Final draft for approval
Integrated Working Framework for meeting the needs of children and young people and their families
2011
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Integrated Working Framework
Contents:
1. Introduction 3
2. What is integrated working? 5
3. Our shared values 6
4. Principles for integrated working 6
5. Identification of needs and services by locality 7
6. Common language and terms 13
7. Communication and information sharing 14
8. Assessment, recording and monitoring of needs 15
9. Team Around the Child and Multi-agency panels 17
10. Connecting Families 18
11. Operational model(s) for integrated working 19
12. Management and governance 21
13. Planning 22
14. Commissioning 23
15. Funding and resources 25
16. Quality assurance (Monitoring and Evaluation) 27
17. Appendices 28
Appendix A: Data on the 5 dimensions of need shown by locality Appendix B: Meeting needs through integrated working - a conceptual model Appendix C: Agencies and potential roles in an integrated child and family support approach Appendix D: Speaking the same language on integrated working Appendix E: Related strategies and plans.
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1. Introduction
The vision for all children and young people in Bridgend County, as agreed by The Children and Young People’s Partnership, is to:
(i) thrive and make the best of their talents; (ii) live healthy and safe lives; (iii) become confident and caring individuals; (iv) understand their rights and responsibilities.
In order to achieve this vision we need to listen to children and young people and their families, be clear about their real needs and build networks of services based in our local communities to meet those needs. Integrated working can take many shapes and forms and will often depend upon the context in which it operates. Within Bridgend County, there is already a good degree of co-operation between agencies and proven success e.g. in the Flying Start programme, but the time is now right to take a more radical approach to collaboration. The purpose of this framework is to give a strong steer on how multi-agency working, for all tiers of need but particularly for children and young people with needs at Tier 2 (additional needs), is to become fully effective in Bridgend County so that services are seen to be working as one. In doing so they will: recognise and understand the needs of the children and young people of Bridgend County; seek to prevent problems arising; be quick to respond when the need arises; give a single point of access to services; provide help and support closer to the point of need; break down barriers between agencies; be integrated, inclusive and of high quality; support parents.
The Bridgend Children and Young People’s Plan sets out a number of priorities for the different services to take on and indicates the outcomes we wish to see in terms of improvements in the lives of children and young people. These are expressed in terms of the 6 outcomes for children and young people which will change their lives for the better and they embrace the Welsh Assembly Government’s 7 core aims. They inform and underpin the rationale for developing principles of integrated working and setting up multi- agency teams.
The Welsh Government’s strategy for Primary and Community Health services, Setting the Direction, while addressing the health needs of the full age range, is clear on the need for more joined up working: The NHS, together with all other public service providers, will need to improve efficiency and redesign services to meet the demographic demands of the
3 Final draft for approval future in a financially challenging environment. It is clear to everyone that the status quo is not an option. This vision for primary and community services has at its heart improved outcomes for the citizen, more effective and efficient ways of working within the NHS and with partners…
The development of this framework also links closely to other projects in Bridgend Council’s Supporting Vulnerable Children 2 Programme (SVC2) which includes the Connecting Families project, a project in each of the three localities (community networks) in Bridgend County to establish multi-agency teams and community hubs, an ICT project to facilitate information sharing and integrated working, a project to improve the lives of looked after children and one to redesign residential provision.
There is a strong drive in Bridgend to develop more integrated working in the field of Adult Health and Social Care and this programme is being aligned with the Supporting Vulnerable Children (2) programme to share developments where possible and make best use of resources to avoid duplication of effort.
The framework relies on certain givens which have been agreed by all partners to the Children and Young People Partnership. In the 2011 CYP Plan, the 6 broad outcomes which we all wish to see are set out in the shared vision:
It is intended that children and young people will:
1. learn and achieve
2. participate and enjoy
3. give and receive respect
4. be healthy
5. be safe
6. be confident and self-reliant
This framework is designed to ensure that each child in need i.e. one for whom some or all of the 6 outcomes will not be or are not being met, has appropriate support. Such support should not be prone to frequent and unsettling change but be from providers of services with whom the child and the child’s family can identify and build a relationship. The forms of working proposed in this framework are also geared to reducing the number of children and young people who require that more intensive level of support provided by a team around the child. Whatever the level of need, therefore, integrated working practices must ensure that:
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support is designed around the needs, progress and development of individual children; there is a strong emphasis on prevention and early intervention, turning this from an ambition into actual practice; where universal services exist e.g. health visiting, their effectiveness is not diminished but helps to direct intervention to where the real needs are; and practitioners reconfigure their services to reflect the particular circumstances and needs of different groups of children and communities and offer children and young people a seamless service.
2. What is integrated working?
If the concept of integrated working, across different sectors and agencies but also within sectors, is to be progressed, there is a need to arrive at a common understanding of what is meant by integrated working, how that might be articulated in broad operational terms of multi-agency working and what principles should underpin its development. The drive towards better collaboration between agencies and therefore a more coherent and satisfying experience for service users is underpinned by the Local Government (Wales) Measure 2009 and more recently by the Families First initiative, the latter replacing Cymorth in 2012 as the vehicle for taking forward the whole child and family centred approach. Other national guidance or requirements, such as the recommendations from the Health Visiting Review by Welsh Government, will need to be taken into account when determining the shape of any integrated working arrangements.
Integrated working, for the purposes of this framework, is defined as: a system and a culture of partner organisations working together with shared values, common goals and agreed priorities to bring about change for the better in the lives of children and young people.
This is a broad definition and does not prejudge what the model or models of service delivery will look like. Integration can take many forms along a wide continuum of practice. To arrive at an appropriate and agreed model or models in Bridgend will require knowledge of the many aspects of integrated working, including data management, common assessment frameworks, extended services and multi-agency locality team building. It will require close working relationships with decision makers in each organisation, managers and front-line staff. The engagement of statutory and non-statutory partners is essential, including the participation of children, young people and families. Integrated working will require commitment from all partners to sign up to a shared set of values and principles. It is also necessary to be clear on the needs which services must seek to meet, how those needs are assessed and recorded, the language and means we use to share our knowledge, how referrals will work, what will constitute a multi-agency team and how it will operate. Underpinning these will be the organisational and resourcing factors to ensure integrated working is sustainable, efficient and effective i.e. proper governance arrangements, a comprehensive and co-ordinated approach to
5 Final draft for approval workforce development, robust commissioning processes, careful service planning, funding and resource mechanisms dedicated to best outcomes for users and rigorous quality assurance.
3. Our shared values
In taking forward integrated working, children and young people, their families and the partner agencies value:
i. children and young people, families and those working in support roles as equal partners; ii. honesty, integrity and openness; iii. respect for others and self; iv. a willingness to contribute to and find solutions to problems; v. the health, safety and wellbeing of the children and young people.
These values will take on particular meanings in different contexts e.g. wellbeing may be spiritual wellbeing within faith communities; working as equal partners may mean ensuring the participation of young people and families in important decisions which affect lives.
4. Principles for integrated working
In putting the child or young person first, partners involved in integrated working will: a) put the interests and wellbeing of the child or young person before those of any one service or group of services; b) ensure that multi-agency working is inclusive so that no child or young person is denied the opportunity to access the services they need; c) give equity of access to provision.
In evolving a culture of integrated working, partners will: d) focus increasingly on prevention and early intervention; e) be willing to take on new challenges, develop understanding of different cultures and legal frameworks and establish new relationships; f) commit to making multi-agency working a success and empower leaders and managers to this end; g) work in a holistic way with children, young people and their families so that they tell their story only once, hear consistent messages and receive co-ordinated support; h) be open with fellow partners and exercise discretion, trust and sensitivity in establishing and operating multi-agency structures and teams;
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i) collaborate to make most effective use of limited resources, pooling budgets where appropriate.
In managing the business of multi-agency working, partners will: j) accept that, without compromising statutory obligations, collaboration may mean giving up some things for the greater good and this translates into positive gains for children and young people; k) safeguard the professionalism (e.g. maintaining professional standards, observing supervision requirements) of those working in a multi-agency setting; l) understand that multi-agency working needs to be geared to the different tiers of need so that multi-agency community (MAC) teams are deployed to defined localities to address the lower tiers of need and they are supported by staff managed centrally when low incidence or higher tier needs cannot be met by the MAC team; m) work towards establishing common or compatible databases which will enable the sharing of information; n) develop agreed means of communication, information sharing protocols and secure practices to facilitate effective multi-agency working; o) invest in workforce development and a programme of collaborative training and development to realise the shared vision and more specific objectives; p) work to the priorities as set out in the CYPP Plan and address any emerging priorities; q) support governance arrangements which allow partner agencies, children and young people and their families to play a part in decision- making; r) agree on robust team structures and working practices with clear lines of accountability.
5. Identification of needs and services by locality
Bridgend’s 4-5-6 model sets out 4 tiers of need, 5 dimensions of need and the 6 outcomes which describe how children and young people would think, feel and act in an ideal world. In mapping needs and the services which seek to meet those needs, the following categories have been applied where it has been possible to do so:
4 tiers of need Tier 1: Basic Tier 2: Additional Tier 3: Complex Tier 4: Critical
5 dimensions of need : Social : Physical
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: Emotional : Cultural : Learning
6 outcomes It is intended that children and young people will: 1. learn and achieve 2. participate and enjoy 3. give and receive respect 4. be healthy 5. be safe 6. be confident and self-reliant
The model is intended to support integrated working by: i. providing a common language which is widely understood and not service specific; ii.defining the needs of children and young people in ways which relate to their lives rather than service provision; iii. establishing agreed tiers of need so that it is clear when a child has crossed a particular threshold and requires a different level of support; iv. providing descriptions of what an unmet need looks like in the life of a child; v. giving pointers to the services which can help a child who has unmet needs; vi. defining the outcomes for children and young people in terms of how their lives change for the better
If there is to be a shared understanding of needs, a programme of training in the model would have to form part of the workforce development plan.
The localities are the three agreed by the Local Service Board and which now form the basis for planning across a range of services including the Police, Health, third sector providers, Housing, Safeguarding and Family Support, Education Inclusion, Education Access, Adult Social Care, Adult Learning, Healthy Living and schools. Each locality will be served by a multi-agency community team (MAC team) working from a community hub. The map below shows the three localities and the possible locations for either 3 or 4 such hubs.
The North Locality is essentially the Llynfi Valley, Garw Valley, Ogmore Valley and Valleys Gateway area (Aberkenfig across to Bryncethin).
The East Locality is the Bridgend and Pencoed areas.
The West Locality is the Cefn Cribbwr, Mynydd Cynffig, Pyle, Corneli and Porthcawl areas.
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Possible locations of community hubs and satellites on the 3 localities model
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Each hub would have “satellites” to serve communities which could not easily access the community hub. The satellite would offer a facility from which MAC team members and members of county-wide Resource teams could engage with children and young people and families. The hubs would offer a comprehensive range of services delivered by co-located staff working to common principles, shared outcomes and shared approaches to assessment, recording and monitoring.
The map below, showing the deprivation rankings by ward, indicates that the higher levels of disadvantage are generally to be found in the North but there are also significant pockets in the West and East too.
Bridgend County showing Wards and Areas of Multiple Deprivation
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Looking at the total population of children and young people in each of the three localities, it can be seen that there are demographic variations by both area and age group. The incidence of need, however, may vary with type and severity of need and this will be a critical factor in determining the level of resource deployed to each area.
Locality Population of % of children % of BCBC children and young and young population people 0-24 in people 0-24 in BCBC BCBC North 14898 38% 11% East 16277 41% 12% West 8431 21% 6% Total 39,606 Source ONS Mid year Ward estimates 2009, Population Age 0 – 24, BCBC Total Population 134197
Locality Population 0-19 % of children and % of total BCBC young people 0- population 19 in BCBC North 12,002 38% 9% East 13,060 41% 10% West 6879 21% 5% Total 31,941 Source: ONS 2010 Ward Population Estimates for England and Wales, mid-2009 (experimental statistics), Population Age 0 –19 31,941, BCBC Total Population 134,197
Locality All Ages 0-4 5-9 10-14 15-19 0-19 North 49306 2985 2872 3038 3107 12002 East 53795 3297 3166 3283 3314 13060 West 31096 1599 1583 1827 1870 6879 Source: ONS 2010 Ward Population Estimates for England and Wales, mid-2009 (experimental statistics), Population Age 0 –19 31,941, BCBC Total Population 134,197
Locality School Population % of school population (a) aged 3-11 (b) aged 11- (a) aged 3-11 (b) aged 11- 19 19 North (a) 4590 (b) 3342 (a) 37.65% (b) 34.32% East (a) 4834 (b) 3812 (a) 39.66% (b) 39.14% West (a) 2517 (b) 2131 (a) 20.65% (b) 21.88% Out of County (a) 142 (b) 398 (a) 1.16% (b) 4.09% Unmatched (a) 107 (b) 56 (a) 0.88% (b) 0.58% Source: PLASC 2010, Population Age 3-11 12190 (Primary) 11-19 9739 (Secondary) by pupil residence, BCBC Total Population 134197
Appendix A sets out a range of data broken down into the 3 localities and offers a snapshot of need at a point in time. The indicators of need are, in some cases, no more than indicative since proxies for need have to be used in the absence of quantifiable data on the need e.g. the number of children on school action for Additional Learning Needs (ALN) does not necessarily imply
11 Final draft for approval that the criteria have been applied consistently from school to school. There are, however, some general points which can be drawn from this data.
Social needs: the social services caseloads are highest in the East which reflects the fact that it has the highest population. However, the referral rate is far higher for the North but referrals do not translate into the same volume of cases; for every one case in the North there are 7 referrals, for every one case in the East there are 2.5 referrals and for every one case in the West there are 3.5 referrals. While the North has the highest number of child protection (CP) registrations, the East gives rise to the highest number of looked after children (LAC). The North has by far the highest number of children entitled to free school meals (FSM) which is 24% of children and young people in that locality. Interestingly, the West has the next highest proportion relative to size, 20%, while the East has 15% of its school population entitled to FSM. The highest number of youth offences is recorded in the East but relative to the size of the locality’s youth population, the West has the highest incidence of offences.
Physical needs: Low birthweight babies are born across the county but there are three areas with higher figures, Brackla in the East, Caerau and Maesteg in the North and Cornelly and Pyle in the West. The percentage of children who are free from dental decay varies from 71% in Bridgend to just 42% in the Garw and Ogmore valleys of the North locality; these are amongst the worst in Wales. Teenage pregnancy rates across the County are higher than the national average with the North having 3 of the 4 wards with the highest rates, the other being in the West. The number of young people presenting as homeless, approximately 240 in 2009-10, is on a rising trend but there is no data by locality. In 2009-10 approximately 270 children and young people were referred for treatment for substance misuse, including alcohol. No figures are available by locality but the downward trend in this statistic is considered misleading as it reflects more the fact that fewer young people see their misuse as a problem and are not coming forward for help.
Emotional needs: Data is limited for this dimension of need. The health records of mothers reflect the high incidence of post-natal depression that directly affects children’s mental health. Children receiving counselling support are referred by the school at primary level but may also refer themselves at secondary level. In both primary and secondary the number of children receiving support in the East is disproportionately low relative to the school population, whereas in the West it is far higher than might be expected. There continues to be a high demand for this service and schools, working with the Inclusion and Educational Psychology Services, are seeking ways of addressing the emotional and resulting behavioural issues through early intervention strategies. The Children and Adolescent Mental Health Service (CAMHS) work primarily, but not exclusively, with cases in the higher tiers and also contribute to the early intervention agenda.
Cultural needs: There is little data currently to provide useful indicators of need for this dimension. The figures for uptake of music tuition reflect quite closely the relative proportions of the population in each locality. The number
12 Final draft for approval of Bridgecards issued to young people suggests that usage of sports and leisure facilities is far higher in the East than the North or West. The number of racially motivated incidents is at such a low level that the figures are not statistically valid.
Learning needs: Outcomes for learners at each of key stages 2, 3, 4 and 5 are indicative of the success or failure in achieving educational potential. There is a very stark contrast between the performance of pupils and students in the North at key stages 2 and 3 with their performance at key stages 4 and 5; the latter two stages showing much poorer results than the former. Although the comparison of performance is for one year and therefore the different cohorts may well have different levels of ability, the variation is so large as to be significant. This interpretation gains credence when the North’s figures are set against those of the East and West. Performance in the East and West is significantly below that of the North at key stages 2 and 3, and significantly above at key stages 4 and 5. The strong implication is that pupils in the North fail to improve at the same pace as those in the East and West after the age of 14. Across the whole school population, there is a much lower proportion of pupils with poor attendance in the East, the highest being in the North. The highest rate of fixed-term exclusions is in the East. The North has the highest number and highest proportion of pupils on the ALN register at the school action level, whereas those with greater needs, at school action plus, are evenly spread across the populations in each of the three localities.
6. Common language and terms
Successful integrated working will require different professionals and groups of staff to develop a common language allowing time to explore difference in language and culture. Other local authorities that have adopted integrated service models have found it difficult to progress until they have developed a common understanding of key terms, including the actual definition of integrated working. Time spent building a real shared understanding of key terms and definitions will provide a strong foundation for joint working. It is through language that we understand the real world and without a common language, different services will not understand each other or be able to work together effectively. Without a common language there is a danger that misunderstandings will undermine effective communication and collaboration, no matter how good our policies and systems are. Inconsistencies in the use of terms can also reinforce some of the cultural obstacles likely to be encountered as organisations and services in Bridgend become more integrated.
The 4-5-6 Model has as one its aims the ambition to “provide a common language which is widely understood and not service specific”. The Model offers definitions of the 4 tiers of need (Basic, Additional, Complex and Critical), 5 dimensions of need (Social, Physical, Emotional, Cultural and Learning needs) and 6 outcomes which are expressed in terms of change for the better in the life of the child (listed on page 4 of the Introduction in this framework). The fact that the definitions of need and the accompanying signs
13 Final draft for approval of unmet needs for each dimension are not written from any one professional’s standpoint, means that they should be widely accessible.
For a compendium of terms and their definitions, refer to Appendix D.
7. Communication and information sharing
The Council’s Supporting Vulnerable Children 2 (SVC2) programme will rely on highly effective communication and information sharing systems. Within the Children’s Directorate, the project to allow information to be shared via a portal between the 3 main databases (Impulse – pupil data warehouse; Draig – social services case management system; Tribal – SEN database) will be fully operational in the summer of 2011. The Connecting Families project will have an information officer in post also by the summer of 2011. These are steps towards what will be needed for the full implementation of SVC2.
Agencies working in a truly integrated way must have access to the same data which gives a picture of the whole child. The 4-5-6 model, if adopted, could provide this without compromising the professional integrity of individual agencies’ methodologies and data security. This could also serve as a portal between databases other than those already linked within the Children’s Directorate, if that were appropriate. The Integrated Information Systems project is due to launch in the Spring 2011 and, in fulfilling its aims, will complement and support the Integrated Working Framework.
The Integrated Information Systems project seeks to co-ordinate and, where possible, integrate data sets and the systems which generate the data. In particular, it is important that the project results in: a. accurate and up-to-date information on individuals, families and populations; b. early identification of children and young people’s needs; c. a comprehensive, accessible and robust information service for managers and front-line workers which will track and measure the effectiveness of support and interventions, quality assurance processes and inform strategic planning; d. systems and processes which have integrity, are reliable and cost effective.
To make these aims a reality it will be necessary to test current information sharing protocols and revise them as appropriate, to have data protection measures in place, which conform to the Data Protection Act 1998 and Code of Connection (Co-Co) regulations, and to develop Sharepoint or a similar e- mechanism for sharing information. The necessary consents from children and young people and family members must also be in place before information is shared between professionals. As importantly, partners must agree on how the data is to be used to best effect by practitioners, managers and strategic planners and what resource is required to make that happen. Knowledge management must be integrated and coherent as far as is
14 Final draft for approval practicable and while this does not have to mean co-location or single line- management arrangements, it does mean a genuine spirit of co-operation is needed to bring into effect the practical solutions to technical issues and to the management and use of the data. Training on the use of data and its implications will be essential for all staff with access to the data.
8. Assessment, recording and monitoring of needs
The assessment, recording and monitoring of children and young people’s needs and those of their families operates on a number of different levels and in different contexts. Two mechanisms, pre-referral forms and Integrated Children’s System (ICS), which are loosely based upon the Common Assessment Framework (CAF), and the 4-5-6 model, present the means of bringing some coherence to this process and the opportunity to share information in a way that is understandable to a range of audiences, including the service users themselves.
The CAF and subsequent referral and ICS assessments preceded the 4-5-6 model but the latter is not designed to supersede or duplicate the former. Essentially, 4-5-6 gives a good indication of the whole range of a child or young person’s unmet needs and a breakdown of those by the different dimensions of need and the tier of need. It does not offer, however, any assessment of the family’s strengths and shortcomings, nor of the wider environmental factors which support or hinder the child’s development. The pre-referral assessment form used by different agencies to refer to Safeguarding and Family Support services in Bridgend is structured to reflect service perspectives i.e. by Health, Education and Social Services, in the section on Child/young person’s development needs. It does not offer an holistic overview of the different dimensions of a child/young person’s needs nor indicate systematically the degree to which needs are not being met. However, unlike 4-5-6, it does provide a wider picture of the context in which the child/young person lives their life by setting out the parent’s or carer’s capacity to meet their needs and the factors affecting both child and family e.g. family history, housing, income. CAFRA is an assessment template employed by health visitors to create an early record of a child’s development, first completed at 6 weeks. It is aligned with the CAF but is completed for every child, not just those who have additional needs or are being referred to social services.
Research shows that families generally value the access to services that a shared assessment of need gives them, the relationship with the worker and not having to re-tell their story. The evaluation of CAF in Wales demonstrates that such a model can only succeed if introduced as part of a wider initiative to reconfigure services to provide an integrated approach to the issues families face. The same would apply to Bridgend in seeking to find a shared and common assessment, recording and tracking mechanism, or at the very least an information sharing mechanism, that all agencies could work with. If this were to happen, it would need to be compatible with the more detailed and specialised assessments carried out by different agencies.
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The two approaches seen in the 4-5-6 model and the Common Assessment Framework are not mutually exclusive. What they offer is complementary to the process of information gathering and sharing which can provide a better picture of children and young people who are becoming causes of concern and moving from Tier 1, where basic needs are being met, into Tier 2 where they have unmet and therefore additional needs.
The principles, as set out below, for developing a more integrated approach for assessing, recording, sharing and tracking needs will inform further work on the operational means of achieving the end goal of having a system which alerts services to unmet needs and brings swift and appropriate support to prevent problems escalating to Tiers 3 and 4. To this end any such system must:
focus on the needs and strengths of the child/young person and her/his family; flag potential and actual child protection issues at the earliest opportunity; allow for early identification of issues e.g. by checking how a child/young person measures up against the 6 outcomes in a quick overview; provide a clear picture of the child/young person’s unmet needs i.e. the sorts of need which are not being met and how far they are not being met; offer an assessment of the parent/carers’ capacity to meet needs; offer an assessment of the family context and environment; employ commonly understood terminology that is also accessible to the lay reader, including the children and young people and the family; be easy to complete; be in an electronic format; demonstrate that the necessary consents have been obtained for sharing information; be accessible via the web to different authorised agencies with proper Co-Co compliant security measures and information sharing protocols in place; contain accurate and validated contextualising data such as name, date of birth, address(es), siblings; complement and allow for straightforward transfer of data into other, more detailed assessment mechanisms e.g. ICS for initial and core assessments by SFS; include names of all agencies, and their contact details, involved with the child/young person/family; provide a summary but dynamic record of contacts with the child/young person/family; specify the support being offered to the child/young person/family and name the key worker.
As a generic assessment, any early means of identifying and recording unmet needs would be distinct from specialist assessments which:
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have a much more specific purpose (for example, assessments under section 17 of the Children Act 1989, where the main purpose is to determine whether a child or young person is a ‘child in need’; whether the child, young person or family requires services; or Onset where the main purpose is to assess the child or young person’s risk of offending); are undertaken by staff from a particular service or sector (e.g., criminal justice) are usually undertaken only by staff of a particular occupational or professional group (e.g. social worker, educational psychologist).
9. Team Around the Child and Multi-agency panels
The Team Around the Child (TAC) approach is central to the effectiveness of many integrated working arrangements. TAC supports particular elements of good professional practice in joined-up working, information sharing and early intervention. The TAC is a model of service delivery that usually involves:
a joined-up, common assessment; a lead professional to coordinate the work; the child / young person and family at the centre of the process; a flexible multi-agency team that will change as needs change; coordination at the point of delivery; a TAC support plan to meet the needs of the child / young person; regular meetings to which the child / young person and families are invited to attend.
The Inclusion Service has developed a version of this in the TAPPAS model (Team Around the Pupil, Parent and School) within the context of a drive to meet additional learning needs more effectively.
The aim of a common assessment is to identify vulnerable children earlier, ideally when still at Tier 1, and share information with the consent of parents/carers so that the strengths and needs of a child or young person can be met more accurately. There are many operational implications arising from a TAC approach and use of a common assessment of need e.g.
how TAC meetings use an initial assessment of needs; how a package of multi agency support would be designed to address a child or family’s unmet needs; what the role of a key worker or lead professional might be in managing a case.
The Team Around the Child brings together organisations which work with potentially vulnerable children and their families to provide help and support through the agreement of a multi agency plan and the allocation of a key worker. A multi agency plan for children and young people who have
17 Final draft for approval additional needs that cannot be met by a single agency is devised and the basis of the joint plan is the assessment of need. A multi-agency meeting allocates services and a key worker or lead professional for the child/young person with clearly defined outcomes which can be used to measure progress of the child but also provide higher level management information about the success of different interventions. The key worker role cannot fall disproportionately on any one service and it should not automatically be the person who initially identifies the unmet needs. Evaluations of the Team Around the Child approach in some local authorities has produced a number of beneficial outcomes e.g. a reduction in fixed term exclusions, prevention of offending and high satisfaction rates by parents.
This process does not replace the Child Protection or Children in Need procedures. Children in need of protection are referred directly to the relevant assessment team in Safeguarding.
There are currently 19 panels in Bridgend County and these can be rationalised if a reconfigured system is devised which has an initial review panel for each of the 3 localities in order to filter and channel early alerts. The panel would consider the best course of action following information which comes through an alert via a completed assessment of need. The route could involve a TAC meeting and/or a statutory panel. The detail of the process will be determined though inter-agency dialogue to arrive at a clear set of procedures for MAC teams to follow.
10. Connecting Families Project
Connecting Families is a project to develop and implement a new model of service to address the needs and behaviours of families who place most demands on public services and have a disproportionate impact upon the communities in which they live.
The overriding objectives when creating the multi-agency service will be: 1. to strengthen and improve outcomes for children and their families; 2. to improve integrated work practice and reduce duplication of resources; 3. to reduce disorder and crime in our communities; 4. to reduce the longer term costs to public services.
This project will focus on the creation of a co-located multi-agency team to work intensively with high demand families within the County Borough of Bridgend. It is anticipated that this service will be a wrap-round provision to complement existing services. It will offer an integrated multi-agency service that deals with the whole family and addresses their problems, including their impact on the community, in a single co-ordinated way. As a project, an evaluation framework will be developed that can accurately assess the impact of the service against an agreed set of outcome measures.
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The BLSB and the BLSB Delivery Board will form the top level of governance for this project. The project will report progress to BCBC’s Programme Management Board within the project portfolio of the Children’s Directorate Supporting Vulnerable Children 2 Programme.
Connecting Families will be a model of integrated working which is designed to meet, predominantly, the very complex needs of particular families throughout Bridgend County. The team will be specifically constituted to meet these high-end needs but will also deliver a range supports and interventions to family members who may not be categorised as high demand. As Connecting Families and the MAC teams evolve, cases may be referred on to Connecting Families when the interventions by the MAC teams are insufficient to address the issues at Tier 2 or Tier 2/3. When the Connecting Families team has met the objectives for a particular family, they may be referred to a MAC team for continued support. The Information Officer within Connecting Families will need to liaise closely with the Knowledge Management staff supporting the MAC teams.
11. Operational model(s) for integrated working
There are many different configurations of multi-agency teams depending on the needs of children and young people and their families, the size and nature of the area they serve and the resources at the disposal of the agencies to commit to a multi-agency team. It is unlikely to be the case that each MAC team in Bridgend County will have exactly the same composition though there would be elements common to all.
The conceptual model in Appendix B indicates the functions which can be carried out through integrated working, the client or target group and the three categories of support which would be available in each locality (MAC team, ‘Resource Team’ and ‘Other’). The level of involvement with or dedication to a team will vary but members of the actual multi-agency community (MAC) team, whatever their expertise and type of support they offer would be part of the core provision within that team, ideally co-located. Resource team support is where a worker would be linked to a MAC team but operate from a central resource and may cover more than one locality. Other support describes potential services which can be commissioned to make provision that is not available from the MAC or Resource teams.
The partnership roles of agencies contributing to integrated working, whether they provide capacity in the actual MAC teams or not, are to be found in Appendix C. This is not an exhaustive list, but a fuller directory of services is being developed by the CYPP and this would provide an up-to-date directory of support services available to meet needs in Bridgend County.
While the precise constitution of any one MAC team might vary, MAC teams addressing mainly tier 1 and 2 needs through integrated working could typically include one or more of: Health visitor
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Primary mental health team Community/school liaison police officer / PCSO Social worker Education welfare officer Family support worker (local authority/voluntary sector) Youth worker Pre-Vent worker Housing officer Inclusion service (TAPPAS - Behaviour support etc) Educational Psychologist
The role of school-based staff, including the School nurse, and their relationship to the MAC team would need closer definition as working arrangements are determined. This relationship may depend to some extent on how far a MAC team is based in a school if it were to form a community hub or satellite to a hub. Also, if a Team Around the Child was set up for a particular child, and the needs of the child were significantly around learning, then the school staff would very properly be part of the TAC for that child. School staff would usually be well placed to complete an early assessment of need and/or initiate an early assessment of need.
Where Flying Start provision is in place, the relationship between a MAC team and the Flying Start team would need clarifying. That relationship could range from the sharing of information on families to establishing Flying Start as an integral but distinct element of a MAC team.
Practitioners in Resource teams would provide additional support to meet some of the lower incidence needs at tier 2 and above and could include:
Drug and Alcohol support agencies CAMHS Youth Service Family planning Parenting services Family Information Service School and Community counsellors Referred services e.g. SaLT, Therapies Adult Mental Health Team CPN Benefits Day care support Want to work Bridges into work Careers service Job Centre Plus Language and Play Number and Play
Other providers commissioned to give support, even as members of the MAC team, might include:
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Local Childcare providers Voluntary Sector services e.g. Action for Children / Barnardos / Youth Works Work experience providers EOTAS providers e.g. Cardiff City F.C., GroundWorks
There is clearly flexibility in how integrated support is configured and the above groupings are not fixed but indicative of a range of provision that can be drawn together in different ways to meet needs for an individual, a family, a defined population (e.g. those at a relatively low point on the ASD scale, those suffering the effects of bullying) or even a whole population (e.g. open-access parenting courses, literacy support).
The operational arrangements will be the subject of a separate project to establish the multi-agency teams in each of the 3 localities. The Welsh Government’s Setting the Direction document is helpful in this respect, recognising that change must be driven locally, informed by common principles and values:
In driving forward this agenda there are a number of key issues that need to be considered by LHBs and their partners as they begin to redesign and realign services within communities. The model describes a number of key themes which can be summarised as follows: • Information Framework • Communications • Locality working arrangements • Enhancing skills in the community The Steering Group has been very clear that it is for local communities to design their own systems in response to local circumstances and as such there is no prescriptive mechanism by which these issues should be considered and addressed.
12. Management and governance
All stakeholders must have proper oversight of the strategy and how this translates into practice. Lines of accountability need to be well documented and not open to interpretation. Confusion between governance and management roles often leads to impaired effectiveness at the operational level.
A natural locus for such governance would reside in the Children and Young People’s Partnership which is accountable to the LSB. Its membership is already representative of the main agencies and stakeholders and its role would be to: a. determine the strategic direction of the multi-agency community teams in line with the Children and Young People’s 3 year Plan; b. agree funding arrangements, including pooling of budgets where appropriate; c. promote best practice and manage joint training;
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d. hold a quality assurance brief and monitor performance and outcomes in each of the 3 areas.
There may be a need to review the constitution of the CYPP and/or to establish a sub-group of the CYPP comprising a co-ordinator or manager for each area and key resource decision makers in order to: determine staffing and other resource requirements to meet needs in the areas; monitor overall performance e.g. of referrals and caseloads; agree the deployment and common operational arrangements of the MAC teams; ensure professional supervision is managed effectively; manage any shared or pooled budget arrangements; report to the Children and Young People’s Partnership Board;
Management and/or co-ordination of the MAC teams can be organised in a number of ways ranging from a loose network of agencies with a co-ordinator through to a team of seconded or appointed staff led by a manager with the authority to manage day to day business. Some of these ways may be characterised by:
Co-ordinator A person who co-ordinates the activity of the different agencies to ensure a joined-up service to families. This would include such functions as: organising the receipt and management of information on a child/young person, arranging panel meetings to filter new cases, facilitating team meetings.
Joint Managers Managers, appointed by each partner, to work together on the developmental/ management arrangements for the shared agenda for managing change and reconfigured services.
Single Manager A person who manages services , staff and budgets from different organisations, at an operational high level, or at operational locality level, or for a client/care group.
13. Planning
Transition plan: this will be required to manage the change from the current configuration of provision to multi-agency community teams. Set out as a time-limited project plan it will be contiguous with the work plans for the teams’ operations. It will need to cover: composition and population of team structure; communication; information management; resourcing; case management; administrative support; quality assurance.
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Work plans: each of the 3 multi-agency community teams will need their own work plan by which to manage the workloads of team members and to co-ordinate activities of Resource teams and additional commissioned services. This will be dynamic to manage the changing circumstances and demands made upon the team. It will also need to incorporate supervision arrangements, quality assurance procedures and reporting schedules.
Workforce development plan: such a plan will have to operate at different levels and include: generic training across teams on a range of common principles and practices e.g. assessment, record keeping, key worker roles; team development e.g. to share intelligence, build team spirit and integrated working practices; individual professional development to raise levels of skill and support career progression.
To take forward the planning and implementation, it is proposed to establish a joint ABMU-BCBC Development Officer post.
14. Commissioning
A MAC team will not be able to provide all the services needed by the children and young people and their families within their locality. Some services will already exist outside of the MAC team, either within the locality and to which referrals can be made e.g. a voluntary run counselling service, or as services from Resource teams for lower incidence needs e.g. hearing impairment.
When a service is required beyond what the MAC or Resource teams can provide or which is not available otherwise, it will be necessary to commission that service. In these cases, the children and young people’s Commissioning Strategy and its accompanying Toolkit can be applied for both individual and population commissioning. It is being trialled in 2011 and, if employed more widely outside the context of the Children’s Directorate, would require more work involving partner agencies. The exact mechanism for doing this in an integrated way between partners will need to be established.
Using a common approach within and across multi-agency teams will give much greater coherence to the process of matching good quality and appropriate provision to the real needs of the child or young person and the family. The commissioning cycle follows the basic “Plan – Do – Review” model but is set out systematically to ensure commissioners are supported at every stage to produce the best outcomes:
Stage 1: Understanding needs Stage 2: Profiling services Stage 3: Gaps analysis and priority setting Stage 4: Delivery planning and implementation Stage 5: Performance management and evaluation
Priorities would flow from stages 1 – 3 of the commissioning process and both MAC and Resource teams would contribute to this process.
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Preparing for Commissioning
a) proportionality guide b) undertake Where am I? assessment Stage 2 Profiling Services c) develop project plan a) identify the services d) risk assess project plan b) map the services e) develop communication plan c) assess quality f) familiarise self with key documents d) nurture the market
Stage 1 Understanding Needs
a) identify the information you need Stage 3 Gaps Analysis and Prioritisation b) identify how you will gather this information c) gather and collate the information a) identify hypothesis d) establish likely trend b) undertake gaps analysis e) understand local need c) decide on priorities and describe outcomes d) establish standards and indicators e) undertake options appraisal f) plan the pattern of services g) secure Sign up
Manage Change
Performance Management and Evaluation Stage 4 Delivery Planning and Implementation Stage 5.1 Operation Stage 5 Performance Management and Stage 4 Delivery Planning and 4.1 Delivery Planning a) monitor service delivery Evaluation Implementation: a) identify delivery mechanisms and timetable Procuring New Services b) manage relationships b) identify budget and funding methodology c) administer contract 5.1 Operation c) develop specification 5.2 Strategy a) determine procurement route d) work towards continuous improvement d) identify performance management arrangements 5.3 Process b) develop tender documents c) complete tender process and award d) support provider business plan 4.2 Implementation Performance Management and Evaluation Stage 5.2 Strategy Stage 4 Delivery Planning and a) assess ‘turning the curve’ Implementation: Reconfiguring Services
a) assess risk and seek advice Stage 4 Delivery Planning and Implementation: Performance Management and Evaluation b) work with provider Decommissioning Stage 5.3 Process c) develop transition plans d) revise contract a) evaluate a) assess risk and seek advice b) revise process b) work with provider c) develop transition plans and exit strategies d) develop protocols of understanding
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15. Funding and resources
There are several ways of looking at how integrated working might be funded and budgets managed.
Joint Resourcing Pot Resources brought together to provide a single focus for the planning, commissioning and delivery of services. Resources can include staff, money, equipment (in its widest sense) and property and any other resources currently made available within each of the existing separate agencies to deliver services.
Aligned Budget This involves the grouping together of separate budgets to improve the joint planning and deployment of resources by local partners. Decisions are taken collectively about the aligned budget but the individual accounts are still technically held within separate agency budgets to allow them to identify and account for their own contribution. This approach does not require new powers.
Pooled Budgets This is a mechanism by which the agencies contribute to a discrete fund. Within this fund or “pool”, contributions lose their original identity and are committed and accounted for against the joint aims of the partners. For accountability and legal reasons a pooled budget is hosted by one of the partner agencies, in accordance with its standards of financial governance and the requirements of the agencies for monitoring and review.
Resource Contributions In all models of joint resourcing and joint management, partners must agree the resources which each will contribute year on year. In so doing, partners need to be transparent about the data under initial discussion and whether it relates to current budgets or current expenditure. All assumptions need to be shared, for example about efficiency savings or known inflationary pressures or commitments. Ideally, assumptions made should, as far as is reasonably possible, be consistently applied by all partners.
Partners must resource the new arrangement in a way that will provide stability and the ability to plan for the medium term, so that the arrangement has a proper chance to bed in and begin to produce results. Partners should set out the potential risks to financial stability over the medium term. The partnership should agree the required period of notice for any significant change in contribution by either partner under any model of joint resourcing and joint management. Partners must also agree a definition of what constitutes “significant” in relation to the joint resourcing pot.
The amount to be provided to cover joint development priorities, inflation and cost pressures, and how to manage efficiency savings, will need to be negotiated and agreed between the partners each year and shown in the Local Partnership Agreement.
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The single manager or co-ordinator joint managers (to be defined at whole partnership level or MAC team level) must be able to influence each partner’s contribution to the partnership. For example, if the manager was a local authority employee, he/she would presumably be able to influence the LA’s contribution but arrangements would have to be made to ensure that the single manager was a member of the decision making structure. The single manager would basically need to ensure that the partnership was allocated a ‘fair’ budget and was not being asked to accept an ‘unfair’ share of savings.
The following terms should be formally agreed, documented and signed off before commencement of joint resourcing and joint management arrangements and only adjusted each year as necessary: a. How much each partner will contribute for the year and where possible projected for future years. b. How much variation from year to year will be acceptable to the partners. c. How much variation in year (to each budget or combined if managed by a single manager) is acceptable. d. How the partners will require the budget to be managed (each budget or combined expectations if a single manager). e. How joint development priorities would be funded. f. How under and overspends will be dealt with including details of the consequent financial responsibility of each partner in such circumstances. g. How inflation will be managed. h. How any efficiency savings will be generated and how savings will be reallocated etc. i. Monitoring arrangements in terms of the nature, timing and recipients of the service, and financial management information. j. Details of service agreements that the partners enter into for the delivery of services. k. Whether resources include capital resources. l. Treatment of overheads.
Mainstream budgets and grants relating to the partnership arrangement can be used and specific grants may be part of the overall budget available to the partners, if appropriate. Ring fenced allocations and specific grants, while treated as part of the holistic resources for the purpose of planning etc will continue to be deployed and accounted for in the usual way.
Resources such as accommodation, information systems, goods and services will need to be agreed between the partners and appropriate recharges and capital charges agreed. There is clearly a need for openness and sharing information early in this process otherwise the aim of the arrangement could be undermined.
Mechanisms available for managing shared resources and the statutory frameworks within which they might operate are already well documented. These will be considered by the projects and workstreams which will be set up
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(some jointly with the Health and Social Care programme as appropriate) to determine the operational arrangements for establishing MAC teams.
Schools, with increasingly devolved and delegated budgets, would work in collaboration with or as part of MAC teams but would also be in a position to commission additional resource from the MAC or Resource team or from other providers of support.
16. Quality assurance (Monitoring and Evaluation)
There are three elements to the quality assurance of integrated working: - outcomes; - provision; - integrated working arrangements.
The outcomes, expressed in terms of change for the better in the lives of the children and young people and their families, are central to any quality assurance process. Using the outcome based accountability approach, the 6 broad outcomes of the 4-5-6 model provide a high level statement of what it is desirable to see in a child or young person e.g. they should learn and achieve, be healthy, be safe, be confident and self-reliant. These will translate into more specific outcome measures or indicators for the particular population or individuals with whom the MAC team is working e.g. all 3 children in a family achieve 90% attendance at school, all children in a family receive the MMR vaccination, child X participates in one out-of-hours activity and reports greater self-confidence; child Y reaches expected reading age. All relevant agencies will be able to contribute to and track progress against selected indicators. The effect of interventions, or combinations of interventions, can then be evidenced and collated to provide useful management information.
The provision of a specialist service has to be quality assured by those competent to do so i.e. through appropriate supervision routes for each particular discipline within the MAC team where that is appropriate e.g. supervision sessions for health visitors, counsellors, social workers by fellow professionals. For professionals who are required to work to a quality framework, their usual quality assurance procedures would apply. Where there are more generic roles e.g. family support worker (who may be also be a key worker), it will be necessary to determine appropriate line management arrangements which include suitable quality assurance procedures. Central to improving the quality of provision will be a structured, progressive and joint workforce development programme.
Review and evaluation of the integrated working arrangements i.e. how effective the structure, organisation and operational processes of the MAC and Resource teams are, should be a team undertaking led by the team co- ordinator. A self-evaluation document will support this process and inform the team about how they might build upon their successes and improve upon their shortcomings. Self-evaluation findings and follow-up actions will then find their way into the team’s work plan and procedural guidance.
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17. APPENDICES
APPENDIX A: data on the 5 dimensions of need shown by locality
Social needs
Locality (a) Child in Need referrals % (b) Child in Need caseloads North (a) 1955 (a) 62.6% (b) 275 (b) 39.7% East (a) 738 (a) 23.6% (b) 295 (b) 42.6% West (a) 407 (a) 13% (b) 118 (b) 17% (a) Source DRAIG 01.04.10 - 31.01.11, based on children’s home address at time of referral Total referrals 3123 (b) Source DRAIG 31.01.11, based on children’s home address CIN population 693
Locality Child protection registrations % North 64 43.5% East 48 32.7% West 35 23.8% Source DRAIG 31.01.11, based on children’s home address CPR population 147
Locality Looked after Children % (by home address) North 99 35.6% East 120 43.2% West 54 19.4% Source DRAIG 31.01.11, based on children’s home address LAC population 278
Locality (a) Primary school FSM pupils % of pupil population (b) Secondary school FSM receiving FSM in Area pupils North (a)1228 (a) 27% (b) 685 (b) 20% East (a) 794 (a) 16% (b) 459 (b) 12% West (a) 556 (a) 22% (b) 363 (b) 17% Source PLASC Jan 2010, FSM based on pupils home postcode BCBC Total Population 134197 School Population 22338
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Locality No of recorded % of recorded Offences per youth offences youth offences 1000 of the youth population aged 10-19 in the Locality North 192 33% 33 East 232 40% 34 West 158 27% 43
Physical Needs
Data is only available on a ward basis currently but is being compiled by locality on: Low birth weights Number of obese and overweight children and young people Perception of physical fitness Dental records of decayed, missing and filled Motor impairment
Emotional needs:
Locality Counselling referrals % of total Counselling (a) Primary (b) Secondary referrals (a) Primary (b) Secondary North (a) 60 (a) 49.6% (b) 119 (b) 38.6% East (a) 21 (a) 17.3% (b) 88 (b) 28.6% West (a) 40 (a) 33.1% (b) 101 (b) 32.8%
Cultural needs:
Locality Bridgecard ownership % of Locality population age 0-19 North 3052 9.56% East 4220 13.21% West 1497 4.69% Out of County 266 0.83% Unmatched 243 0.76% Source: Torex 0-19 ownership 9278, ONS 2010 Ward Population Estimates for England and Wales, mid- 2009 (experimental statistics), Population Age 0 –19 31,941
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Locality Participation in school/county % music North 472 36% East 544 41% West 309 23% Total cohort: 1465 (March 2011) Excludes special schools
Locality Racially motivated incidents % North 6 East 3 West 2 Source: YOT – Offences recorded during period 1-1-10 to 31.12.10
Locality play group places % play group attendance North 273 90 East 273 90 West 115 90
Learning needs:
Locality Pupils achieving Total pupils in % pupils by Locality CSI at KS 2 cohort achieving CSI at KS2 North 516 567 91.01 East 420 645 65.12 West 272 341 79.77 Out of County 10 16 62.50 Unmatched 9 9 100.00 Source: Impulse 2010 Result Data. Cohort for 2010 1578– Information based on pupil residence not school attended
Locality Pupils achieving Total pupils in % pupils by Locality CSI at KS 3 cohort achieving CSI at KS3 North 430 492 87.40 East 263 627 41.95 West 190 356 53.37 Out of County 36 63 57.14 Unmatched 6 8 75.00 Source: Impulse 2010 Result Data. Cohort for 2010 1546 – Information based on pupil residence not school attended
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Locality KS4 Pupil Total points score at Pupils average points Cohort KS4 score at KS4 North 539 181888.95 337.46 East 667 265502.3 398.05 West 345 136456.6 395.53 Out of County 72 24652.5 342.40 Unmatched 7 2485 355 Source: KS4-5 Result Data - Cohort 1630 Statistical Release SDR 208/2010 Average wider point score per pupil (age 15) Wales – 394
Locality Age 17 Pupil Total points score at Pupils average points Cohort age 17 score at age 17 North 268 118113.1 440.72 East 369 235601.2 638.49 West 176 103798.5 589.76 Out of County 36 21143.5 587.32 Unmatched 5 2214 442.8 Source: KS4-5 Result Data – Cohort 854 Statistical Release SDR 208/2010 Average wider point score per pupil (age 17) Wales - 748, total cohort 603 (cohort @ PLASC 10)
Locality Pupils failing to achieve over % of locality % of BCBC 90% school attendance school school population population North 2470 30.0% 11.0% East 2227 23.8% 9.9% West 1160 24.6% 5.2%
Locality No of school exclusions (fixed % of BCBC exclusions term) North 211 28.7% East 366 47.1% West 181 24.2%
Locality Number of pupils educated % of total EOTAS number other than at school (EOTAS) North 34 41.5% East 31 37.8% West 17 20.7%
Locality (a) pupils on SEN school action % of BCBC % of locality (b) pupils on SEN school action cohort cohort plus North (a) 1334 (a) 45% (a) 18% (b) 538 (b) 38% (b) 7% East (a) 1195 (a) 40% (a) 13% (b) 563 (b) 40% (b) 6% West (a) 448 (a) 15% (a) 10% (b) 322 (b) 22% (b) 7%
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Locality (a) pupils receiving 1:1 % of BCBC pupils in defined behaviour support group (b) pupils with ASD North (a) tba (a) (b) 82 (b) 41% East (a) tba (a) (b) 72 (b) 36% West (a) tba (a) (b) 47 (b) 23%
32 Final draft for approval Appendix B: Meeting needs through integrated working - a conceptual model
The model as set out below draws on the 4-5-6 model which describes the
4 tiers of need Tier 1: Basic Tier 2: Additional Tier 3: Complex Tier 4: Critical
5 dimensions of need : Social : Physical : Emotional : Cultural : Learning
6 outcomes 1. learn and achieve 2. participate and enjoy 3. give and receive respect 4. be healthy 5. be safe 6. be confident and self-reliant
For each dimension of need there is a set of functions or needs which will need addressing and if this can be done, at least in part, by a local multi-agency community (MAC) team, then a support worker, whatever their expertise, is noted as being a potential member of the MAC team. Resource team support is where a worker would be linked to a MAC team but operates from a central resource and may cover more than one locality. Other support describes potential services which can be commissioned to make provision that is not available from the MAC or Resource teams. The size and exact make-up of any team will be determined by the level of need in the given area. THE ENTRIES IN EACH COLUMN ARE NOT NECESSARILY EXHAUSTIVE OR CORRECTLY PLACED. THE MODEL SERVES AS A STARTING POINT FOR DISCUSSION WHEN THE MAC TEAM FOR EACH LOCALITY IS CONFIGURED.
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Social needs Functions to address Service user MAC support Resource support Other support social needs Child care Pre-school children Care Worker Early Years team Voluntary settings School age cyp FIS team Private settings …………………………… Genesis School settings Working parents Youth service Parents attending parenting or other skills training Moving Forward parents Parenting All parents – entry level Family support workers Parenting trainers Voluntary Sector (e.g. Triple P levels 1 – may be same as…. Incredible Program and 2). Case workers (EWO + Years WAG Parents requiring others) Or Approved specific interventions TAPPAS team member Healthy Start (e.g. at Triple P levels 3- Family Support Team 5) Mediation Families in conflict Family support workers Restorative Justice worker Tros Gynnal
Advocacy Children and young Case worker for referral Advocacy services - people in need of Tros Gynnal advocacy support Community safety Victims of anti-social Police liaison officers behaviour / crime YOS worker Young offenders – Counselling service potential offenders Volunteering and Presenting volunteers Community activities co- CFS manager Organisations, public community service Persuaded volunteers ordinator BAVO volunteering officer services, schools and businesses offering volunteering
34 Final draft for approval opportunities Safeguarding Looked After Children Social workers CP Education Children in Need S&FS Team Disabled Children’s Team including in need of Case worker / key Schools’ designated CP protection, worker co-ordinator Family Support Opportunities to Children and young Inclusion team Play co-ordinator Third sector providers socialise people with ALN Case worker Special schools (Heronsbridge)
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Physical needs Functions to address Service user MAC support Resource support Other support physical needs Accommodation LAC Housing officer Housing and benefits CAB Homeless young person team Local authority Homeless family Fostering and adoption residential provision Family in inadequate or teams for young people unaffordable After Care Team V2C accommodation Disabled Children’s Private settings Team Occupational Therapy Financial issues Economically Case workers Benefits team disadvantaged families Student finance officer Credit Unions Post 16 students
Disability Children and young Disabilities team Heronsbridge people with disabilities HI, VI, MI, ASD, SLD, Bridgend Day Centre Families of the above ADHD, SpLD, PMLD Out of County settings specialists. Occupational Therapy Disabilities Nurse (POW) Community Nursing Team SALT Sexual health Young people needing Health worker School nurse GP services practical advice Counsellor Public Health Wales Schools Youth Service / Just@sk Alcohol and Children and young Case worker YASH Voluntary organisations substance misuse people in need of advice Health worker ABMUHB Young people misusing Counsellor Public Health Wales alcohol and drugs Social worker CPN
36 Final draft for approval Families with misusing YOS worker parents Families with misusing children Teenage pregnancies Teenage mothers and Health worker (e.g. Youth Service (Moving GP Services fathers school nurse / health Forward) visitor) School/College/training Counsellor provider Case worker Midwives ABMUHB
Paediatric support Children and young Case worker Public Health Wales GP services people with medium to EOTAS team long-term illness Paediatric team Domestic and Children and young Case worker Frelom Programme Emotional Violence people Health visitors (A/C) support Parents Women’s Aid
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Emotional needs Functions to address Service user MAC support Resource support Other support emotional needs Advocacy Children and young Key workers Commissioned service - people needing Tros Gynnal representation and MEIC support Families needing representation and support School/college based Primary aged children Educational psychologist Counsellor with Schools counselling Counselling Service Secondary aged young Counsellor with Schools (primary) people Counselling Service (11+) College students College counselling service Community based Young people not in Youth Service Commissioned voluntary Bethlehem Life Centre counselling school or college Community counsellor sector counsellors YMCA Young people in Bridge Mentoring Plus education or training but unable/unwilling to access support through school/college Mental health advice Children and young Educational psychologist CAMHS GP services people presenting with Health visitor Midwives Princess of Wales – Way actual or potential Counsellor Community Psychiatric Forward mental health issues Social worker Nurse (CPN) MIND Primary Mental Health Mental Health Matters team
38 Final draft for approval Mental health therapy Children and young Social worker CAMHS Princess of Wales – Gail people presenting with EOTAS Way Forward actual mental health issues who require referring to specialist support
Behaviour Children and young Case worker Parenting trainers Care and support staff in people with behavioural Educational psychologist Police schools difficulties in the home Behaviour Support YISP workers Voluntary agencies or/and at school/college teacher providing support and or/and in wider society YOS worker improvement Health Visitor (0 – 5 programmes - Bad years) Bikes, Groundwork, KPC F and R Service Peer mentoring and Children and young Restorative Justice team Young people providing mediation people presenting YISP workers support to peers - SAP, emotional/behavioural Care and support staff in difficulties schools Young Carers support CYP Who Care for Social worker Young Carer (A/C) – Family Members Brackla Disabled Children’s Team
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Cultural needs Functions to address Service user MAC support Resource support Other support cultural needs After school use of Children and young Community co-ordinator FIS School run provision time people requiring Case workers Schools’ Catering extended hours child service care Third sectors providers Families in need of Childminders additional support. Children and young people needing a structured day to extend learning potential and/or improve social skills Before school use of Children and young Community co-ordinator FIS School run provision time - breakfast clubs people requiring Case workers Schools’ Catering extended hours child service care and improved Third sectors providers nutrition. Youth leisure Children and young Community co-ordinator School extra-curricular people needing Youth worker activity opportunities to develop Third sectors providers – socially, make e.g. Boys and Girls constructive use of Clubs, YMCA, Solid leisure time and acquire Rock, Just @sk. recreational skills.
Access by first Children and young EAL team language people whose first language is not Welsh or English and require
40 Final draft for approval additional support to become functionally literate Sport and recreation Children and young Community co-ordinator Healthy Living team GP services people requiring “fitness Case worker Third sector providers – for life” support and/or Cardiff City Football recreational activity to Club, Local sports engage socially and teams. build confidence Music / Play / Art / Children and young Community co-ordinator Youth service Third sector providers Drama therapies people more likely to Case worker engage with and be Inclusion team member responsive to non-verbal Counsellor and/or non-literate approaches Welsh Medium Welsh speaking children URDD and welsh sector Cultural Activity and young people and school provision Meithrin Support for Travellers Children and young Traveller structure (NPT) ? Schools people and families who Ethnic minority / EAL are travellers. team
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Learning needs Functions to address Service user MAC support Resource support Other support learning needs Literacy and Pre-school children with Early Years team Book Start Numeracy skills language deficits support School age children and On Track Parenting trainer School teaching and young people needing Big Lottery non-teaching staff additional support in School / Home Workers Basic Skills team literacy and numeracy Volunteer support Case worker Family members Bridges into Work requiring support to Genesis develop own basic skills LAP and help their children NAP Family Programmes Early years Pre-school children and Health visitor Parenting trainer Third sector providers development parents Early Years team Portage (health visiting) Case worker
MLD support Children and young Inclusion team people with specified additional learning need SpLD support Children and young Inclusion team Specialist inclusion e.g. dyslexia people with specified support additional learning need Speech and language Children and young Inclusion team SALT support people with specified additional learning need ASD support Children and young Inclusion team Outreach CAMHS people with specified SALT Early Birds Team
42 Final draft for approval additional learning need ADHD support Children and young Inclusion team Specialist inclusion CAMHS people with specified support additional learning need Outreach SLD support Children and young Inclusion team Specialist inclusion Y Bont people with specified support additional learning need VI support Children and young VI team people with specified additional learning need HI support Children and young HI team people with specified additional learning need Motor impairment and Children and young Disabled Children’s complex medical people with specified Team (DCT) support additional learning need LACE support Children and young Social worker LACE team Out of county providers people who are LAC and Inclusion team receiving educational Case worker provision Health Visitor Informal and non- Young people requiring Case worker School support staff Providers of informal and formal learning less formal learning 14-19 team especially non-formal learning - support opportunities Heronsbridge Amelia Trust, Cardiff City EOTAS FC PreVENT Career planning Young people requiring Case worker School’s careers Careers Wales additional support to teacher/support staff YELLOW plan learning/training Complementary Children and young Case worker EOTAS team Studio 34 curriculum people for whom neither Inclusion team member Access team / work Third sector providers mainstream nor special experience co-ordinator KPC schooling is appropriate
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Appendix C: Agencies and potential roles in an integrated child and family support approach.
The CYPP is developing a more comprehensive Directory of Services which will be available to signpost agencies and commissioners to appropriate service providers. The template below is illustrative of how the Service Directory might be used to inform the development of integrated working and assist agencies in seeing how appropriate support can be accessed. This is work in progress.
Voluntary Sector
Agency Services provided Sector Tiers of need catered Role Referral route Public for MAC Voluntary Basic Resource Private Additional Other Complex Critical Action for Children Childcare and parenting Voluntary Childcare – universal Other Various (Social Parenting – referral Services, Health and basis – tier 2-4 self) Barnardo’s Childcare and parenting Voluntary Tros Gynnal Family Mediation support Voluntary Universal Other As above for young people advocacy, mentoring
Wallich Clifford Housing support and Voluntary Tiers 2- 4 Other Professional and self benefit advice Bridge Mentoring: Support for young people, Tiers 2 – 4 Other “ Advocacy, Basic Skills.
Yellow: Homelessness and Voluntary Tiers 3 - 4 Other “ associated issues
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CAB General advice on any Voluntary Universal Other subject Homestart Parenting support and be- Voluntary 2-4 Other friending
Statutory Health services
Agency Services provided Sector Tiers of need catered Role Referral route Public for MAC Voluntary Basic Resource Private Additional Other Complex Critical Health visitors Statutory Service: Child Public Universal MAC N/A (statutory and health promotion and universal to all wellbeing parents) Midwives Statutory Service: Child Public Universal MAC N/A (statutory and and mother health universal to all promotion and wellbeing parents) CAMHS Statutory mental health Public Tiers 3-4 Resource GP, professional services to children and adolescents. Community Statutory – mental health Public Tiers 3-4 Resource GP, professional Psychiatric Nursing services and support.
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Statutory Community Safety services
Agency Services provided Sector Tiers of need catered Role Referral route Public for MAC Voluntary Basic Resource Private Additional Other Complex Critical Police Preventative work and Public Tiers 1-2 MAC or universal PCSO support to communities re; Resource incidence of low level crime and anti-social behaviour School Liaison Preventative work and Public Tiers 1-2 MAC support to schools YISP Preventative work and Public Tier 2-3 Resource Professional support to families and young people at risk of offending YOS Support re: rehabilitation Public 3-4 Resource Courts for young offenders
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Statutory Social Care services
Agency Services provided Sector Tiers of need Role Referral route Public catered for MAC Voluntary Basic Resource Private Additional Other Complex Critical Safeguarding and Statutory services, Public Family Support preventative and protection of vulnerable children and young people Social Workers Statutory – supporting and Public 3-4 MAC Professional & self protecting vulnerable children & families. LACE Support LAC pupils re Public 3-4 Resource Professional access to education Day care Statutory service linked to Public 3-4 MAC Professional & self support SaFS
Family support Statutory or voluntary Public/Voluntary 2-4 MAC Professional & self workers service supportive, referral signposting, advice around behaviour management parenting, General Family support with a focus on advocating for parents and children and young people. Key work. (And or any of the above) Budgeting, home conditions, practical
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Disabled Support to disabled young Public 3-4 Resource Professional & self Childrens team people and their families
Statutory education services
Agency Services provided Sector Tiers of need catered Role Referral route Public for MAC Voluntary Basic Resource Private Additional Other Complex Critical Education Welfare Statutory service Public Tier 2-4 MAC School & self referral Service supporting schools, parents and pupils to ensure regular school attendance. Education Psychology Identification of special Public Tier 2 - 4 MAC School Service needs and advice and support on meeting needs Behaviour Support Support and training for Public Tier 2 - 3 MAC School Service schools on managing behaviour issues Inclusion Service Support on all aspects of Public Tier 2 - 4 MAC School meeting ALN Careers Wales Signposting advice referral Public Tiers 1-4 Other Universal at tier 1 – inclusion mentoring, professional and self benefit advice, training 2-4
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Other services Agency Services provided Sector Tiers of need catered Role Referral route Public for MAC Voluntary Basic Resource Private Additional Other Complex Critical Basic Skills Team Support in improving basic Public Tiers 2-3 Other and key skills of children and young people and families Housing Benefit advice, referral, Public Tier 3-4 MAC Professional & self signposting, financial advice. Key work Youth Service Peer mediation, basic Public Tiers 1 – 3/4 Resource? tba skills, advocacy, key MAC? worker, social inclusion, engagement, healthy lifestyles, leisure, Drug and alcohol advice Sexual health. 14-19 Learning Support for those who Public 2-4 Resource? tba Pathways / Pre-VENT have or are likely to MAC? become NEET Community Various to support families Public 2-4 Other tba Resources:Communities to meet needs Voluntary First Bridges into Work, Genesis, Flying Start, Homestart, Y Bont, SNAP.
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Appendix D: Speaking the same language on integrated working
Term Definition
Integrated working
Integrated working Integrated working is where everyone supporting children, young people and families works together effectively to put them at the centre, meet their needs and improve their lives. Integrated working, for the purposes of the framework in Bridgend is defined as:
“a system and a culture of partner organisations working together with shared values, common goals and agreed priorities. Collectively we should bring about change for the better in the lives of children and young people in Bridgend County by striving to meet their needs.”
Who are we?
Term Definition Integrated workforce An integrated workforce is one that works effectively together with a diverse range of skills to improve the lives of children, young people, families and carers. This is explained through the Integrated Framework, which sets out the vision for an integrated workforce.
Children and young people’s The children and young people’s workforce includes workforce. all people working with children and young people in Bridgend. This includes volunteers and people who work with children and young people all the time, or who do so as part of jobs which also involve working with adults
Where do we need to focus?
Term Definition Safeguarding Safeguarding is about keeping children and young people safe from harm and abuse. This means keeping children and young people safe from accidents, crime and bullying and actively promoting their well-being in a healthy, safe and supportive environment
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Children and young people with Children and young people who are at risk of poor additional needs outcomes and who would benefit from additional tailored support to that offered by universal services, for example, to address additional educational, health, social welfare or behavioural needs
Children and young people with Children and young people with additional needs complex needs which are complex and meet the threshold for statutory involvement or specialist intervention, for example, social care or youth justice intervention
What approach should we take?
Term Definition Bridgend’s 4-5-6 model The model sets out 4 tiers of need, 5 dimensions of need and the 6 outcomes which describe how children and young people would think, feel and act in an ideal world and how signs of unmet needs might be recognised. Assessment Gathering information on the various strengths and needs of a child or young person and their family, through conversations with them and any practitioners already working with them. Assessment of need This is a shared assessment and planning framework for use across all services which support children and young people; it aims to help the early identification of children and young people’s additional needs and promote co-ordinated service provision to meet them. Assessment of need record A standard form for recording information collected from an assessment of need of a child or young person
Delivery plan and review This allows practitioners to record an agreed set of actions against the desired outcomes, and record progress against these actions and outcomes
CAF process The process a children’s services practitioner will follow when completing a common assessment of a child or young person. The CAF follows a four step process: identify needs early; assess those needs; deliver integrated services; and review progress.
Episode This is a central concept within the early assessment of need system. It corresponds to one complete journey through the assessment of need process – from identifying needs early until all identified needs are met (or the episode is closed
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for another reason). It describes the assessment of a child or young person’s strengths and additional needs and the actions taken to meet those needs. A child or young person can have more than one episode at different points in their development but never more than one at any given time e- 4-5-6 Portal A secure IT system for storing and accessing information captured though an early assessment of need. The system would not be limited for use within single local authority areas. It will help practitioners to share information across borders and agencies, improving the service experience and continuity of care for children, young people and families who move locations or use multiple services in different areas.
Information sharing Information sharing is the term used to describe the situation where practitioners use their professional judgement and experience on a case-by-case basis to decide whether and what personal information to share with other practitioners in order to meet the needs of a child or young person
Information sharing protocols Information sharing protocols (ISPs) are formal, signed agreements between organisations that relate to a specific information sharing activity. An ISP explains the terms under which the organisations have agreed to share information and the practical steps that need to be taken to ensure compliance with those terms. Information sharing protocols may be useful in data sharing situations but are not appropriate for situations where front- line practitioners have to make case-by-case decisions about whether and what to share
Data sharing Data sharing is the term used to describe bulk and / or pre-planned sharing of personal information between organisations or systems where the information to be shared and who it will be shared with can be fully predicted in advance
Privacy notice also called ‘fair A privacy notice is the statement that tells you who processing notice’ is collecting information about you and what it will be used for. Privacy notices take a number of forms, for example a notice on a website or a script read out over the telephone. A privacy notice should be in clear language and must be truthful. A privacy notice should say who is collecting information about you; what it’s going to be used for; and
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whether it’s going to be shared with other organisations. This is the legal minimum. However, privacy notices can be used to tell you about other things, such as the right of access to your information; how to get inaccurate information corrected; and the organisation’s security arrangements
Consent Consent is agreement freely given to an action, based on knowledge and understanding of what is involved and its likely consequences
Explicit consent Explicit consent is consent detailing exactly what the consent is for and in what circumstances it will apply. Explicit consent can be given orally or in writing
Informed consent Informed consent means that the person giving the consent must understand what is being proposed and what the implications of giving or not giving their consent may be
Common Core of Skills and This is the skills and knowledge that everyone in the Knowledge children and young people’s workforce needs in order to contribute to one or more of the five Every Child Matters outcomes. It applies to everyone in the children and young people’s workforce, even though the detailed application may be different for individual workers and for those working with different groups and ages of children and young people
How shall we organise ourselves?
Term Definition Multi-agency working Multi-agency working brings together practitioners from different sectors and professions within the workforce to provide integrated support to children, young people and families, for example a ‘team around the child’
Multi-agency services Multi-agency services are provided by agencies acting together, drawing on pooled resources or a pooled budget and a joint plan, for example, youth offending teams
Integrated services An integrated service acts as a service hub for the community by bringing together a range of services,
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usually under one roof, whose practitioners then work in a multi-agency way to deliver integrated support to children, young people and families, for example, extended services or sure start centres
Multi-agency community teams A multi-agency community team is when (MAC) practitioners are seconded or recruited into a team, share a team identity and are generally managed by a manager, though they may maintain links with their home agencies through supervision and training. This is a term coined to describe the teams as they would operate in Bridgend County.
Multi-agency panels A multi-agency panel is a group of people from different agencies that meet regularly for short periods of time to discuss children and young people with additional needs who may require multi- agency support. Panels are often used to allocate resources to new cases and to review progress across a range of cases. Members of multi-agency panels remain employed by their home agencies
Team around the child (TAC) A multi-disciplinary team of practitioners established on a case by case basis to support a child, young person or family. The TAC model is also referred to as TAYP (team around the young person)
Lead professional (or key The person within the team around the child worker?) responsible for coordinating the actions identified in the assessment, delivery and review process and who acts as a singe point of contact for the child, young person or family
What is our philosophy?
Term Definition Early intervention This describes the process or act of providing support or services when a child or young person, of whatever age, shows signs of having difficulties. Early intervention aims to ensure that individuals receive the help they need as soon as possible, thereby preventing a problem escalating and becoming more difficult to deal with. It is often used when referring to action in relation to a child in their early years but is not exclusively confined to that age group. It can refer to prompt action at any point designed to address emerging difficulties Prevention Services or strategies put in place to stop something happening or to stop someone from
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doing something that might affect the life of a child or young person
Intervention When someone steps in and does something, with the intention of making the child or young person’s future better
What are we seeking to achieve? Term Definition Embedded This is where processes or practices that were once considered new are now an on-going part of what everyone does during their daily job
Outcome What has changed (and ideally improved) for children and young people as the result of taking action
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Appendix E: related strategies and plans
- Children and Young People’s Plan 2011 - Setting the Direction 2010 - Health, Social Care and Well-being Plan 2011 - Inclusion Strategy 2010 - Families Together – a Family Support Strategy 2011 - Disabled Children and Young People’s Strategy 2009 - Children’s Emotional Wellbeing Strategy 2011 - Commissioning Strategy 2010 - Participation Strategy 2010 - Learning Communities Strategy 2010 - School Modernisation Programme 2007 - Autism Plan 2010 - CYPP Directory of Services
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