Level 3 competencies

Expectation – Expertise and action

This builds on levels 1 and 2, and as such any training at this level should incorporate all competencies outlined in earlier levels.

Job roles – all health care professionals and staff who deliver a clinical service to children and young people. Mental health and drugs and alcohol rehabilitation services who deliver care to adults, but where the situation has significant impact and risk for children and young people/families, are included.

Introduction

Within level 3 there is an expectation the staff member will ensure a cyclical refresh of knowledge and gain new skills, and competencies related to safeguarding children and children in care recognising emerging themes and application to their areas of work. Specific levels of expertise may differ slightly e.g. a higher level of expertise for plastic surgeons regarding burns, maternity & gynaecology clinicians regarding FGM (female genital mutilation), and orthopaedic surgeons and emergency medicine doctors regarding physical trauma.

Those with specific safeguarding duties are expected to have higher levels of competence.

Groups of staff included in level 3:

• health care professionals and staff working exclusively or predominantly in paediatric and neonatology services. Including community services,
• adult mental health psychiatrists and mental health nurses in adult mental health, forensic clinicians, perinatal psychiatrists and other perinatal staff, psychiatrists, and psychologists (child and adolescent),
• health care professionals working in adult-based services with caseloads (assessment, planning or delivery of care and support) involving young people under 18 years old, including those who regularly treat 16 –18 year olds as part of their job role
• health care and staff professionals who regularly provide services to children including out of hours/on call and emergency including ,
• doctors and nurses treating children in care and care leavers
• practitioners with specific responsibility for children and young people e.g. dentists, diagnostic radiographers, orthoptists

Areas of work include – health care professionals working in youth justice services, sexual health services, substance misuse services, early pregnancy services, Family Nurse Practitioners (FNP), school nurses, learning disability (children) services, Special Education Needs (SEND) staff including inclusion services, children’s hospice services and children’s continuing care in community.

Competency at this level is about individuals being able to:

• use knowledge and skills in safeguarding children and young people and have an awareness of what it means to be a child or young person in care, or care leaver to respond and manage additional vulnerabilities and need
• know their role and responsibility in working together with other staff to meet the needs of vulnerable children and young people; staff who work directly with children and young people all the time or as part of the service they provide, and those who work in adult services, each have a different but vital role to provide the whole picture in safeguarding. Professionals should recognise the impact being involved in safeguarding can have on their own personal and professional wellbeing and seek support when needed
• utilise professional curiosity and proactively respond to any safeguarding concerns or additional intervention needed for care experienced children and young people and children and young people in care; it is an individual’s responsibility to respond and engage, within their area of expertise

Health care staff at this level should:

• utilise clinical and professional knowledge and expertise to understand the range of complex forms of abuse and maltreatment children and young people are subject to (*See range of knowledge required)
• recognise other related health needs that may be uncovered relating to abuse and neglect that need specific intervention (role dependent)
• recognise and respond appropriately to the impact of adversities on healthy child development, for example where the child lives with a parent/carer who experiences poor mental or physical health, issues with substances or experiences domestic violence and abuse
• recognise the potential impact of an adult parent/carer’s physical and mental health on the wellbeing of an unborn child, child or young person; in specific services, e.g. adult mental health and drug/alcohol addiction, staff should have an understanding of the associated risks to children and young people and be able to recognise and act on concerns
• apply knowledge of the physical, developmental, emotional, and mental health needs/risks for child or young person in care and understand their role in offering health promotion/protection information to minimise medium/longer term impacts of being in care/experiencing abuse etc
• have an awareness of the impact of trauma and adverse childhood experiences on children and young people including those children and young people in care, care-experienced and care leavers, and have additional understanding of how pre-care experiences and being care-experienced continues to affect in adulthood, this includes the need for continuous and consistent availability of support and building relationships through trauma informed practice
• understand and recognise the presentation and features of diseases and practices (such as cupping, FGM and non-medical circumcision) in children and young people from different ethnic and cultural backgrounds; a
• offer appropriate advice and apply knowledge about the physical, developmental, emotional, and mental health needs/risks regarding children who may have been exploited
• recognise and respond to the additional needs of child or young person seeking asylum or refuge (CYPSAR) and to share concerns appropriately with the wider team
• contribute to multi-agency safeguarding children and young people assessments including strategy meetings, providing written information relevant to role, and analysis of risk
• recognise the importance of and expertise needed to complete statutory review health assessments for children and young people in care including holistic assessment, analysis, and continuous support to meet health needs and minimise the impact of previous adverse events
• specifically, for those working with children and young people in care, holistically assess health and wellbeing, in order to implement, deliver, and evaluate the child/young person’s health care continuously, acknowledging this is not a one-off process
• recognise the need for and take steps to avoid compassion fatigue, vicarious trauma, and burnout to remain effective in their roles
• understand principles of transitional safeguarding in health services, the risk created by different approaches and criteria for safeguarding intervention by Local Authority teams as the young person transitions to adult services
• initiate and understand the need for interventions to support reliance and reduce the risk of emotional harm for children and young people
• Advocate and escalate, if needed, to facilitate access to the additional support/structured interventions that will enable children and young people to develop further coping strategies and receive additional support which reduce the impact of the abuse/environment that they have experienced; this impact may be more than emotional
• effectively communicate with other agencies and professionals to ensure accurate documentation of facts and opinions and an effective action/plan for the child or young person
• enable constructive engagement on matters relating to safeguarding and child or young people in care and care leavers
• provide appropriate reports and opinion on safeguarding and child protection, in line with legal requirements, seeking specific expertise and guidance as their role requires
• ability to provide a professional opinion, within scope of professional practice, commenting on the short and long-term impact of abuse on the health and wellbeing of a child or young person; staff should be able to share information including their opinion effectively, and be confident to give advice, challenge and escalate
• understand the interdependence between health, education, and social care with regards to children and young people, including children and young people in care, care-experienced and care leavers
• work in partnership with other agencies who may be involved with the child or young person including, but not limited to, social care, education, police, probation, youth offending teams (and other custodial health services) to understand the importance of this multi-agency working
• contribute to multi-agency assessments using advanced communication skills; staff should work in a developmentally appropriate way that adapts communication and interaction to incorporate neurodiversity and cultural requirements (working with interpreters when required)
• Offer advice and guidance to colleagues regarding information sharing considering Consent and confidentiality issues related to safeguarding, children and young people in care, and care leavers
• have knowledge of own capabilities and when to seek support from the specialist safeguarding and children and young people in care health leads/teams
• actively participate in individual and team reflective practice and service improvement activity to ensure learning and development
• utilise various resources and opportunities, such as participation in peer review, case discussion, audits, effectively to enhance, develop and enable best practice to be delivered for safeguarding children and young people, and children and young people in care
• contribute to an environment that supports and challenges practice, provides a safe space for reflection, and prevents harm
• apply the lessons learnt from Child Safeguarding Practice Reviews (England), Child Practice Reviews or Single Unified Safeguarding Reviews (SUSR) (Wales), Child Death Reviews (Scotland), Learning Reviews (Scotland), Case Management Reviews (Northern Ireland), and other relevant formal local and national reviews to improve professional practice and drive system change
• recognise and understand the specific statutory duties regarding the safeguarding of unborn babies within context of pregnancy and the legal position of the foetus, and act if there is a potential risk of harm to an unborn child

Child protection medical examinations and children and young people in care health assessments are specific situations that require additional knowledge and skills alongside the expectation of level 3 competencies.

Child protection medical assessments are undertaken as part of the social care assessment once the threshold has been reached for significant harm. This includes medicals undertaken for suspected physical abuse, neglect, and child sexual abuse/forensic sexual offences. The consequences of these medicals can be substantial, contributing to the social care assessment and permanency plans for the child, and used as evidence in Court proceedings (criminal and family).

Additional guidance:

• Standards for delivery of child protection medical assessments are set out by the RCPCH in the Child Protection Service Delivery Standards and radiological investigation of suspected physical abuse in children
• Competencies related to child sexual abuse (CSA) forensic medical examinations are set out by the Faculty of Forensic and Legal Medicine (FFLM), supported by RCN and RCPCH, which explicitly states the RCPCH service delivery standards apply for all children and young people under 18 years old

Professionals conducting a child protection medical assessment, requested by children’s social care, (as part of Section 47 of Children Act 1989 (c.41) enquiries in England and Wales), should be a medical professional who has a working knowledge of children and young people’s normal development, normal patterns of accident and injury, alongside level three competencies and knowledge, and advanced communication skills. Most will be paediatric doctors and, as such, have completed a GMC/RCPCH agreed curriculum gaining expertise and experience in child protection. If at non-consultant level, professionals undertaking child protection medical assessments will need appropriate supervision and review of examination and opinion. Equivalent competencies and knowledge in paediatric health and years of experience is expected if this is not the situation.

Specific areas of the assessment may need specialised professional expertise, e.g. plastic surgeon to give an opinion about burns, forensic odontologist to give an opinion about bites. Another scenario is a qualified dental professional who examines the oral cavity as part of a child protection medical assessment, to give a full picture of a child’s health relating to oral injuries and oral health.

Additional competencies required of health care staff undertaking child protection medical examinations:

• should have skills and use evidence-based medicine, critical thinking, and analysis to formulate an opinion
• need to have skilled communication and ability to collaborate with partner agencies
• must have credibility and expertise conducting a child protection medical and producing a suitable report
• must be able to consider the impact of abuse and factors in the family/carers and environment
• should undertake child protection medical assessments regularly enough to keep experience and knowledge up to date
• should access and attend regular peer review to enable quality assurance, review of practice and continued learning
• should access senior or colleague support as necessary, recognising learning and supervision needs
• level 3 competencies must be kept up to date within a rolling program of knowledge/evidence updates

Initial and review health assessments, review health assessments, and other relevant health assessments across the UK are undertaken regularly, and form part of the statutory requirement for a child or young person in care until their permanency arrangement is reached and they are no longer in the care of the local authority/council/health and social care trust. They are undertaken to meet all health needs – new or missed concerns, physical health, emotional health, contributing to health promotion and giving the child or young person an opportunity to ask questions about their health and wellbeing.

The purpose of health assessments is to improve the health outcomes for children and young people in care, by enabling health care staff to work collaboratively with social care and reduce health inequalities. To support the delivery of this work, specific legislation, and guidance sets the expectations and outlines the criteria of professionals responsible for health assessments:

• Promoting the Health and Wellbeing of Looked After Children (2022) (England and Northern Ireland)
• NICE guidance (England and Wales)
• Scottish Government Guidance on Health Assessments For Looked After Children and Young People 2014
• Codes of Practice, 2025 issued under Section 145 – Part 8 of the Social Services and Well-being (Wales) Act 2014 – anaw 4  (Wales).

Currently, standards for IHAs are being developed by the RCPCH, and further details will be made available following the conclusion of this work.

Professionals undertaking IHAs and other relevant health assessments must have significant clinical experience and knowledge of children and young people. This includes (but is not limited to) experience of history taking and examination, medical conditions, management and treatment, typical and atypical development, impact of adverse childhood experiences and abuse, advanced communication skills, knowledge of public health needs across all ages and emotional health presentations, assessment, and ability to refer and recommend management.

In England, qualified medical professionals conduct health assessments, and in Scotland, assessments are undertaken by a registered medical practitioner or a registered nurse. In Wales, a registered medical practitioner (or a registered nurse, or a registered midwife acting under the supervision of a registered medical practitioner) is responsible for performing health assessments of children and young people in care. Whilst in Northern Ireland, the health assessments are overseen by Specialist Community Public Health Nurses, as well as Health Visitors and School Nurses, Family Nurses (Family Nurse Partnership) and children and young people in care Specialist Nurses.

Most professionals undertaking IHAs will be paediatric doctors, and as such have completed a GMC/RCPCH agreed curriculum, gaining expertise and experience in safeguarding including children in care, and all areas of general paediatric health. Equivalent competencies and years of experience is expected if this is not the situation.

Additional competencies required of health care staff undertaking children in care health assessments:

• should have skills and use evidence-based medicine, critical thinking, and analysis to review all health needs including a physical examination, and formulate appropriate health management plans, considering missed health opportunities or appointments and public health screening, this includes implications and recommendations related to physical and mental health in wider family and pregnancy
• should be able to identify the need for assessment of and support for the management of neurodiversity, Foetal Alcohol Spectrum Disorder (FASD), attachment disorder (see Attachment and child development), special educational and disability needs (SEND), and emotional trauma
• should be able to address the specific needs of child or young person seeking asylum or refuge (CYPSAR) and understand the legal implications for this group of children in care
• should have skilled communication and ability to collaborate with partner agencies
• should recognise the health and wider needs based on the history and assessment of a child/young person, and be able to initiate appropriate health interventions and effectively communicate the complex interplay of factors for children and young people in care with multi-agency colleague
• should be able to initiate interventions to facilitate and support child resilience and reduce risk of emotional harm
• should support, challenge, and work collaboratively with child mental health services to provide support and interventions to meet the specific needs of children and young people in care
• should be able to interpret and communicate on a broad range of health information in a social and education context for children and young people in care; this may include provision of advice relating to prospective carers to an adoption/fostering panel, and advice to social workers about impact of different environments on health conditions
• should utilise expertise and the ability to contribute to Court reports or information used in other legal processes, e.g. the Children’s Reporter within England and Wales, and in Scotland via the Scottish Children’s Reporter Administration (SCRA)
• should have expertise and ability to support young people leaving care or transitioning to adult services; this may include support to access specialist advice on contraception and sexual health, promoting physical and mental health, enabling access to primary care services, and facilitating seamless transfer of care leavers with complex needs, including those with disabilities, to adult services
• should be able to elicit, understand and consider the views of a child or young person and how these should be included in the health assessment
• should have credibility and expertise conducting a formal health review and effectively analyse multi-agency health history and provide a written comprehensive report that is meaningful person-centred and with Specific, Measurable, Achievable, Relevant, and Time-bound (SMART) actions
• must be able to consider the impact of adverse childhood experiences including previous abuse and factors in the family/carers and environment
• should access colleague/peer review of health recommendations and reports to enable quality assurance, review of practice and shared learning
• should access senior or colleague support as necessary, recognising learning and supervision needs
• level 3 competencies must be kept up to date within a rolling program of knowledge/evidence updates

All health care professionals with responsibilities requiring level 3 competence will need a broad range of clinical knowledge, and this is role specific and evolving all the time; certain areas of knowledge and skills may also be relevant and depend on the population and professional role. The list below is not exhaustive, and will overlap, but it demonstrates the different areas of expertise required for professionals working with children and young people:

• Adolescent health
• Development, atypical development, neurodevelopmental disorders and impact on presentation and behaviour and increased vulnerability
• Child or young person seeking asylum or refuge (CYPSAR) (health screening and different health needs, emotional health and trauma, impact of different social and cultural background)
• Trauma-informed practice, family approach, strength-based interventions
• Principles of documentation, information sharing, legislative frameworks, evidence-based practice.
• Specific responsibilities e.g. LADO process and electronic systems e.g. Child Protection – Information Sharing (CPIS, only in England)
• Deprivation of Liberty Safeguards) and Mental Capacity Act 2005; due to be amended to Liberty Protection Safeguards in England and Wales
• Safeguarding children’s referrals, e.g. MASH referrals and escalations, sections of Children Act 1989 (c.41) relating to social care assessments and health involvement, Social Services and Well-being (Wales) Act 2014 and Wales Safeguarding Procedures

• Child exploitation
• Domestic abuse, direct and indirect
• Perinatal violence and abuse
• Forced marriage
• Online and social media abuse
• Impact of adult carer difficulties e.g. mental health, drug and alcohol misuse, social depravation, parenting ability
• Violence including children who are violent towards parents and others, online influence

• Disguised compliance
• Young parents (people under 18 years old who have children living with them)
• Young carers
• Kinship carers, and types of permanency arrangements for children and young people in care e.g. foster, Special Guardianship Order (does not apply in Scotland), adoption

• Definitions related to which children are in the care of local authority/council/health and social care trust and care leavers; who has Parental responsibility and can give Consent; corporate parents and responsibility
• Statutory duties e.g. Initial and review health assessments, Review Health Assessments
• Specific considerations for health, emotion, education, and social needs of children in care and impact of disrupted long-term/adoption placements

• Adolescent brain development and risk taking (which continues after turning 18 years old)
• Binary approaches to legislation and impact of restrictive care pathways and eligibility criteria
• The 6 principles of Transitional Safeguarding and how the approach can be applied in health services (see: Transitional Safeguarding: Knowledge Briefing for health professionals)
• Understanding of the statutory duties under Section 58 of the Care Act to assess a child’s needs for care and support before they turn 18, and the responsibility to identify needs and refer for assessment accordingly
• Training for level 3 staff groups should make clear reference to the safeguarding adults training that the staff will be undertaking, to ensure that knowledge and competencies for either age group are not viewed in isolation

Child physical abuse

including

• Female genital mutilation (FGM)
• Gender based violence
• Non-fatal strangulation and associated risk; sexual violence

Child emotional abuse

Neglect e.g. physical, emotional, educational, medical, dental, nutritional

Child exploitation,

for example

• County lines and drugs
• Radicalisation and/or gangs (in real life and online) and Prevent duty
• Modern slavery and people/child trafficking

Fabricated or induced illness (FII)

Child sexual abuse

• Child sexual abuse – intra-familial
• Child sexual abuse – extra-familial, including child sexual abuse images
• Child sexual exploitation, e.g. online grooming, and gangs
• Children and young people with harmful sexual behaviours

Examples:

• Collaborating with Safeguarding Adults Boards & Designated Professionals for Adult Safeguarding:
• safeguarding referrals for adults who may be at risk of abuse/neglect (Section 47 of Children Act 1989 (c.41)) (applies to England and Wales)
• knowledge about the adults at risk section of the Safeguarding Procedures (only in Wales)
• Interagency Referral Discussions (IRD) and Adult Protection Committees (only in Scotland)
• Local Safeguarding Children Partnerships (LSCPs) role and accountability (only in England) – applies to equivalent joint agencies working across other UK nations
• Impact of external reviews and inspections, e.g. joint targeted area inspections (JTAI) in England and joint inspection of child protection arrangements (JICPA) in Wales
• UK government directed reviews (see resources)
• Learning from national safeguarding children practice reviews (see resources)
• Learning from national and local child death reviews (see resources)

Role of senior child protection and children and young people in care professionals in support, escalation, training and strategic level service provision and responsibility

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