Section 4: Managing Safeguarding Practice Reviews

Good Practice Advice

The Chair will determine membership of the group. The size will be determined by the complexity of the case and the available resources but is likely to be four to five people. This is not intended to add an additional layer of bureaucracy, but to administer and manage the Review process. This will include who will be the point of contact for the Reviewer, the victims and survivors or their family and the respondent. The Chair has discretion to appoint other members with relevant expertise, if required.

The Group is likely to involve the following roles, but it will depend on the case and the resources:

• A member of clergy e.g. chaplain, archdeacon.
• A HR officer if the Church Officer is employed or a volunteer in a lay role.
• A member of the safeguarding team, if there is a member who was not involved in the original case.
• An individual who can make commitments about resources.
• An independent member e.g. from statutory services or the DSAP.

Where the case is likely to be very high profile, either locally or nationally, consideration should be given to having an additional independent person on the Review Group.

Given the resource implications of a SPR, consideration should be given to whether there should be someone on the group who can give those commitments. Alternatively, the Group needs to clarify how those decisions will be made. Other professionals may need to advise the Review Group depending on the circumstances of the case. The victims, survivors and Church officers/respondents need to be made aware of who is on the Review Group.

The Review Group is responsible for signing off the final report. See section 4.6 for further details.

The Review Group is not a legal entity from a data protection perspective, and the data controller will therefore be the relevant members who make the decisions about the processing of personal data by the Review Group. The Review Group should put in place a document which sets up and governs the management of the Group, and sets out which individual(s) manage the Group on behalf of its members and are likely to act as the controller, or the members of the Group act as joint controllers.

As the data controller, the Review Group are responsible for complying with the UK GDPR, including being able to demonstrate compliance with data protection principles, and taking appropriate technical and organisational measures to ensure processing is carried out in line with the UK GDPR. The members of the Review Group may, however, be exempt from paying the data protection fee under the not-for-profit exemption. The Review Group should undertake the ICO self-assessment to check if this applies.

Good Practice Advice

A template checklist for producing the Terms of Reference is available at Appendix B.

The ToR set out how the Review will be conducted and will start with the Key Lines of Enquiry (KLOE).  Defining the KLOE helps to ensure that the Review is focussed. Exactly what the KLOE will be will vary from case to case and will be based on the initial areas of concern that have been identified by the core group. For example, the quality of relationships between people, organisational culture, adequacy of resources, arrangements for oversight of safeguarding activity. One important KLOE, although not applicable in all cases, will be the extent to which learning from previous Lessons Learnt Case Reviews, including Past Case Reviews (PCR and PCR2), has been implemented or not, as the case maybe. Where these exist, the Reviewer must be given access to them.  Additional KLOE might emerge in the course of the Review process.

The Review Group will set specific and clear timescales by with the Church Body must provide the relevant documentation which is required for the Review.

There will be specific tasks which the Review Group requires the Reviewer to undertake.  For example, a review of recent research relevant to the case in question, reference to any further documents, whether the Reviewer will be required to periodically meet the Review Group and/or any other performance indicators, and whether the Reviewer is responsible for contacting victims and survivors, respondents, other Church officers or the police and other statutory partners as part of the SPR.

The ToR will also inform the Data Processing Agreement (DPA)  which is the instruction to the Reviewer about what processing activities they must undertake, if the Reviewer is a data processor.  If the Reviewer is a data controller in their own right, then a joint data controller agreement should be put in place with the Review Group, and the responsible church body. There will be a number of different actions/responsibilities for the reviewer, therefore it needs to be made clear this may not be simply a data processing agreement.

Structure of the report

Whilst every Review will be unique, and the report is not the main product of the process, nonetheless, there are some key themes which should be addressed. These include:

• A section outlining the independence and qualification of the Reviewer
• A chronology of the case
• Consideration of previous reviews/repeat learning and current research
• Reporting on the KLOE will form the central body of the report. This needs to be not just a description but an analysis of what happened in respect of each KLOE – providing the “why” answer in respect of the “what” description. For example, what descriptions might include:

1. How victim/survivor-centred the responses of the Church and Church Officers were from disclosure onwards;
2. Whether Church safeguarding guidance at the time of the events in question was followed;
3. The quality of safeguarding arrangements and practice – both strengths and deficits.

Why answers might include:

• Whether any ‘contextual factors’ impacted on the case and in what way, for example:

1. Availability of adequate guidance.
2. Resourcing of safeguarding/workloads/staffing levels.
3. Training/supervision/support for relevant Church Officers.
4. Organisational culture and relationships.
5. Personal constraints (e.g. excessive or onerous responsibilities).

• The Reviewer’s conclusions: what are the key lessons and changes required of specific Church Bodies and/or the whole Church system?

The Reviewer’s recommendations:

• These should be focussed on a small number of high priority, outcome focussed, SMART recommendations, normally between six and ten in number. The aim is to have a smaller number of achievable, impactive recommendations, rather than a large number of recommendations which are not impactive.
• Recommendations need to be aligned to the National Safeguarding Standards:

1. Prevention
2. Culture, Leadership and Capacity
3. Recognising, Assessing and Managing Risk
4. Victims and Survivors
5. Learning, Supervision and Support

• Within this, recommendations should be grouped under the following headings:

1. Strategic: Recommendations relevant to the whole Church system.
2. Local/operational: Recommendations relevant to the specific Church Bodies involved in the case. This must include whether further action is needed to manage on-going risk, and whether consideration of further investigatory action should be undertaken by Church Bodies within their capability and disciplinary frameworks (These latter would not be published.)

• In making recommendations, Reviews must:

1. focus on the most pressing and priority issues, rather than presenting a high number of minor points.
2. state the outcome each recommendation is intended to achieve.
3. provide an evidence base for why and how the recommendation will achieve the outcome required.
4. address issues of organisational culture and relationships as well as process.

Outcome-based recommendations

SPRs which take a long time to come to fruition and generate an excessive amount of high-level recommendations which may or not be realistic in terms of implementation do not adequately fulfil the purpose of creating opportunities for learning and improvement. Therefore, the focus should be on a smaller number of recommendations, which clearly evidence what the outcome of that recommendation will be and adhere to SMART objectives (Specific, Measurable, Achievable, Realistic, Timeline).  At a simple level, this is the difference between saying:

“Recruitment and selection processes relating to members of the clergy should be the subject of review” and

“Recruitment and selection processes relating to members of the clergy should be reviewed so that they are in line with the Requirements of the Safer Recruitment and People Management guidance, including making sure that all those involved in the process have undertaken the Safer Recruitment and People Management Training. A phased timetable should be implemented so that both these issues have been addressed within 12 months.

Outcome: All those involved in the recruitment of clergy have undertaken their SRPM training and are evidencing its use in their practice by this time next year. This will ensure that all the required checks as outlined in the SRPM guidance are being followed in respect of clergy appointments, which will mean that any safeguarding risks are identified and dealt with at the earliest possible stage."

4.3 Tone and Methodology

The way in which the SPR is conducted should form part of the ToRs, and needs to be completed before a Reviewer can be appointed.  However, there needs to be scope to amend the detail of the ToR once the Reviewer is appointed, as they should be advising on the best way to conduct the Review.

Learning does not start and end with the SPR, and the purpose of the exercise is not to produce a report. The SPR is merely one part of the process designed to facilitate discussions to produce learning and improvement.

Adopting an appropriate tone and methodology is essential if the Review process is going to help to deliver learning which results in actual change. This is particularly the case if change in beliefs, values, behaviours and culture are needed.

An approach which:

• treats all involved (that is victims, survivors, respondents, clergy and staff, volunteers) with empathy, respect and compassion as valuable and complex human beings who matter;
• is dialogical, seeing all those involved as partners in the development of understanding and solution finding;
• is marked by genuine curiosity and transparency;
• is marked by creative ways of exploring issues relevant to the circumstances;
• prepares those who will be involved to address anxieties and fears,
• is more likely to help bring about genuine change than one marked by fear, threat, fixed and strongly held positions, and inflexibility.

This also applies to informal reviews, where the opportunity to be more creative in approach is much greater.

This might mean that as well as the more “formal” aspects of the Review such as the chronology and meeting with those who were involved, there may be more informal aspects which might help the Reviewer to “get inside” the organisation to really understand why things happened the way they did. This might include things like attending particular services,  observing meetings to fully understand the dynamics involved or convening groups of relevant people and facilitating a reflective dialogue.

The consultation with respondents about the ToR and any follow up communication and explanation relating to the final version of the ToR can be done by a member of the Review Group, providing the required information sharing agreements are in place.

Two examples of specific methodologies which could be adopted are below. The Learning Together model by the Social Care Institute of Excellence focuses on how organisations can improve their practice by learning about the causes of the safeguarding incidents, taking the wider context of other ‘systems’ that they interact with. It specifically focusses on:

• using systems thinking to gain a deeper understanding of current local practice and cultivate an open, learning culture;
• building internal capacity by having staff trained and accredited in the Learning Together approach to reviewing;
• undertaking rigorous case reviews and audits using a core set of principles and analytic tools;
• building on the experience and findings of previous reviews

The website contains helpful advice for organisations about commissioning reviews, deciding on the skills of the Reviewer suitable for their purposes, and quality assurance.

Practice Review Framework – developed in Wales and suitable for reviewing both children and adults’ safeguarding failures, this model emphasises speedy completion of reviews to ensure quick implementation of learning. This has been compared favourably to more traditional approaches to reviews in the study ‘Comparing Safeguarding Review Methodologies'.

Good Practice Advice

Final responsibility for the selection and appointment of the Reviewer rests with the Review Group.

Independence of the Reviewer

‘Independence’ does not require a Reviewer to have no connection whatsoever with the wider Church of England. For instance, a Reviewer’s independence may not be undermined if they attend a church in another diocese, or another cathedral, or they led previous safeguarding work in the Church. However, there may be cases where the Review Group and victims and survivors agree that a Reviewer must be entirely independent of the Church of England.

Reviewers may come from a variety of backgrounds and are likely to be identified via professional networks. These might include:

• someone who has completed a review before;
• a recommendation from DSAP members;
• a recommendation from statutory or third sector services.

It is important to note that just because someone is recommended, that does not automatically mean they will be appointed. The Review Group will still need to satisfy themselves that the individual meets all the desired criteria.

Experience of the Reviewer

In addition to the requirement for independence, all Reviewers will have the relevant personal qualities and professional experience to conduct the Review:

• The Reviewer should possess the inter-personal skills and experience to engage sensitively with victims and survivors, respondents and other Church officers. Being able to evidence the soft skills required to hold detailed and painful conversations with people (both individually and in groups) is of as much importance as their experience. Ideally, they should have experience of successfully involving survivors in case reviews.
• The Reviewer should have the relevant skills and experience for the matter being reviewed. This would normally consist of experience derived from employment in social work, police, probation, law, but may also, depending upon the case, include other professional backgrounds such as psychiatry or psychology. ‘Relevant’ here means ‘specifically relating to’ rather than just in the same general field. For instance, a retired senior police officer with an extensive experience in fraud investigations would not be an appropriate person to review a case involving child sexual abuse.
• The Reviewer would normally be expected to have held ‘senior management responsibility’ as part of this experience. ‘Senior management’ means responsibility for leadership and management of an organisation which included leadership of organisational change, improvement and quality assurance. They need to demonstrate understanding of how organisational systems work, how change happens and the significance of organisational culture. They need to have a good understanding of the requirements of data protection law in the operational context.
• The Reviewer should have proven analytical skills, experience of quality assurance and service improvement in safeguarding. This experience may include formal, structured reviews of complex casework, for instance, Serious Case Review, Serious Further Offence Review or Domestic Homicide Review work, and have had these reports published.
• The Reviewer will also need experience of organisational culture and change, and experience of being able to “get inside” of an organisation, in order to fully understand the challenges and dynamics, and see beyond the surface. A key skill will be the ability to ask the right question, of the right person, at the right time to unlock the capacity for learning and improvement. It will be an advantage if this has been previously carried out in a Church context, as an understanding of the workings of the Church will be needed. Where they do not, the Review Group will need to ensure that the Reviewer has adequate access to material, briefings and individuals who will help them understand any relevant issues. It is for this reason that the Reviewer will need to contribute to the methodology section of the ToR – they should have the experience to be able to provide advice on what methodologies are best suited to achieve the outcomes needed from the Review.
• In high profile cases, it may be appropriate to consider a Reviewer with experience in managing media and public scrutiny.
• The Reviewer will need to confirm they can commit sufficient time to conclude the Review within the time parameters set.
• The Reviewer must be able to demonstrate the ability to properly anonymise data and carry out representation processes.

It is expected that a published SPR will include a section outlining how the Reviewer meets the above criteria and an ‘Independence Statement’ showing their separation from the matters being reviewed. The Reviewer needs to be made aware of this in advance and it must be included in the Privacy Notice.

After the appointment of the Reviewer, the Review Group must give the Reviewer any specific instructions as to the conduct of the Review. These might include:

• That the victims and survivors should be asked what they wish to contribute, and what support they might need to do so.  They should also be asked if any of the information they have already provided as part of the case can be used if they do not want to give it twice.
• That the Reviewer must, as part of the process of interviews of respondents and other Church officers, put any potential criticism or judgement to them so that they have a right to reply before the report is written.
• The Reviewer must also take notes of interviews and send them for approval to interviewees, to mitigate the risk of challenge at the representations stage.
• The Review Group will also supply the Reviewer with a detailed chronology of the case, which will be published within the final report, subject to anonymity considerations.
• The Reviewer must work closely with the Church body’s legal and data protection lead throughout the SPR.

Continuous/real time feedback loop and dialogue

The SPR must be a time-limited, dynamic process. As key aspects of good practice or areas for improvement are identified, they should be fed back to the Review Group during the process of the Review as a continuous dialogue. Any progress made during the course of the Review should be included in the final report.  Because the SPR process focuses on organisational learning, there may be a limited number of cases where it has to proceed without the involvement of the victim/survivor and respondent if they choose not to participate.

Involvement of Children

The framework outlined here also applies to children in terms of giving them the opportunity to be engaged, however additional care should be taken to ensure that they are not harmed by their involvement. Children and their parents (where appropriate) must be asked what support they might want and if the offer of a Support Person has been taken up, they will be required to identify children’s ‘circle of support’, for example parents, guardians and any professional network, to assist with the work. Given that cases will already have been subject to a core group, it is expected that the additional data protection considerations which apply when processing children’s data will be in place, along with what information will be shared with the parents. If there are no such arrangements in place, these do need to be implemented before the Review commences.

Involvement of the respondent

SPRs will also have an impact on respondents and potentially their families, and therefore they will need appropriate support, to be treated with respect and care and have their needs taken into account. The continued support of the Link Person may help provide this.

Involvement of families  

There may be circumstances, e.g., with children or deceased clergy, where the involvement of families is required. This will be subject to all the same  requirements and data protection that apply to victims, survivors and respondents as applicable, including the provision of appropriate support.  

4.6 Quality Assurance and signing off the report

The Review Group is responsible for “signing off” the Report (i.e. it has fulfilled the brief given in the ToR to the required standard). The Review Group should not feel they need to sign off any report which does not meet the ToR to the required standard. This is one of the reasons why the ToR need to be very clear about what is expected, and regular check-ins with the Reviewer will help keep this on track. In order to sign off a report, the Group will need to be satisfied that the report has:

• Addressed the Key Lines of Enquiry, and any additional lines of enquiry which arose during the process.
• Delivered SMART recommendations.
• Been reviewed by legal and data protection colleagues with regard to confidentiality issues.
• Met any other criteria specified in the Terms of Reference. Has been properly anonymised, and any instructions form data protection and/or legal colleagues have been followed

The Quality Markers template at Annex C provides two markers, number nine and ten, in relation to the report and publication, which may be a helpful starting point to review the report by.

The remainder of the Quality Markers can help the Review Group understand how well the Review has been carried out, and feedback from the victims, survivors, respondents and other Church Officers will need to be sought. This feedback will also help the NST understand what is working well in terms of these Reviews.