internal review to ensure mistakes are not being replicated locally. The review may not raise any issues about replicating mistakes. However, it may highlight issues in other areas.

The Individual

I tend to be of the opinion that if as you (as an individual worker) are committed to your work, quality assurance will be a critical part of your overall practice. Not just token quality assurance – coming from a perspective of political agendas, but from a point of doing the absolute best and delivering a high standard of services. In this way you can catch any mistakes before they become tragic events. You won’t be able to account for absolutely ever eventuality but it is inevitable that you will be able to catch a few things before they escalate. Of course, a big part of this and good practice in general is evidencing the work you’re undertaking. So, if there is ever a time when something tragic does happen, there is documentation of the actions you took to do all that you could with the information available to you as a practitioner.

The Organization

It is the responsibility of management to convey messages from serious case reviews in terms of how this will impact the way of working within the local authority and what changes are coming. This is where I believe there is a gap.

Change management programs are not managed as well as they could be from what I have seen. They all start with recognition of a need for change. It is then discussed at the executive and senior management levels (which also happens to be where the final decisions are made); and may include one or two staff consultations though I am not sure to what degree these are considered in the final decision making. Then, the change program starts. It is almost like the decision is a target holding practitioners over a dunk tank and senior management have the ball. The final decision is the ball hitting the target, dropping everyone sinking into the water.

If we look at change programs in the private sector you can see why they are successful. Two of the more popular change models are Kurt Lewin’s model and John Kotter’s model. Both models emphasize the importance of a staged change program. “Change needs to understood and managed in a way that people can cope effectively with it.[1]” Management need to ensure if they cannot get complete agreement from their staff that their staff at least understand the need for change. It is suggested to use workshops to achieve understanding, involvement in plans, measureable aims, actions and commitments. It is the responsibility of management to manage change. It is their responsibility to facilitate and enable change.

Within social care, it appears that there are lots of reflection and lots of thought, work groups etc. that get established as part of change programs. What’s missing is the lack of work to embed learning and help practitioners internalize lessons learned from serious case reviews. Without this any change management programs that need to occur will not be as effective as they could be. Embedding only works when the lessons are internalised by frontline staff; that is, they need to understand how it applies to them and the work they are doing.

One possible reason for this is the lack of space for practitioners to understand the lessons and assimilate it. They are busy trying to manage the day to day that they don’t get much time to take on new ways of working. It would help for management to give staff the same space they are afforded to think about lessons and any possible changes that could be made to assimilate the new knowledge into practice. I think there need to be designated practitioners to be part of management meetings who are tasked with taken messages back to staff in workshops where they are given space to come up with some solutions that they believe would work on the ground. They could then own the change instead of having changed imposed upon them. Involving staff will also give the message that they are valued. Allowing them to drive the change on the frontline will empower them to make changes. It will give them confidence to speak up and give them a voice so they can identify areas that need to be changed before these issues come to light in serious case reviews.

Management needs to help staff understand what is in the real m of possibility. Staff need to understand the limitations present so when they are a part of the change process they can make informed decisions. Fore warned is fore armed.

Going forward

1. I think it is crucial that managers’ institute staged change management programs with thorough plans to feedback to stakeholders to alleviate any fears about drift and avoid being pushed into quick change programs that produce token change at best.

2. Involving frontline social care staff is another part of the process that will yield longer term change. If they are involved from the start in the readiness evaluation, planning and implementation it is a change they can own; a change in which they are invested. Critical to this is that staff understand the why and the how.

3. Annual reviews of improvement and quality assurances frameworks which include frontline staff. It is important that staff understand the standards against which they are being judged. It is important for them to understand why this process is important, what it is and what it isn’t. I believe involving staff in these processes gives them a better understanding and demystifies anxiety provoking processes. It also helps with their ability to do individual quality assurance. They are more aware of what is being scrutinized.

4. Anticipated or planned changes can be incorporated in the learning and development strategy for the local authority. Internal audits can produce a wealth of information that would be invaluable in terms of courses needed to ensure that staff are prepared to do the job for which they were hired. Change management programs can inform strategy by informing management what new skills their staff may need or skills they may need to develop.

5. Even though we can recognise that senior management are getting better at identifying themes and reviewing performance from serious case reviews, but they cannot ignore the need to make sure frontline staff are on board because the culture of the organisation may need to change and this means changing the way they work. As I have already mentioned this is important because if they are able to own some of the changes it is more likely to be embedded into practice and become a lasting change.

6. I mentioned this previously but we need to make sure that not only the messages from serious case reviews are filtered to staff but it needs to be communicated just how the organization intends to use this learning. That is, does this learning mean there will be changes in the Social Workers own organization.

The key to ensuring lessons are learned and embedded are to ensure there is a strong stable line of communication throughout the organizations. This communication needs to incorporate key learning, what is going right in the home authority (if this is an external serious case review) and what might need to change within the organization to ensure it is not replicating the mistakes outlined in the review. This is setting the stage. Once you have done that, then managers needs to sit down and plan (or outsource) a change management program, a thorough one. Making sure that staff are involved and kept informed at every stage of the process. There is too much shrouded in secrecy. People operate much more openly in a structure that not only supports such thinking but operates within it.

[1] Organizational and personal change management, process, plans, change management and business development tips

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Posted by on July 16, 2014 in Uncategorized


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Why is it so hard to fail social work students in practice learning settings?

This article in community care asks the above question.  The issue is the way the system is how do you justify failing someone who provides all the evidence that is requested to pass. Can you justify failing someone who provides all the “evidence” requested but there is something that tells you they may not be suitable? Because someone is able to garner the experiences they need in order to gather suitable evidence doesn’t mean they are suited for the spectrum of Social Work. As someone who is trained in another country where Social Work is a broader profession with many areas in which to get involved, I find the narrow road of Social Work here absolutely stifling.

I had a student that would not be suitable for long term Social Work but it would have been insane to ignore the fact that she is able to gather and compile information to a high standard for her assessments. But there was no where for me to make that distinction in her assessment and failing her would have been unfair. Where is there a way to make it clear what their strengths are while stipulating that as the person assessing their practice you don’t believe they strengths lie in particular other areas?

Not everyone is suited for every type of work but it would be wrong not to acknowledge someone’s strengths and contributions he/she is able to make to the profession. Where is there room to say that while a student may not be suitable for a particular type of Social Work but might be very good at another or in another team?

As a “Practice Educator” I find that alot goes in to assessing practice and these students. There is a lot of paperwork generated to provide this evidence that they are capable. When I did my Bachelors we didn’t have any paperwork that my Field Instructor needed to do but my process recordings (reflections) were regularly reviewed by my advisor, my assignments were scrutinised by professors/educator for insight into my abilities. There were regular meetings between my advisor and field instructor regarding my progress and where I need to improve. I managed to become a Social Worker without the massive amounts of paperwork (which is a parallel to the paperwork they will have to do once on the job even though everyone says they understand that the on the job bureaucracy is a hindrance to the profession!). The other side of that is the fact that I was well trained. For my placement, which was the equivalent of statutory children’s Social Work, I had to commit my summer to being trained before I could go onto placement. I still have my certificates. There was a group of about 20 of us that bonded that summer and created a support network for ourselves throughout our placement. Several even went on to be employed and the employers could be confident in their skills because they had not only witnessed their practice but they trained them!

I have said it in previous posts and I will say it again. There needs to be a distinction between Social Work education and Social Work training. Social Work education should be the history of the profession, the various elements of the profession, the struture of the profession, what makes it a profession, necessary skills – basically the generic or generalist elements of Social Work that could be applied in any industry/segment of Social Work. Social Work training should be on the job and should include those things you need to know in order to do the job you were hired to do.

In answer to the question, it is hard to fail students because if they provide the evidence you have no substantial grounding to fail them.



Posted by on July 9, 2014 in Uncategorized


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Accessory After the Fact….

ImageStuart Hall has now admitted to sexual assualts after categorcially denying it. Jimmy Saville got away with abusing children and this only came out after his death. There were professionals who were noted as saying they wondered which one he would take into his special room on the day. This might be a bit harsh but anyone who knew, had a suspicion or saw these children and this man should be charged as an accessory after the fact. There is no one that should be allowed to get away with having knowledge of something like this and be able to get away with it. When I first read about Saville’s tasks I was disgusted. When I found out that professionals knew or even had an inkling of what was going on I was physically ill. We can argue that it was a different time, we could argue that things were different then…what we cannot argue is that he was excused because he was a celebrity. Celebrity does not make someone exempt from the law. I cannot imagine that any of these professionals would be so non chalant about things or even let it go without getting some sort of law enforcement investigation if any of these, were their children. Or, mabe they would, especially if there was a pay out??? I have no idea what is going on when I see things like this. It is so incredibly disheartening. It is heartbreaking, and it just fills me with a sadness that feels jagged and raw. I want to know if these children are okay (as adults). I want to know that they were able to develop positive attachments and healthy relationships. I want to know that their parents were able to support them enough where these experiences did not leave them with stains on their childhood that overshadowed any other goodness. I know this makes me seem naive but I’m sorry, hearing about adults taking advantage of a child’s innocence and trust with no regard to the blatant wrongness and disgusting nature of their behaviour is disturbing. I just hope beyond all that at least some (better, all) the victims of these two people are able to work through their feelings about these experiences and not let them darken the possibility of happiness and healthiness in the future.

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Posted by on June 16, 2014 in Uncategorized


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Sometimes I think we forget to give people the basic respect they deserve as individuals when we are in the work place.

I was always taught that when you’re working you leave your personal feelings at the door and it’s all the work. As managers, this is even more true. Despite what we may think of an individual worker, we need to be professional and fair. We need to be practicing in anti-discriminatory and anti-oppressive ways.

I have recently been witness to a manager speaking to someone in a very condescending, dismissive and flippant manner then obviously reacting to the workers understandable distaste of this treatment. As someone who has been through the same type of treatment I can honestly say it is incredibly undermining especially when done publicly. It can damage a worker’s confidence. It can damage their ability to be efficiency. It can create a tense and contentious work environment.

When it comes to my Social Work practice, I treat people the way I would want someone to treat my family should they every need to access services. When it comes to management, I do my best to give my workers the same respect I want to be given. It’s a basic human principle. As managers, workers see the way they are treated and the way others are treated. I am not ignoring the fact that there are some workers that require a level of authoritative management that others do no, but I am not talking about their individual needs as workers. Here I am simply talking about the way in which people communicate with each other.

Respect is paramount in any working relationship and if the working relationship is to work that respect has to work both ways, it cannot be one dimensional. I think as professionals when we learn to treat people they way we would like to be treated, talk to people the way in which we would want to be spoken, help others the way we would want ourselves or our family members helped we would create working environments that are free flowing open, honest and transparent.

I have never been one to play politics. I despise the entire practice. But I have been a witness and party to people who do, those who have their own agendas, those who make assumptions about my character without ever having engaged with me, those who have appreciated me as long as I went along with their plans and didn’t exercise any amount of individual personality what so ever. It’s leaves you in a very bad place; a place in which you can feel stifled and belittled in the work environment.

I urge Social Workers, Social work managers, and likewaise any other professionals, to keep personal issues and problems outside of the office. When you come to work, be prepared to work and to focus. There are times when things are going on in your personal life that effect you in a way that inhibits your ability to focus, maybe these are days you need to stay away from work and reflect on how to improve your disposition.

As human beings we all want to be respected and in many instances understood as individuals and not made victims of other people’s opinions of us. Give people an opportunity to show you who they are. Judge people on their own merit and not assumptions and be open to being proven wrong. Learn to be the person you expect others to be and we can create environments where people learn, grow, and make positive contributions.

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Posted by on June 9, 2014 in Uncategorized


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danger sign - boundariesI mentioned this briefly in my previous post but felt like this topic deserved its own post. What I was taught as an undergraduate in the Social Work program was that you leave your personal “stuff” at the door. You don’t bring your issues across the threshold of the office because when you turn a clients situation into a conversation about yourself you are further victimizing an already vulnerable individual. I have taken that to heart (although when I did my Masters they taught us about the therapeutic use of self and how this can help develop a working relationship). I have seen Social Workers who can do this and I have seen those who don’t. It creates a very complex working relationship and blurs the boundaries. Although we would like to have positive, non-contentious relationships with are clients sometimes this cannot be avoided and we are not there to become friends. We are there as professionals for a specific reason. I myself have met clients who have made me think, you know, in a different life and under different circumstances you are someone I could be friends with, but this was never vocalized because I did not want to blur the line between professionalism and friendship.

I cannot emphasize enough how important boundaries are and how destructive blurring these lines can be both with clients and with colleagues.

confused face-200x200I was in a situation as an assistant manager where a team manager, upon hearing that a new employee (that I was supervising) was single and listening to his colleagues joke about this, came running out to give him her cousin’s phone number and encourage him to call her at that moment. Yes folks, this is a true story! I sat in my office and cringed. As her subordinate, and as someone who was encountering a difficult time in that working relationship at any rate, I had no clue what to do. I ended up addressing it with him one to one in supervision and luckily he took it in good spirits and wasn’t offended though he did admit it was awkward. Oh my, can we say, all together now, NON EXISTENT BOUNDARIES!!!!

WTH?!?!?!? This person was a qualified Social Worker and a Team Manager!! How do you justify that type of thing in your own mind, let alone to all the staff that was listening??? I shouldn’t have been surprised as I found out that she’d previously try to introduce one of her supervisees when she was an assistant manager to another cousin of hers. We all make friends of colleagues on the job, but this was 20 steps beyond that.

I have listened to other colleagues who are not necessarily Social Workers discuss their mental health issues with clients and not just in a “we all have our issues and the important thing is to address them with the appropriate professionals” sort of way but actually going into her diagnosis and medication and all sorts of information that would be considered personal and potentially illegal had they been shared by someone other than this person. This individual on a regular basis exhibited boundary issues on the job and it just made the working environment awkward.

I supervised an older male gentleman who thought it okay to visit a house full of fecontemplative facemale clients after 7pm. Need I even say anything else? The funny thing about this situation is I made a joke about it and he got very offended because he said anyone who heard might have gotten the wrong idea!!! Hello?!?!?!?!?!? Did it not even cross your mind that doing such was not a good idea?????

In the work we do as Social Workers, boundaries – that is clear lines between what is the professional relationship and what might be considered friendship – need to be explicit. There are times where sharing may be appropriate to help facilitate the professional relationship but this is a skills that has to be learned and practiced appropriately. It should not be done lightly. There is nothing wrong with exhibiting compassion in the work that we do, but there are lines that should not be crossed because doing so will actually inhibit our ability to work objectively with people. Once that happens, the client may develop a separate set of unrealistic expectations because they then do not view you as a professional or an authority.

Lack of boundaries can make or break a professional relationship. If you aren’t sure what is acceptable to share and what isn’t, err on the side of caution and don’t share. Go, do some research on “therapeutic use of self” then put it into practice in supervision before ever using it with clients. This will help you to not only maintain professional boundaries but also develop your Social Work skill set and improve relationships with clients

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Posted by on June 5, 2014 in Uncategorized


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The Social Work Hero


Dear Fellow Social Worker,

Having been in management now for a little over two years, I wanted to say to my fellow Social Workers that I have not abandoned the front line. I still feel the pangs of the difficulties of day to day work. I know how difficult it is to truly want to help and be challenged at every end. But hang in there because the work you’re doing is crucial. I applaud your courage and bravery, coming in every day to deadlines and case notes and management targets and verbal abuse from clients, having other professionals undermine the work you do and being given more work on top of that. YOU are my heroes.

There is such a broad discrepancy between what we can do legally and what other professionals and even clients, sometimes, would like us to do. There is such a feeling of being depressed when working with professionals who are more inclined to expect you to do everything than to be a contributory party. But you are the heroes. Social Workers are out there every day working with clients who don’t want us there but we know we need to be there. We need to be there for the clients who don’t yet have a voice. We need to be there for those whose voices are being drowned out by all the white noise of life. We need to be there for those who have had their voices taken from them. I am passionate about Social Work. I have never wanted to do anything other than Social Work and as Social Worker who has been in the business of Social Work for 10+ years, who has not succumb to cynicism or complacency, I applaud all your efforts. I am grateful for the work you do for the most vulnerable of us out there.

When others seek to put you down or undermine the work that you do remember why you are there. You are there to speak for those who for whatever reason are not being heard. When you’re inundated by paperwork (well electronic paperwork) and bureaucracy remember why you’re doing it. As a professional you have a responsibility to the organization which employs you, however the paperwork you do is to document the work you have undertaken with the family so that should you not be around anyone can pick up on the work you do and be able to help that family. So although the bureaucracy is dictated by the organization, it serves to help you evidence your professionalism, your work and all the pertinent information needed for anyone to be able to go through and help a family in your absence.

It’s hard to keep up with it all, all of the time, so, my fellow Social Workers, learn to be advocates for yourselves. Don’t be afraid to tell management that you need some protected time to be able to get caught up. Don’t be afraid to take holidays, you are entitled. The work you do is emotionally draining. You are taking on the problems of others and trying to come up with solutions. Don’t be afraid to respectfully challenge superiors when you have evidence of why you are making the decisions on your cases. You are the experts on your cases. Don’t be afraid to tell people your limitations and guide them in the direction of those that can help them. You can’t know everything there is to know about everything. Don’t be afraid to stand your ground when you are being challenged by other professionals. You know what you are tasked to do and no one has the right to pressure you into things that are beyond you.

If no one else says it to you I am proud of you. I am proud that you have decided to embark upon one of the most difficult professions. I am proud that you continue despite of the negative stereotypes that cloud the profession. You are not the local baby snatcher. You are the Social Worker who wants to make sure every child has their basic needs met and are able to live and develop in an environment that allows them to thrive.

I applaud your efforts. I applaud your commitment. I applaud your dedication. I applaud you skills. I applaud your knowledge. I applaud your bravery. I applaud your work.

I ask only one thing, as a colleague. No matter what organization you work for, no matter how many places you work for, please remember those who you work with. I know the work can be burdensome and tedious and repetitive and time consuming, but please remember that everything you do is to improve the life chances and circumstances of vulnerable children and adults.

And for all that you do – Image

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Posted by on June 2, 2014 in Uncategorized


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BOOK REVIEW: Report Writing by Daisy Boggs

I was asked to write a review of this book and I thought I would just share a piece of it for anyone looking for resources.

I think this book is useful for professionals throughout their career but specifically for students and newly qualified social workers who are starting out and may be just getting used to information gathering and report writing.

the main competing books to this one?

From an American perspective, “Where to start and what to ask”, “The Social Work Interview”; though I don’t think these are used here in the UK. From a UK perspective, the “Framework for Assessment of Children in Need and their Families”, “Report Writing for Social Workers (Post-Qualifying Social Work Practice Series)”, “Writing Skills for Social Workers (Social Work in Action series)”

advantages over other books on the market?

This book is compact and can be carried daily. It is easily accessible and readable. I can see the good practice points being valuable to newly qualified Social Workers and student Social Workers.

key strengths of the current edition?

It is relevant in terms of good practice points, having a standard of writing assessments, it is accessible, it is portable without weighing someone down, it breaks down the key aspects of Social Work reports and incorporates key elements (such as the voice of the child) that have been found essential by inspectorates.

How easy do you find it to locate the information you need in the book?

Because the table of contents was laid out in such a clear and useable way, it was easy to skip through and find the information. The headings in each chapter and the sequencing of information helped as well.

Would you recommend the book to other social work professionals? What would you say about it?

I would. I would say that it is a good resource to have when conducting initial visits as a reminder to review on the way. I would say that it is an integral resource if they are supervising students or managing newly qualified Social Workers. I would say it can be used with practitioner who struggle with assessments. I would say that it is a good resource to have as part of an organizational Social Work library.

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Posted by on May 27, 2014 in Uncategorized


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