Annual Report Looked After Children Health Service Camden 2016/17

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1 Central and North West London r /:bj NHS Foundation Trust Camden Clinical Commissioning Group Annual Report Looked After Children Health Service Camden 2016/17 Gita Croft Designated Dr for Looked After Children Medical Advisor for Adoption and Fostering Anne Akamo Designated Nurse for Looked After Children Camden Looked After Children Health SeNice Annual Report 2016/2017 G Croft June 2017 Page 327 of 490

2 Camden Looked After Children Health SeNice Annual Report 2016/2017 G Croft June 2017 Page 328 of 490 2

3 Annual Report 2016/17 LAC Health Service (Camden) CONTENTS Section 1 Executive Summary 2 Local demographic data 2.1 Demographic information 2.2 National LAC data 2.3 Camden local statistics (numbers, age, gender, duration of care, ethnicity, placement type) 3 Service Summary / / 3.1 Staffing / ( 3.2 Supervision and peer review 3.3 Governance and reporting arrangements \,. 4 Performance Indicators,'\,. 4.1 National targets 4.2 Local statutory performance against national data... 5 LAC Team Clinical Activity '\,. 5.1 Health Assessments, / / '\,. 5.2 lmmunisations "' '\,. I / 5.3 Dental Checks '\, Registration with GP Interim reviews (local requirement) 5.6 Health care plan outcomes (local requirement) 6 Other Clinical Activity 6.1 Sexual Health and Children at risk of Sexual Exploitation 6.2 Teenage Pregnancies 6.3 Substance Misuse 6.4 Emotional Health & Wellbeing / 6.5 Health improvement activities ( ' 6.6 Overweight/obesity '\,. 6.7 Unaccompanied asylum seeking children Sleep 6.9 Care leavers 6.10 Other complex case work 7 Adoption & Fostering 8 Training 9 Service Improvements 9.1 Other specific improvements 9.2 Audits 9.3 Partnership working 9.4 User surveys 9.5 Inspection Updates 9.6 Professional development (and publications) 9.7 Committee work 10 Priorities for 2016/17 Appendix 1 LAC Health Team Work plan Appendix 2 Integrated pathway for unaccompanied asylum seeking minors Appendix 3 Example health care plan Camden Looked After Children Health Serv1ce Annual Report 2016/2017 G Croft June 2017 Page 3 Page 329 of 490

4 1. Executive summary This Annual Report has been produced for CNWL Camden Community Health Services within Central and North West London NHS Foundation Trust, Camden Clinical Commissioning Group and the London Borough of Camden Corporate Parenting Board. The report outlines the delivery of health services to children looked after (LAC) by the London Borough of Camden (LBC) during the period from 1 April 2016 to 31 March 2017, in line with National Statutory Guidance. It reviews performance indicators, clinical work undertaken by the LAC health team, service improvements and plans for further development. The aim of the LAC health service is to ensure that children looked-after by the borough of Camden have their health needs addressed. This includes the provision of a detailed, high quality assessment of children's health needs (statutory initial health assessment) when received into care and a statutory review health assessment, annually for children over five years of age and 6 monthly for those under five years of age. The team works in partnership with the London Borough of Camden and local health providers to ensure that appropriate services are developed to meet the health needs of Camden LAC. The key points below provide a short summary of areas covered within the main report. 1. Statutory performance indicators continue to show strong performance by the LAC health team. During 1 April March 2017, of those LAC who had been looked after for at least one year: o 98% had had their statutory health assessment in the previous year o 94%-100% had had their statutory health assessment in the quarter in which it was due o 93% had had a dental assessment in the previous year o 94% were up to date with all immunisations o 100% of under 5's up to date with developmental checks 2. A third of new entrants to care were years old and a further third were 16+ years, with a high proportion of unaccompanied minors. There has been excellent overall attendance for statutory initial health assessment, but delays in referral and non-attendance or cancellation of 1st appointment resulted in a low number being completed within the statutory recommended timescale. 3. On-going outreach work to attempt engagement with young people who refuse health assessments, a system for review of their health needs and liaison with other involved professionals ensures that health needs of individual 'hard to reach' looked after young people are kept in mind and addressed in a holistic manner, even when they have refused to be seen by the LAC nurse or doctor. 4. The team has a system for recording and monitoring health recommendations which require action for individual LAC. 93% of care plan outcomes were met by end March Immunisation uptake for children looked after for > 1 year remains high at 94%, though slightly lower than due to the number of unaccompanied minors still in the process of completing the schedule. 5. The LAC health professionals identify children with weight management problems and arrange interventions. Across Q1 to Q4 in , between 6% and 18.8% of looked after children and young people were identified as overweight or obese. 6. The LAC health team offers a range of other clinical input to individual LAC. This includes health improvement sessions, for example, on healthy eating and lifestyles. Assessments are undertaken for developmental delay and for complex developmental disorders. Emotional health is assessed in liaison with CAMHS. Sexual health advice is given and there is regular liaison with sexual health services. There were 3 known pregnancies in The LAC health improvement practitioner offers health workshops for young people in supported accommodation units. Sleep has been identified as a significant issue for many young people and an advice leaflet is given to all at their initial health assessment. Camden Looked After Children Health Service Annual Report 2016/2017 G Croft June Page 330 of 490

5 7. The North Central London integrated care pathway for unaccompanied refugee children, led by the Camden team, was finalised during 2016 and is running well. A psychotherapist attends the initial health assessment with the paediatrician and there are clear lines of referral for infectious disease and sexual health screening. 8. The LAC Health Improvement Practitioner set up drop-in sessions at The Hive Camden youth hub, alongside sessions run by the sexual health and substance misuse teams. However, these were poorly attended. A proposal is underway to move these to young people's residential placements and will complement plans for other health promotion work currently being discussed with the Care Pathways manager. 9. There is on-going close liaison with the Camden & Islington Sexual Health Network to ensure that looked after young people receive the services they need, through individual and group work. This includes identification and monitoring of LAC who are vulnerable to child sexual exploitation and ensuring that appropriate interventions are put in place. It also includes advice sessions for carers and individual work with teenagers who have learning needs. 10. There is routine screening for emotional and behavioural disorders at the initial health assessment using the Strengths and Difficulties Questionnaire and close liaison with the social worker and CAMHS team for children requiring interventions. Strategies to enhance resilience are incorporated into health care plans. 11. The LAC health team shares relevant health concerns about LAC with social work and health colleagues to ensure holistic care, while maintaining confidentiality where appropriate. In addition to routine liaison work, this is done via attendance at social care LAC review and strategy meetings and through regular forums including the Health & Development panel and meetings with the Disabled Children's team manager. 12. The LAC health nurses contribute to foster carer support groups with health sessions on a variety of topics tailored to the needs of carers and the children currently placed with them. The LAC nurses also offer direct support to individual foster carers on health issues such as behaviour management, therapeutic parenting, sleep promotion, sexual health etc. 13. The LAC health service also provides training for prospective adopters and a range of professional health colleagues including health visitors, school nurses and paediatricians. 14. The designated doctor provides an advisory service to Camden Adoption and Fostering team with regards to the health of adult fostering and adoption applicants and provides assessments for children placed for adoption. The designated professionals attend the adoption and fostering panels. 15. This report summarises the partnership working with other disciplines and agencies which is essential to providing holistic care for LAC. The report also summarises professional development and peer review activities which ensure LAC team members are up to date with knowledge and training. 16. The report concludes with an outline of areas for development for These include reducing delay to initial health assessments, implementing routine 6 week follow up after IHA, further develop health input to residential unit settings, develop a 'health passport' for care leavers, undertake user surveys, undertake an audit of health outcomes and finalise the guidance for adoption records. Camden Looked After Children Health Service Annual Report 2016/2017 G Croft June Page 331 of 490

6 2. Local information 2.1 Local demographic information The term 'Looked After Children' (LAC), Children Looked After' (CLA) and 'Children in Care' (CIC) are all used to refer to children who are placed into the care system. The term 'Looked After Children' is currently used within statutory and government documents and is used widely to refer to teams working with this group of children. However, some Local Authorities prefer the term 'Children Looked After' and teams are thus named to reflect this. In the past the use of 'Children in Care' became popular, so may also be a preferred term within some organisations. The terms are therefore interchangeable, however, in Camden this group of children is referred to as 'Looked After Children'. Local demographics: o o o o o o Camden had an estimated resident population of 225,140 people in 2013 (Greater London Authority Round 2012 'Camden Development v2'. Interim 2011 Census based). The age and sex profile of Camden is very similar to that of London but relatively younger than England with significantly greater proportions of younger adults aged between 25 and 40 years. 39,300 children and young people aged 0-17 years are estimated to live in Camden accounting for approximately 17% of Camden's population. This includes approximately 14,300 children aged % of school children are from a minority ethnic group. The health and wellbeing of children in Camden is mixed compared with the England average. The level of child poverty is worse than the England average with 27.6% of children aged under 16 years living in poverty. Source: Camden Child Health Profile March 2016, Camden Looked After Children Health Service Annual Report 2016/2017 G Croft June 2017 Page 332 of 490 6

7 2.2 National data: children looked after in England (including adoption and care leavers) year ending 31 March 2016 ( data will be available September 2017). Numbers: Nationally, the number of looked after children continues to rise. There were 70,440 looked after children at 31 March 2016, a rate of 60 children per 10,000 population. This is an increase of 1% compared to 31 March 2015 and an increase of5% compared to 31 March Age profile: There has been a change in the age profile with a steady rise in the number of children aged 10 years and older starting to be looked after. 62% of children looked after in 2016 were over 10 years, compared with 56% in There has been a reduction in the number and proportion of looked after children aged 1-4 years. Gender: At 31st March 2016,56% of looked after children were male and 44% female. These proportions have varied little over recent years. Reasons for rise: The rise over time reflects the higher number of children starting to be looked after than ceasing. It is largely accounted for by the rise in the number of unaccompanied asylumseeking children (UASC), which increased by 54% between 2015 and There were 4210 UASC in March 2016, 2740 in March 2015 and 1950 in % of children looked after at 31st March 2016 were UASC. This partly accounts for the changing age and ethnicity profiles. Placement type: 74% of looked after children in 2016 were cared for in a foster placement and 11% in a secure unit, children's home or hostel. 5% were placed with their parents and 4% were in an adoptive placement. Adoption: the number of adoptions in 2016 decreased by 12% from Please refer to for more detailed demographic information 2.3 Camden LAC demographic information: This information is provided by the London Borough of Camden Children's Safeguarding and Social Care Quality Assurance Unit Numbers of LAC There were 198 LAC children on The number of LAC at any one time has stabilised at around 200 since June The total number of LAC over the course of the year will be higher due to turnover (children entering and leaving care). 295 children were looked after at any time during 1st April st March 2017 (a slight increase from 285 in ) There were 107 new admissions to care for 102 children (3 children entered care twice and 1 entered care 3 times during this period) Of these 102 children, 34.3% were aged 16+ years (39.4% in ), 34.3% aged years (35.4% in ) and 31.4% aged under 10 years (25.3% in ). 97 children left care during this period. Camden Looked After Children Health Service Annual Report 2016/2017 G Croft June Page 333 of 490

8 Between and , there were 36 new unaccompanied asylum seeking minors who became looked after (compared with 25 in ). Comparison with the national average, inner London and statistical neighbour rate per 10,000 under 18 populations for the same period, is not yet available for 2016/ Age distribution of Camden LAC at There was a shift upwards in the age of LAC during There are fewer 0-9 year aids and a significant increase in the 16+ age range. The proportions have stabilised in 2017 with a small reduction in 16+ year aids and an increase in 0-9 year aids this year compared to Age Groups Of Camden LAC at 31/3/17 Age Groups Of Camden LAC at 31/3/ years yeors 16+ yeors Q..-9years HHSyears 16+ ye<7lrs Gender of Camden LAC at There has been a small increase in the proportion of male LAC compared with previous years. Gender Split- 31/3/16 Gender Split- 31/3/17 60% I emole Mole Female Male Camden LAC duration of care at Camden Looked After Children Health Service Annual Report 2016/2017 G Croft June Page 334 of 490

9 40% 35% 30% 25% 20% 15% 10% 5% Duration of Time in Care as at 31/3/17 0%* <6months 6-12 months 1-5 years 5-9 yearslot years Duration of care category of all Camden LAC on %, % % % % % % 10.00% 5.00% 0.00% Under 3 months 3 to 12 months 1to 5 years 5 years+ Figure demonstrates that an increasing number of children and young people are looked after for< 1 year, a likely reflection of the higher age at entering care Ethnicity of Camden LAC at Ethnicity of Camden LAC at 31/3/17 40% 35% 30% 25% 20% 15% 10% 5% 0% Asian or Black or Chinese or Mixed White Asian British Black British other ethnic groups Reasons for entering care Data for are not yet available. Abuse or neglect has been the primary reason for accommodation in recent years, demonstrated in nearly 48% of looked after children in Family dysfunction, absent parenting (unaccompanied minors), parental mental health and families in acute stress are other significant factors. There was a higher proportion of unaccompanied minors in A number of children become looked after because of severe disability necessitating accommodation in specialist placements including residential schools Camden LAC placement type at Camden Looked After Children Health Service Annual Report 2016/2017 G Croft June Page 335 of 490

10 52 % of Camden looked after children are in foster placements and 35.4% in residential homes/supported accommodation units. 6% are fostered within their family/friends network. The remainder are in a variety of other placements as seen in this graph below. Type of Placement at 31/3/17 60% % 40% 30% 20% 10% 0% 3. Service Summary 3.1 Staffing for service in 2016/ The designated doctor and nurse fulfil a strategic role in service planning and advising CCGs in meeting their responsibilities as commissioner of services to improve the health of looked after children. The CCG Designated roles in Camden are commissioned from and hosted by the provider services for LAC The LAC provider services health team is based at Crowndale Health Centre in Camden All members of the Provider LAC health team are experienced, suitably trained within their area of expertise and fully up to date with safeguarding training. They undertake on-going training in relevant subjects in order to maintain their competencies. The doctors and nurses within the team are registered with the General Medical Council I Nursing and Midwifery Council and have undertaken additional training working with children in the community. They fulfil the requirements of the Competency Framework (RCGP/RCN/RCPCH 2013 and 2015). They undertake regular appraisals and as required, are subject to revalidation The team comprises of Designated nurse for LAC (band 8) (1.0 w.t.e) Specialist nurse for LAC (band 7) (0.8 w.t.e) Specialist nurse for LAC (band 7) (1.0 w.t.e) Health Improvement Practitioner (band 5) (1.0 w.t.e) Designated doctor for LAC, med adviser for adoption &fostering and LAC age 0-9 years (0.4 w.t.e) Named paediatrician for LAC (0.2 w.t.e) Camden Looked After Children Health SeNice Annual Report 2016/2017 G Croft June Page 336 of 490

11 3.1.5 Administrative support is supplied for the LAC clinicians by the Safeguarding Children's Service Supervision and peer review Camden LAC health team has the following supervision and governance arrangements in place The LAC nurses are managed and supervised by the Designated Nurse for LAC on a 1:1 basis and meet regularly for discussion of issues within the service including any individual LAC cases. The team is co-located with the Camden Safeguarding Children Team and with easy access to discuss any safeguarding issues The LAC designated nurse has 4-6 weekly supervision with the Designated Nurse for Safeguarding The LAC health nurses, medical staff and health improvement practitioner have a weekly team meeting for case allocation, review of care plans and case discussions. There is an established monthly business meeting attended by the Children's Services manager for review of operational issues and service developments The LAC designated doctor attends bi-monthly peer review with designated doctors from North Central and North East London to discuss difficult cases (particularly around adult adoption and fostering medicals), to share ideas with regards to service developments and ensure uniform high clinical standards Clinical staff also attends a range of regional and national meetings such as the London LAC nursing group, London CoramBAAF health group, the Royal College of Nursing LAC forum, CoramBAAF annual health conference as outlined in the section on professional development (8.7) The Designated Dr was elected to sit on the Health Group Advisory Committee for CoramBAAF in 2011 and will have completed 2 terms by June Governance & Reporting Arrangements For CNWL, the designated nurse attends the provider meeting covering the Goodall Division (i.e. community services in Hillingdon and Camden). In addition, the designated nurse produces a bi-monthly governance report for the Clinical Governance team, which provides information on KPis, audits, incidents, compliments and complaints, policies and guidance, risks and compliance with CQC The LAC health and safeguarding teams attend commissioner-provider meetings with Camden CCG, frequency 2-4 times per year as determined by the strategic commissioning manager. This meeting reviews the LAC work plan, performance, Camden LAC commissioned targets and any other areas for commissioning to consider. In addition the designated doctor provides an annual report to the CCG and an interim update report at 6 months The designated nurse attends the Camden Children's Management meeting with Universal Children's Services to provide service updates and information on projects undertaken. 1 CNWL Provider Service Camden Looked After Children Health Service Annual Report 2016/2017 G Croft June Page 337 of 490

12 3.3.4 The designated doctor is a member of Camden Corporate Parenting Board and participates in its quarterly meetings. The LAC annual health report is presented alongside other service developments as they arise The designated doctor or designated nurse attends the bi-monthly health subgroup meeting of Camden Children Safeguarding Board to represent issues relating to Looked After Children The clinical team are located in a building adjacent to the London Borough of Camden (LBC) LAC team which greatly facilitates interagency working. The LAC nurses are co-located with the LBC fostering and Looked After Children's team on 2 days per week. The health team are available via and telephone within working hours for consultation with all social work teams. A formal meeting takes place monthly (Health & Development Panel, section ) CNWL have set up a programme of peer reviews to ensure providers are able to evidence meeting CQC standards. The 5 key lines of enquiry (KLOEs) include being safe, effective, caring, responsive and well-led. The peer reviews are undertaken by managers in the organisation who are independent of the service being reviewed. The feedback from CQC peer reviews of the Camden LAC health team has been consistently positive, with all domains being judged good to outstanding during the reporting cycle The clinical team undertakes quarterly essential audits in record keeping and infection control. Any gaps in standards are promptly rectified and an action plan sent to the Quality Governance team. 4. National Health Performance Indicators and Camden performance The following health statistics are reported on nationally by local authorities: In children looked after at 31 March who had been looked after for at least 12 months: Number of children whose immunisations were up to date Number of children who had their teeth checked by a dentist Number of children who had their annual health assessment Number of children aged 5 or younger whose development assessments were up to date Number of children identified as having a substance misuse problem during the year Number of children for whom an SDQ score was received Statutory health requirements: An Initial Health Assessment (IHA) should be undertaken within 4 weeks of a child entering care and statutory guidance states that this assessment should be completed by a doctor. A review health assessment (RHA) should be completed annually for over 5 year olds and every 6 months for children under 5 years. These assessments can be completed by a suitably trained health professional. Camden Looked After Children Health SeNice Annual Report 2016/2017 G Croft June Page 338 of 490

13 Health recommendations are completed by the health professional undertaking the health assessment and the social worker should use these to complete the child's health action plan. All LAC are required to be registered with a GP and, if over 2 years of age, with a dentist. LAC should be fully immunised in line with the national immunisation schedule Camden performance: statutory reporting by LB Camden to Department of Health Statutory reporting by local authorities to the Dept. of Health for health and dental checks comprises the % of children who have been looked after for > 1 year who have had a statutory health assessment within the year and % of children looked after for >1 year who have had a dental check within the year. The most recent available data for other inner London boroughs is given for comparison and identifies Camden as consistently among the highest performing boroughs for statutory health requirements. This data is provided by the Children's Safeguarding and Social Care Quality Assurance Unit. Camden Looked After Children Health Service Annual Report 2016/2017 G Croft June 2017 Page 339 of

14 Table 1: Statutory reporting by LB Camden to Department of Health- comparison of national tar et erformance over last 4 ears Inner London comparators performance indicators Of those LAC for at least a year, % of those who had an annual health assessment in the previous year Of those LAC for at least a year, % of those whose teeth have been checked by a dentist in the previous year Of those LAC for at least a year, the average (i) % whose teeth have been checked by a dentist in the previous year, (ii) % who had had an annual health assessment in the previous year 94% 91% 92% 98% 96% 98% 93% 94% 93% data not March 2016: Camden -96% City of London - x Hackney- 84% H'smith & Fulham- 87% Haringey- 94% Islington- 96% K & Chelsea- 100% Lambeth- 82% Lewisham- 95% Newham- 94% Southwark- 96% Tower Hamlets- 85% Wandsworth - 100% Westminster- 100% March 2016: Camden -94% City of London - x Hackney- 82% H'smith & Fulham - 96% Haringey- 81% Islington- 86% K & Chelsea- 92% Lambeth- 74% Lewisham- 82% Newham- 96% Southwark- 91% Tower Hamlets- 82% Wandsworth - 92% Westminster- 100% March 2016: Camden -95% City of London - x Hackney- 83% H'smith & Fulham- 91% Haringey- 87% Islington- 91% K & Chelsea- 96% Lambeth- 78% Lewisham- 88% Newham- 95% Southwark- 93% Tower Hamlets- 83% Wandsworth - 96% Westminster- 100% England average 88.4% Of those LAC for at least a year, % of those whose 91% immunisations are up to date % of LAC aged under 5 years whose 100% development checks are up to date 93% 97% 100% 100% 94% 100% (LAC health team data) England March 2014: 87.1% (this is most recent data available) England March 2014: 86.8% Camden Looked After Children Health Service Annual Report 2016/2017 G Croft June Page 340 of 490

15 4.2 Local targets set by Camden CCG for Camden LAC Health Service %of LAC receiving a Review Health Assessment (RHA) where this is due in the quarter Number and % of clinical outcomes from care plan met or exceeded at review %of children in care who are overweight or obese Teenage pregnancy rate %of LAC who have been in care for >12 months whose immunisations are up to date Table 2: Performance against Camden LAC commissioned targets % LAC receiving annual health assessment where this is due in the quarter Number and% clinical outcomes from care plan met/exceeded at review % children in care aged 2-18 years who are overweight or obese Teenage pregnancy rate Of those LAC for > 1 year,% immunisations up to date Q1 April-June 2016 Q2:July-Sept 2016 Q3:0ct-Dec 2016 Q4:Jan-March % 100% 94% (2 refusers) 96% 100% 100% 66% 93% 10.5% 6% 11.9% 18.8% N=3 97% 94% 94% 94% 5. LAC Health Team Core Clinical Activity and Targets 5.1 Health assessment data The LAC health team are required by statutory guidance to ensure that all children looked after by the London Borough of Camden have a statutory health assessment within 28 days of becoming looked after, and thereafter every 6 months (under 5 years) or annually (over 5 years). The following data refers to all Camden LAC (both those placed within Camden and out of borough) who have had health assessments completed April March Camden Looked After Children Health SeNice Annual Report 2016/2017 G Croft June Page 341 of 490

16 5.1.1 Number and type of health appointments Table 3: Total health appointments undertaken or supervised by LAC Health Team = 315 recorded health appointments Initial health assessments (doctor) Review health assessments Nurse -led IHA 2 1 N/A Statutory health assessments undertaken by 7 7 out of borough specialist nurse, paediatrician or GP Pre- and post-adoption medical assessments and counseling Interim reviews (face to face contacts) Paediatric clinic=16 Nurse-led= In , 102 children entered care of whom 74 received an IHA in the looked-after children's Paediatrics clinic. 2 young people had an outreach initial health assessment undertaken by the specialist LAC nurse because of failure to attend 3 appointments in the clinic. An IHA care plan was completed on paper for 3 young people who were persistent refusers. The 17 nurse-led reviews included 8 young people newly arrived from Calais as unaccompanied minors for whom a brief health screen was done. Figure: LAC health assessments by type: so 40 % % and type of health appointments 2016/17,. v v v v I v-- I - Camden Looked After Children Health SeNice Annual Report 2016/2017 G Croft June Page 342 of 490

17 5.1.2 Unattended appointments for initial health assessment (IHA) 44 appointments for initial health assessment (IHA) were not attended, including 31 cancelled appointments, 9 missed 1st appointments with no explanation, 2 missed 2nd appointments and 2 missed 3rd appointments. An outreach nurse-led IHA is offered to young people after the 3rd missed appointment. Analysis of the 17 cancelled/non-attended appointments during January-March 2017: o 5 cancelled because no interpreter booked by social worker. o 1 cancelled because of clash with home office appointment. o 3 cancelled because day/time inconvenient for foster carer. o 2 non-attenders, no reason given. o 4 non-attenders because foster carer did not receive appointment in time (attended at 2nd appointment) Discrepancy between number of new LAC and number of completed IHA There is a discrepancy between the number of new LAC (102) and number receiving an IHA (74). All cancelled appointments are rebooked. All persistent non-attenders are offered an outreach IHA (3 LAC). 2 looked after young people failed to attend 3 or more appointments and therefore had only a paper Care Plan completed. 2 were in specialist residential placements and the IHA was completed by the local paediatrician. This potentially leaves 21 newly looked-after children and young people who did not receive an IHA. The reasons for this are: Child /young person was in care for a short time only before returning home and the referral therefore not made by the social worker to the health team. A number of young people reach their 18 1 h birthday shortly after becoming looked-after so the referral not made by the social worker and/or health assessment not carried out before leaving care Timescale to initial health assessment According to statutory guidance, the initial health assessment (IHA) should take place within 28 days (20 working days) of becoming looked after. There have been persistent problems in Camden with achieving this target. Of 24 IHA which took place between Jan- March 2017, 4 were completed within 28 days, a further 14 within 3 months (92 days) and 5 took longer than 95 days. Reasons for the delays have been identified as follows: Cancelled appointments which need re-booking and contribute to delay (see 5.1.2) Delayed notification by social workers Referral received but no signed consent from parent for health assessment (required for section 20 placements) or information sharing (required for all LAC). Consent needs to be arranged by social worker Nurse -led initial health assessments Statutory guidance states that the IHA should be completed by a doctor; however, many services across the UK enable LAC nurses to perform IHA, particularly where young people Camden Looked After Children Health Service Annual Report 2016/2017 G Croft June Page 343 of 490

18 persistently refuse to attend a paediatric clinic. The Camden LAC nurses will undertake outreach IHA where the young person has refused to attend for 2 or 3 booked appointments with the paediatrician at the clinic. These are discussed with the LAC paediatrician who also obtains the past medical history from available GP records. Any concerns will be raised with the GP and the social worker/keyworker contacted to facilitate a GP appointment Analysis of non-attenders for statutory review health assessment: 98% of all children and young people who had been looked after for> 1 year had at least one statutory health assessment within the year to March Over the course of the year, 6 young people persistently refused their statutory review health assessment, 4 of whom are no longer looked after as they have reached 18 years of age. 2 remain outstanding: 1 is in a secure unit because of criminal activity and ongoing efforts are made to engage the other young person Out of borough health assessments and outreach work At any one time, only approximately one third of Camden LAC live within the borough, however, Camden local authority retains responsibility for their care, including overview of health care. The arrangements for statutory review health assessments vary across the UK: in some areas they are undertaken by local LAC health teams and charged to the placing health authority according to the national tariff. In Camden (and most London boroughs), LAC health nurses are commissioned to undertake statutory health assessments on an outreach basis for all LAC within reasonable travel distance. The benefits of Camden LAC nurse outreach work are: quality of health assessments is ensured timeliness; not dependent on capacity of other health services ensures continuity of care for vulnerable looked after children who may move through several foster and residential placements, both in and out of London anecdotal feedback from carers is that they value the outreach service highly some young people who live within travelling distance but refuse to attend the clinic are willing to have their health assessment at their placement. enables a more holistic health assessment for pre-school children and an opportunity for the LAC specialist nurse to observe the child in his or her home environment where tailored advice to carers on health, developmental, behavioural and safety issues can be given. Camden LAC nurses completed 96% of statutory review health assessments. This entailed regular visits outside London within the South East and some further afield. The remaining 4% (n=7) are children with severe physical or learning disabilities placed in residential homes or specialist foster placements outside London and whose health assessments were completed by their paediatrician or special school nurse. 5.2 lmmunisations The LAC health improvement practitioner is responsible for the monitoring and recording of immunisations to ensure the accurate identification and tracking of children who are not up to date with their immunisations. Rigorous follow up takes place to ensure that regular reminders are given to social workers, foster carers, key workers and young people by telephone and text as well as health promotion work with looked after young people. Vaccinations are generally undertaken at GP practices and occasionally by the Camden Community Immunisation team. Camden Looked After Children Health SeNice Annual Report 2016/2017 G Croft June Page 344 of 490

19 94% of all Camden children looked after for> 1 year were up to date with immunisations at end March % of 0-16 year old Camden children who have been looked after for > 1 year are up to date with immunisations. 8 young people looked after for > 1 year have outstanding immunisations: 1 is a 13 year old unaccompanied minor who has not yet completed the schedule. 6 are aged years and currently refusing interventions 1 is post-partum and will complete the schedule shortly. In addition there are 25 young people aged years who have been looked after for < 1 year and who have outstanding immunisations. Of these: 19 are unaccompanied asylum-seeking minors who are in the process of completing the immunisation schedule as per Public Health England recommendations 6 are UK children due catch up vaccinations by their GP practice. The LAC service has had an increase in the number of unaccompanied minors which has in turn affected the numbers requiring recommended vaccinations. Comparative data Recent up to date comparative data for looked after children are not yet available but Camden LAC immunisation figures generally compare very favourably with immunisation figures for looked after children in other Inner London boroughs (72.2% uptake in ) and data for England (83.2% in ) (Source: Children's Safeguarding and Social Care quality Assurance Unit) (See section Table 1: Statutory reporting by LBC to Dept. of Health) In the non-lac Camden population, in % of children had received the 1st dose of MMR by age 2 and 79.9% had received the 2 required doses of MMR vaccine by age % of non-lac children had received the other required vaccines (Dtap/IPV/Hib) by age 2 years ( Public Health England Camden Child Health Profile 15 March Dental Checks The recorded uptake of dental care for children and young people looked-after for> 1 year stood at 93% for as reported to the Dept. of Health (4.1.3 table 1). This figure has remained stable since 2014, following a significant improvement from 87% in Dental checks are recorded by the individual child's social worker. Maintaining a high uptake of dental care is achieved jointly with the local authority LAC social work teams by: Identification and tracking for all children & young people with outstanding dental checks Assisting carers who have difficulty registering with a dental practice An agreement for LAC to access the Camden community dental service, where they are among the priority eligible groups. In practice this is rarely required. The looked after children with outstanding dental checks are all young people over 14 years who are currently refusing dental care. 5.4 Registration with GP Camden Looked After Children Health SeNice Annual Report 2016/2017 G Croft June Page 345 of 490

20 Of children looked after as at , 183 of 199 LAC have a GP/GP surgery recorded on their social care record. All foster carers and residential units are required to ensure that children and young people in their care are registered with a GP as soon as possible and almost all are registered at the time of initial health assessment. 5.5 Interim reviews Many children and YP are seen for review at times other than for their scheduled statutory health assessment. An increasing number of children and young people are looked after for< 1 year, likely to be a reflection of the higher age at entering care. Many will therefore leave care (reaching the age of 18 years) during the months after their initial statutory health assessment by the LAC paediatrician and before they are due for their annual statutory review assessment by the looked after children's nurse. This reiterates the importance of follow- up health interventions and health promotion work by the LAC nursing team and Health Improvement Practitioner (HIP) from the very beginning of a young person's care period, as well as ensuring access to health advice for care-leavers. The LAC specialist nurses and HIP follow up on a variety of health needs in older LAC. These include, for example, puberty and personal hygiene, sexual health needs, sleep related issues, emotional needs, diet and weight. This mostly takes place in liaison with other local health services such as CAMHS and sexual health services, facilitating referrals and offering support to young people, their keyworkers and foster carers. Young children are followed up by the specialist LAC nurse for developmental or weight/feeding concerns. Infants with drug withdrawal symptoms are followed up by the LAC paediatrician. Young children are seen by the LAC paediatrician for formal developmental assessment when clinically indicated or requested by court. Post adoption follow up is offered for all adopted children by the paediatrician. A number of older LAC are seen in the LAC paediatric clinic for assessment and follow up of medical problems, psychosomatic issues and psychological support, jointly with a CAMHS worker where needed. 5.6 Health Care Plan outcomes It is a statutory requirement for each looked after child to have a Health Care Plan in place, which is renewed after each statutory health assessment. Previous local and national audits have identified very poor execution of health plan recommendations for LAC. A system for follow up is crucial to ensuring good outcomes because of the unique difficulties looked-after children face in terms of placement moves, out-of-borough placements, and changes of carer and social worker. An excel spreadsheet is used by the LAC health team to track recommendations and actions arising out of individual health care plans. A monthly meeting is held to ensure these are implemented and outcomes met within an agreed time frame. The % of actions detailed within the health care plan that have been completed within the set timescale is reported quarterly and ranged from 66% to 100% across Q1 to Q4 in (Section 4.2 table 2). The main reasons for non- completions were: (1) non-compliance by looked after young people or foster carer and (2) information awaited from out of borough services for LAC placed Camden Looked After Children Health SeNice Annual Report 2016/2017 G Croft June Page 346 of 490

21 outside Camden. All outstanding actions are carried forward to the following quarter, thus ensuring regular review of all recommendations. 6. Other Clinical Activity 6.1 Sexual health and children at risk of sexual exploitation Sexual health The Looked After Children's health team works very closely with Camden & Islington Young People's Sexual Health Network to ensure that vulnerable looked after young people receive the services they need. This includes provision of individual clinical services and sex and relationships education. Clinical services LAC health clinicians discuss sexual health and relationships with individual young people at annual health assessment appointments and at any interim health reviews. Young people are given information on local sexual health services, including clinics at Brook Euston, The Brandon Centre and Pulse. Where sexual health needs are identified at the initial health assessment, the LAC Health Improvement Practitioner (HIP) contacts the sexual health team and facilitates attendance for individual work. Liaison with sexual health outreach workers in other boroughs where Camden children are placed. Information is shared with the sexual health team on LAC known to be at risk of sexual exploitation and on LAC about whom there are concerns such as non-compliance with contraceptive use. Health promotion and education: In addition to routine health promotion and discussion about sex and relationships at each health assessment, the LAC nurse and HIP also undertake the following: The LAC nurse offers individual sessions for looked after children attending mainstream school who have learning needs,with use of training materials to help them understand how the body works as well as sexual health and relationships education. As identified at the review health assessment, particular attention is paid to preventive interventions at critical periods of risk for LAC, such as those transitioning to secondary school, moving into semi-independent placements or leaving care. Outreach clinical and health promotion activity sessions with looked-after young people in youth settings, including weekly clinics at The Hive, have had low uptake. The LAC Health Improvement Practitioner has therefore concentrated on facilitating sexual health promotion "Clinic in a Box" sessions with the sexual health outreach nurse in supported accommodation and residential unit settings. The sexual health outreach team offer "Clinic in a Box" sessions: a mobile confidential sexual health service for young people under 25 in Camden providing: C-card (condom card), condoms and lube Self-taken tests for chlamydia and gonorrhoea Pregnancy testing and advice Emergency (morning after) pills Camden Loo Contraception - pills and patches Sexual health and relationship advice 21 Signposting to other services Page 347 of 490

22 6.1.2 Work with children missing from care and children at risk of sexual exploitation (CSE) (Appendix 1 work plan item 2) All LAC health staff have had training on Child Sexual Exploitation (CSE). Improved recognition of LAC who are vulnerable to CSE is ensured by completing a CSE risk assessment for all LAC of secondary school age at their health assessment. Children and young people about whom there are concerns are discussed with their social worker and at the monthly Health & Development Panel meeting so that a CSE plan can be drawn up if indicated. Children missing from care are especially vulnerable to CSE. Information on missing children is shared with the team by the social worker or the named nurse for safeguarding. LAC health staffs liaise with carers and keyworkers to contact and engage missing young people, assess risks, provide support to the young person and/or carer and follow up on progress. Health followup is provided as appropriate, including sexual health, emotional support and referral to other resources and services where required. 6.2 Teenage Pregnancy The national teenage pregnancy rate has fallen significantly in recent years; by 2013 it was 24.3/1000, down 13% from 2012 and 40% from 47.7/1000 in 1998, although it is still the highest in Western Europe (ONS 2013). In Camden, the under 18 conception rate is significantly lower than the national average, falling to 17.2 per 1000 by 2013 (most recent data). (Source: Public Health England Camden Child Health Profile 15 March However, teenage parents are more likely to be, or to have been, Looked After Children. The national rate of teenage motherhood is around three times higher among girls under age 18 who are in care compared with those not in care. There were 3 reported pregnancies in Camden LAC in the year April 2016-March 2017, representing 6% of the > 13 year old female LAC population (3/49). (section 4.2, table 2)This number has remained stable over recent years. However, it is acknowledged that there may be undisclosed pregnancies which are terminated early and not known to social care or LAC health staff. The LAC health team does not offer specific pregnancy related or postnatal care though facilitates referral to the Family Nurse Partnership service which ensures access to local maternity services. 6.3 Substance Misuse Screening is undertaken by the social worker using the DUST (Drug Use Screening Tool) on all looked after children as part of the core assessment and is coordinated by the LAC teams in partnership with FWD (Forward), the drug and alcohol service responsible for implementing Camden's substance misuse strategy for children and young people. The highest numbers of referrals to FWD are for cannabis use with alcohol being the second highest reason for referral. Substance use is discussed routinely as part of a looked after young person's health assessment and individual advice given where indicated. Where substance use is identified and Camden Looked After Children Health Service Annual Report 2016/2017 G Croft June Page 348 of 490

23 there is no intervention already in place, the social worker is informed and advised to make the referral to Forward or other local services data: of the children who had been in care for at least 12 months in Camden, 27 (21.3%) were identified as having a substance misuse problem during the previous 12 months, compared with 16.2% in and 10.1% in 2012/2013. Of these children, 100% received an intervention with none refusing (information from Children's Quality Assurance Unit). 6.4 Emotional Wellbeing Screening and referral for emotional difficulties Discussion on emotional health is an integral part of all statutory health assessments. The Strengths and Difficulties questionnaire (SDQ) is completed at each initial health assessment for early identification of children and carers who need timely support. The SDQ is sent for scoring to the LAC CAMHS clinical psychologist, along with a copy of the health report and request for CAMHS assessment where needed. Children about whom there are concerns are discussed at the monthly LAC Health and Developmental panel (see section ) There is regular phone and liaison between CAMHS and LAC health staff regarding individual children, and attendance by the LAC health team at case discussions as necessary. A psychotherapist from the Tavistock refugee team attends the initial health assessments for unaccompanied minors (see 6.7) Promoting resilience Promoting interventions to help build long term resilience of looked after children is a core aim for the LAC health team. Practical application includes detailed routine enquiry and discussion at health assessments of enjoyable activities and other interventions that can help build selfesteem, self-efficacy and a secure base for the individual child. Strategies to enhance resilience along with emotional and behavioural goals are incorporated into the child's health care plan (appendix 3). The designated nurse has developed a handbook on promoting positive outcomes (resilience enhancing strategies) as a training and reference tool for LAC clinicians as well as a support pack for carers which outlines strategies to strengthen the care of vulnerable traumatised LAC CAMHS services for looked-after children Mental health services for Camden looked-after children are provided by the LAC CAMHS team in liaison with the Tavistock Clinic and other Camden CAMHS providers. Referrals to the LAC CAMHS team can be made directly by LAC health professionals where there is no existing therapy input. Problems occasionally arise when a child placed out of London requires a psychological service in a resource-poor area; it is the responsibility of the CAMHS team and the child's social worker to liaise with local services to ensure access to appropriate assessment and interventions Strengths and Difficulties (SDQ) questionnaire outcomes The Strengths and Difficulties questionnaire (SDQ) is a good screening tool for emotional wellbeing in looked after children (Goodman & Goodman 2012). Since 2009, local authorities have been required to administer SDQs to LAC aged 4-16 years who have been in care for at least Camden Looked After Children Health Service Annual Report 2016/2017 G Croft June Page 349 of 490

24 one year, and the mean value of the total difficulties score is included in statutory reporting. Screening at care entry is completed at the initial health assessment and subsequent annual statutory screening is arranged via the social worker and LAC education team. Of the 88 children aged 4 to 16 years (inclusive) and who had been in care for at least 12 months at the end of March 2017, carers returned 86 fully completed questionnaires (97.7%). Of the 86 completed questionnaires, the mean value of the total difficulties score was This is a slight increase on the average score over the last 3 years of 12.6 ( ) and slightly lower than the average score of 14.7 in the 3 years prior ( ). 6.5 Health Improvement activities for looked after children Improving long term health outcomes is one of the key tasks towards meeting health needs of children in care. Children and young people entering care have disproportionate health needs arising from prior missed opportunities for universal children's health programmes and limited knowledge of health promotion activities. The Health Improvement Practitioner liaises with the LAC Health Team, foster carers and looked after young people to identify health promotion needs and offer targeted work. Individuals are supported in developing a personal health plan to make the changes they want thereby supporting behavioural change and fostering healthy life styles. Advice and information on health promotion is offered in the form of health workshops for Looked After Children, foster carers and residential unit staff. These cover healthy eating, weight management, improving oral health, smoking, physical activity, sexual health, sleep hygiene and other areas as necessary. Offering 1 to 1 sessions to young people as indicated for individual health promotion work, usually for specific interventions and advice such as formulation of healthy meal plans. Working with foster carers and young people to improve the numbers who are accessing regular dental and vision checks Identifying and tracking missing immunisations and liaising with general practitioners to arrange immunisations catch-up Advising on local services including sexual health, weight management services and local leisure activities Working with Camden & Islington Young People's Sexual Health Network outreach nurse (see 6.1.1) Drop-in sessions: A recommendation of the Young Inspectors following their inspection of the LAC Health Service in 2014 was for improved access to the LAC health team for young people by instituting drop-in sessions. These were set up initially at the team's health centre base and were subsequently moved to the borough-wide health and well-being service at Camden's new 'The Hive' youth hub. However, the uptake has been very low despite wide advertising by poster, leaflets and texts to young people. The proposal is for these sessions to take place at residential units and supported accommodation settings. 6.6 Overweight/ obesity An audit of the prevalence of obesity undertaken in Camden looked after children published in 2011 identified that 25% of LAC aged 2yrs yrs were either overweight (12% of total ; BMI Camden Looked After Children Health Service Annual Report 2016/2017 G Croft June Page 350 of 490

25 > centile) or obese (13% of total; BMI>98 1 centile for age). This was therefore h included as an area for monitoring and action by Camden Clinical Commissioning Group. Growth is measured at all health assessments. Children and young people aged 2-18 years who fall into the overweight or obese category are monitored; including those placed out of borough, and this is reported quarterly. The percentage of children looked after for > 1year identified as overweight or obese ranged from 6% (Q2) to 18.8% (Q4) across the year (section 4.2, table 2). In Q4, 95% (19/20 overweight or obese children) were over 12 years of age Comparative data Direct comparison with Camden and national data is not possible because the LAC data refers to children aged 2-18 years, whereas public health data is collected at primary school entry and in school year 6 (10-11 year olds) only. The most recent available data refer to , when 9.5 % of Camden children aged 4-5 years and 20.7% of Camden children aged years were classified as overweight or obese. The available data suggests that the rate of obesity in the LAC population is comparatively low. (Public Health England Camden Child Health Profile 15 March Interventions for overweight and obese LAC: h Individual health promotion work, offering detailed consultations on healthy eating and regular weight review, is provided by the LAC health team. A referral to the Camden Healthy Lifestyles Outreach Practitioner is offered. For looked after children who are very obese (with a body mass index > h BMI centile), a referral is made to University College Hospital Child and Adolescent Weight Management Clinic for further investigation. Liaison with local health services takes place for children who live too far from Camden. Those in residential school placements are monitored at their placement Promotion of healthy eating for all LAC: Advice on healthy diet and exercise is included on every child's LAC health care plan. Training on health eating is delivered to foster carers and LAC in residential I supported accommodation. Foster carers identified on their own fostering medical assessment as significantly overweight are sent an information leaflet outlining the health risks to the carer and potential health risk to the child (in terms of healthy diet and lifestyle promotion). 6.7 Unaccompanied minors and asylum seeking children (UASC) (Appendix 1, work plan item 3 and appendix 2) Since June 2015, there has been an increase in the number of UASC referred to the LAC health clinic for assessment. There were 36 newly arrived unaccompanied minors who became Looked After during Aprii2016-March An integrated care pathway for UASC has been developed across North Central London, led by the Camden LAC paediatrician in liaison with the other NCL LAC health teams, sexual health services, hospital infectious disease clinics and the Refugee team at the Tavistock clinic. This incorporates physical health, infectious disease screening and treatment, sexual health and Camden Looked After Children Health SeNice Annual Report 2016/2017 G Croft June Page 351 of 490

26 psychological health (appendix 2). Catch-up immunisations are organised according to Public Health England guidance. A translator and an outreach psychotherapist from the Tavistock CAMHS team are present with the paediatrician for each UASC health assessment, for which 1.5 hours are allocated. Onward referrals are made according to the pathway. All UASC are referred to UCLH for infectious diseases screening. Unfortunately only a 1/3rd of young people attended their screening appointments, despite appointment letters being sent to the young person as well as their key worker and social worker. Audit has shown a high disease pick-up rate over the last year with almost half the UASC found to have an infectious disease; this includes 4 cases of latent tuberculosis, 2 cases of malaria, 2 cases of schistosomiasis, 2 cases of tapeworm, and 2 cases of giardia infection. The importance of screening and attendance at appointments has been raised with senior social work managers. An audit project has been registered with CNWL to look at the health outcomes for onward referrals following Initial Health Assessments (IHA) for unaccompanied minors presenting to the Camden looked after children's team. Data will be used to identify key health needs of this cohort and further develop the integrated health pathway across the North Central London Looked After Children (LAC) network. Similar audits will be taking place in Islington, Haringey, Enfield and Barnet. The work on the pathway and audit has been accepted as a presentation at the International Society for the Prevention of Child Abuse and Neglect in The Hague in September Improved quality of sleep for looked after young people (appendix 1, work plan item 4) Poor sleep is a major problem for many looked-after young people. This can be caused by a noisy environment within a residential care home; poor sleep hygiene practices, substance and alcohol use, emotional problems and a variety of other reasons. Sleep workshops have been held in residential care settings by the health improvement practitioner. A "do's and don'ts' of sleep" leaflet has been developed which is given to all LAC at their IHA. Sleep advice will be incorporated into the BACKCHAT website. 6.9 Improving services for care leavers (appendix 1, work plan items 6 and 8) Leaving Care health discussions/reviews are offered to young people reaching their 18 1 h birthday whose most recent health assessment took place > 6 months previously, in order to assess and support health needs of LAC when they leave care. This will be complemented by the proposed additional support to the Leaving Care Pathways! supported accommodation units. Currently, a paper summary with personalised health information including birth details, health history, immunisations, allergies, medications is provided for all LAC leaving care, together with information on how to access health services. Development of a more user-friendly 'healthpassport' is underway. Health advice Drop-in at The Hive is offered to care leavers up to age 21 years but uptake has been low Other complex case work Health and Development panel Camden Looked After Children Health SeNice Annual Report 2016/2017 G Croft June Page 352 of 490

27 The Health and Development Panel is a formal monthly meeting to discuss any child aged 0-15 about whom there are concerns to ensure that children's needs are identified early and services put in place in a timely manner. Issues discussed may be related to children's physical health, behaviour and mental health, developmental progress, learning needs and educational issues, carer or placement issues, non-engagement and safety concerns etc. This multi-agency meeting is chaired by the LAC team manager and includes the LAC health team, LAC psychologist and Fostering & Adoption team manager. The LAC Academy and Sexual Health team managers have attended recently with the aim of improving regular formal liaison between services Liaison with Disabled Children's Team A small number of Camden's looked after children (approximately 5-8 % at any one time) are managed by the social care Disabled Children's Team under Camden MOSAIC services. These children are often placed in residential units outside London and have multiple complex health, developmental and emotional needs such as severe learning disabilities, autism, neurological disorders and severe behavioural problems or psychiatric disorders. The designated doctor for LAC liaises regularly with the Disabled Children's Team social workers and meets monthly with the team manager, in order to provide advice on medical issues and guidance on consent for any proposed medical interventions, alongside discussion and liaison with local health professionals Improved multi-agency and interdisciplinarv liaison. (see also sections 5.5 and 9.1.2) Much work is undertaken with looked after young people in between statutory reviews by the LAC specialist nurses and the health improvement practitioner, which requires good liaison between services. The LAC specialist nurses are based with the social work teams approximately 2 days per week and have built good links with the Sexual Health team, the Youth Offending Team, Substance Misuse Team and CAMHS to ensure a holistic approach for every looked-after young person and avoid duplication of services. The LAC specialist nurse regularly attends Social Care LAC reviews and strategy meetings to provide the health input where there are concerns about medical issues, sexual health, sexual exploitation, behaviour and engagement with services. 7. Adoption and Fostering 7.1 Panel work The LAC Designated Nurse holds the post of health adviser to Camden Fostering Panel. The LAC Designated Doctor holds the post of Medical Adviser to the Adoption and Permanency Team and Panel. Panels take place fortnightly, half day or full day and are attended by either the LAC designated nurse or doctor. 7.2 Adoption clinic work: The designated doctor sees all prospective adopters for counselling prior to matching and offers longer term follow up for adopted infants and children where there are actual or potential developmental issues such as foetal alcohol spectrum disorder. This is particularly important for children who have histories of antenatal drug and/or alcohol exposure, in whom developmental prognosis is uncertain and where adverse effects may not manifest until school age. Camden Looked After Children Health SeNice Annual Report 2016/2017 G Croft June Page 353 of 490

28 7.3 Adoption records Under current legislation, an adopted child is given a new identity including new NHS number, which creates issues with regards to health records and pre-adoption health information relating to the child. There is no nationally agreed adoption records guidance and processes vary depending on local health information systems. With the move from RIO to System One, current processes in Camden have required review. Joint guidance across CNWL is currently being drafted in consultation with the Camden LAC designated doctor. 7.4 Adult medical reports 71 adult medical assessments (AH forms) were reviewed and reported on during the year from April2016 to March This compares with 97 in All applicants for short and longterm fostering, Special Guardianship, adoption and respite care are required to undergo a health assessment and medical examination by their GP, which is repeated every 2 years for foster carers. The information on the AH forms is reviewed with respect to medical history, mental health history, family history and life-style factors. Additional information is obtained from the GP, hospital consultants or other health staff where necessary. A written report on each applicant is then provided to the Adoption and Fostering team by the LAC medical advisor, with a summary of the medical issues and recommendations. 7.5 Quality and safety assurance: Bi-monthly peer review meetings are held with the medical advisors for adoption and fostering from six north London boroughs to share difficult cases, obtain advice from colleagues and ensure that standards and advice are uniform. Appropriate safeguards are in place for client anonymity. 8. Training 8.1 Foster carers Health training sessions for foster carers take place within a support group setting as this format has been found to achieve the best uptake and engagement by carers. The LAC nurse is invited to participate in sessions by the fostering team as dictated by needs of the current cohort of carers. Each session lasts 2 hours and is facilitated by a social worker and LAC health worker, with time for informal discussion and sharing of problems and ideas. Health training for foster carers and residential unit staff includes: Health awareness for foster carers: accessing health services for looked after children, where to find information on common health conditions, understanding of their complex health needs. Foster carer's role in promoting healthy lifestyle choices, nutrition and healthy eating Child development workshop, including developmental milestones, promotion of learning through play, language development Management of common behavioural and sleep issues in young children Camden Looked After Children Health SeNice Annual Report 2016/2017 G Croft June Page 354 of 490

29 Sexual health and access to services for looked after young people. How foster carers can support teenagers through puberty, how to talk to young people about sex and relationships. Some sessions will involve a specialist trainer. Supporting carers in managing transition of children starting secondary school in September 2016 Health and safety; first aid Frequency: as dictated by service needs and feedback from foster carers 8.2 Social workers: training is provided for social workers on the role of LAC health professionals and on procedures for arranging statutory health assessments. Social workers are also invited to attend the training for foster carers and prospective adopters. Frequency: as dictated by service needs and feedback from the local authority. 8.3 Health visitors and school nurses: the designated nurse has redesigned the training programme for health care professionals to take into account the impact of trauma and attachment disruption on a child's development. The training includes the basics of the neuro-scientific evidence for long term adverse effects of abuse and trauma on the brain, attachment theories, child development, loss and separation, therapeutic parenting, and resilience building. The aim is to heighten professional understanding of the complex and diverse needs of these vulnerable groups of children and young people. Frequency: as dictated by service needs. Next session will be on Prospective adoptersa Preparation Group for prospective adopters is delivered twice per year by Camden's adoption team and includes a session by the LAC designated paediatrician on potential medical and developmental issues facing adopted children. These include the impact of antenatal drug and alcohol exposure, postnatal abuse and neglect, medical and genetic problems and mental health diagnoses. Frequency: usually twice yearly, as requested by the adoption and permanency team 8.5 Medical staff: Formal teaching on the health needs of Looked After children is provided as requested 3 to 4 times annually by the LAC paediatricians for trainee paediatricians. This includes an annual half-day teaching session on the MSc in Paediatrics at the Institute of Child Health, a half-day teaching session in May 2016 at the Royal Society of Medicine and regular teaching incorporated into the regional postgraduate training programme. In addition, there is weekly clinic based teaching for community paediatric trainees. 9. Other Service work and Service Improvements 9.1 Other specific improvements Timeliness of initial and review health assessments Camden Looked After Children Health Service Annual Report 2016/2017 G Croft June Page 355 of 490

30 According to statutory guidance, the IHA should take place by a doctor within 4 weeks (20 working days) of becoming looked after, with a health care plan provided for the child's social worker. Actions taken to address delays during included: Monthly data produced by Camden local authority to identify outstanding referrals to the health team by social workers; this is followed up by the social care LAC team manager The health improvement practitioner contacts the young person and/or their carer or keyworker by telephone before the IHA, to explain the process and encourage attendance. A service information leaflet is sent out with the appointment letter. Phone or text reminders sent prior to appointments Later appointments and flexibility in appointment times offered where possible. Social worker or keyworker expected to attend with young person. These measures led to an improvement in the overall non-attendance rate. However, there are persistent delays with achieving the 20 day target in Camden, with reasons for delay varying over time (see and 5.1.4). On-going efforts are required to improve timescales and action is needed to reduce the number of cancellations, for example due to failure of attendance of interpreter Progress on engagement with health services for "hard to reach" LAC (appendix 1, work plan item 1) Where a young person has missed 2 appointments at the LAC clinic, the following updated procedure was put in place during 2016: An outreach nurse-led IHA is offered at the young person's placement (see 5.1.5) If the young person (YP) continues to refuse, the health team liaises with the social care LAC team to identify factors in child/yp's life that may affect engagement. Developing a health care plan for non-attenders ensures that the health needs of these most vulnerable LAC are considered. Existing health information from GP or hospital services, assessments by CAMHS, LAC academy/education services, sexual health services, Missing Children practitioner, substance misuse team etc, is reviewed to identify areas of health concern which require action and involvement by the LAC health team. A LAC health care plan is drawn up based on this information and sent to the social worker. All LAC about whom there is concern regarding engagement with health services are discussed in the monthly Health and Development Panel meeting. A self-administered health questionnaire is being developed for young people who do not wish to attend Support for Leaving Care Pathways and residential units (appendix 1, work plan item 6) The designated nurse has held discussions with the Care Pathways manager to offer practical support and training to staff and looked-after young people in residential units. This is expected to take the form of regular drop-in sessions and will contribute to life skills programmes for young people. The aims and anticipated positive outcomes are: To help staff and young people understand the role of the LAC health team and encourage engagement with statutory health assessments and health services Camden Looked After Children Health Service Annual Report 2016/2017 G Croft June Page 356 of 490

31 to reduce attendances at hospital Accident and Emergency departments by offering advice and training on management of common minor ailments, accident prevention, first aid etc. to empower young people to manage their own minor health issues engage staff (in their roles as substitute parents) in ensuring that health care plan recommendations are carried out. Support for foster carers LAC health staff offers direct support to individual foster carers who have concerns about children in their care and require targeted support best delivered by a health professional (e.g. behavioural or sleep issues, sexual health risks), in addition to support and advice given via the Support Group forum. 9.2 Audit and improvement projects: These are ongoing and include: o Improving timeliness of initial health assessment o Clinical audit underway of health needs of unaccompanied minors (see 6.7) 9.3 Partnership Working The LAC health team continues to work in partnership with a wide range of professionals and clients in order to maintain a high standard of care. Members of the LAC health team are actively involved in the following partnership roles: Camden Corporate Parenting Board which oversees the services for looked after children and includes LBC Children, Schools and Families division Director and Assistant Directors; local Councillors; Education; Early Years Services; Youth Services; Foster Carers; LAC Care Leavers; LAC service Principal Officer and LAC designated doctor. NHS Camden Safeguarding health subgroup of Safeguarding Board bi-monthly meeting Health and developmental panel meeting monthly: social work team managers, CAMHS, fostering and adoption team, LAC educational psychologist, sexual health nurse and LAC health team, to discuss individual children with difficulties. Regular liaison and meetings with fostering team, residential unit and Care Pathways managers Disabled Children's Team monthly meeting Regular liaison with LAC CAMHS team Sexual Health Network Children's Society and representation at MASE meetings where appropriate, regarding looked-after children at risk of sexual exploitation Regular and ongoing liaison with primary care services, hospital services, youth offending team services, public health and education services Regular meetings with Camden's Looked after children Participation Officer to ensure children's/yp views are heard and ensure their involvement in service development. Adoption and fostering panel, attended by designated professionals LAC health staff attend London and National LAC and Adoption Forums 9.4 User survey None conducted during Due to commence in June 2017 Camden Looked After Children Health SeNice Annual Report 2016/2017 G Croft June Page 357 of 490

32 9.5 Inspection updates No inspections of LAC health services by CQC or Ofsted during 2016/ Professional Development LAC paediatrician attends the regional BAAF health group meetings 3 times per year in addition to the annual national BAAF health group educational conference and is a member on the national BAAF Health Group Advisory Committee Bi-monthly designated doctor peer review meetings with colleagues in Islington, Hackney, Barnet, Enfield and Haringey All LAC team members are up to date with mandatory training including the required Safeguarding training up to level 3. Other clinical meetings/study days on issues relevant to LAC are attended by LAC nurse specialists and paediatricians as they arise. The LAC nurses have attended training of relevance to Looked After children on the following during : o Mental Health First Aid: Supporting the mental health and emotional wellbeing of young people aged o Health Promotion Champion study day organised by NHS England o Young Person centred communication o C Card training o Chlamydia and Gonorrhoea screening training o Breaking the silence: Working to end Abuse and Honour based violence in Camden 6/6/16 o Infant mental health o BAAF conference on health of refugee children o Public Health Insight Day 27 June 2016 o QNI meeting- Revalidation & FGM o Non-Medical Prescribing Update - Prescribing for Common Childhood Conditions (Camden Community) o LAC- Enhancing the journey conference RCPCH o Safeguarding Refresher for senior staff o Paediatric Life support o Exploring the causes and consequences of modern day slavery RCGP o PHE Health protection o Adult safeguarding level o A Message from National Children's Bureau : Supporting Children's Emotional and Mental Health o CSE workshop- level o Abuse Linked to Faith and Belief o Working with Calais Young People o Supporting Looked After Children with Autism (TDS training) o Key Milestones in Adolescence and the Impact of Abuse- safeguarding level The Designated Nurse has attended training on: o Tools for working with sexually exploited children, o Involving children in decision making o Understanding Bonding and attachment o Mental Capacity Act and Deprivation of Liberty Safeguards o Introduction to commissioning Camden Looked After Children Health SeNice Annual Report 2016/2017 G Croft June Page 358 of 490

33 9.7 Committee work The designated doctor is currently serving a second 3 year term on the national CoramBAAF Health Group Advisory Committee, which contributes to national policy on adoption and fostering and provides advice and guidance to the Department of Health on a wide variety of issues with relevance to provision of health services for LAC. 10. Areas for development The LAC health team is making excellent progress in addressing the areas for development outlined in the March 2016 annual health report as documented in this report and the LAC health team work plan (Appendix 1). The following areas for development have been identified by the LAC designated nurse and doctor for : 10.1 Work with the social care LAC manager to reduce delays in referral by social workers for initial health assessment when children enter care. The aim is for a health care plan to be in place for 90% of LAC (including non-attenders) within 2 months and 100% within 3 months by December The LAC designated doctor will monitor progress. Actions needed: Ensure existing and new social workers are aware of processes for notification, relevant consents and forms required. Streamline the process for obtaining relevant consents from parents for health assessments and information sharing, without which the IHA cannot take place. Review process for booking interpreter services Develop a user-friendly health questionnaire for young LAC who refuses to attend for health assessment, for completion with their keyworker or social worker. This will help inform the young person's health-care plan Formalise the process for health care plan review and follow up contact for all LAC with complex needs within 6 weeks of initial health assessment. The LAC designated nurse will lead on this jointly with the health improvement practitioner Build on recently improved links with managers and staff at residential and supported accommodation settings, aiming to: train and involve staff in active health promotion for young people in their care LAC nurse to attend residential manager's meeting and individual care settings on a regular formal basis for health advice on young people causing concern and encourage staff to assist in implementation of health care plan recommendations re-visit the possibility of holding regular nurse-led drop-in sessions for LAC in these settings (previously unsuccessful at The Hive and at the LAC clinic premises) Develop a user-friendly "health-passport" for care-leavers, which will summarise their personal health information including birth details, health history, immunisations, allergies, medications and relevant family health history, along with details on how to access health services such as GP and dental registration. It has not been feasible to develop a smart-phone health app for this purpose as had been hoped User-engagement survey: Camden Looked After Children Health SeNice Annual Report 2016/2017 G Croft June Page 359 of 490

34 A paper form survey will commence in June 2017 to obtain feedback from foster carers and young people on their experience of initial and review health assessments. Consider arranging focus groups with looked after young people for their feedback on the service and support offered by the LAC health team. Ideally this would include feedback from both UK-born young people and recently arrived unaccompanied minors. If possible, obtain feedback and ideas for improvement from care-leavers 10.6 Audit project Undertake an audit of health outcomes to demonstrate the value of the service: to what extent are health issues identified at initial health assessment resolved to improve the health of LAC by the time of their review health assessment. Consider an audit to profile the health needs of Camden looked-after children 10.7 Finalise Camden guidance for management of pre and post-adoption electronic health records G Croft A Akamo ***************************** Designated Doctor for Looked After Children Designated Nurse for Looked After Children APPENDICES 1. Looked After Children's team work plan Integrated pathway for unaccompanied asylum seeking minors 3. Example health care plan Camden Looked After Children Health Service Annual Report 2016/2017 G Croft June Page 360 of 490

35 Looked after Children's team Work Plan 2016/2017 New Objectives/Areas for development Action Planned Who When Status Open/Closed Action Completed Identify and support LAC YP refusing health assessments. Improve uptake of initial health assessments U!:!A) and increase use of nurse led IHA Identification of vulnerable LAC with physical or mental health needs who are not engaging with health services. Liaise with social care LAC team to identify factors in child's life that may affect engagement. Check existing assessments by Education/LAC academy, MALT, substance misuse teams, sexual health, missing practitioner etc. Work with partner agencies to identify elements that can be used as leverage to engage with young person (incentives etc, e.g. gym membership) To be discussed at allocations meeting LAC Team member allocated to coordinate case. To be operationally embedded by September Active Open Monitoring criteria will be number of health care plans in place within 3 months of a YP becoming looked after, whether or not seen. GC to start monitoring from January Consider different approach to undertaking assessment of health needs such as selfadministered health questionnaire. LAC workplan updated January 2017 Page 361 of 490

36 Health care plan to be drawn up based on available information. 2. Contribution to multi-agency CSE prevention of child sexual exploitation Liaise with Sexual Health Networks to identify any LAC causing concern (e.g. noncompliance with contraceptive usage) and regarding LAC known to MASE AA Ongoing from 1st July 16 Active Incorporate CSE prevention strategies into health care plans of YP considered at risk. Liaise with key workers in Care Pathways and relevant health professionals to identify young people who 6 monthly audit of YP known to be at risk (from CSE register) go missing from care and provide support as required. 3. Development of an integrated care pathway across the NCL LAC network to ensure the physical, sexual and emotional health needs of unaccompanied asylum seeking minors are addressed. This involves joint working with the paediatric infectious diseases team at UCLH, the CAMHS refugee team at the Tavistock and adolescent sexual health services. AW GC By end Q2 Active Trial of joint LAC IHAICAMHS clinic. Referral forms for infectious disease clinic developed. Monitoring of clinical activity Pathways in place for physical, sexual and emotional health LAC workplan updated January 2017 Page 362 of 490

37 4. Improve quality of sleep for looked after children. Identify factors contributing to poor sleep at child/yp's health assessment - in the proforma for IHA and RHA All LAC staff By end of Q3 "Do's and don'ts of sleep" leaflet devised and handed out to all YP. Sleep advice to be incorporated into BACKCHAT website. KAwill send to EC 6. Improve links with Care Pathways and residential unit staff for 16+ LAC. Contribution to existing life skills programmes on topics such as managing minor ailments, accident prevention, first aid, with aim of reducing A&E attendances and empowering young people to manage their own minor health issues. Support for YP on how to access health services including use of pharmacies and nhs websites AA KA FL SP Will be ongoing Agreement reached: drop-in sessions not practical but contact details with photo of LAC nurses to be displayed at residential/supported accommodation units. LAC nurses can be contacted when required for advice and/or ad hoc sessions depending on need. Ongoing liaison with Pathway management team. 7. Reiterate preventative AA Will be LAC workplan updated January 2017 Page 363 of 490

38 interventions on critical periods of risk in LAC such as transition to 2ry school, leaving care or moving into pathways or semiindependent lodgings. 8. Increased support and health information to care leavers Offer C -Card, one-to-one advice as required To support LAC YP who have an EHC plan with individual puberty, sexual health and relationships education. Offer leaving care HA if not recently seen within 6 months. Provide last I HA or RHA inci family history Health information letter- about access to services and access to GP services. KA SP AA KA SP AW GC ongoing 9. Unmet Health needs audit How service shows that issues identified at IHA are picked and resolved by RHA JF 20 IHA's from last November cases on shared drive, quantifying other work Get list of IHA's from Nov 15 May need paper letter LAC workplan updated January 2017 Page 364 of 490

39 NORTH CENTRAL LONDON LAC HEALTH NETWORK INTEGRATED HEALTH PATHWAY FOR UNACCOMPANIED ASYLUM SEEKING CHILDREN INFECTIOUS DISEASES SEXUAL HEALTH EMOTIONAL HEALTH Symptomatic for TB ' Refer NCL South Hub TB Clinic (Whittin gton) via Asymptomatic for TB but (A) (B) (C) Include IHA with referral details Country of origin a high risk TB zone >40/100,000* Asylum JOUrney through hi g h risk TB zone Significant period of exposure to others at high risk oftb e.g. detainment in refugee camp OR Country of origin (or prolonged stay in country) hi g h risk for tropical disease or parasites** Specify if need for langua ge a dvocat e Specify conta ct det ai I s of soci al worker, key worker or foster carer Known HIV or hepatitis " If acutely unwell - refer to local urgent paediatric services Otherwise -refer directly to P aed i atric Infectious Diseases team at Grea t Ormon d Street Hospita l I SIGNPOST ALL YOUNG PE OPLE TO LOCA L SEXUA L HEA LTH SE RV I C ES FOR Allegation historical FGM Refer to FGM clinic at UCLH SCREENING AN D SEXUAL HEALT H ADVICE Allegation sexu al assault/a bu se I Acu te cases: refer to th e Ha vens via l ocal safegua rding pathway Historica l ca ses: ref er to l oca l sexu a l a bu se assessment clini c; Al l remaini ng UASC For th ose wi th evident signifi ca nt m e nta l health diff i cu lt ies Refer to Archway Centre f or Sexua I heal th. " With con sent: Ra pid a n d di rect access to level 3 G U M a n d contra ception services. se xual h ealth scree n ing, sexua l vi ence screening and referral, contracept i on, edu cat i on and s i gn post i ng wi thi n a ' on e sto p shop' Refer to l oca l CAM HS service. For Ca m den, Enf ield, Hari n gey and Barnet consider Tavist ock CA M HS refu gee tea m (via CA M HS Joi nt I ntake pathway). Provide wri tt en inform ati on leaf let (various l a ngu ages ava ilabl e) Si gn post a ll refugees to relevant s u pportive charities and a genci es Consider: Ref ugee Cou neil htt:uwww.ref ugeecounci l.o[g.uk /mvvie w Freed om f rom Tort u re reedomf romtortu re.org BAOBAB www. ba oba bsurvi vors.org Afruca Red C ross htt:uwww.redcross.org.uk What - we-do Ref ugee-suort Suortfor-young-refugees Barnet Ref ugee Se rvi ce youth d ub E.g. UCLH Safegu a rdi ng an d Sexua l Abuse Refer Paedi atric Infectiou s Diseases Clinic UCLH via UCLH Referrals Centre HUB (Ca mden, Ba m et, Enfi el d ), St A n ne's clinic (H arin gey, I sli ngton) Include IHA with referral Screening for BBV, G C an d CT to occur at Specify need for l angua ge a dvocate these assessment, with considerat i on of Specify conta ct detai I s of soci a I worker, key worker or foster ca rer su bsequent h ep B immuni sat i on. *ALL COUNTRI ES LISTED I N TABLE 1 of: k/government/u pi oad s/system/ uploads/atta chment_data/file/491527/wh 0_estima tes_of_tu bercu losis_incidence_by_co untry_2014_v2.pdf **Countries in Sub-Saharan Aricd, South East Asia, Latin America.. Additional actions f or health practitioners; Consider catch -up immunisa tions as per curren t PHE guida nce Vision screening Hearing screening Den ta l assessment Pathway lead: Dr Allison Ward, Consultant Paediatrician for L ooked after Chil dren in Camden. allison.ward1@nhs.net. Version 1(2016/2017 review date December 2017). Page 365 of 490

40 Appendix 3 Example health care plan to show incorporation of health promotion, sleep hygiene and resilience factors Form IHA- YP LOOKED AFTER CHILDREN CONFIDENTIAL Name of young person: J D.O.B.: age 17 HEALTH RECOMMENDATIONS FOR YOUNG PERSON CARE PLAN Personal or sensitive health topics should not be put in this plan or discussed in group settings without the express knowledge and consent of the young person. Date of next health assessment: J will turn 18 before his next health assessment is due. Issues Action required By when Named person res onsible Sue Pritchard (our looked after Now and Faith Lee (HIP) Raised body mass index children's specialist nurse) ongoing spent some time speaking to B Staff at his placement to health today about increasing support healthy eating physical activity levels and and increase participation eating a more healthy diet. in physical exercise. I have also requested that Faith Lee (our looked after children health improvement practitioner) follows this up further with J Sleep difficulties Social worker to look into gym membershi for J. J to be supported to improve his Now and J to make changes to sleep hygiene by: ongoing sleep hygiene and be supported by key worker a) developing a consistent and staff at placement calming night time routine b) Minimising noise and light disturbance at his residential unit after 10pm at night c) no screen time for at least 2 hours before time of desired onset of sleep e.g. target "fall asleep time" 11pm, no mobile hone/com uter/tv after 9 m Review in the paediatric Appointment Key worker I social Reported episodes of epilepsy clinic at the XXXX scheduled for worker to ensure altered consciousness -we Hospital xx/xx/2017 attendance at this need to exclude seizures appointment. Social worker and Key Vision - Outstanding eye J to attend high street opticians 1 month worker to encourage J to test for eye check attend Page 366 of 490

41 Appendix 3 Example health care plan to show incorporation of health promotion, sleep hygiene and resilience factors Social isolation and past history of deliberate self harm - indicative of emotional health needs J to let his social worker or key worker know if he would like a referral to CAMHS. Now and ongoing Social worker and key worker Dental care- No recent dental check 1 month Social worker and Key worker Lifestyle: healthy eating and Healthy eating: J would benefit Now and J exercise from eating 3 healthy meals a ongoing day that contain 5 portions of fruit and/or veg per day. He should try hard to reduce his portion sizes and avoid frequent snacks on calorie rich foods such as sweets, crisps and fried foods and fizzy drinks. Exercise: J should engage in 30 minutes strenuous (heart beat goes faster) exercise per day. This could be achieved by participation in football or attending the gym. Resilence promotion J should be supported to Now and continuing engaging with his ongoing college training. J should be supported to engage in activities he enjoys such as playing football and attending the gym. J should be supported to maintain health frienshi s. Social worker and Key worker Aller ies lmmunisations u to date? Re istered with GP? Permanently registered with GP? YES- FOOD ALLERGIES TO SOYA SAUCE, PRAWN AND RAW NUTS Yes Yes Yes Name: Registered with dentist? No Name All issues to be reviewed b Social Worker at Looked After Youn Person Reviews Page 367 of 490

42 0 Central and North West London r /:bj NHS Foundation Trust r l:b1 Hillingdon Clinical Commissioning Group t+illing DON LOIIOON Annual Report Looked After Children Health Service (Hillingdon) 2016/17 Deborah Price Williams Designated Dr for LAC Medical Advisor for Adoption and Fostering Teresa Chisholm Designated Nurse for LAC Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 368 of 490

43 CONTENTS Annual Report 2016/17 LAC Health Service (Hillingdon) Section Paqe 1 Executive Summary 3 2 Local Information Demographic Information Benchmark with National Data Local Statistics (a!=)el!=)ender/ethnicity) UASC summary and health needs 10 3 Service Summary Staffing Supervision and Peer Review Governance & Reporting Arrangements 14 4 Performance Indicators National Targets Local Tar!=)ets 16 5 LAC Team Clinical Activity Health Assessments lmmunisations Dental Checks Local Requirements (GP, Optician) 23 6 Other Clinical Activity Sexual Health Teenaqe Preqnancies Substance Misuse Emotional Health & Wellbein!=) Other (Complex Case Work) 27 7 Adoption & Fosterinq 31 8 Training 33 9 Service Improvements Specific Improvements I Team Achievements Audits (research) Partnership working User survey Inspection Updates Professional development (and publications) Other (policies, committee work, references) Priorities for 2017/18 40 Appendix 1 Glossary 41 Appendix /16 Annual Report 42 Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 369 of 490

44 Executive Summary This Annual Health Report has been written to outline the delivery of health services to Hillingdon's Looked After Children (LAC) during 2016/7 in line with National Statutory Guidance. It reviews performance indicators, clinical work undertaken by the LAC health team, service improvements and gaps or challenges identified. The key points below provide a short summary of areas covered within the main report. The report begins with an outline of LAC, information on LAC demographics and benchmarking local data against national statistics. During 2016/17 funding for the provider team was withdrawn by LBH and the shortfall was provided by Hillingdon CCG. The funding negotiations took several months to resolve, however, the provider continues to work with significantly lower staffing levels in comparison to those recommended within the Intercollegiate Competency Framework (2015). The report reviews the LAC team's performance against local KPis and issues, such as late notifications, which prevent targets being achieved. The provider team continues to save Hillingdon CCG money by bringing LAC placed out of borough back for their health assessments. Completing these assessments within Hillingdon ensures timescales are met and quality is maintained, however, this impacts upon an already pressured workforce. Care leavers continue not to receive a health service from the LAC health team, Care leavers of any age do not receive a service from the LAC team as it is not commissioned and this ongoing gap has been discussed within the health assessment chapter. The report reviews other clinical activity such as immunisations. The LAC provider team have made very good use of the Immunisation Task Force service to ensure that the immunisations of LAC are complete according to UK schedules. This service has been decommissioned as of the end of this financial year , and the LAC team will need to review the impact of this loss of service in The report shows some examples of how the LAC health team work with complex cases. The increasing number of complex children coming into care continues, and these cases require a highly trained workforce with significant time to coordinate care, develop relationships with young people and to case work as required. The report then considers achievements based on the priorities set within the last annual report. It concludes with priority areas for 2017/18 which are: Hillingdon CCG and CNWL to work together to address capacity issues within the LAC provider team Hillingdon CCG to commission a care Ieaver service Hillingdon CCG and CNWL to agree and sign an up to date SLA CNWL to monitor the uptake of immunisations following the decommissioning of the Immunisation Task Force. Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 370 of 490

45 2 Local Information The term 'Looked After Children' (LAC), Children Looked After' (CLA) and 'Children in Care' (CIC) are all used to refer to children who are placed into the care system. The term 'Looked After Children' is currently used within statutory and government documents and is used widely to refer to teams working with this group of children. However, some Local Author ies prefer the term 'Children Looked After' and teams are thus named to reflect this. In the past the use of 'Children in Care' became popular, so may also be a preferred term within some organisations. The terms are, therefore, interchangeable, however, in Hillingdon this group of children are referred to as 'Looked After Children'. 2.1 Demographic Information The London Borough of Hillingdon (LBH) is the second largest and westernmost London Borough and has been in existence since The population density varies between the semi-rural north and urban south.. Hillingdon is an ethnically diverse borough with 43% of residents from Black and Minority Ethnic groups The LBH has a population of 273,936 (2011 census); Greater London Authority population projections estimate that in 2016 there are 304,000 people living in Hillingdon. 23,000 (7.6%) are aged 0-4 years and 42,000 (13.8%) are aged 5-15 years. Population change from a 2014 baseline -.l-london Hillingdon Westminste r Hounslow Brent Figure 1: Population Change in LBH compared to other NWLondon Boroughs from 2014 Baseline Harrow - England - Ealing - Hamme rsmith and Fulham Kensington and Chelsea Sou ru:2014snpi",,.,.iomi StW.tio The figure above shows the percentage change in the population for boroughs in North West London compared with London and England. The proportion of the population aged 0-9 and is greater in Hillingdon than in England and that aged is greater in Hillingdon than in London. Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 371 of 490

46 From the JSNA population statistics 2016 projection there are 80,220 children and young people aged 0-19 living in Hillingdon -26.3% population (JSNA July 2016). People england Looked after children continue to be included in the JSNA priority themes as in last year's annual report: 2.2 Benchmark with National Data including UASC data data/file/556331/sfr Text.pdf National data published March 2016 quoted below from above link: The number of looked after children has continued to rise; it has increased steadily over the last eight years. There were 70,440 looked after children at 31 March 2016, an increase of 1% compared to 31 March 2015 and an increase of 5% compared to The rise this year reflects a rise of 1,470 in unaccompanied asylum seeking children, compared to a rise of 970 in all looked after children. In 2016 the number of looked after unaccompanied asylum seeking children increased by 54% compared to last year's figures, up to 4,210 children at 31 March 2016 from 2,740 in 2015 and up from a low of 1,950 in At 31 March 2016, unaccompanied asylum seeking children represented 6% of the looked after children population. Unaccompanied asylum seeking children are predominantly male, 93% in 2016 (up from 88% in 2012), and 75% are aged 16 years or over. 5, Number of urwoccomparied 4,5m 1sytums.e chidren 2016:4, Figure 2: Increase in UASC nationally C f11 20CB U In the latest year, we have seen a rise in the number of unaccompanied asylum seeking children in care, with 3,440 unaccompanied asylum seeking children entering care, and 1,980 leaving care. Many of the changes seen in the characteristics of the looked after children population as a whole have been influenced by this increase, for example with a Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 372 of 490

47 rise in the number of children aged 16 and over, and a rise in the number of children with an ethnic background of 'Any other Asian', 'African' or 'Any other ethnic group'. If we remove unaccompanied asylum seeking children from the count of looked after children, we see that there has been a decrease in the looked after children population of 500 (1%) since National data for LAC show that 56% were male and 44% female which has remained fairly consistent over the last 6 years. The age profile has continued to change over the last four years, with a steady increase in the number and proportion of older children. 62% of children looked after were aged 10 years and over in 2016 compared with 56% in Over the last year we can see a rise in the numbers from some minority ethnic groups, in particular 'Any other ethnic group', 'African' and 'Any other Asian background' (excludes Indian, Pakistani or Bangladeshij. This is likely to reflect the increase in the numbers of unaccompanied asylum seeking children National figures show that "Most looked after children are up to date with their health care. Of the 48,490 children looked after continuously for 12 months at 31 March 2016: 87% are up to date on their immunisations 90% had their annual health check. 84% had their teeth checked by a dentist 2.3 Local Statistics (age/gender/ethnicity) On 21st March 2017, a total of 304 children were looked after by LBH.39% (119) were within the age group compared to 23% in England in March % UASC males and 71% UASC females are in the age group. At the end of March 2017 were 7 missing children, of whom 4 were LAC at the time they went missing During (29%) of the total LBH LAC were UASC. Of those many had a more complex and challenging history prior to arrival than in the past; there are a number who have been trafficked, with increased risks for safeguarding and trauma. Many have had long and traumatic journeys to the UK overland, (via Turkey, Greece and through Europe by foot/boat/train/bus/concealed in lorries or from Sudan and Eritrea via Libya and the Mediterranean by horse and cart/bus/car/lorry/boat and then lorry/train) rather than via Heathrow and continue to present at Uxbridge and Polar police stations having climbed out of lorries in the area. Their health needs have changed and are explored below. A number were received from 'The Jungle" and a few following the Dublin 3 agreement As in previous years there are a number subject to age assessment; there are also some UASC who come into care in LBH and who are then are dispersed to other local authorities (from July 2016) Local LAC continue to include a number of complex/young people including those subject to CSE and those with complex health needs. Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 373 of 490

48 Gender and age and UASC status: a breakdown of the LAC in LBH shows male;female ratio to be 61%:39% compared to 56%:44% nationally (Figure 3). Nationally the UASC population is 90%male:10%female with the majority being in the oldest age group. Figure 3- Comparison of LBH and National data - Gender 80.00% 60.00% 40.00% 20.00% 0.00% Comparison of the LBH and National data for Gender in the LAC population March l.oo% 56.00% Male Female LBH overall c National Figure 4- Comparison of LBH and National data - Age 45.00% 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Comparison of age distribution between LBH and National data Jan 2015 Oto4 5to9 10to15 16 to 17 Age in years Figure 5: Age range of UASC compared to local LAC in age bands 60 Male local D Male UASC 50 D Female local u <!; 40 D Female UASC '. 0 Q) 30..c E z ::J to 4 5 to 9 10to to 18 Age Group in years Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 374 of 490

49 Ethnicity: LBH LAC ethnicity was also compared to National data and this can be seen in figure 6. LBH LAC- 44% were of white ethnicity 20% any Asian, 21 %black/ British/ African and Chinese and other 8%. This reflects the nationalities of the UASC population and does not reflect the local 0-18 child population 80% Figure 6-70% Comparison of 60% LBH and 50% National data - 40% Ethnicity 30% 20% 10% 0% Comparison of ethnicity between LBH LAC and National Data Jan 2014 LBH LAC National LBH 0-18 population White Asian Black Mixed Other Refused Placement: In March % LAC were placed within 20 miles of where they used to live with an average over the year of 77% being placed within 20 miles. This is shown on the following page on a map kindly provided by Helen Smith Corporate Parenting Manager from LBH (data from December 2016) Health assessments for out borough placements have been commissioned either from other provider organisations (or GPs) using SLAs and PbR since April2014. Currently, CNWL provide a service for LAC for IHA where they are placed within reasonable travelling distance of LBH but this is still not supported by an agreed SLA and funding. Sourcing CAHMS continues to be an issue for some LAC placed out of LBH. It can be seen from the map that while the majority of LAC placed within London are within the 20 mile radius there are a significant number for whom travel back to Hillingdon will not be possible. Even within London travel from the South can be challenging when outside the underground system and with long travelling times by car. For some LAC with additional needs or small children this will not be possible LAC brought back into LBH for HA continue to provide a financial saving in addition to a significant quality benefit for the CCG but add pressure to the overstretched Provider LAC Health service which needs to be considered at contract meetings. Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 375 of 490

50 Figure 7: Map showing placements of LAC/YP with red circle showing approximate 20 mile range Northumberland County Newcastle upon Tyne District Legend LAC Placement Lincolnshire County -Norfolk County West Sussex County Dorset Devon County Annual Report- Looked After Children Health Service (Hillingdon) 2016/17 18th August Page 376 of 490

51 Reasons for Entering Care: Reason for coming into care All children who started to be looked after in year ending 31"' March 2016 Abuse or Neglect % Child's disability % Parents illness or disability % Family in acute stress % Family dysfunction % Socially unacceptable behavior % Low income % National Outer London Hillingdon X X Absent parenting % Figure 8 - Comparison of reasons given for entering care as a percentage of total LAC taken from Table LAC4: Children who started to be looked after during the year ending 31 March by category of need, by Local Authority This is taken from data published in September 2016 and updated in February 2017 (reference below) to It can be seen that LBH has fewer children coming into care as a percentage of the total number for abuse and neglect than either nationally or by comparison with other outer London Boroughs and a significantly higher rate of LAC through absent parenting. 2.4 Unaccompanied asylum seeking children and young people summary UASC make up 29% of LBH LAC population and present with their own particular needs. These are similar to those found in the Kent sample in published research. The needs of the UASC in LBH were relatively uncomplicated in the past when they only presented to Heathrow but there are an increasing number who present having travelled by lorry/from the Calais jungle with more complex needs (travel through multiple countries/abuse en route/prison/ptsd) The age range of those presenting as UASC can be seen in section 2.3. The highest number of UASC males are in the age group are and this represents 76% of all UASC males. In this age group are also 71% UASC females. It is also important to look at the counties from which they came. An audit was undertaken to inform the presentation given at the annual CoramBAAF health group conference (June 2016) by ST5 Dr Claire Edmondson which explored Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 377 of 490

52 Hillingdon's LAC population (Appendix) and the results are as below. In this sample of UASC there were 16 countries of origin and 15 languages requiring interpreters. Figure 9: Chart showing countries of origin of UASC as recorded in survey of LAC UASC caseload 8% Afghanistan China Ethiopia Iraq Middle East Sudan Somalia Syria Albania Eritrea Iran Guinea Nigeria Saudi Arabia Srilan ka Vietnam Number of UASC% Missing Figure 10: Chart showing language required for interpretation of UASC as recorded in survey of LAC UASC caseload nguages required for Interpretation Albanian Arabic French Mandarin Pashto Tamil Somali Amharic Dari Kurdish Oromo Tigrinya Persian Urdu Vietnamese In terms of translation services 36% of the young people seen spoke Arabic, with Persian (or Farsi) and Albanian next. These 3 languages totalled over 50% of the patients seen Religion was recorded as 46% Muslim; 15% Christian (Pentecostal/Orthodox/Catholic) and 39% not recorded/missing. Previous access to education was also reviewed and none 10%; little 23%; yes 57% not recorded 10% (In terms of the classification of education selection was based on: "little" when the young person may have attended Madrassa or a family member for Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 378 of 490

53 instruction about the Qu'ran; where "limited" to primary age or by war; and ''yes" would be selected if attended secondary age education with variety of subjects studied even if limited by other factors) Health needs for this group were also reviewed and it was found that 73% had emotional issues and of the 27% who did not have these issues only 2 had no physical health needs. Emotional issues included sadness, low mood, trauma, anger, anxiety, diagnosed PTSD, learning difficulties, sleep issues, depression and self-harm % had no physical health needs, 26% had one health need, 23% two health needs, 27% three health needs, 15% four health needs and 2% five health needs. These included dental caries/gum disease/overcrowded teeth/enamel issues >50%; trauma and injuries (which included one instance of severe disability from burn injuries) in 50%; skin disorders including scabies, ringworm and acne in 26%; blood borne infection risks/malaria/anaemia 8%; FGM in two cases; vision problems 28%; heart murmurs heard at IHA 10%; respiratory problems and allergies 16%; genitourinary 10%; CNS problems 15%; weight problems 6%- under and over weight; other 8%; physical and sexual abuse 5%; gastrointestinal problems such as indigestion 12%. Figure 11: Bar chart showing physical health needs of UASC sample Vl "0 Q) Q) c.. ṛ. :. 1'5 Q) I PFGM abuse Iother Iweight GU issues heart murmur s Iinfections IGI ICNS respiratory s kin di sorders Ivision problems Itrauma Identa l issues Number of UASC During 2016/17 26% of total number of children seen for IHAs) were 17 year olds of whom majority (83%) were UASCs- children who had had no previous health check in UK. A significant gap in service is the lack of a care Ieaver service which is of particular importance to this group who have little understanding of the NHS or ability to advocate for their health needs to be met. Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 379 of 490

54 3.1 Staffing (CCG and Provider) 3 Service Summary Hillingdon CCG- The Designated Doctor and Nurse role assists in service planning, improve and monitor the health of LAC and to advise CCGs in fulfilling their responsibilities as commissioner of services. It is a strategic role. The CCG Designated roles in Hillingdon are commissioned by Hillingdon CCG and hosted within CNWL, which is the provider for LAC services. The Designated Doctor (Associate Specialist/SASG) has 1 PA per week for this role. The Designated Nurse has 0.2 WTE for this role, 0.1 of which is sited within the CCG. The Designated professionals meet and maintain competencies as per the Competency Framework (RCGP/RCN/RCPCH 2015) CNWL - The provider of LAC health services is CNWL who are commissioned to provide this service by Hillingdon CCG. Historically, funding was jointly provided by the CCG and LBH, however, this year LBH has withdrawn its contribution, and CNWL have been working with Hillingdon CCG to address the shortfall. The Lead Nurse provides management, leadership and supervision for the team within 0.8 WTE per week and has some clinical commitments. The lead nurse is supported by two LAC Nurses, one working 0.8 WTE, one 0.53 WTE per week. These nurses complete health assessments, work to promote the health of children with complex needs and assist the lead nurse with the promotion of health services for LAC. An Associate Specialist provides both a clinical service and undertakes the role of Medical Advisor for Adoption and Fostering. These roles are carried out in 4 PAs per week. There is a ST (specialist trainee) who works in community (for 3-6 months) while being on the on call rota for Acute Paediatrics and who undertakes some limited clinical work. This equates to 1 PA per month on average. The clinical members of the team are supported by the administration team. Two members of the team undertake this role in 0.98 WTE per week. This is a complex and time consuming role, tracking the large number of LAC health assessments, working with partners and ensuring robust systems are maintained. The nursing and admin team are based at Westmead clinic; medical staff are based at the Child Development Centre at Hillingdon Hospital. Members of the provider team are experienced and suitably trained to undertake their roles. They meet and maintain competencies as per the Competency Framework (RCGP/RCN/RCPCH 2015) Within last year's annual report, the Designated Nurse completed a staffing comparison with local CCGs I Providers, which resulted in a disparity. A review of the recommended minimum staff required within the Intercollegiate Competency Framework (2015) showed that a further Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 380 of 490

55 4.37 VVTE would be required to meet the required standard (see Annual Report 2015/16). A business case had been turned down based on this evidence and, although staffing levels continue to be a concern, this year the focus has been on maintaining the current budget following the withdrawal of funding from LBH. 3.2 Supervision and Peer Review (CCG and Provider) The LAC health team have the following supervision arrangements in place: Hillingdon CCG- The Designated Doctor and Nurse meet on a weekly basis to review and discuss cases, quality assure work undertaken and ensure consistently high quality health assessments are undertaken by Hillingdon staff. This well established meeting provides opportunity to discuss any concerns, compliments, areas for development and strategic issues to be addressed. The Designated professionals attend Brent, Harrow and Hillingdon (BHH) safeguarding meetings every two months in their CCG roles. In addition, this year, LAC meetings have been set up with the Central London, West London, Hammersmith and Fulham, Hounslow and Ealing Collaborative (CWHHE) on a quarterly basis CNWL- The LAC Nurses are managed and supervised by the Lead Nurse. All staff have annual appraisals, monthly 1:1s and ad hoc meetings as part of learning, development and supervision. The Hillingdon team is co-located with the Harrow LAC team, and peer safeguarding supervision is undertaken within this forum. Complex cases such as children at risk of sexual exploitation are discussed and time for reflection offered. Any safeguarding issues are also addressed with the CNWL Hillingdon Safeguarding Children team Clinical staff also receive support from external meetings in both CCG and provider roles: Quarterly North West London LAC peer group meeting Quarterly London LAC Nurse meeting Quarterly CoramBAAF London and SE health group Annual RCN LAC forum Annual CoramBAAF conference 3.3 Governance & Reporting Arrangements The LAC health team have the following reporting arrangements in place: Hillingdon CCG- This year the Designated Nurse has met with the Children Commissioner and Designated Nurse for Safeguarding to discuss LAC Key Performance Indicators (KPis), achievements and service gaps. In addition the Designated Doctor and Nurse have met with the Chief Operating Officer to inform her of any issues relating to the LAC service or any areas for commissioning to consider CNWL- The Lead Nurse attends a monthly safeguarding meeting with the Head of Children Services in Hillingdon. She will also attend the quarterly Goodall Divisional Safeguarding meeting which reviews progress within Hillingdon and Camden. Annual Report - Looked After Children Health Service (Hillingdon) 2016/ " August Page 381 of 490

56 In addition, the Lead Nurse ensures that a bi-monthly governance report is submitted to the Clinical Governance team, providing information on KPis, audits, incidents, compliance with CQC and any service risks. The LAC health team have identified the late requests for health assessments as a risk, and this is now on the CNWL risk register. In order to ensure CNWL are meeting CQC standards, every team completes a quarterly selfassessment report on five key lines of enquiry (KLOEs) ie. being safe, effective, caring, responsive and well-led In March 2016 the LAC team self-evaluation results were: KLOE Rating Safe Effective Caring Responsive Well-led Outstandinq Outstandinq Good Good Good Requires improvement Requires improvement Requires improvement Inadequate Figure 12 - KLOE self-assessment results The areas which require improvement are "safety", based on low staffing levels which have an impact upon the service that can be delivered, and "effectiveness" which is compromised due to the lack of timely requests for health assessments; an ongoing issue for the team. Both issues have been added to the CNWL risk register. An independent management annual peer review based on these standards is imminent LBH -The Designated Doctor and Nurse attend the health and wellbeing group every two months. At this forum there is an overview of health targets for LAC, work on projects and an analysis of reasons for delay in meeting KPis. This group reports into the Hillingdon Corporate Parenting Board, of which the Designated Doctor and Nurse are members The LAC heah team are accessible to LBH social workers as and when advice and support is required, and can be contacted via and telephone within working hours. 4.1 National Targets 4 Performance Indicators Local Authorities are required to report on eleven performance indicators i.e. the National Indicator Set (NIS), which refer to looked-after children or care leavers The health outcomes are reported on as follows: Number of children looked after at 31 March who had been looked after for at least 12 months Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 382 of 490

57 Number of children whose immunisations were up to date Number of children who had their teeth checked by a dentist Number of children who had their annual health assessment Number of children aged 4 or younger at 31 March Number of children aged 4 or younger whose development assessments were up to date Number of children identified as having a substance misuse problem during the year Number of children for whom an SDQ score was received. 'Outcomes for children looked after by local authorities' Local Targets From April to July 2016 Hillingdon CCG set the following KPis: To complete 100% of LAC initial health assessments (IHAs) within 20 operation days Numerator: Number of in borough LAC initial health assessments conducted within 20 operational days of receipt of referral Denominator: Total number of in borough LAC initial health assessments conducted For reporting purposes expressed as a percentage of those coming due for completion in the reporting month Operational days are Mondays to Fridays inclusive Exceptions: Young people who refuse, DNAs or missing children, out of area, UASCs undergoing age assessment To complete 100% of review health assessments (RHAslwithin six calendar weeks Numerator: The number of completed Review Health Assessment Action Plans within 6 weeks of an in borough Looked After Child hitting their due date for a RHA (whether they be on a 6 month or 12 month review cycle) Denominator: Total number completed Review Health Assessment Action Plans for in borough LAC RHA's Exceptions: Young people who refuse, DNAs or missing children, out of area, UASCs undergoing age assessment, notifications from Social Services later than one month before the review date From August 2016 to March 2017 there was a change to the KPis which came in line with Statutory Guidance requirements. Complete 100% of LAC Initial Health Assessments!IHAs). including Health Plan in time for the first statutorv review. within 20 operational days of child coming into care. Numerator: The actual number of LAC Initial Health Assessments (IHA)- including completed within 20 operational days of a child coming into care Denominator: the number of children who should be seen for a IHA within 20 operational days of coming into care Exceptions: Young people who refuse, DNAs or missing children, out of area, UASCs undergoing age assessment, late referrals ie not received within 48 hours of child becoming LAC, consent delays, young people in custody Annual Report - Looked After Children Health Service (Hillingdon) 2016/ " August Page 383 of 490

58 Children have review health assessments (RHA) completed within (national) regulatory timescales (children < 5 years every 6 months. >5 years annually) Numerator: Total number of LAC Review Health Assessments (RHA) conducted, in period; within statutory timescales Denominator: Number of LAC due to have a Review Health Assessments (RHA), in period; to meet statutory timescales Exceptions: Young people who refuse, DNAs or missing children, out of area, UASCs undergoing age assessment, notifications from Local Authority with less than 3 months' notice, consent not obtained by Local Authority, young people in custody 5 LAC Provider Team Clinical Activity 5.1 Health Assessments This chapter will focus on the performance of the LAC health team against national and local targets The LAC provider health team have completed 100% of IHAs and 100% RHAs as per the required CCG key performance indicators for 2016/17 and have completed breach reports where relevant. The LAC provider health team are required to ensure all looked after children have a statutory health assessment within statutory guidance i.e. within 20 working days of becoming looked after and thereafter every 6 months (under 5s) or annually (over 5s) The LAC heah team also assist the LBH in meeting national targets for LAC: - Ensuring all Hillingdon LAC have an annual health assessment within timescales -To record and report dates of dental checks following health assessment -To report immunisation status of each LAC following health assessment where available The following data relates to all Hillingdon LAC (both those placed within Hillingdon and out of borough) and has been taken from health assessments completed April March requests for IHA and 325 requests for RHA were received (521 total); the number of IHA for UASC is still increasing despite the National transfer scheme as initially the moves to other LA were taking some time so an IHA was requested from the LAC Provider team in Hillingdon. During 2016/ requests for health assessment were received within the LAC health team. A total of 465 health assessments were required compared to 443 assessments in the previous year Initial Health Assessments (IHAs) A total of 196 requests for IHA were received and 162 seen for health assessment. Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 384 of 490

59 Of the 34 children not seen for IHAs, there were children missing from care at the time of the appointment (3) and those who became no longer LAC (9), those transferred on National Transfer scheme (9), refusers (3) and completed after (10). For all of these children, the LAC provider team were still required to undertake all of the necessary processes to arrange and provide appointments. Those for transfer often moved very shortly before the appointment which meant that it could not be reallocated. A number of appointments were cancelled on the day due to lack of interpreter. Another appointment had to be made for those children who remained in care and who had not been seen. Of the 162 (100%) IHAs, 72 (45%) were seen within 20 days of the child becoming LAC (compared to 46% in previous year). Of the 37 not seen within 20 days of request, exceptions within KPis applied. Of the 162 (100%) IHAs, 125 (77%) were seen within 20 days of receipt of request (compared to 79%) in previous year). The health team, therefore, met 100% of IHAs seen within CCG KPI targets Issues contributing to the overall performance in IHA Monthly breach reports show that the most significant reason for children not being seen within 20 days of becoming looked after is the late notification of requests I consents from LBH. During 2016/17 data shows that 8% of IHA requests were received within 48 hours (expected target) compared to 12% of requests in the previous year. 26% were received between 3-5 days compared to 36% in the previous year. 41 requests (26%) were received on day 20 or over, meaning that these children could not be seen in statutory timescales. This shows that late requests have worsened since last year. Other issues which impacted upon meeting statutory timescales were, DNAs, Out of Borough placements, children or carers who refused/cancelled appointments or could not attend, interpreters who DNA and children who changed placement. The major issue impacting upon meeting IHA targets during 2014/15, 2015/16 and 2016/17 are late requests from LBH. Every year, this has been raised as a concern within Health and Wellbeing Board and at Corporate Parenting Board. In order to meet the demands of the number of IHAs within the team, joint Or/Nurse clinics continue to be arranged so that 6 children can be seen within one session as opposed to 3 children (seen by one clinician). The advantages are that more appointments are available to be offered to those coming into care and means that the team are able to meet timescales more effectively. However, the disadvantages noted in the previous annual report continue to be evident. Clinics are particularly busy and there is little time to address issues such as late arrivals or interpreter issues. It has been noted that the level of quality is reduced and with additional admin required, it is difficult to return health recommendations in a timely manner. Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 385 of 490

60 Review Health Assessments CRHAs) A total of 325 requests for RHA were received during 2016/17 (compared to 314 in previous year). Of these 325 requests, 22 children were no longer LAC or did not require a health assessment leaving a total of 303 to be seen (compared to 293 in previous year). Of the 303 LAC to be seen, 230 (76%) were seen in statutory timescales (compared to 66% in previous year). Of the other 73 children, 52 were not seen in timescales, 11 were in progress and 10 were refusers. For those children not seen in timescales, exceptions within KPis applied. The health team, therefore, met 100% of RHAs seen within CCG KPI targets. The total number of children seen was 282 (93%) compared to 94% in previous year. The LBH returns data on the DfE 903 based on those children who have remained as LAC for over 12 months which for 2016/17 was 193 children. This figure differs from those above, as some children would have left care during the year and thus not included in this report and for under-fives two health assessments are required in a year per child. Of the 193 children 178 (92%) had an annual health assessment. This is the same % as last year Issues contributing to the overall performance The designated nurse maintains a database of reasons which contribute to performance, and again, this year, the most significant reason for children not being seen within statutory timescales is late request. 209 (69%) RHA requests came with 12 weeks' notice or more which is the agreed timescale (compared to 55% in previous year) 54 (18%) requests came with 5-11 weeks' notice, and 40 (13%) of requests came with less than 5 weeks' notice. 16 (5%) of the late requests were received with zero or minus weeks' notice, up to minus 46 weeks' notice in one instance. In these cases CNWL were unable to provide a timely health assessment. In order to improve the timeliness of RHA requests, LBH and CNWL have piloted a new way of being 'tasked' a request from LBH Protocol system since August The consent continues to be sent by due to functionality issues. This new process has made some improvements to the quality of the information received within the request. It has also improved the timeliness in some cases, however, this has not been consistent, and this has been discussed within Health and Wellbeing group and is being monitored. Other issues which have impacted upon meeting statutory timescales were, DNAs, Out of Borough placements, children or carers who refused/cancelled appointments or could not attend, missing children, children who changed placement and children who were difficult to engage. In order to minimise DNAs, the team contact the carer I young person by telephone to offer flexibility in venues, dates, times (as per meeting timescales). All appointments are followed up by letter with this copied to the child's social worker. A reminder telephone call before the appointment improves attendance. The LAC health team work with our out of borough colleagues to minimise these problems, however, capacity issues in out of borough teams have an impact upon timescales. The LAC Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 386 of 490

61 health team have a reminder system in place, contacting the out borough provider to ask for details of the appointment. Should this date be provided, the child's social worker is copied into this information. Despite several reminders and processes in place, LAC may still DNA appointments. Reasons for children not being seen within statutory timescales are discussed within the Health and Wellbeing group and at Corporate Parenting Board Gaps in Service I Areas for Improvement A significant gap in service is the lack of a care Ieaver service. During 2016/17 42 (26% of total number of children seen for IHAs) were 17 year olds. The majority (83%) of these children were UASCs- children who had had no previous health check in UK- or children with complex health needs, both groups who would benefit from a review at 18 years of age. In addition, 70 (23%) RHAs were completed on children who were 17 years old of which, at least half of these children would have benefited from a follow up post 18 years. This gap will be focused upon during 2017/18 Timeliness of health assessment requests is an area for improvement. LBH and the LAC health team continue to look at new ways of working to improve the timeliness of requests and consents being sent by LBH social work teams. Within the Health and Wellbeing group, LBH managers delve into the reasons behind the late requests in order to identify themes and plan ways to minimise gaps Quality of Health assessments and Cost Savings Quality improvement has been driven by the needs of the LAC population who require a high quality health assessment, especially the IHA, to ensure that health needs are identified and recorded as SMART actions on the health recommendations. Health assessment paperwork (both the IHAIRHA paperwork and the health recommendations) returned to the provider LAC health team is reviewed by either the designated doctor or nurse and a sample of the IHA was graded as one of five categories with excellent being the highest and poor the lowest (excellent, good, satisfactory, needs improvement, poor) An excellent HA results in an to the professional who has completed the HA (wherever they are s uated) and, where possible, a copy to their manager. This often results in a '1hank you" from the recipient A poor, needs improvement or satisfactory health assessment and health recommendations from within CNWL results in action being taken in the form of training form the LAC team. One received from out borough may result in a letter to the relevant professional, a note not to use that provider where possible in the future or if poor a return of the paperwork for more thorough completion. Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 387 of 490

62 Quality of health assessments RHA lila 0% SO% 100% 150% excellent good satisfactory needs improvement poor IHA (26% returned health assessments audited): 96% excellent or good (71% excellent; 27% good; 2%NI) RHA (81% returned health assessments audited): 94% excellent or good (59% E 35% G 5% S; 1%NI) Figure 13- Quality of health assessments There has been a noticeable drop in quality sampling for IHA and dr/nurse clinics from 59% to 26% which needs to be improved over the next year As in previous years in order to maintain quality of health assessments LAC placed within travelling distance were brought back to clinics in Hillingdon In LAC were placed in Hillingdon at the time of their IHA and 50 placed out borough (OB). 32 of the OB placed LAC came back to Hillingdon for the IHA. A dip sample of these showed that 39% were quality assured and all were graded as excellent For the 18 IHA completed outside Hillingdon there were examples of excellent and good IHA both from other LAC teams and from GPs with a variety of providers and placement as shown on the map (page 9) but also one Nl (GP) The use of CNWL provider LAC team for health assessments for IHA for LAC placed out of LBH saved 17, (33x PbR for IHA of 534) For RHA 139 LAC were placed outside Hillingdon and of those 85 health assessments were completed in Hillingdon or by the CNWL provider team. Of those 97% were graded as excellent or good (61% excellent and 36% good) Of the 49 which were commissioned from other providers 30% were graded as excellent, 47% good and 8% as satisfactory or needs improvement. (7 have not yet been completed). In general the standard of HA has improved. Those assured as satisfactory were completed by a LAC team and one community paediatrician. Feedback has been given to the relevant community services. Both the "needs improvement" were completed by GPs The use of CNWL provider LAC team for health assessments for RHA for LAC placed out of LBH saved 26,520 (85 x PbR for IHA of 312) In totalthe provider saved the CCG 44,142 in year ( 42, in ) by completing HA for outborough placed LAC rather than the CCG having to commission this from other providers. Annual Report- Looked After Children Health Service (Hillingdon) 2016/ h August Page 388 of 490

63 5.2 lmmunisations The LBH returns data on the DfE 903 based on those children who have remained as LAC for over 12 months which for 2015/16 was 195 children. Of 195 LAC 160 (82%) were recorded as up to date with immunisations. Nationally, 87% are up to date on their immunisations The National COVER programme monitors immunisation coverage data for children in the United Kingdom who reach their first, second or fifth birthday and for HPV and teenage booster/meningitis C (now Meningitis ACWY) during each evaluation quarter. This information is promptly fed back to local level, creating the opportunity to improve coverage and to detect changes in vaccine coverage quickly The Cover stats for the LAC population have been compared with those for the non LAC population in Hillingdon at the ages above and is summarised in the table below (snapshot report from LAC caseload in March 2017). lmmunisations Number of LAC immunised/ number in age cohort LAC Caseload Total percentage Hillingdon child health population 5 in 1(at 12m age) 16/16 100% 91% PCV booster by 2 years 13/13 100% 84% Hib/MenC booster by 2 years 13/13 100% 85% MMR 1by two years 13/13 100% 84% Preschool booster by 5 years MMR2 20/21 20/21 95% 82% 95% 85% HPV School Year 13/14 Teenage booster 13/14 15/16 15/16 One refuser 17/22 No data (2);0ne no reason; two being chased Part 1-94% Part2-88% Part 1-84% Part 2-76% 81.4% 83% Figure 14- Total LAC immunisation rate as per Hillingdon LAC caseload on SystmOne Figure 21 shows that the rates of immunisation for Hillingdon looked after children continue to be comparable to Hillingdon's non LAC population, and in almost all cases, are better. This means that we are safeguarding our children from preventable infectious diseases. Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 389 of 490

64 The health team continue to work closely with local GPs and with the Immunisation Task Force but the latter has been decommissioned by NHSE as from March The LAC heah team works closely with the TB service at Hillingdon Hospital to implement a process for all UASCs to be referred for new entrant TB screening and with GPs for those over 16 who are eligible for IGRA screening as newly registered with their GP The immunisation status of all LAC having a health assessment is reviewed, information is requested from their GP and recommendations about outstanding immunisations made; a copy of the health recommendations is shared with the GP Immunisation records continue to be shared with professionals undertaking the health assessments and with foster carers and young people. 5.3 Dental Checks All LAC over 3 years of age are required to be registered with a General Dental Practitioner (GOP) and all LAC should have a dental check (oral check for those under 3 years) Within the LAC health assessment, discussion routinely takes place to promote good oral hygiene and young people are advised to attend for regular dental checks as recommended by their GOP. This may be at longer intervals than 6 months if there no concerns The LBH returns data on the DfE 903 based on those children who have remained as LAC for over 12 months which for 2015/16 was 195 children. Of the 195 children, 165 (87%) had an up to date dental check Nationally 84% had their teeth checked by a dentist. So the LBH figures are better than National data. 5.4 Local Requirements Registration with a General Practitioner The provider of LAC health services ensure that at every health assessment the child being seen is registered with a local GP Those children who have been recently accommodated, may be in the process of registering with a local practitioner, as they may have moved and not able to remain with their original GP. For newly arrived unaccompanied asylum seeking children, the registration process may take some time due to immigration status Should the child not be registered, this would be one of the recommendations made to the social worker within the health plan This year, with the increased numbers of UASCs from Calais, the team have noticed that some children were not being registered with a local GP, as they were due to move to another Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 390 of 490

65 area. The team advised LBH that this was not acceptable practice, and that all children should have a local GP to consult. On the whole, this has now been remedied Following health assessments, the GP is sent a copy of the health plan, in order for this to be recorded on the child's main medical records. Optician Checks The provider of LAC health services ensure that at every health assessment discussion relating to optician checks and wearing of glasses if prescribed is part of the assessment. Should LAC have an outstanding optician check, an up to date check is always recommended within the health plan which is returned to the child's social worker The health team do not routinely keep this data and the London Borough of Hillingdon do not report this within the annual DfE 903 report. 6.1 Sexual Health 6 Other Clinical Activity In order to improve the sexual health of LAC and promote healthy relationships, a LAC nurse chairs a multi-agency sexual health meeting. The group assess work undertaken within all the main Hillingdon care homes to ensure sexual health and relationship sessions are offered and provided. Bringing the services together for this meeting is a good way to identify any gaps in service To help to safeguard LAC at risk of child sexual exploitation a LAC nurse attends the Hillingdon multi agency child sexual exploitation meeting (MASE) every 6 weeks. The meeting is chaired by the Hillingdon CSE manager and consists of social workers, police, education and early intervention workers. Up to 50% of the young people discussed at panel are LAC and information from this meeting is shared within the LAC health team. The Hillingdon safeguarding nurse is also in attendance and this partnership working ensures the right agencies are made aware and support to safeguard these young people is put into place. The LAC nurse follows up the LAC young people and the safeguard nurse follows young people not in care The LAC nurses assess all LAC A&E attendances received from the Paediatric liaison health visitor who is based at the Hillingdon A&E department. The LAC nurses follow up any concerns with social care and attend strategic meetings in serious cases. These notifications highlight sexual assaults, or LAC who may be pregnant or need support with their sexual health The LAC nurses work in partnership with the CNWL Hillingdon Chlamydia screening and condom distribution service. The LAC nurses offer condoms and screening services (e.g. chlamydia and gonorrhoea screening) to sexually active teenager's living in care. This work Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 391 of 490

66 assists the chlamydia screening team's target is to reduce the spread of chlamydia within years old, hard to reach young people of which LAC are a high risk group The LAC nurses recommend 1:1 PSHE support for LAC that have a history of sexual abuse so sex and relationship can be discussed In a safe environment where they feel able to ask questions and discuss their fears. The LAC nurses recommend that LAC who have been sexually abused have a full sexual health screen and promote the HPV vaccine for teenage girls and gay young men. The hepatitis B vaccine is also recommended for gay young men. At health assessment the LAC nurses discuss sexually transmitted infections and protection through correct condom use The LAC nurses network with all young people's services in Hillingdon such as the befriending unaccompanied minors support group, Hillingdon LGBT youth group, FGM support service and Children in care council. This ensures the nurses are able to refer young people to services that will best support their needs All LAC are offered a statutory health assessment and sexual health and relationships is discussed within this assessment. 6.2 Teenage Pregnancies The LAC heah team work closely with LBH social workers and sexual health services to prevent unwanted teenage pregnancies within the LAC population The LAC team ensure that each child who is seen for a health assessment is provided with sexual health and relationships advice which promotes positive sexual health messages such as contraception and prevention of sexually transmitted infections The team refer to sexual health services should they consider that a young person is at risk of pregnancy The LAC heah team will also work with social workers in cases where young people are at particular risk. This is especially important for those young people who are pregnant or have experienced a termination of pregnancy as research shows that they are at risk of a second pregnancy within 12 months The following data for all of Hillingdon's under 18 year population is taken from CHIMAT report dated March 2017: In 2014, approximately 20 girls aged under 18 conceived for every 1,000 women aged years in this area. This is similar to the regional average (approximately 22 per 1,000). The area has a similar teenage conception rate compared with the England average (approximately 23 per 1,000) There is no recorded data specifically for Hillingdon LAC. Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 392 of 490

67 The LAC heah team have identified the need to provide a service to care leavers who may be most vulnerable to an unwanted teenage pregnancy and made a business case for this which was unsuccessful. 6.3 Substance Misuse National data shows that 4% of all children in care (male and female) have a substance misuse problem identified. It appears from the data to be similar in males and females but reported only in 10+ age groups. Similar numbers of males and females refuse interventions In the National tables there is no data recorded for substance misuse for LBH Substance use was recorded in the UASC survey and there were noted to be 16% smokers- rolled/cigarettes/sheesha; 12% other drugs all cannabis and 3% alcohol (2 LAC) There is no additional data from health needs survey this year as this was not undertaken. 6.4 Emotional Health & Wellbeing Nationally 75% LAC had completed SDQ with the average score being 14.7 for males and 13.2 for females (overall average 14). 46% of male LAC and 53% female LAC had normal scores recorded, with 13% having borderline scores and overall38% having scores which were a cause for concern In LBH 96% LAC had recorded SDQ scores with an average score of % were banded as normal, 12% as borderline and 33% as cause for concern Thus LBH LAC had slightly lower scores than nationally with higher recorded rate of completion of SDQ However, the SDQ does not identify those who have PTSD particularly well and if used soon after a UASC is received into care may be an underestimation of their emotional needs. This was an identified as a high area of need in the last health needs audit and also identified by research from Kent SDQ are not seen by the LAC health team at every health assessment and the Health and Wellbeing group of the corporate parenting board are working on improving the availability of this information for review health assessments. Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 393 of 490

68 6.6 Other (Complex Case Work) During 2016/17 the LAC health team continue to work with a range of LAC who have complex health and wellbeing needs. Members of the team have been available for telephone advice and have made visits in cases where additional support is necessary. As a result of these case discussions, members of the team have been actively involved in advocating for LAC health needs, attending reviews or professionals meetings This area of work is both time consuming and requires the ability to work within the multidisciplinary team. A few examples of work undertaken are given below, with some changes of information to protect the confidentiality of the LAC Complex Case 1! Child A- 17 year old, Somalian male, brought up in the UK.! Entered care 2014, as safety issues raised when Child A informed his family that he is gay. Family angry- Father and brother violent towards him.! Concerns also regarding forced marriage. Passport held by Police in relation to Forced Marriage Order.! Placed in borough in semi-independent children home.! Initial Health Assessment completed in ! Immunisation Task Force already visiting placement and outstanding immunisations given.! Attended clinic for annual RHA with LAC nurse.! Child A feeling fearful to go out due to local placement and possible meeting with family members.! LAC nurse noted poor diet, weight loss, poor dental care and overall poor self-esteem. Child A was also smoking cannabis, buying medication off the internet, and not in education.! Child A unhappy in placement, and unhappy with potential new placement. LAC nurse listened to child, reassured that new placement would assist him in his difficulties. Encouraged him to move out of his comfort zone.!! LAC nurse provided Child A with contact phone number for general emotional support following placement move. LAC nurse took case to supervision and discussed case with team leader. Annual Report - Looked After Children Health Service (Hillingdon) 2016/ " August Page 394 of 490

69 ! LAC nurse made contact with Child A's Advocate with his consent.! LAC nurse made contact with National Youth Advocacy Service for details of specific support needed for Child A.! With Child A's consent, LAC Nurse made contact with Mosaic LGBT manager to support Child A.! Child A is over 18 years, however, continues to maintain occasional telephone contact with LAC nurse. LAC nurse directs him to his advocate and any appropriate services. Child A states that he values the support he has had from his LAC nurse. Figure 15- Complex Case 1 Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 395 of 490

70 Summary of Complex Case 1 This case shows how the LAC nurse - identified child A's health issues and gathered information relating to case -dealt with physical health needs and provided some support regarding emotional health needs -built trusting relationship with child A, so that he could be assured that a placement move may be beneficial for him -communicated with child's social work team, NYAS and Advocate, LGBT manager, and placement staff. - used supervision with team regarding safeguarding issues. -child A is now 18 years, and although he is a care Ieaver, he will make contact with LAC nurse on occasions- LAC nurse signposts to his personal advisor, appropriate health service Complex Case 2! Child B - 16 year old girl, entered care She has complex needs due to her disability. Both her hands were seriously burnt as a child in a fire. Placed in a high level support semi-independent care home. Initial Health Assessment completed in May 2016.!!!!!!!! LAC Nurse undertook home visit to complete Review Health Assessment LAC Nurse concerned regarding issues of the young person is experiencing pain in hands. Can carry out most task independently but gets daily pain in both hands so needs help if in pain LAC nurse concerned young person is in pain and has not been reviewed by a doctor. Referral made to GP asking young person be referred to a pain specialist Referral to GP asking young person be referred to a burns and plastics specialist LAC nurse took case to designated doctor for advice regarding pain and review of burns Lac nurse asked that young person has funding for an electric tooth brush to help may tooth brushing easier LAC nurse recommends young person has a review with occupational therapist LAC nurse followed up immunisations- next booster immunisations due in 2021, young person informed will need to make an appointment when this is due! Young person did not have TB screening post initial health assessment though a referral was made, letter wrote to GP asking TB screening be completed as looked after young person from a high risk country. LAC nurse will follow this up to ensure completed!! LAC nurse recommends regular educational health care plan (EHCP) meetings continue LAC nurse advises young person see a careers advisor as she wants to be a secretary Annual Report - Looked After Children Health Service (Hillingdon) 2016/ " August Page 396 of 490

71 ! As young person enjoys swimming LAC nurse advises young person is eligible for discounted swimming lessons as a looked after child- application form given!!! LAC nurse asks for funding for the young person and a friend to attend a football match of favourite football team LAC nurse concerned that young person may be getting depressed due to pain in hands, discussed with young person who agrees to be referred for counselling Young person also agrees to be referred to unaccompanied minor support group Figure 16- Complex Case 2 Annual Report- Looked After Children Health Service (Hillingdon) 2016/ h August Page 397 of 490

72 Summary of Complex Case 2 This case shows how the LAC nurse -worked with a child with a disability and contribution to educational health care plan (EHCP) -at home visit, noted hand pain which had not been followed up -made referral to GP for specialist assessment -discussed at supervision -looked into aids to assist child B and made referral to occupational therapist -followed up immunisations and TB screening which was outstanding -advised child B to discuss career options with advisor -actively encouraged and promoted physical activities I hobbies, by accessing funding -made referral for counselling and to local group for emotional support These complex cases provide some examples of how the team work with some LAC who have identified concerns which need follow up and where other named nurses eg health visitor or school nurses are not involved. The cases show how the team provide a holistic approach to healthcare The health team are aware that LAC may be particularly vulnerable or susceptible to exploitation. They are also vulnerable to poor physical and mental health needs. The children that are prioritised are those which are assessed as those who are of high risk The health team are aware that LAC may also be drawn towards the process of radicalisation as they may view their situations as unfair or who are searching for identify, meaning and belonging The number of complex cases is rising, especially those children at risk of child sexual exploitation. Complex cases will be monitored as the time taken to work with these children has a significant impact upon the health team. 7 Adoption & Fostering The CCG commissions from CNWL the role of medical advisor to the adoption and fostering panel for LBH. In common with many CCGs this role is fulfilled by the designated doctor and nurse in their provider roles. These roles are set out in the Intercollegiate document from RCPCH, RCN and RCGP The Provider LAC health team are actively involved in adoption and fostering panels and processes. The team meet with colleagues both regionally and nationally to discuss and develop new ways of working and have regular peer group electronic discussion to consider issues which arise plus regular face to face peer group meetings as detailed elsewhere in the annual report. Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 398 of 490

73 There have been 19 fortnightly panels in the year and the medical advisor has been present at 18 of those and the designated nurse for LAC has attended 4 panels There have been 105 cases heard by Panel and a summary is taken from the Panel chair's report in the table below:- Type of case Number Of cases Adopter approval 7 Adoption match 17 Approval of child For adoption 2 Review of adopters 9 Resignation of adopters 5 or 6 Regulation 25, extension of approval of connected person 9 Regulation 24 approval of a connected person as a Foster carer 1 Foster carer approval 11 Foster carer resignation or de---registration 13 Foster carer review 19 Foster carer review following an allegation 7 Long term fostering match 4 Panel updated The medical advisor undertook all the comprehensive medical adoption panel reports for the children for the ADM meeting (23) and for the matching panels (17) but the data for special guardianship is missing from this data as is the number of reports for care proceedings/approval to place for adoption. These reports are time consuming as they require summary of the health needs of the child and the family plus the possible consequences for the LAC Paper reading for panel is equivalent or more than time spent at panel -for example, a match requires the child's CPR plus the adults' PAR or Form F to be read plus the APR/ASP so for 45 minutes panel time there is usually 2 hours of reading time. Following panel the minutes have to be read and approved within 5 working days The medical advisor continues to have meetings with the majority of prospective carers Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 399 of 490

74 for LAC placed either for a match with adopters, long term foster carers or special guardians to inform them about health needs and history The medical advisor's role encompasses assessment of reports on adults applying for adoption and fostering, special guardianship and connected persons..lt is not clear if the medical advisor is commissioned for those for special guardians but historically they have been seen and reported upon. In panel reports were written for a minimum of143 applicants for either fostering or adoption (AH and AH2 medical forms). This has increased from 137 last year. Some cases are complex and require much research and liaison with other medical practitioners and social care. 8 Training The team aim to offer training to a range of hea h service and local authority professionals. In last year's annual report it was reported that capacity issues had resulted in the team prioritising KPis and complex cases. During 2016/17 staffing capacity has meant that only essential training has been provided. For further comparison, please see Annual Report 2015/16 in appendix Health Staff During 2016/17 the LAC health team provided essential induction training for Registrars and update training for Health Visitors and School Nurses. 27 health care professionals received induction training with 17 staff receiving an update. In addition, we noticed that student nurses were not rece1v1ng information about the health needs of LAC, and have begun to deliver some training to their 'Thursday club'. A total of 18 student nurses have attended one of these sessions Social work and residential staff During 2016/17 the LAC health team were unable to offer extensive training to social work or residential staff due to capacity. Some as and when training was offered for 13 social workers and 2 residential care home staff. The LAC health team are available for support should a member of the local authority staff require health information and will provide on a 1:1 basis Foster carers and Children in Care During 2016/17 the LAC health team were not asked to deliver induction training to new foster carers in Hillingdon. The LAC health team prepared to deliver an update for experienced foster carers, however, due to low uptake of bookings, the session was postponed. CoramBAAF requested some bespoke LAC/sexual health training for a group of foster carers, and one of the LAC nurses delivered this to 11 foster carers. The LAC team were able to provide some training to children in care during 2016/17 for 48 young people at conferences or on a 1:1 basis. Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 400 of 490

75 As noted in 2015/16 Annual Report, the reduction in training is evident due to staffing capacity, although it should be a priority to ensure everyone has sufficient knowledge on dealing with the health needs of LAC. 9 Service Improvements 9.1 Specific Improvements I Achievements During 2016/17 the LAC health team have worked on the gaps and challenges set out in last year's annual report. The following results were achieved: Designated role To continue to highlight staffing capacity issues within the LAC provider health team as this continues to impact upon meeting the needs of LAC and quality of health assessments as the numbers of requests continue to increase. The funding of the provider health team has been under negotiation this year, due to the withdrawal of funding from LBH. The shortfall of funding has been agreed by Hillingdon CCG, however, this only maintains the current service, and is not an increase in capacity To ensure that the SLA is updated, agreed and signed The Designated professionals have updated the wording of the SLA, however, this has not been updated from the Statutory Guidance, as this would require agreement for increased activity. This work is still ongoing To continue work with new managers in LBH to improve the timely requests for initial and review health assessments (in designated role) Designated professionals continue to work with LBH managers. New processes are being trialled to improve the receipt of requests; however, requests are not consistently being received in timescales To submit a further business case regarding health senices for care leavers The Designated professionals have not submitted any further business cases, as the focus has been on maintaining the staffing within the provider service To ensure that all health assessments are completed within agreed timescales including those commissioned from other providers All health assessments are being completed by the provider service within agreed timescales. Exceptions are monitored and feedback to CCG I LBH To review quality of completed health assessments Designated professionals assess the quality of all health assessments and feedback to those where improvements are required. A well done is sent to those who complete excellent health assessment paperwork New KPis will be implemented to recognise requirements within statutory guidance - Designated professionals to ensure quality is maintained New KPis have been implemented to the standards required by the Statutory Guidance. KPis are being met by provider service and quality maintained. There is concern that Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 401 of 490

76 should requests for IHA be received in timescales, that the provider service would not have the administrative time to complete health plans within timescales To liaise with children's commissioner/coo in the CCG about obstacles to the provider meeting KPis Designated professionals have met with commissioner I COO in the CCG and have provided information regarding issues which are affecting the provider service. This is ongoing work To provide breach reports if the KPis are not met and to work with CCGILBH to reduce barriers to meeting KPis Designated professionals review the monthly KPI report which has been sent to the CCG. The report contains a breach report, showing all areas where assessments have not been completed in timescales and reasons why. This report is shared with LBH, and those senior managers look into breaches and issues eg. Late requests. Provider role: To ensure that all health assessment requests are received with a valid consent form The provider liaises with LBH to ensure that all requests are sent with a valid consent. A new combined Section 20 /health assessment consent form will be used next year to see if this improves the timeliness of requests To explore new ways of using IT The provider is working with LBH to implement a new way of requesting RHAs via the IT system. The provider and LBH continue to work together to identify a way of producing a care Ieaver passport via the LBH IT system To undertake an audit of LAC refusers and DNA's for health assessments The provider has undertaken this audit - results and actions taken can be located within the annual report Work with Little Talkers, Step Up and Stepping Out (LBH Children in Care Council) on a variety of initiatives such as care Ieaver services to inform service delivery The provider has had limited opportunities this year to consult with the children in care councils due to capacity within the service, and the amount of work the councils are having to achieve mean that their capacity is limited To work with LBH with children who are at risk of child sexual exploitation. The provider prioritise complex cases especially those who are at risk of child sexual exploitation. The provider team has attended professionals meetings and strategy meetings as required. The provider team attends MASE panel and shares any concerns from that meeting To work with other services who support LAC who smoke or use substances The provider works with individual LAC to support them as required New KPis will be implemented to recognise requirements within statutory guidance - Providers to ensure KPis are met and to discuss with CCG breaches The provider has a process in place to ensure that the new KPis set by the CCG are met. The lead nurse produces a monthly breach report to CCG with KPI information. This breach report contains all exceptions with brief report on each. Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 402 of 490

77 To work together with Camden/Milton Keynes/Harrow LAC health teams to share good practice The Hillingdon provider team is co-located with the Harrow children looked after team, and this ensures that sharing of good practice is easily achieved. The Hillingdon team has had limited time to work with Camden, although some cross work has taken place regarding the safe transfer of adoption records. There has been no opportunity to work with Milton Keynes this year. This is an area which will be prioritised during 2017/ Audits (and research) During 2016, a retrospective audit looking at children who did not attend (DNA) or who were not brought (WNB) to their health assessment from April 2015 to March 2016 was undertaken. This was led by our Registrar at the time, supported by Designated Dr and Nurse The audit showed an overall DNA rate of 4%, (2.9% of IHAs; 4.4% of RHAs- made up of 3.8% DNA and 0.6% refusers) The mean age of those who DNA was 16 Y2 years. The child's ethnicity was not seen as a factor as this ranged between all ethnic groups. However, more male than females DNA'd ie. 71% male DNA'd IHA; 58% DNA'd RHA Overall, a larger number of UASCs were seen to DNA, possibly due to language issues and the difficulty arranging interpreters. In addition, those in late adolescence especially those about to leave care did not attend, a time which they are at most need of additional health support Recommendations were made to improve the service as follows: -A DNA pathway to be established -this was formally produced and is currently being used. -Information to be sent to child's GP- this has been established within the team for some time. -Care Ieaver's health pack to be available- this is one of the projects being discussed within the health and wellbeing group. -To ensure appointments are offered when young person is available- this is always considered for RHAs, however, there are limited IHA appointments due to doctor capacity, so it is not always possible to be so flexible and meet timescales. -Survey children in care council as to why LAC do not always engage- due to staffing capacity, this has not been completed as yet No other audit was undertaken during 2015/16. Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 403 of 490

78 9.3 Partnership working The LAC health team continues to work in partnership with a wide range of professionals and clients in order to maintain a high standard of care. Members of the LAC health team are actively involved in a range of partnerships such as: Health and Wellbeing Group Work with Youth Council Hillingdon Hospital A&E Liaison Health Visitor Health promotion in children's homes- working with CASH, Youth services Adoption and Fostering Panel Colocation with Harrow Children Looked After team -this provides the team with an opportunity to share good practice, support and quality assure work CCG Designated Professionals meetings RCN Nursing Group- Designated Nurse sits on organisation committee. CoramBAAF Health Advisory Group- Designated Dr elected member of health committee LAC health staff attend London and National LAC and Adoption Forums The LAC health team have not had the capacity to arrange meetings with colleagues in Milton Keynes. Camden and Hillingdon LAC are in the same CNWL Division, thus there has been some sharing of information between services. 9.4 User survey The LAC heah team undertake an annual client satisfaction survey to review how young people rate the health assessment service which is provided. This took place between April to September questionnaires were completed, a similar number to last year. The samples are representative of the total LBH LAC population, cover both IHA and RHAs and assessments completed by a range of health professionals Young people or their carers (if too young to respond) were asked about their health assessment experience. Results continue to show a high rate of satisfaction with 93% rating the health assessment as a 4 or 5 out of As part of our family and friends survey, 91% said they would "definitely" or "likely" recommend us to other LAC Young people were asked if they fethat they were treated with respect of which 100% responded pos ively. As respect is a CNWL core value, this is an essential requirement for the service. Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 404 of 490

79 Young people are encouraged to provide a comment in relation to their health assessment. Some comments are shown below: 'I am satisfied as I have discussed my problems to someone' 'I feel happy with the help I got today' 'I feel that they done a great job with me and respect me very well' 'I felt better, I could explain my problems and it was quite useful for me and the treater was helpful as well' 'I felt that I was fine. I got upset telling how I hated my life when I lived with my mums boyfriend before. But I feel ok' 'I think the assessment has been very good. I am glad to have been given the chance to speak about my concerns and the way I feel' 'It was really good. I felt comfortable talking about everything and when I was asked questions I was happy to answer all of them' 'It was very calm and relaxed -very secure' 'It is fantastic that... comes to our home to see..., this is really helpful for a child with autism to reduce anxieties. Thank you' 9.5 Inspection Updates During November I December 2016 Ofsted and CQC carried out a joint inspection looking at meeting the needs of Children and Young People with SEND. Based on the 2014 Children and Families Act the inspection sought to understand! How effectively are needs of SEND children identified! How effectively are these needs assessed and met! How effectively are outcomes improved for SEND children Both the Designated professionals and provider staff were interviewed as part of the inspection. Inspectors also reviewed some of the looked after children who fall into this group and cases were discussed No other inspections of LAC health services by CQC or Ofsted were undertaken during 2016/ Professional development (and publications) During 2016/17 the LAC health team have continued to attend training in order to ensure safe delivery of services and compliance with the knowledge, skills and competencies outlined in guidance for health staff (RCN, RCPCH March 2015) Staff have completed training including: Mandatory training - CNWL Adoption and fostering panel training - LBH Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 405 of 490

80 North West London LAC peer review group National Designated Professionals Conferences RCN National Conference Designated Professionals Updates- Brent Harrow and Hillingdon CCG Consortium training day for adoption panel members- LBH Working together level 3 safeguarding update - CNWL PREVENT update training Update for named and designated professionals level 4-5 training safeguarding Coram I BAAF health group meeting London BAAF health group annual conference NNDHP safeguarding conference Leicester level 4 Team Awayday including Domestic Abuse training - CNWL Article published on the 'Health Needs of LAC in Hillingdon' published in health notes of Adoption and Fostering - Health needs audit of LAC and young people in the care of the LBH -Two poster presentation for the London School of Paediatric Conferences 1. How to reach the difficult to reach 2. Overview of unaccompanied asylum seeking children. Registrar presentation at the Coram BAAF conference June 2016 'Health Needs of LAC -The Hillingdon Experience. 9.7 Other (policies/committee work) Policies The LAC heanh team have continued to work with CNWL IT services to develop a local policy for the recording of data for children who are in the process of being adopted/have been adopted. No comprehensive national guidance is currently available. This policy is currently being considered by governance group and should be agreed for use during 2017/18. Committee Work The Designated Doctor continues to sit on the National Health Advisory group committee for Coram/BAAF The Designated Nurse continues to work with Royal College of Nursing as part of the LAC nurse committee. Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 406 of 490

81 10 Priorities for 2017/18 The following have been identified as areas for local improvement within 2017/18: Hillingdon CCG and CNWL to work together to address capacity issues within the LAC provider team Hillingdon CCG to commission a care Ieaver service (see page 20) Hillingdon CCG and CNWL to agree and sign an up to date SLA CNWL to monitor the uptake of immunisations following the decommissioning of the Immunisation Task Force. Deborah Price Williams Associate Specialist Designated Dr for LAC Medical Advisor for Adoption and Fostering Teresa Chisholm Designated Nurse for LAC Contributions from Katie O'Sullivan and Audra Linklater LAC Nurses Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 407 of 490

82 Appendix 1 Glossary of Terms Abbreviation ADM APR/ASP CAMHS CASH CCG CDC ChiMat CNWL coo CPR CQC CSE CST DfE DNA DoH ED FGM GDP HA Hep B Hib HPV IHA IRO JSNA KICA KISS KLOE's KPI LAC LARC LBH LGBT MAPS MASE MMR MYE NICE NIS OB Meanin Agency Decision Maker Adoption Placement Report I Adoption Support Plan Child and adolescent mental health services Contraceptive and Sexual Health Clinical Commissioning Group Child Development Centre Child and Maternal Health Observatory Central and North West London NHS Foundation Trust Chief Operating Officer Child Permanence Report Care Quality Commission Child Sexual Exploitation Chlamydia Screening Team Department for Education Did Not Attend Department of Health Emer ency Department Female Genital Mutilation General Dental Practitioner Health Assessment Hepatitis B Haemophilus influenzae type b Human Papilloma Virus Initial Health Assessment Independent ReviewinOfficer Joint Strategic Needs Assessment Kids In Care Award Keep It Safe and Simple Key Lines of Enquiry Key Performance Indicators Looked After Children Long Acting Reversible Contraceptive London Borouh of Hillin don Lesbian, gay, bisexual, and transgender Multi Agency Psychological Support Team Multi -Agency Sexual Exploitation Measles Mumps Rubella Mid Year estimate National Institute for Health and Care Excellence National Indicator Set Out borouqh Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 408 of 490

83 PA's PAR PCV booster PbR PSHE RCPCH, RCN AND RCGP RHA SDQ SLA STI TB UASC ucc WTE Programmed Activities Prospective Adopter's Report Pneumococcal ConjuQate Vaccine booster Payment by Results Personal Sexual Health Education Royal College of Paediatrics and Child Health, Royal College of Nursing and Royal College of General Practitioners Review Health Assessment Strengths and Difficulties Questionnaire Service Level AQ reement Sexually Transmitted Infections Tuberculosis Unaccompanied Asylum Seeking Children UrQent Care Centre Whole Time Equivalent Appendix 2 LAC Annual Health Report 2015/16 IIDII )- LAC ANNUAL HEALTH REPORT 201 Annual Report - Looked After Children Health Service (Hillingdon) 2016/ h August Page 409 of 490

84 Central and North West London r.!/:kj NHS Foundation Trust r l:b1 Harrow Clinical Commissioning Group Annual Report Children Looked After Health Service (Harrow) 2016/17 Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August 2017 Page 410 of 490

85 Annual Report 2016/17 CLA Health Service (Harrow) CONTENTS Section Page 1 Executive Summary 3 2 Local Information Demographic Information Benchmark with National Data Local Statistics (age/gender/ethnicity) 6 3 Service Summary StaffinQ Supervision Governance & Reporting Arrangements 12 4 Performance Indicators National Targets Local TarQets 13 5 CLA Provider Team Clinical Activity Health Assessments Immunisations Dental Checks Developmental Assessments Local Requirements (GP, Optician) 19 6 Other Clinical Activity Sexual Health Teenage Pregnancies Substance Misuse Emotional Health and WellbeinQ (CAMHS) Other (Complex Case Work) 23 7 Adoption & Fostering 26 8 Training 27 9 Service Improvements Specific Improvements /Team Achievements Involvement of CLA and Care Leavers Non -Attenders Audits (research) Partnership WorkinQ Feedback Inspection Updates Professional Development New Processes Priorities for 2017/18 39 Appendix 1 Glossary of Terms 40 Appendix /16 Annual Report 40 Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 411 of 490

86 1 Executive Summary This Annual Health Report has been written to outline the delivery of health services to Harrow's Children Looked After (CLA) during 2016/17 in line with National Statutory Guidance. It reviews performance indicators, clinical work undertaken by the CLA health team, service improvements and gaps or challenges identified. This is the second Annual Health Report for the Harrow CLA service. An OFSTED inspection was undertaken in February 2017 and services for CLA were rated as good. The key points below provide a short summary of areas covered within the main report. The report begins with an outline of CLA, information on CLA demographics and benchmarking local data against national statistics. The report continues with a focus on staffing, supervision, governance and reporting arrangements, clinical activity, health assessments and quality. With regard to the number of RHA's undertaken for those CLA for at least 12 months, CNWL have maintained 93% achieved last year despite significant increases in the number of CLA seen for health assessments. The report looks at other clinical activity including immunisations and there has been an increase of 3.4% from last year and almost 10% increase in the number of CLA with up to date immunisations since CNWL took over the service 2 years ago. Dental checks have increased 4.6% since last year and 100% of children under five have had up to date developmental assessments. The CLA health team have delivered a variety of training to foster carers, professionals and students, and case studies have been included to show how the CLA health team have worked with CLA, carers and professionals. We had a 1 year celebration of the service which was well attended and highlighted the strength of partnership working. Service improvements include the introduction of the process for requesting adoption and medical advice, reminder system should requests not be made in timescales, medical summaries requested for all CLA from their GP, and the redesign of the health recommendations form. Other new ways of working include the introduction of a peer support group and the development of a carer's information form. The SDQ process was implemented resulting in a completion rate of 90.6%, an increase of 49.6% from last year due to a concerted effort from the social workers and CLA health team. During the second year of the service the CLA health team have met their Key Performance Indicators (KPI) of 100% every month with the exception of June 2016 where 93% of RHA's was achieved. Monitoring meetings continue to be held each month with Harrow CCG and Harrow Council and these meetings are transparent and productive. We have worked with CLA and Care Leavers to obtain their views about the service and CLA have been involved in the development of health passports and a health questionnaire for nonattenders. TheCLA health team have undertaken a survey focusing on the health needs of CLA and have also completed our first client satisfaction audit This annual report has been written with help, advice and information from the Hillingdon LAC health team, Harrow CCG and Harrow Council. Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 412 of 490

87 2 Local Information The term 'Looked After Children' (LAC), Children Looked After' (CLA) and 'Children in Care' (CIC) are all used to refer to children who are placed into the care system. The term 'Looked After Children' is currently used within statutory and government documents and is used widely to refer to teams working with this group of children. However, some Local Authorities prefer the term 'Children Looked After and teams are thus named to reflect this. In the past the use of 'Children in Care' became popular, so may also be a preferred term within some organisations. The terms are, therefore, interchangeable, however, in Harrow this group of children are referred to as 'Children Looked After.' 2.1 Demographic Information The London Borough of Harrow (LBH) is situated to the north-west of London. It borders Hertfordshire to the north and other London boroughs: Hillingdon to the west, Ealing to the south, Brent to the south-east and Barnet to the east and has been in existence since In its current form it is made up of 21 wards and is the 12th largest borough in Greater London in terms of size. Harrow has both high levels of affluence in such areas as Harrow-on-the-Hill, Pinner, and Stanmore and high levels of deprivation in Wealdstone and South Harrow. Harrow is a diverse borough, having 63.8% of its population from the BME (Black and Minority Ethnic) communities The LBH has a population of 239,056 (2011 census); Harrow JSNA (2016) states that around 243,500 people live in Harrow and just over half of them are female. Harrow is home to 55,800 children aged 0-17 and seven percent of the population are children under 5 years old. The percentage of children living in poverty is just slightly below the England average mentlnewslchild-health-profiles-2016-published-by-public-healthengland Looked after children continue to be included in the JSNA priority themes as in last year's annual report: 2.2 Benchmark with National Data including UASC data mentluploadslsystemluploadslattachment datalfilei sfr Text.pdf National data published March 2016 quoted below from above link: The number of looked after children has contin ued to rise; it has increased steadily over the last eight years. There were 70,440 looked after children at 31 March 2016, an increase of 1% compared to 31 March 2015 and an increase of5% compared to The rise this year reflects a rise of 1, 470 in unaccompanied asylum seeking children, compared to a rise of 970 in all looked after children. Annual Report- Children Looked After Health Service (Harrow) th August Page 413 of 490

88 In 2016 the number of looked after unaccompanied asylum seeking children increased by 54% compared to last year's figures, up to 4,210 children at 31 March 2016 from 2,740 in 2015 and up from a low of 1,950 in At 31 March 2016, unaccompanied asylum seeking children represented 6% of the looked after children population. Unaccompanied asylum seeking children are predominantly male, 93% in 2016 (up from 88% in 2012}, and 75% are aged 16 years or over. S.OOJ 4, J Nurrber olumo:onjnric'd ;nyll.m eckillgchildrcn 10D 2016:4,210 18D Figure 2: Increase in UASC nationally 3,500 >.OOJ 2,JOO 2,')00 l.=>m tooj 500 In the latest year, we have seen a rise in the number of unaccompanied asylum seeking children in care, with 3,440 unaccompanied asylum seeking children entering care, and 1,980 leaving care. Many of the changes seen in the characteristics of the looked after children population as a whole have been influenced by this increase, for example with a rise in the number of children aged 16 and over, and a rise in the number of children with an ethnic background of 'Any other Asian', 'African' or 'Any other ethnic group'. If we remove unaccompanied asylum seeking children from the count of looked after children, we see that there has been a decrease in the looked after children population of 500 (1%) since National data for LAC show that 56% were male and 44% female which has remained fairly consistent over the last 6 years. The age profile has continued to change over the last four years, with a steady increase in the number and proportion of older children. 62% of children looked after were aged 10 years and over in 2016 compared with 56% in Over the last year we can see a rise in the numbers from some minority ethnic groups, in particular 'Any other ethnic group', 'African' and 'Any other Asian background' (excludes Indian, Pakistani or Bangladeshi). This is likely to reflect the increase in the numbers of unaccompanied asylum seeking children National figures show that "Most looked after children are up to date with their health care. Of the 48, 490 children looked after continuously for 12 months at 31 March 2016: 87% are up to date on their immunisations 90% had their annual health check. 84% had their teeth checked by a dentist Annual Report- Children Looked After Health Service (Harrow) th August Page 414 of 490

89 2.3 Local Statistics (age/gender/ethnicity) The following information and data has been provided by Harrow Council, (Corporate Parenting report April 2017) Numbers of CLA have remained stable since last quarter but do represent a 3 year high of 211. The numbers of CLA 1yr+ have also seen an increase from last quarter. The overall rate of CLA per 10,000 children (Harrow rate- 37) remains below the national (60) and statistical neighbour (41) average. There are no significant changes to the profile of the CLA cohort. However comparator data published for shows Harrow to have a higher proportion of CLA aged 16+ and a lovver proportion in aged children will be turning 18 this year and eligible for leaving care services. Harrow has a higher percentage of males in care. CLA by ethnicity compared with statistical neighbour average show a very different picture due to the make-up of Harrow's population. More than two thirds of Harrow's CLA population is from BME (Black and Minority Ethnic) groups and in line with the local population breakdown though Mixed, Black British and Other Ethnic Backgrounds are overrepresented. Harrow has a lower proportion of CLA in foster placements and a higher proportion in placements in the community (independent and semi- independent placements) A higher proportion of care leavers were in suitable accommodation and in employment education and training at 31/03/2016 compared to statistical neighbour averages. Harrow have had a similar proportion of CLA who had a missing episode in the year compared to previous year whilst statistical neighbours' and England trend is an increase from previous year. Rate of CLA per 10,000 children aged under H<rrnw ;::::_...SN -.-l:.ngland -- JO :lulu :LOll CLA numbers have continued to increase throughout the current year vvith overall numbers showing a gradual increase from The overall numbers of CLA and CLA 1year+ have increased. The rate of CLA per 10,000 is increasing but continues to remain below the England and statistical neighbour averages. Annual Report- Children Looked After Health Service (Harrow) 2016/ h August Page 415 of 490

90 CLA by Age Group 90, RO bu u b SO +-,A- ---.r.r Y" Comparator data has been published for , this shows Harrow to have a higher proportion of CLA aged 16+ and a lower proportion in aged Higher numbers of CLA aged 16+ will continue to have an impact on leaving care services. 44 children will be turning 18 this year. Comparative data (%) year ending March 2016 Age Under 1 1to4 S to 9 10 to Harrow Stat Neighbour England : Comparator data shows Harrow has a higher percentage of males in care. This number has increased in 1 I : the last 2 quarters to a peak of 128, whilst the number of females has remained moderately stable since 1 I : September I I I - Comparative data(%) year ending March 2016 Male Gender Female Harrow Stat Neighbour England AnnualReport- Children Looked After Health Service (Harrow) 2016/17 25th August Page 416 of 490

91 CLA by Ethnicity 80, Comparative data{%) year ending March 2016 White Mixed Ethnicity Asian or Asian British Black or Black British Other Ethnic Groups Harrow Stat Neighbour England Ethnic breakdown of young people aged under18, In line with population projections, Harrow's Black and Minority Ethnic groups are considerably higher than England and the statistical neighbour average. Overall two thirds of Harrow's children looked after population are from BME groups and more in line with the local population breakdown, Mixed, Black British and other ethnic backgrounds are overrepresented in the LAC cohort. J Harrow borough have also got a smaller number of Unaccompanied Asylum Seeking Children (UASC) compared to statistical neighbours in Hillingdon. The numbers over the year have remained stable at an average of 30 with a high of 32. This equates to 3 new UASC being looked after by Harrow each month. However as these children enter the UK with significant needs, this vvill have an additional impact upon services. Of the 100 children who have remained looked after for over 12 months 11 (11%) are UASC , : The number of dual allocated CLA who : I I : also have a Child Protection Plan has : 1 I : decreased. The number of CLA who are : : UASC has remained stable at 28. I L Annual Report- Children Looked After Health Service (Harrow) 2016/ h August Page 417 of 490

92 Number of LAC who are also CPP or UASC (snapshot) - Number of UA who also have a Chlid 1-Totection Plan (snapshot) - Number of CLJ\ who are UASC (snapshot) 45 -, = r,m.n.e,.-/numnljl ei""""i5tlc't"ctprmect10rrpian (snjpshot}r u ;'!; ;'!; "...'.."..'.."..'.."..'.."..'. "' "'...,..., <.0,._,._ "'."..'. "' c "' "' "' "' "' ::. <i >- 7., 6. 2 J: " <i > J: u <i > '; J: < ' < "' C5 z0 " "'.f ::;: < ::;: < " C5 z0 ::;: < "' -': < " "' u C5 z 0 0 "' ::;: % CLA placed more than 20 miles from home -+-% of New CLA placed more than 20 miles from home (YTD) Luw ---% of CLA pcled more thn 20 milesy from home (sn pshot) Low Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-1 6 Jan-17 Feb-17 Mar- 17 The percentage of all new CLA in the current performance year has varied throughout the year, currently 10.2% of CLAwho started in the year are placed more than 20 miles from home. The percentage of all CLA at the end of each month who are placed more than 20 miles from home has averaged around 22.2% throughout the year and is currently at 19.3%. In order to give a balanced view, these indicators exclude looked after children who are placed with parents, adopted or are unaccompanied asylum seekers. Annual Report - Children Looked After Health Service (Harrow) 2016/17 25th August Page 418 of 490

93 The chart below shows Harrow CLA placement details at 31' 1 March 2017 There are no significant changes to placement types. In house foster placements remain the most common placement type accounting for 46.9% of all placements. Slight increase in children in residential placements. Comparator data with statistical neighbours shows Harrow to have a lower proportion of CLA in foster placements and a higher proportion in placements in the community (independent and semi- independent placements) CLA by placement types _ Placed for Adoption nesdi entialschools Semi Independent1- lnd penrlent Iiving Young Offenders Institution or Prison Foster Carer - Inhouse Annual Report - Children Looked After Health Service (Harrow) 2016/ h August Page 419 of 490

94 3 Service Summary 3.1 Staffing The CLA provider services health team is currently based at Westmead Clinic and CNWL hosts the professionals who provide the designated roles The Designated Doctor and Nurse role is to assist in service planning and to advise CCGs in fulfilling their responsibilities as commissioner of services to improve the health of children looked after. It is a strategic role. The CCG Designated Doctor role for Harrow is commissioned from and hosted by the provider services for CLA All members of the CLA health team are experienced and suitably trained within their area of expertise, being fully up to date with their safeguarding training. They undertake ongoing training in relevant subjects in order to maintain their competencies. They fulfil the requirements of the Competency Framework (RCGP/RCN/RCPCH 2015). They undertake regular appraisals and as required are subject to revalidation. Current Staffing Nursing Team Designated Nurse for CLA- 30 hours per week Specialist Nurse for CLA hours per week Medical Team Designated Dr for CLA I Medical Advisor for Adoption and Fostering- 1PAper week GPwSI- 3 PA's per week Administrative Team Administrator for CLA hours per week We successfully recruited to the GPwSI post in March 2016 and again in September The Designated Doctor and Medical Advisor post is currently being covered by the Designated Doctor and Medical Advisor for Hillingdon. We expect there to be ongoing staffing issues with recruitment and retention in our third year due to the small numbers of PA's for the Doctor posts. 3.2 Supervision The Specialist Nurse and Administrator for CLA are managed and supervised by the Designated Nurse. The Designated Nurse meets with The Designated Nurse for Hillingdon every month for supervision. All staff have annual appraisals, monthly 1:1sand ad hoc meetings as part of learning, development and supervision The Harrow team is co-located with the Hillingdon CLA team, and peer safeguarding supervision is undertaken within this forum. Complex cases such as children at risk of sexual exploitation are discussed and time for reflection offered. The nurses have access to discuss any safeguarding issues with the Harrow Safeguarding Children Team. (Designated Nurse for Safeguarding Children) Supervision is also provided within monthly team meetings as cases, such as those who are at risk of child sexual exploitation, are raised. Staff are also encouraged to reflect upon difficult to manage situations so that learning can be shared. Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 420 of 490

95 The Nurses receives individual clinical supervision every 6-8 weeks. However arrangements are in place for case discussion and debriefing on a daily basis. Clinical staff also receive support from external meetings Quarterly North West London LAC peer group meeting Quarterly London LAC Nurse meeting Quarterly CoramBAAF London health group Annual RCN LAC forum Annual CoramBAAF conference The Designated Doctor and Nurse meet on a weekly basis to review and discuss cases, quality assure work undertaken and ensure consistently high quality health assessments. This well established meeting provides opportunity to discuss any concerns, compliments, areas for development and strategic issues to be addressed The Designated professionals attend Brent, Harrow and Hillingdon (BHH) safeguarding meetings every two months. In addition, this year, LAC meetings have been set up with the Central London, West London, Hammersmith and Fulham, Hounslow and Ealing Collaborative (CWHHE) on a quarterly basis. 3.3 Governance & Reporting Arrangements In terms of reporting arrangements, the CLA health team are accountable to the Head of Children's Services and Operations (CNWL) and have the following arrangements in place. For CNWL, the Designated Nurse provides a progress report and updates to the Goodall divisional safeguarding meeting which reviews issues and learning within the community services in Hillingdon, Harrow and Camden. In addition, the Designated Nurse produces a bi-monthly governance report for the Clinical Governance team, which provides information on KPis, audits, incidents, compliments and complaints, policies and guidance, risks and compliance with CQC The CLA health team have identified the late requests for health assessments and the lack of sharing of health information between health providers as a risk, and both of these are now on the CNWL risk register For Harrow CCG, the health team have continued to strengthen the partnership working, and to inform them of any issues relating to the CLA service and any areas for commissioning to consider. Joint monthly monitoring meetings held at Harrow Council and attended by the Designated Nurse for Harrow, Designated Nurse for Hillingdon, Head of Children's Services and Operations Hillingdon, Designated Nurse for Safeguarding Children Harrow, Integrated Children's Commissioner for Children and Families, Children's Commissioner for Harrow, and the Head of Service for Corporate Parenting The Specialist Nurse for CLA attends a monitoring meeting every Wednesday at Harrow Civic Centre to monitor the timeliness of requests for health assessments and their completion. She is available to the Social Workers every Wednesday afternoon to provide support and advice, and the health team are available via and phone, within working hours for consultation with all Social Work teams. Feedback from Harrow Council continues to be very positive about the health team being accessible every week for the Social Workers. Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 421 of 490

96 The Designated Nurse compiles a monthly breach report, health needs report and additional report for Harrow CCG and Harrow Council which is discussed at the monthly monitoring meetings. These meetings are productive, transparent and positive CNWL have a programme of peer reviews to ensure providers are able to evidence meeting CQC key lines of enquiry. The 5 key lines of enquiry (KLOEs) are being safe, effective, caring, responsive and well-led. The peer reviews are undertaken by managers in the organisation who are independent of the service being reviewed. The CLA health team are due their 2nd peer review in April Performance Indicators 4.1 National Targets Local Authorities are required to report on eleven performance indicators ie the National Indicator Set (NIS), which refer to looked-after children or care leavers The health outcomes are reported on a follows: Number of children looked after at 31 March who had been looked after for at least 12 months Number of children whose immunisations were up to date Number of children who had their teeth checked by a dentist Number of children who had their annual health assessment Number of children aged 4 or younger at 31 March Number of children aged 4 or younger whose development assessments were up to date Number of children identified as having a substance misuse problem during the year Number of children for whom an SDQ score was received. 'Outcomes for children looked after by local authorities' Local Targets Outline of Targets Set by Harrow CCG and Harrow Council During 2016/17 the following targets were set by Harrow CCG and Harrow Couneil as set out in the joint specification. To complete 100% of CLA initial health assessments (IHAs) within 20 operational days/28 calendar days. Operational days are Mondays to Fridays inclusive Exceptions: Young people who refuse, DNAs or missing children, out of area, notifications from Harrow Couneil later than 3 working days. Apr May June July Aug Sep Oct Nov Dec Jan Feb Mar % 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 422 of 490

97 From the above table the data shows that the health team have met the targets set in the second year of the service for initial health assessments Review Health Assessments (RHAs) To complete 100% of CLA review health assessments (RHAs) completed on time. Exceptions: Young people who refuse, DNAs or missing children, out of area, notifications from Harrow Couneil later than 3 months before the review date. Apr 2016 May 2016 June 2016 July 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017 Mar % 100% 93% 100% 100% 100% 100% 100% 100% 100% 100% 100% The health team have achieved all targets for RHA's set within the agreed service specification with the exception of June CLA Provider Team Clinical Activity 5.1 Health Assessments This chapter will focus on the performance of the CLA health team against national and local targets Initial health assessments are undertaken at Westmead Clinic, South Ruislip and Alexandra Avenue Clinic in Harrow. This enables some flexibility of venue and day. Review health assessments are undertaken at the above clinics, schools, and at the child's home offering increased flexibility for day, time and venue to enable completion and promote engagement in health assessments Health promotion is discussed at every health assessments and includes but is not limited to physical health, emotional well-being, diet, exercise, safety, immunisations, dental care, eye care, hygiene, sexual health, substance use and radicalisation The CLA health team also assist Harrow Council in meeting national targets for CLA: -Ensuring all Harrow CLA have an annual health assessment within timescales -To record and report dates of dental checks following health assessment -To report immunisation status of each CLA following health assessment -To report up to date developmental assessments TheCLA health team are required to ensure all looked after children have a statutory health assessment within statutory guidance i.e. within 20 working days of becoming looked after and thereafter every 6 months (under 5s) or annually (over 5s). The following data relates to all Harrow CLA (both those placed within Harrow and out of borough) and has been taken from health assessments completed April March Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 423 of 490

98 5.1.6 Initial Health Assessments (IHAs) A total of 194 requests for IHAs were received compared to 109 in 2015/16 A total of 154 children were seen for IHAs from April 2016-March (This includes 1 child from another authority placed in Harrow) The following table shows a comparison to previous years. Apr May June July Aug Sep Oct Nov Dec Jan Feb Mar Total No No Data Data Apr 2016 May 2016 June 2016 July 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017 Mar CNWL took over the service in June 2015 a total of 130 children were seen for IHA's (June March) compared to 88 during 2015/16, an increase of 47.7% Of the 40 children not seen for IHAs, these included those who became no longer CLA as well as those children who were seen in April For all of these children, the team were still required to undertake all of the necessary processes to arrange and provide appointments. Of the 154 (100%) IHAs, 83 (54%) were seen within 20 days of the child becoming LAC compared to 50% in 2015/16 Of the 70 not seen within 20 days of request, exceptions within KPis applied Issues contributing to the overall performance Since the start of the service monthly data has been produced for Harrow CCG and Harrow Council to show timescales of requests for IHAs. Overall, this data has shown that the most significant reason for children not being seen within 20 days of becoming looked after is late requests received. Other issues which impacted upon meeting statutory timescales were, DNAs, Out of Borough placements, children or carers who refused/cancelled appointments or could not attend, children who were missing, interpreters who DNA and children who changed placement Review Health Assessments (RHAs) A total of 208 requests for RHAs were received during 2016/17 compared to 145 requests in 2015/16. A total of 148 children were seen for RHAs compared to 114 during 2015/16, an increase of 30%. (This includes 4 children from another authority placed in Harrow) Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 424 of 490

99 The following table shows a comparison to the previous year. Apr May June July Aug Sep Oct Nov Dec Jan Feb Mar Total Apr 2016 May 2016 June 2016 July 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017 Mar Harrow Council returns data on the DfE 903 based on those children who have remained as CLA for over 12 months which for 2016/17 was 100 children. This figure differs from those above, as some children would have left care during the year and thus not included in this report. Of the 100 children 93 (93%) had an annual health assessment within time scales. Of the 7 not seen within timescales, exceptions within KPis applied. England Statistical Harrow Harrow Harrow Number of 2015/16 Neighbours 2014/ / /17 CLA 90.0% 93.9% 82.5% 93.7% 93.0% 93/100 The table above shows a comparison to previous years of RHA's being undertaken within time scales. CNWL have maintained the 93% achieved last year, this is higher than the England average but slightly lower than statistical neighbours Issues contributing to the overall performance There is an established process to ensure that RHA requests are received giving 12 weeks notice. Overall, data analysis has shown that a significant reason for children not being seen within statutory timescales is late requests received. Other issues which impacted upon meeting statutory timescales were DNAs, Out of Borough placements, children or carers who refused/cancelled appointments or could not attend, missing children, children who changed placement and children who were difficult to engage. In order to minimise DNAs, the team contact the carer I young person by telephone to offer flexible venues, dates, times (as per meeting timescales). All appointments are followed up by letter with this copied to the child's social worker. A reminder telephone call and text before the appointment improves attendance. TheCLA health team work with our out of borough colleagues to minimise these problems, however, capacity issues and KPI's in out of borough teams have an impact upon timescales. The CLA health team have a reminder system in place, contacting the out borough provider to ask for details of the appointment. Should this information be provided, the child's social worker is copied into this information. Despite several reminders and processes in place, CLA may still DNA appointments Areas for improvement The CLA health team have identified late requests I consents from Harrow Council Social Work teams as an area for improvement during 2017/18. The Designated Nurse produces monthly breach reports for the Senior Managers in Harrow Council. Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 425 of 490

100 Quality of Health assessments Quality improvement has been driven by the needs of the CLA population who require a high quality health assessment, to ensure that health needs are identified and recorded as SMART actions on the health recommendations. Each health assessment returned to the provider CLA health team is reviewed by either the Designated Doctor or Nurse and graded as one of five categories with excellent being the highest and poor the lowest (excellent, good, satisfactory, needs improvement, poor). Health assessments undertaken by the Designated Doctor or Nurse in their provider roles are graded independently. An excellent health assessment results in an to the professional who has completed the health assessment (wherever they are situated) and where possible, a copy to their manager. This often results in a 'thank you' from the recipient. A poor, needs improvement or satisfactory health assessment from within CNWL results in action being taken in the form of training from the CLA team. One received from out of borough may resuit in a letter to the relevant professional, a note not to use that provider where possible in the future or if poor, a return of the paperwork for more thorough completion IHA's- 45% excellent, 43% good, 9% satisfactory, 2% needs improvement 1% (2 health assessments were not graded, 1 child's neonatal summary and 1 health questionnaire) The graphs show that due to a concerted effort by the CLA health team quality of health assessments is high with 88% of IHA's graded as excellent or good and 96% of RHA's graded as excellent or good RHA's- 76% excellent, 20% good, 2% satisfactory, 2% (3 health assessments were not graded 3 health questionnaires) The majority of excellent health assessments are completed by CLA team members due to their experience of working with CLA. Quality improvement has been driven by an increased number of health assessments being undertaken by the CLA health team for those children placed out of borough (within 20 miles) or where the previous quality was poor. The 2% graded as satisfactory were completed by health professionals out of borough. 120 Health Assessment Quality expressed as a percentage IHA RHA excellent good satisfactory needs improvement poor The Designated Nurse for Safeguarding Children (Harrow CCG) has planned to undertake a dip sample of quality of health assessments during Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 426 of 490

101 5.2 lmmunisations The Harrow Council returns data on the DfE 903 based on those children who have remained as CLA for over 12 months which for 2016/17 was 100 children. Of 100 CLA 76 (76%) were recorded as up to date with immunisations. England Statistical Harrow Harrow Harrow Number of 2014/15 Neighbours 2013/ / /16 CLA 87.2% 82.10% 66.1% 72.6% 76.0% 76/100 Nationally, 87% are up to date on their immunisations, down slightly from 88% last year. The above table shows that the rates of immunisation for Harrow CLA are below both our statistical neighbours and the national average. There has been an improvement of 3.4 % from 2014/15 and almost a 10% increase in the number of CLA with up to date immunisations since CNWL took over the service, this continues to be an area the CLA health team has prioritised for 2017, to ensure that we are safeguarding our children from preventable infectious diseases TheCLA health team identified 44 CLA who were not up to date with their immunisations. A letter was sent to their carers to encourage them to book an appointment with their GP. A copy was also sent to the child's Social Worker and Independent Reviewing Officer The CLA health team works closely with the TB service at Northwick Park Hospital and has implemented a process for all UASCs to be referred for new entrant TB screening. Recently this has been replaced with a directive from NHSE, where for those over 16 who are eligible for IGRA screening, are referred to their GP. In response to this change the CLA health team are undertaking a project to ascertain the impact on our UASC The Specialist Nurse for CLA has continued to develop links with the CLA health teams in the Tri- Borough that covers Harrow, Ealing and Brent to discuss TB referral pathways The immunisation status of all CLA having a health assessment is reviewed, information is requested from their GP and subsequently arrangements are made for any outstanding immunisations with the GP. This is always included in the CLA health recommendations returned to the social worker for the health care plan A letter is sent to all GPs with a copy of the health recommendations and this has led to faxes/ s being received from the GPs with additional data about immunisations which in turn has been updated on SystmOne Immunisation records are shared with professionals undertaking the health assessments and with foster carers and young people Meeting with Dr Small (Named GP for Safeguarding Children Harrow CCG) to discuss improving immunisations for UASC and the need for additional training for Harrow GP's Specialist Nurse, GPwSI for CLA, Infectious Diseases Consultant and TB Registrar met with the Northwick Surgery GP's to discuss the health needs of UASC including immunisations, TB Screening and screening for blood borne infections. Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 427 of 490

102 5.3 Dental Checks All CLA over 3 years of age are required to be registered with a General Dental Practitioner (GOP) and all CLA should have a dental check (oral check for those under 3 years) As part of the CLA health assessment, discussion takes place to promote good dental hygiene and young people are advised to attend for 6 monthly dental checks. Should children not be registered with a GOP or have not attended a dental check, this would be recommended as part of the health plan for thatchild The Harrow Council returns data on the DfE 903 based on those children who have remained as CLA for over 12 months which for 2016/17 was 100 children. Of the 100 children, 93 (93%) were recorded as having a dental check compared to (88.4%) during 2015/16 an increase of 4.6% which is higher than both the England and statistical neighbours average. 5.4 Developmental Assessments All CLA aged 4 or younger are required to have their developmental assessments completed. 100% of Harrow's CLA were up to date with their developmental assessments which is the same recorded figure as last year. 5.5 Local Requirements Registration with a General Practitioner In order to establish numbers of CLA registered with a GP, the CLA health team assessed data taken from the SystmOne database. Every health assessment is audited for health needs and registration with a GP is one of the data areas collected. The results were as follows: Of Harrow's 154 CLA seen for IHA, 13 children (8%) were showing as not registered with a GP Of the 13 children not registered with a GPat IHA 5 were new born babies and had not been registered with the GP yet but had an appointment to be registered. 8 were newly arrived asylum seeking children and would be in the process of being registered once immigration papers were sorted. Optician Checks The provider of CLA health services ensure that at every health assessment discussion relating to optician checks and wearing of glasses if prescribed is part of the assessment. Should CLA have an outstanding optician check, an up to date check is always recommended within the health plan which is returned to the child's Social Worker, young person, carer, GP and Health Visitor or School Nurse. Table showing percentage of CLA with up to date eye checks at time of health assessment. Apr 2016 May 2016 June 2016 July 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017 Mar 2017 IHA 62% 0% 64% 100% 29% 44% 40% 45% 20% 70% 55% 57% RHA 88.9% 78% 100% 100% 80% 67% 60% 75% 83% 75% 100% 82% Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 428 of 490

103 6 Other Clinical Activity 6.1 Sexual Health TheCLA health team have established partnership working with the Sexual Health Outreach Nurse in Harrow. We have had regular meetings and this is now established as a monthly liaison to discuss CLA in need of sexual health advice and support The CLA health team ensure that each child/young person who is seen for a health assessment is provided with sexual health and relationships advice appropriate to their age and understanding, which promotes positive sexual health messages such as contraception and prevention of sexually transmitted infections. Discussions with younger children include 'the pants are private', 'underwear rule', 'growing up, and body changes' The Specialist Nurse for CLA has established a monthly joint health drop in clinic with the Sexual Health Outreach Nurse at The Gayton. Social Workers can also refer UASC to the clinic to be seen by the CLA Nurse and interpreters are arranged Links have been made with the Harrow sexual exploitation manager (CSE) and the Gangs Co-ordinator Female genital mutilation (FGM)- TheCLA health team and Sexual Health Outreach Nurse are working together to ensure all young people from high risk countries are asked the important questions about FGM. One young person has been referred for follow up, support and counselling The Specialist Nurse for CLA regularly attends Harrow Council's MASE panel and the Children At Risk Panel. Following these meetings, the CLA are discussed with The Designated Nurse and a plan devised TheCLA nurses assess all CLA A&E attendances received from the Paediatric Liaison Health Visitor who is based at Northwick Park A&E department. TheCLA nurses follow up any concerns with social care and attend strategic meetings in serious cases Information shared with the Harrow CSE Manager via The Safeguarding Children Advisor for CNWL to help with mapping cases to assist in the development of the profile around harmful and sexual behaviour in children and young people, to inform the collective strategy Designated Nurse assisted children and young people's participation worker by sharing resources for sexual health and relationships and child sexual exploitation for her session with young people aged 15+ who are looked after The CLA health team have referred young people to local sexual health clinics and local support groups to support them with their sexual health and understanding their sexuality Creative Working GPwSI and Specialist Nurse for CLA undertook a joint IHA for a young person with complex needs as the Specialist Nurse had attended the MASE panel where the young person was discussed. Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 429 of 490

104 6.2 Teenage Pregnancies The CLA health team work closely with Social Workers and sexual health services to prevent unwanted teenage pregnancies within the CLA population The CLA team ensure that each child who is seen for a health assessment is provided with sexual health and relationships advice which promotes positive sexual health messages such as contraception and prevention of sexually transmitted infections The team refer to sexual health services should they consider that a young person is at risk of pregnancy The CLA health team will also work with Social Workers in cases where young people are at particular risk. This is especially important for those young people who are pregnant or have experienced a termination of pregnancy as research shows that they are at risk of a second pregnancy within 12 months The following data for all of Harrow's under 18-year population is taken from CHI MAT report dated March 2017: In 2014, approximately 11 girls aged under 18 conceived for every 1,000 women aged years in this area. This is lower than the regional average (approximately 22 per 1,000). The area has a lower teenage conception rate compared with the England average (approximately 23 per 1,000) The Specialist Nurse for CLA has liaised with the Teenage Pregnancy Midwife at Northwick Park Hospital and discussed two young people who are pregnant. 6.3 Substance Misuse National data shows: "The percentage of children looked after who were identified as having a substance misuse problem was similar to the previous year. Of the 48,490 children looked after for at least 12 months in the year ending 31 March 2016, 4% were identified as having a substance misuse problem. Half of these (50%) received an intervention for their substance misuse problem, compared to 48% last year, and down on the 56% receiving an intervention in A further 40% were offered an intervention but refused it, up slightly from 38% last year and up from 34% in Comparable rates for all children are not available." Substance misuse is slightly more common in males and is more common in older looked after children. 4% of males were identified with a substance misuse problems compared to 3% of females. 11% of 16 to 17 yearolds were identified with a substance misuse problem in the year ending 31 March 2016, compared to 4% of 13 to 15 year olds. data/file/575531/sfr Additional Tables Text.pdf In the National tables there is no data recorded for substance misuse for Harrow The CLA health team continue to work with partners to support young people with health advice on smoking, drug and alcohol issues. Substance misuse is discussed at an age appropriate level with CLA during their health assessment and referrals are made to Compass, smoking cessation, GP's and pharmacists. Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 430 of 490

105 6.4 Emotional Health & Wellbeing Nationally 75% LAC had completed SDQ with the average score being 14.7 for males and 13.2 for females (overall average 14). 46% of male LAC and 53% female LAC had normal scores recorded, with 13% having borderline scores and overall 38% having scores which were a cause for concern In Harrow, 90.6% CLA had completed SDQ recorded which is higher than the national average. The rates of recording have significantly improved from the previous year (which was 41%) due to a concerted effort from the Social Workers and CLA health team CLA specialist Nurse liaised with the clinical lead for Tier 2 service and the UASC team manager to enable them to share SDQ's in other languages. of thanks from team manager received CLA health team have been instrumental in the implementation of schools completing SDQ's for CLA through meetings with the Virtual Head Teacher, Tier 2 service and CLA Manager Emotional health is discussed with all CLA during their health assessments. The 'how I feel chart' is discussed with young children and older children use a scale of Specialist Nurse for CLA trialled an emotional health and wellbeing questionnaire for CLA to complete during their health assessment for those who may require counselling or referral to CAMHS. This has now developed into SDQ's being completed with children/young people during their IHA and RHA, where emotional needs have been highlighted and where an SDQ has not been received During 2015/16 the CLA health team have undertaken partnership work with a range of professionals in order to consider the emotional needs of Harrow CLA CAMHS Monthly meetings with CAMHS YOT to discuss the health needs of children/young people under the YOT Quarterly meetings with CAMHS and CLA team manager. Liaison and discussion of CLA with CAMHS- Agreed sharing of information process Specialist Nurse attended 'Future In Mind' workshop and raised CLA as a priority in the redesign of mental health services for Harrow TheCLA health team continue to work to address emotional health needs by linking with other local services. The CLA health team receive information from the Liaison Health Visitor within the Northwick Park Emergency Department (ED) or Urgent Care Centre (UCC) relating to any CLA who attends this service with an emotional need such as self- harming behaviour Specialist Nurse for CLA asked to complete a bereavement referral. Decision made to bring forward young person's RHA as the carer/iro and Social Worker have requested the referral. The young person was reticent to talk to anyone about her feelings about the bereavement, and the nurse knew that if she discussed the referral as part of the RHA, it would mean a more holistic approach. The young person also completed an SDQ as part of the health assessment and this was scored by the Tier 2 manager. Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 431 of 490

106 6.5 Other (Complex Case Work) During 2016/17 the CLA health team have been involved with a variety of cases which are complex and require health input. Members of the team have been available for telephone advice and have made visits in cases where additional support is necessary. As a result of these case discussions, members of the team have been actively involved in advocating for CLA health needs, attending reviews or professionals' meetings and taking on the role of lead professional This area of work is both time consuming and requires the ability to work within the multidisciplinary team Follow up home visits have been made by the Specialist Nurse for CLA regarding health needs: weight, healthy eating, Diabetes, and follow up and support regarding FGM Liaison with GP's, Health Visitors, School Nurses and other health professionals both in Harrow and out of borough regarding the health needs of CLA. A few examples of work undertaken are given below, with some changes of information to protect the confidentiality of the CLA. Designated Nurse helped care Ieaver aged 25 with learning disabilities, with support from her Social Worker to look at accessing her medical records at Northwick Park Hospital. Two siblings had refused to have their health assessments undertaken. 3 appointments had been made and they did not attend. They were placed OOB and regularly went missing. Liaison with their Social Worker, Carer, Birth Parent and the young people themselves resulted in them agreeing to complete a written health questionnaire about their health. We also asked for their feedback about the health questionnaire. Once the completed forms had been received the Specialist Nurse contacted the siblings about their forms and they both agreed to telephone health assessments. This has opened the way for a face to face assessment in the future. 6 year old child placed out of borough with complex health needs. CLA health team completed review health assessment resulting in identification of unmet health needs including outstanding immunisations. Liaison with GP resulted in referral to Community Paediatrician, Occupational Therapy and local Epilepsy Specialist. Liaison with School Nurse to undertake eye and hearing assessment at school. CLA Doctor wrote a letter to the child's GP stating that the child could be given his outstanding immunisations. Designated Nurse liaised with Social Worker to discuss completion of health recommendations and funding for physiotherapy. Designated Nurse liaised with Foster Carer and appointment for outstanding immunisations arranged for September. 10 year old child requested information about her birth from her Social Worker. CLA health team liaised with health professionals and accessed this information from the hospital where the child was born as current GP and School Nurse had no record. Information given included length of pregnancy, type of delivery, length of labour, time of birth, weight at birth and Apgar scores. of thanks received from Coram-Harrow Adoption Partnership Manager. Designated Nurse assisted local children's home when a staff member was diagnosed with TB. Liaison with home, Head of Service, TB Nurses in Harrow and Hillingdon which resulted in a plan of action for the home and staff as children looked after by Harrow are placed there. Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 432 of 490

107 Complex Case Study Case Study 1 17 year old female with Insulin Dependent Diabetes Mellitus CLA Specialist Nurse liaison between Social worker and hospital ward staff following emergency admission for young person CLA Specialist Nurse liaison between Paediatric Diabetic Liaison Team (London Hospital) and Social Worker and carer CLA Specialist Nurse liaison with Paediatric Liaison Officer Support given to Young Person by CLA Specialist Nurse Liaison and referral to Diabetic Psychology services Health planning meeting arranged at London Hospital attended by young person, birth mother, carer, Social Worker, Supervising Social Worker, CLA Specialist Nurse, Consultant, Paediatric Nurse and Dietician. This was to ensure smooth transition prior to the planned move to a semi-independent placement and to ensure that the young person and all professionals involved were aware of the future health plan. Further liaison with Social Worker to give advice on future care CLA Specialist Nurse attended Placement Planning Meeting at new semi-independent placement. Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 433 of 490

108 Case Study2 17 year old male with Epilepsy Liaison with current GP to ensure that we have copies of all clinic and hospital attendance informing us of dates, medication and plans. Regular liaison with Social worker to discuss management of noncompliance and further planning. Liaison with Intensive Care Doctors. Liaison with the Young person to reassure them prior to the MRI scan. Liaison with Care staff at residential homes x2 (placed at 2 different placements). Attendance at meeting to discuss care planning Liaison with Neurology Consultant and letter sent requesting Emergency Care Plan to enable Care staff to manage his seizures. Telephone contact with Neurology Consultant following receiving letter- plan made to enable joint up working, sharing of health information and future planning. Professionals meeting to discuss further management. Review Health assessment completed July 2016 has been previously non-compliant. Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 434 of 490

109 7 Adoption & Fostering The CCG commissions from CNWL the role of Medical Advisor to the adoption and fostering panel for Harrow Council. In common with many CCGs this role is fulfilled by the Designated Doctor and Nurse in their provider roles. These roles are set out in the intercollegiate document from RCPCH, RCN and RCGP The Provider CLA health team are actively involved in adoption and fostering panels and processes. The team meet with colleagues both regionally and nationally to discuss and develop new ways of working and have regular peer group electronic discussion to consider issues which arise plus regular face to face peer group meetings There have been 9 joint fostering and adoption panels between April 2016 and March The Designated Nurse attended all panels while the Medical Advisor/Designated Doctor attended 8/9 panels. A Medical Advisor attended all adoption cases The breakdown of cases discussed show that there were 5 adoption matches, 1 long term fostering match and 6 connected persons matches There were 4 foster career approvals, 3 deregistrations and 9 annual reviews discussed at the panel During the year 2016/17, 25 SGO's (Special Guardianship Orders) were granted in respect of Harrow's looked after children. The panel considered 4 SGO applications. Although there is not a requirement for such cases to be considered by the panel it is good practice for there to be some scrutiny and oversight of this type of permanence plan The Medical Advisor undertook all the comprehensive medical adoption panel reports for the children for the ADM meeting and for the matching panels. These reports require summary of the health needs of the child and the family plus the possible consequences for the CLA Paper reading for panel is equivalent or more than time spent at panel- for example, a match requires the child's CPR plus the adults' PAR or Form F to be read plus the APR/ASP so for 45 minutes' panel time there is usually 2 hours of reading. Following panel the minutes have to be read and approved within 5 working days The Medical Advisor met with all the prospective adopters prior to panel to discuss the health needs of the children involved The Medical Advisor's role encompasses assessment of reports on adults applying for adoption and fostering, special guardianship and connected persons. These reports are completed by the applicant's GP and the role of the Medical Advisor is to assess any possible implications for the applicant's ability to care for a child till the age of independence. In 2016/17 the medical advisor reviewed 1-2 AH (Adult Health) forms a week. Some cases are complex and require much research and liaison with other medical practitioners and Social Workers young people seen by Specialist Nurse for CLA, for follow up of health needs raised during review health assessment prior to being presented at fostering and adoption panel. Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 435 of 490

110 8 Training The health team has delivered training to a range of professionals from health services and Harrow Council Training about CLA and their health needs has been delivered bi-monthly as part of the 'partnership induction' for Harrow Council Training delivered to the First Response Team induction day with 20 people in attendance. This has resulted in improvements in the timeliness of requests for IHA's Training, support and liaison has taken place with Health Visitors and School Nurses. Designated Nurse attended Health Visitor team meeting to discuss the health needs of CLA and the role of the lead health professional Designated Nurse delivered a teaching session about CLA and their health needs at Oxford Brooke's University to Health Visitors and School Nurses in training. Thank you received from Jennifer Kirman (Course Lead) stating that the students gave 'extremely positive feedback regarding approachability, knowledge and compassion and welcomed the sharing of expertise and championing of the good work the team excel in.' Student Nurses have benefited from training delivered by the Health CLA team with one student sending a thank you card TheCLA health team have delivered joint training with the Tier 2 Manager to foster carers in Harrow regarding the emotional needs of CLA. Evaluations have been very positive with carers valuing the health information and support given. In addition, the health team have asked carers if there were any specific aspects of health that they would benefit from having further training in. This has resulted in specific training sessions planned for 2017 regarding weaning, puberty and hygiene, and child development Training delivered to the Safeguarding Leads in Harrow CCG (30+ GP's and 2 Practice Nurses) on the health needs of CLA, immunisations and TB screening. Positive feedback received via from Dr Small (Named GP for Safeguarding Children Harrow CCG) Designated Nurse, GPwSI and Named GP for Safeguarding Children Harrow CCG, delivered a joint training session for GP's in training at Northwick Park Hospital regarding safeguarding and children looked after. This session was well attended and positively evaluated. Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 436 of 490

111 9 Service Improvements 9.1 Specific Improvements I Team Achievements Monthly joint commissioner meetings with CNWL, Harrow CCG and Harrow Council Monthly meetings with Morning Lane- Tier 2 mental health Quarterly meetings with CAMHS Designated Nurse for CLA attended the early intervention service consultation where needs of CLA were discussed CLA health team attended 'Future In Mind' workshop and highlighted CLA as a priority group Discussion with CoramBAAF regarding best practice in adoption processes Liaison with NHSE regarding immunisation records for CLA Redesign of health recommendations form TB leaflet developed by team available on the CNWL website which can be downloaded Development of health assessment decline pathway Health Passports We devised a questionnaire to obtain the child's voice with regard to what they would like in their health passports and have received both verbal and written feedback. CLA and young people's views regarding their health passports shared with Frameworki Children's Workstream Lead, Corporate Parenting Manager, Quality Assurance Manager and Children's Participation Officer Meeting with Harrow Council and the Frameworki team to develop the recording process and to agree content of health passport to go live in June Pathway of completion and assessing SDQ's agreed with Harrow Council and Morning Lane Tier 2 service Designated Nurse attended the foster carer's award ceremony. This was a lovely celebration and raised the profile of the health team We have been working with Harrow Council to look at late requests of health assessments. As a result a single frameworki episode has been created which has resulted in improvements in the timeliness of requests. Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 437 of 490

112 9.2 Involvement of CLA and Care Leavers We have met with the 'Beyond Limits' CLA and care leavers group along with the Children's Participation Officer to obtain the child's voice in the development of the CLA health service. This has included the development of the health passport CLA Specialist Nurse presented at Care Leaver conference June care leavers in attendance. The theme was a healthy lifestyle and she devised a young person friendly, simple to read health quiz. Interpreters were present to help the young people to understand the questions. Some care leavers took health leaflets and some asked specific questions which were answered, and they were also signposted to relevant services. Presentation at Care Leaver event in December care leavers in attendance. 25+ weighed and measured and health information given. Specialist Nurse for CLA gave feedback to the UASC Team Manager to evidence changes in practice from the previous care leavers' conference Specialist Nurse for CLA devised a health quiz for the 'Beyond Limits' group magazine Health stall provided at Harrow College health fair with health information and health resources for CLA as many care leavers attend Harrow College UASC Support offered to The Gayton for UASC observing Ramadan. Liaison with the manager of The Gayton to discuss having a leaflet holder for health information. CLA Specialist Nurse designed an interpreter's crib sheet so that the interpreter will understand what areas of health will be discussed with the young person during their health assessment. Our Designated Doctor shared this document at the National Meeting of the CoramBAAF health group. of thanks received from the Designated Doctor for CLA in Portsmouth A children and young people's comments and views form is given to each CLA following their health assessment. Some of the following comments have been received: 'I feel that were good for me because it shows me how tall and weight I am. Also I can share to her about my health, what I did and what I should do to improve. I feel I would like to have same day like this because it make me better' (17 UASC) 'I think that it went well' (11) 'It helped me with how tall I am and how much I grown. Also what I weigh. I helped her set up the equipment and helped her put it away. I answered the questions she asked me' (8) 'I felt happy after this session, team being was communicating and helpful. Questions were good' (17) 'The assessment was alright overall. It wasn't boring or painstaking and I found it useful and enjoyable' (14) 'Today very good and helpfui. I learnt a lot of things, thank you' (16 UASC) 'It was very useful and helpful and helped me a lot' (16 UASC) 'I am very happy the way they talk to me is very polite. I was very comfortable with both of them and I was very open to talk to them. They talked all about my general health need and I am happy about it' (16 Or/Nurse) 'I think that the health assessment was really good and the nurses at the clinic are friendly. I didn't feel uncomfortable answering or telling them anything. Overall the health assessment was great' (16 Or/Nurse) 25th August Page 438 of 490

113 'It was good' (13) 'I enjoyed it. It's so fun but we didn't do the weighing' (9) 'The meeting with the doctor went very well' (16 UASC) 'I thought everything was really good today' (10) 'Everything was fine' (16) 'It was good and helpful' (11) 'It's good' (14) Worried about what might happen but did not need to worry everything was fine' (7) 'It was very informational. I liked the new info and good length of meeting. Nice to know I've grown' (14) 'I enjoyed it because I know what I can do to help myself in life so my life will be better in the future' (10) 9.3 Non-Attenders The CLA health team strive to reduce non-attendance for health assessments by engaging with young people who do not attend by offering flexible times, venues and respecting the young people's wishes For young people who DNA, follow up is via the telephone and health information is then sent with details of how to contact the CLA health team. This includes the 'Handy Hints' leaflet which includes health promotion information regarding diet, exercise, dental hygiene, immunisations and emotional well-being as well as local service information regarding sexual health, youth stop and national websites/telephone numbers Currently the CLA health team have 5 young people who have refused to have their health assessment's this equated to 1.7% DNA rate- 5 out of 302 health assessments. TheCLA Specialist Nurse has liaised with Social Workers, carers, birth families, health professionals and key workers to ascertain the young people's health needs. Written health questionnaires have been sent and 2 young people have planned face to face appointments A health questionnaire is sent to young people who DNA and refuse their health assessment. A health plan is produced from the questionnaire and shared with the Social Worker. To date we have received 4/5 questionnaires from young people. This method often opens the way to a telephone health assessment or a face to face assessment The CLA health team have now developed a health assessment decliner pathway Flexible Working With Young People who DNA or refuse Young person refused to attend for their IHA whilst living out of borough. Young person had periods of being missing from care. Specialist Nurse for CLA spoke with the young person and they agreed to complete a health questionnaire. Following completion the Specialist Nurse contacted the young person to discuss their responses and the young person agreed to a face to face assessment, which was completed by our Specialist Nurse. Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 439 of 490

114 9.4 Audits (and research) The CLA health team undertook our first client satisfaction to discover how CLA rate the health assessment service provided. This took place between May 2016 and August All CLA who attended for their appointment in Harrow were given the opportunity to provide feedback. Our criteria included all CLA, however if the child was not able to complete the questionnaire, their carer was asked to complete this on their behalf. In total 48 questionnaires were returned. This represented 25% of the total number of Harrow Children Looked After (191 average between May and August). The samples are representative of the total Harrow CLA population and cover both I HA and RHAs. Results show a high rate of satisfaction with 96% rating the health assessment as great or good. As part of our family and friends survey, 94% said they would "definitely" or "likely" recommend us to other LAC. Young people were asked if they felt that they were treated with respect of which 100% responded positively. As respect is a CNWL core value, this is an essential requirement for the service. CLA are encouraged to provide a comment in relation to their health assessment. 41 out of 48 wrote responses this equates to 85%. Some comments are shown below: Laurie spoke to me and I feel I am safe and I feel very good. My health assessment was very good she helped me. She spoke to me about my health and to many thanks to her Great and enjoyable It was an absolutely great. I am really happy with my assessment how it was It was good, I felt relaxed and didn't feel uncomfortable It was really helpful to update with my health assessment It was very good and very helpful It wasn't scary it was ok and gave me extra information It went great the lady was a good listener and supportive It went very well Useful and helpful I always feel listened to and informed by the health assessor Very good. Pleasant and very informative and overall pleasant Today was good, Laurie was really good It was brilliant and I was made to feel at ease very informative all my questions were answered to perfection. Lovely nurse It was really good, I have learned new things and made new decisions about my life and my health e.g. not eat chocolate that much It was great because I've learnt quite a lot about health and now I will run round the green and use a skipping rope and I will hoolahoop around the garden and stay fit and healthy. I have enjoyed it Learnt a few new things, was very helpful and useful The health assessment was good for me because I found it useful and informative Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 440 of 490

115 Comments made by Carers: Today's assessment went well. The doctor was very clear in her questioning and also gave us information in regards to her questions. I gain an understanding as to why certain questions were being asked and what I could be looking out for developmentally Health assessment, went very well gave a lot of information and support A child I care for was having a medical. Friendly and kind It was good my son actually completed it Emma was lovely and listened to me, and Alison gave advice when was needed This is the first Harrow CLA Audit completed by the CLA health team and findings have been positive. Results are good and staff are to be congratulated on this. We plan to re audit in September 2017 to compare this year's results Meeting with Dr Boullier (Child Public Health Registrar) and Dr Williams (Consultant Paediatrician) to discuss mapping of UASC and their health needs. We shared our UASC health needs audit and our health needs audit tool which they want to adapt and use for research across Harrow, Brent and Ealing Dip Sample A dip sample of IHA records taken from April July 2016 were looked at in terms of calculating the number of days taken to return the completed health assessment to Harrow Council. 43 records were included. 19 out of 43 (44%) of IHA's were completed and returned within 20 working days of child becoming looked after. 24 out of 43 (56%) of IHA's were completed and returned within 21 working days of child becoming looked after. 37 out of 43 (86%) of IHA's were completed and returned within 28 working days of child becoming looked after. 43 out of 43 (100%) of IHA's were completed and returned within 42 working days of child becoming looked after. The assessments taking the longest time to return, 38 and 42 days were from out of borough teams. Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 441 of 490

116 The following health needs audit was compiled from 12 months of data collected by the CLA health team. It includes the health needs for CLA living in Harrow and for Harrow children placed out of the borough. The focus is on the health needs highlighted during both initial and review health assessments. The greatest health need of Harrow's CLA is immunisations- which includes TB screening. Neighbouring boroughs including Hillingdon have a dedicated Immunisation Task Force that is commissioned for CLA and Camden has a Health Improvement Partner. These initiatives have led to consistently high rates of immunisations for CLA We implemented a TB referral process that ensured UASC were screened for TB and blood borne infections. This has currently been superseded by a recent NHSE directive. TheCLA health team is currently monitoring the impact that this is having on our UASC. The second highest health need is that of dental health-this incudes needing to register with a local dentist, dental checks, increase tooth brushing, braces, dental caries and fillings. This data reflects the national trend for CLA Substance use includes smoking and Cannabis use By far the largest majority of substance use amongst CLA is smoking and we need to look at more creative ways to engage young people in smoking cessation. There is a high prevalence of emotional health needs for CLA and good working protocols are in place with Morning Lane and CAMHS. Emotional health needs identified include attachment disorder, self-harm, low concentration, anger, sleep, bed wetting, PTSD, suicidal thoughts, anxiety, depression, panic attacks, low mood, and bullying. CHILDREN LOOKEDAFTER HEALTH NEEDS 2016/ 1 7 l'vt'llll<f).atic:f\s ':lh\-al f'eatr FYF f'=a Tf' \. J '>\TA'JF J\F ;r. 11!TI IY -r;rv r S<J'J OF!'FVS F."JT -!VOTIO.\Jt\1 I T/\ Tl OriVS(I'I NJ,JI?'I',..,, r: r;y ASTH.A,.o. w.ss;'\ic S\ICK.r-..c nni/wnjim n 1C'F f.i.fi'jt /\OJ.0.-x:JI\IITI\ ()(..)!!;l _Ll ' -- '/itn/i'j/dcc 1\CY - hbai- <1 CO.'J.J 1.01\' - U/\jJ/(..J 'f'..'j'\1\l - I<JT"SV;irRC::::. - -::I:CI- - IIL".U/\U 'L - lcfv:pu:.."><.r' l:.cl.:: / _(_Ji :Cc - _,.l.?cg'\ja, '\11 - (_()'\f.>i '/'1.01'\' - rlfi.nu ll.d:.fv I;HL::\,) 'r c;zzr,e Yre:: 10 IS 70 7S,. :;:r-; 40 4S 'JO s-: h':. {J'"i 70 7S F:O Fr: 9 1 9'i loci IO'i Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 442 of 490

117 9.5 Partnership working We held a one year celebration event at Harrow Civic Centre for all stakeholders in June which was really well received. This was shared on the CNWL website- news section The CLA health team have established and developed strong partnership working with a wide range of professionals and clients in order to maintain a high standard of care. Members of the CLA health team are actively involved in the following partnership roles: o Harrow CCG and Harrow Council o Corporate Parenting Managers quarterly meetings o Weekly monitoring Meetings with Harrow Council o Attendance at Social Work team meetings o Business Support Officers at Harrow Council o 'Beyond Limits' o Northwick Park Hospital A&E Liaison Health Visitor o Sexual Health Outreach Nurse o Head Teacher of Virtual School Morning Lane o CAMHS o CAMHSYOT o Health Visitors and School Nurses o Harrow GP's o Children's Participation Officer o Foster Carer Training and Development Officer o Harrow Council Learning and Development Officer o CORAM Partnership Team o o o o o o o Specialist Nurse for CLA attends monthly MASE meeting Specialist Nurse for CLA attends monthly Children At Risk Panel Attendance and initiation of strategy meetings and professional meetings for CLA both in Harrow and out of borough Helped Social Worker obtain CHAT (comprehensive health assessment tool) for young person on remand. Designated Nurse attended 10 year celebration of CORAM and Harrow Council partnership and TheCLA health team were thanked for their support. Designated Nurse and Designated Doctor met with CORAM Manager and Adoption Team Manager to confirm process for medical advice and adoption medical. CLA health team continue to meet with the Head Teacher of the Virtual School, CLA Team Manager and YOT CAMHS Nurse on a 6-8 weekly basis The Specialist Nurse for CLA has liaised with the Brent and Ealing CLA health teams as part of the Tri- Borough to look at closer partnership working. TheCLA health team have not had the capacity to arrange meetings with colleagues in Milton Keynes this year. There is some overlap of work with Camden during safeguarding meetings and processes are being reviewed to ensure the safety of electronic adoption records Joint working and sharing of learning between the Harrow CLA health team and the Hillingdon LAC health team. Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 443 of 490

118 9.6 Feedback Feedback from Partners including: Thank you received from one of the I RO's regarding sharing of health assessment information. Thank you received from CORAM- Harrow Adoption Partnership Manager in helping to prevent an adoptive placement breakdown for a Harrow child placed OOB. 'Very helpful for children to let their feelings and emotions loose' (Social Worker) I have noticed a remarkable change in how the CLA health team works since Emma and Laurie came into post. They are easy to reach and keen to flexible to make it easier for the young people to engage with them. In the last year we have set up a monthly meeting between Laurie from CLA health and YOT health staff. This is improving how we support the health needs of our young people. Laurie's enthusiasm for trying new ideas has greatly assisted in establishing this project. (Specialist Nurse YOT Harrow CAMHS) Again!!! Wow. What can I say. Working with you guys has tremendously improved the health outcomes for our looked after children. Your work and involvement has continued to support the team work with their young people in relation to their health needs and concerns. Young people are more confident in approaching Social Workers and requesting appointments/ consultations with yourselves due to your approachable nature and professionalism. You are always available, informative and helpful with advice and support. Thank you very much. This year like the last has been GREAT. (Pam Johnson, CLA Team Manager) The service over the past 2 years has been excellent. The CLA Nurses have been very proactive and persistent in engaging with Looked After Children and Care Leavers. This has included going to the homes of young people reluctant to attend clinics and being very accessible and available. Emma and Laurie have managed to build up trust and provided advice and support over a range of health issues. They have also built up positive working relationships with the social work teams and staff to ensure very strong joint working on cases. Emma and Laurie have offered regular advice and support to social workers, foster carers and young people and their families (Peter Tolley Head of Service Corporate Parenting) The CLA Health team are invaluable in the matching process of adoption. They have provided an excellent service over the last year and all of the children that have been placed for adoption have benefitted. They are always really helpful in giving the team advice on medical matters for the children and prospective adopters that we work with. They are easy to contact and always reply to messages and phone calls. In addition to this the CLA health team have gone the extra mile and facilitated meetings with Hospital doctor's and consultants where the child has had additional health needs. Overall we feel that we have had an outstanding service which we very much appreciate. (The Coram Harrow Partnership Team) Annual Report- Children Looked After Health Serv1ce (Harrow) 2016/17 25th August Page 444 of 490

119 9.6.2 Feedback from birth parents, carers and key workers 'Very good and helpful' (Birth Mother) 'A very good assessment with lots of actions/outcomes. Warm, calm approach. Engaged a very difficult young person. X was thinking about things and considering different services and support. A great session" (Key Worker) 'The nurse was very helpful and spoke to me and my granddaughter very kindly' (Grandparent) 'I think the looked after nurse service has improved considerably since Laurie has taken on the cases of the children in my care. I believe the service is comprehensive and shows that she is in tune with the complete health of the children that she works with. I am pleased with this service and hope it continues' (Carer) 'Emma was lovely and listened to me and also gave advice when needed' (Carer of 2 year old) 'I think the assessment went really well. I'm happy with the assessment' (Grandmother) 'Everything went well' (Carer) 'Very interesting and helpful service for X as he learnt not only new things but more about himself too' (Carer) 'It went very well' (Carer) 'Very good pleasant and informative' (Carer) Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 445 of 490

120 9.7 Inspection Updates An OFSTED inspection of services for children in need of help and protection, children looked after and care leavers and a review of the effectiveness of the Local Safeguarding Children Board occurred during January and February Involvement of the CLA health team included: Preparation work undertaken. Designated Nurse and Specialist Nurse for CLA based themselves at Harrow Civic Centre during the inspection. Specialist Nurse for CLA attended FGM meeting. Production of case study regarding health input to CLA who had undergone FGM in her home country. Specialist Nurse asked by young person's Social Worker to discuss case with OFSTED inspector and highlighted good practice and partnership between the CLA health team and Harrow Council. Designated Nurse, Specialist Nurse and Designated Doctor had a 2 hour interview with OFSTED inspector. In 2012 OFSTED rated the health of Children Looked After as 'inadequate'. CNWL took over the service in June 2015 and in 2017 OFSTED have rated CLA, care leavers, adoption and leadership as "good". The recent OFSTED inspection in relation to health stated that: 'Children's health needs receive significant oversight and monitoring from the children looked after health service and as a result, their health outcomes continue to improve'. The report highlighted strong partnership working, information sharing, effective tracking systems and communication as well as children's involvement being pivotal to this success. All of these areas were criticisms in the previous inspection. Other areas of positive work include children's needs being identified quickly, active monitoring of the health needs of children placed out of the local authority, improvements in timescales for completion of initial and review health assessments, improvements in completion of SDQ's, attendance at strategy meetings and the development of health passports. All of these areas were again criticisms in the previous inspection. 'During our recent Ofsted inspection (January 2017) the inspectors were very positive about the CLA Health service and their positive impact on young people.' (Peter Tolley, Head of Service Corporate Parenting') A recommendation regarding health was made to 'ensure that children looked after receive timely therapeutic support when they need it.' Harrow CCG and Harrow Council have identified the emotional health needs of CLA as a priority in the redesign of mental health services for Harrow. The CLA health team attended the 'Future In Mind' workshop and raised CLA as a priority and we will ensure that we work closely with the new service provider Information regarding YOT sent to Harrow Council for planning for future YOT OFSTED inspection Information from Hillingdon SEND OFSTED inspection shared with Harrow Council and HarrowCCG for future planning. Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 446 of 490

121 9.8 Professional Development During 2016/17 the CLA health team have continued to ensure that team members have attended training in order to ensure safety and compliance with the knowledge, skills and competencies outlined in guidance for health staff (RCN, RCPCH March 2015) Staff have undergone a range of training sessions including the following training: Mandatory training- CNWL North West London LAC peer review group RCN National Conference for CLA Nurses Designated Professionals Updates- Brent Harrow and Hillingdon CCG Team Away day to discuss CQC, health recommendations and adoption processes- CNWL GPwSI attended Adult Health Assessment Training- Coram BAAF GPwSI attended Child Refugees course- RCPCH Specialist Nurse for CLA attended Afghanistan awareness study day- MIND Harrow Frameworki training- Harrow Council Designated Nurse attended Safeguarding CLA conference - Health Safeguarding Designated Nurse attended fostering and adoption panel training- West London Consortium Specialist Nurse for CLA attended Advanced Domestic and Sexual Violence study day- HSCB Specialist Nurse for CLA completed a 3 month course Understanding The Emotional Needs of Care Leavers- Tavistock and Portman Hospital 9.9 New Processes TheCLA health team have set up new processes based on those already established within the Hillingdon LAC team. This shared learning and support has been invaluable and has contributed to the Harrow CLA health team's success. Request for adoption and medical advice process has now been implemented. SDQ process has been implemented. Medical surnrnary for all CLA is now requested for all CLA from GP's both in and out of the borough of Harrow. Reminder system established should requests not be made in timescales. Meeting with Senior Performance Analyst and Business Information Partner at Harrow Council to agree monitoring process for immunisations, dental checks and developmental assessments. Meeting with CNWL Performance and Information Analyst to amend spreadsheets for data collection. Specialist Nurse for CLA has set up a peer group for the CLA Nurses in Harrow and Hillingdon to discuss complex and safeguarding cases. Carer's information form developed to obtain health information from the carers of CLA to input into their health assessments. This is also working well for non-attenders as well as monitoring CLA who live OOB. Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 447 of 490

122 Meeting with Liaison Health Visitor for Hillingdon Hospital to agree process of sending A&E and UCC attendances of Harrow CLA directly to our team rather than via the Liaison Health Visitor at Northwick Park Hospital to enable better communication. 10 Priorities for2017/18 The following have been identified as areas for local improvement within 2017/18: To continue to work with managers in Harrow Couneil to improve the timely requests for initial and review health assessments To ensure that all health assessments are completed within agreed timescales To review quality of completed health assessments To work towards the implementation of the new KPI's to recognise requirements within statutory guidance - Designated professionals to ensure quality is maintained To continue to liaise with the commissioners in Harrow CCG and Harrow Council about obstacles to the provider meeting KPI's Work with Beyond Limits (Harrow Council Children Looked After Council) on a variety of initiatives such as care Ieaver services to inform service delivery To fully implement care Ieaver health passports To explore sharing of information between IT systems To work with Harrow Council to implement process for requesting AH forms electronically. To work with Harrow Council and Harrow CCG to improve the uptake of immunisations for CLA To work with Harrow Council to ensure that SDQ's are received with health assessment referrals. To undertake a project to ascertain the impact of the new TB referral process for UASC To undertake a client satisfaction survey Emma Hedley Designated Nurse CLA Individuals from the CLA Harrow health team have contributed to this report. Thank you to the Hillingdon LAC health team for their continued support. Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 448 of 490

123 Appendix 1 Abbreviation ADM APR/ASP CAMHS CCG CLA ChiMat CNWL CPR CQC CSE DCSF DfE DNA DoH ED FGM GOP GLA GP/ GPwSI HSCB IHA IRO KLOE's KPI LAC LADO LBH MASE MRI NHSE NICE NIS OOB PA's PAR RCPCH, RCN AND RCGP RHA SDQ SLA TB UASC ucc Glossary of Terms Meaning AQency Decision Maker Adoption Placement Report I Adoption Support Plan Child and adolescent mental health services Clinical Commissioning Group Children Looked After Child and Maternal Health Observatory Central and North West London NHS Foundation Trust Child Permanence Report Care Quality Commission Child Sexual Exploitation Department for Children, Schools and Families Department for Education Did Not Attend Department of Health Emergency Department Female Genital Mutilation General Dental Practitioner Greater London Authority General Practitioner/ General Practitioner with Special Interest Harrow Safeguarding Children Board Initial Health Assessment Independent ReviewinQ Officer Key Lines of Enquiry Key Performance Indicators Looked After Children Local Authority Designated Officer London Borough of Harrow Multi -Agency Sexual Exploitation Magnetic Resonance Imaging NHS England National Institute for Health and Care Excellence National Indicator Set Out of Borouqh Programmed Activities Prospective Adopter's Report Royal College of Paediatrics and Child Health, Royal College of Nursing and Royal ColleQe of General Practitioners Review Health Assessment Strengths and Difficulties Questionnaire Service Level Aqreement Tuberculosis Unaccompanied Asylum Seeking Children Urgent Care Centre Youth Offending Team YOT Appendix 2 CLA Annual Health report 2015/16 lid }- Harrow CLA Annual Health Report 2016 F Annual Report- Children Looked After Health Service (Harrow) 2016/17 25th August Page 449 of 490

124 milton keynes council Central and North West London NHS Foundat O"' Trust Milton Keynes Community Health Services Milton Keynes Clinical Commissioning Group Milton Keynes Annual Report on the Health of Children in Care 1April March 2017 Report compiled by: Carol Baines- Named Nurse Children in Care In conjunction with: Dr Adeola Vaughan- Designated Doctor for Children in Care Andrea Piggott- Designated Nurse, Safeguarding Children and Children In Care 1 Page 450 of 490

125 Annual Report 2016/17 CIC Health Service (Milton-Keynes) CONTENTS Section 1 Executive Summary 2 Local demographic data 2.1 Demographic information (Graph 1} 2.2 National CIC data 2.3 Milton Keynes local statistics (numbers, age, gender, duration of care,ethnicity, placement type} 3 Service Summary 3.1 Staffing Supervision and peer review r ' < 3.3 Governance and reporting arrangements I [ 4 Performance Indicators I 4.1 National targets 4.2 Local statutory performance against national data 5 CIC Team Clinical Activity 5.1 Health Assessments Graph 4,Graph 5,Graph lmmunisations! 5.3 Dental Checks 5.4 Registration with GP I 2 Page 451 of 490 ' I I \ I 6 Other Clinical Activity I \ \ I I 6.1 Sexual Health.r \ \ 6.2 Teenage Pregnancies \ ',. I - \.., '---._.1 _ Substance Misuse 6.4 Emotional Health & Wellbeing 6.5 Health improvement activities (Appendix 1} 6.6 Overweight/obesity 6.7 Unaccompanied asylum seeking children 6.8 Sleep 6.9 Care leavers (Appendix 2} 6.10 Other complex case work 7 Adoption & Fostering 8 Training 9 Service Improvements 9.1 Other specific improvements 9.2 Audits 9.3 Partnership working 9.4 User surveys 9.5 Inspection Updates 9.6 Professional development (and publications} 9.7 Committee work 10 Priorities for 2016/17 Appendix 1 Health Improvement Activities Page

126 Appendix2 Care Leavers Health Record Format 3 Page 451 of 490

127 Section 1Executive Summary I am pleased to present the Eighth Annual Health Report; an overview of the statutory health services provided to Milton Keynes Children in Care (CIC) from April 2016 to March The report provides assurance to our stakeholders including Milton Keynes Clinical Commissioning Group and Milton Keynes Council that Central and North West London Milton Keynes NHS Trust (CNWL-MK) are compliant with National Guidance; the Statutory Guidance on Promoting the Health and Well-being of Children In Care (DCSF&DH 2015) and NICE guidance: Promoting the quality of life of Children In Care and young people (2010). The vulnerability of children and young people in the care system is widely recognised both locally and nationally. Abuse and neglect remain the main reason why children come into the care of the local authority. Developmental issues particularly speech and language delay remain the most common health related problem in children under the age of five years and emotional health and behavioural difficulties in the older age group. The Saturday clinics continue to be run successfully. However due to the significant increase in the number of health assessments week day clinics have been introduced. The service continues to strive to retain flexibility in clinic appointments within the challenge of ensuring compliance with statutory timescales. The increase in both the numbers of children and young person's coming into care and complexity of cases continue to put pressure on service delivery. Despite the challenges our performance indicators continue to compare favourably with national figures and our statistical neighbours. During the year we had both CQC and Ofsted inspections. The inspection highlighted many aspects of very good practice as well as some areas where health services could make improvements. A joint action plan is being progressed with all our partners. It has been a very busy but rewarding year. There is still more to do and we are proud of the joint working culture between all our partner agencies. We plan to strengthen existing partnerships, and develop new relationship all to ensure the health needs of Children In Care are met. We look forward to the coming year. we will continue to do our best to deliver high quality health service, achieve our performance indicators, promote the 'voice of the child' and be strong advocates for children and young people in care. Dr Adeola Vaughan Consultant Community Paediatrician Designated Doctor for Children In Care Of Note: The term 'Children In Care' (CIC), 'Children Looked After' (CLA) and 'Children in Care' (CIC) are all used to refer to children who are placed into the care system. The term 'Children In Care' is currently used within statutory and government documents. However, all terms may be used interchangeably. Within this annual report for Milton Keynes we use the term Children In Care. 3 Page 452 of 490

128 Section Milton Keynes Demographic Information: (Statistics provided by MK Planning and Transport Service Group June 2017} Milton Keynes Population Projections (Milton Keynes Population Bulletin } 100% r "c ' 0 "' "' -10!110 Graph 1:Cumulative Population Change since 2013 in Milton Keynes Key Points from the Population Projections: The Milton Keynes population is growing in size and diversity. It was one of the fastest growing UK cities between 2005 and 2015, expanding by 17.1per cent {Office for National Statistics, Mid-year population estimates,2005 and 2015 data}. In 2017, the estimated population of Milton Keynes Borough will be 268,029.The population is expected to rise by around 15.1% from 268,029 to 308,498 by School Age Population 5-16 year aids: Milton-Keynes is more ethnically diverse than the England average and within the school population the percentage of children from black or minority ethnic heritage is 39.3%. {MK School Census 2016}.The school age population is projected to be around 45,116 in The population is projected to rise by around 16.5% from 45,116 to 52,550 by It has a relatively youthful population with 2017 figures showing the under 16 age group estimated at 24.2%. The average age of population is 34.5 years, compared to an average age of 50 years in England. {Milton Keynes Population Bulletin }. 4 Page 453 of 490

129 MKAge range ( ): Early Year's- 0 to 4 Year olds- projected to remain at a consistent level of around 20,000. School Age Population - 5 to 16 year olds - projected to rise by 16.5% from 45,116 to 52,550 by Young Adults -17 to 24 year olds- projected to rise from 21,475 in 2017 to 23,795 in With the population growing within Milton-Keynes the above projections are key for Milton Keynes Children's Social care (MK-CSC} in terms of future planning and provision of services. 2.2 NationalChildren In Care data: (Department of Education National Statistics 2016) National Children In Care data: (Department of Education National Statistics 2016) As of 31st March 2016 there were children in the care of local authorities in England compared to a figure of in Looking at figures over the last 5 years there has been an increase of 4940 (7.5%}. Ages and male/female ratio of children in care: Of the figure, 39,670 (56%} were males and 30,780 (44%} were females. 5% of children were under 1 year old, 13% were between 1 and 4 years old, 20% were between 5 and 9 years old,39% were between 10 and 15 years old and 23% were aged 16 and over. The reasons why children start to be looked after have remained very stable; Absent Parenting has increased from 8% to 12%, this is due to an increase in Unaccompanied Asylum Seeking Children who fall into this Category. The majority of Children In Care in 2016 started to be looked after due to abuse or neglect (54%} Commencing Children in Care status: A total of 32,050 children became children in care during the year ending 31st March This is an increase of 2.3% from the previous year's figure of 31,340 and an increase of 12.9 from In 2016 there was a small decrease in the number of children aged 9 and under. The percentage of children aged 10 to 15 decreased from 31% in 2011 to 29% in The number aged 16 and over has increased steadily each year since In 2015, 18% were aged 16 and over, compared with 12% in Page 454 of 490

130 Ceasing Child in Care status: The number of children ceasing 'child in care' status has increased over the past five years; however the increase from 2015 to 2016 was very small. 31,710 children ceased 'child in care' status during the year ending 31't March 2016, an increase of 1% from the previous year's figure of 31,320 and an increase of 17% from In 2015, 7,830 children aged 1-4 years ceased to be 'child in care' status. The percentage of 1-4 year olds dropped from 27% in 2015 to 25%. The percentage of children who ceased 'child in care' status when they were 18 years old has remained fairly stable since In 2015 there were 7,970 children who ceased 'child in care' status when they were 18 years old. This represents 25% of all children ceasing to be a 'child in care'. Unaccompanied Asylum Seeking Children: Of the 70,440 children in care, 4,210 (6%} were unaccompanied asylum seeking children.the number of unaccompanied asylum seeking children increased by 34% between 2014 and 2015 and 54% between 2015 and A higher percentage was boys (90%} with 74% reported to be aged 16 and over. 2.3 Milton-Keynes Children In Care Statistics: (Statistics supplied by Performance Management Team Children's Social Care) There were 540 children in the care of Milton Keynes Local Authority at some point in the period in comparison to last year's figure of 523. This indicates an increase of 17 cases (3.2%} and an increase of 69 cases (13.6%} since 2015.This figure fluctuates month by month as children and young people come into care but then may leave depending on individual need and circumstance. The number of children continuously looked after by Milton Keynes Children's Social Care for 12 months or on 31/3/17: Total: 255. Data indicates a significant rise of 35 cases (16%} when compared to last year's figure of 220. The number of children in the care of Milton Keynes local Authority as on 3Pt March 2017: Total: 395. Data indicates a significant rise of 50 cases (14.5%} when compared to last year's figure of 345. There have been several large siblings groups that have been brought into care and this has had a level of impact on total figures of children needing CIC status. 6 Page 455 of 490

131 Rates of Children In Care: s c ::J cu n0 E s;: z Mar 2015 Mar 2016 Mar Number of Milton Keynes LAC - Rate per 10,000 England - Rate per 10,000 South East Region - Rate per 10,000 Milton Keynes - Rate per 10,000 Statistical Neighbours td - Graph 2: Numbers and Rates of Children In Care Captured ( ) This indicates the rate per 10,000 children and young people in the care of Milton Keynes Local Authority (age 0-17} has reached the current recorded rate (2015/2016} for our Statistical Neighbours and England. Compared to national data and our statistical neighbours, the number of children in care is below average although slightly higher than the average in the south East. NB: The statistics for England, South East and our Statistical Neighbours have yet to be reported on for 2016/2017 so they may have experienced a similar increase. Age and Gender: Under1 22 (5.5%} 1-4 year's 56 (14%} 5-9 year's 73 (18.5%} year's 153 (39%} 16/17 year's 91(23%} Gender split: Males/Females ratio: 233/162 The age distribution of Milton Keynes Children In Care (MK-CSC} is comparable to national data. The smallest number of children continues to be within the under 5 age group. The clear majority remains within the 10-15year age group. The overall picture of causes for why children become looked after remains fairly consistent. 7 Page 456 of 490

132 Causes for children becoming looked after by Milton Keynes LocalAuthority: CATEGORY OF NEED FOR CHILDREN LOOKED AFTER AT 31MARCH 2017 Abuse or neglect 163 Disability 42 Parental illness or disability 30 Family in acute stress 58 Family dysfunction 53 Socially unacceptable behaviour 7 Low income 2 (Includes UASC} Absent parenting 40 TOTAL: 395 It must also be recognised that most cases have more than one cause for being in care. Ethnicity breakdown for CIC as of March 31st 2017 CYP Grou[2 A - White Background B - Mixed Background c - Asian Background D - Black Background E - Other L Not Available MKC 0-19* 67.0% 8.0% 12.0% 12.0% 1.0% CIC 65.4% 10.3% 6.9% 10.1% 7.4% There is a clear dip in CIC from an Asian background when looking at the MKC population as a whole. The increase in 'Other' Ethnicities in CIC is in the main due to Unaccompanied Asylum Seekers who continue to be supported as CIC. Distance of Geographical Placements: Children in Care Placement figures for in and out of Milton Keynes (April 2016-April 2017). 41U Jb() Distance of placements from MK9 3HS in miles 310 lw llo M ar-lg Jun-lG Sep-lG Dec-IG Ma r-17 - less than 20 miles miles miles -101miles and over - % 0-20 miles -+-Number of LAC Graph 3: This shows children and young people in the care of MK-CSC are predominantly placed in and around the Milton Keynes area within a 20 mile radius. A small proportion of children are placed between 8 Page 457 of 490

133 21-50 miles and miles out with Milton Keynes. The smallest number placed 101miles and over. When comparing to other local authorities, Milton Keynes does not have a significantly greater number of distant placement. Many of these placements are for positive reasons such as an adoption or being with a family member. There may be safeguarding and risk management issues identified indicating an out of area placement is needed or a child/young person may need to access specialist provision to meet a complex need. Children and young people with disabilities: There are currently 18 children/young people who are CIC and who are cared for within a specialist team- The 'Children With Disabilities Team' (CWD}. This team works exclusively with children who have profound and significant learning and/or physical disabilities or life threatening illnesses and their families. They offer advice, guidance, signposting and support working in partnership with families and other professionals to safeguard all children and promote their well-being. If a child/young person with complex disabilities becomes a CIC, they will require their health needs to be assessed in an Initial Health Assessment and thereafter to have a RHA in accordance with statutory guidance. The health team and the CWD are acutely aware this is a highly vulnerable group. Placements for these children may include highly specialist units, residential schools and foster care. On-going parental involvement may be central to the child's world and that of their family, depending on individual circumstance and as such they may be involved in the health assessment process. These children will also have a range of named professionals involved in their health care on an ongoing basis. The CIC Nurses are acutely aware of the importance of effective assessment avoiding duplication and over assessment for the child. Information and medical reports are gathered to assist the assessment and also ensuring the voice of the child is central to that process. Number of CIC for 12 months or more and type of placement: (As of March 31't 2017} Total children/young people placed with foster carers: 195. This is an increase of 29 from last year's total of166. Total children/young people requiring support placed in residential children's home: 28. This is an increase of 7 from last year's total of 21. Total children/young people placed with a parent: 9.This is a decrease of 2 from last year's figure of 11. Total children/young people placed for adoption: 2.This is a decrease of 4 from last year's figure of 6. Total children/young people placed in residential school/residential setting: 18. This is an increase of 8 from last year's figure of 10. Total young people placed in supported living: 18. This is an increase of 12 young people from last year's figure of 6. Service Summary 3.1 Staffing The Children In Care Health Team is made up as follows: Designated Doctor The Designated Doctor is a Consultant Community Paediatrician employed by Central and North West London- Milton Keynes (CNWL-MK} and commissioned by Milton Keynes Clinical 9 Page 458 of 490

134 Commissioning Group (MK-CCG} to deliver the role and function of the Designated Doctor. This role combines operational and strategic responsibility for children in the care of Milton Keynes local authority allowing both CNWL- MK and MK-CCG to deliver on its responsibilities to children in care in Milton Keynes. The post holder is also the Medical Advisor for Adoption and Fostering, managing these roles along with other responsibilities within a full time paediatric neurodisability post. All the doctors in the team are involved in the provision of clinical services for children in care. Regular training is provided to ensure consistency in service provision. Designated Nurse The Designated Nurse is employed by MK-CCG and also undertakes the role of Designated Nurse for Safeguarding Children. The Designated Nurse for CIC works alongside the Designated Doctor to assist MK-CCG in effectively fulfilling its role as a commissioner of services to improve and monitor the health of all children in the care of Milton Keynes Local Authority. Named Nurse for Children In Care The Named Nurse CIC post is jointly funded by CNWL-MK and MK-CSC as a full time position. This is predominantly a strategic role, working to develop, implement and monitor local policy within CNWL-MK and MK-CSC,in line with national policy and guidelines. This post is based within MK-CSC. Specialist Nurse for Children In Care The Specialist CIC Nurse is employed by CNWL-MK and is a full time position. This is her 7th year working in and developing this role. The Specialist CIC Nurse completes review health assessments for children in the care of Milton Keynes Authority above the age of 5 year's. One significant advantage of this role is that review health assessments are completed by the same nurse promoting consistency for the child/young person and their carer and instilling a sense of security with the health assessment process. For children placed a significant distance from Milton Keynes, an 'Out of Area' request for a local CIC Team to complete the assessment, is made. The Specialist CIC Nurse will travel a distance of up to 2 hours to assess a MK child placed out of area. This post is based within MK-CSC. Administration It is a complex task to track the volume of children entering and leaving the care system and ensuring assessments take place within statutory guidelines. Administration for the CIC team has been jointly reviewed this reporting year by CNWL-MK and MK-CSC. Business Support CIC has been increased by MK-CSC and the post is now full time. The complexity of working across CNWL Health systems, Out of Area health systems and CSC systems has been further recognised. Ensuring paperwork is co-ordinated across services and various electronic systems adhering to statutory timescales and ensuring confidentiality is recognised as a complex and fragmented task. In addition, Out of Area Assessment requests to and from other health authorities, is extremely time consuming. Administration for the Community Paediatric Clinic is funded by CNWL-MK for 12 hours per week. This post is based at CNWL-MK Trust Head Quarters. In light of the increase in children coming into care and as such requiring a health assessment, this does affect the pressure not just on health but also on administrative staff. 10 Page 459 of 490

135 3.2 Supervision Arrangements: Health Team Supervision Meetings The Named CIC Nurse is managed and supervised by the CNWL-MK Named Nurse for Child Protection. The Named Nurse and Specialist Nurse meet regularly for individual supervision providing an opportunity to consider individual cases, management of case-loads and practice issues. The Designated Nurse for CIC also meets regularly with the Named Nurse providing the opportunity to consider service provision and wider issues relating to the CIC service. Once a month there is a whole team meeting with Designated Professionals, Named and Specialist Nurse to consider system wide partnership developments and to monitor quality assurance. Effective liaison between services and enhancing good practice spanning all areas of health for children in care is paramount. The relationship and communication process between CIC Nurses and the Community Paediatricians in Milton Keynes is very well established. Weekly meetings are held between the CIC Nurses with the Designated Doctor to review and discuss assessments which have taken place at the Community Paediatric Clinics and as part of overall quality assurance for health assessments within the team. These meetings also offer a supervision forum to discuss individual cases, practice issues and service development. Cases discussed are documented and scanned to Systm1and LCS. The Designated Doctor is member of the BAAF health group and the forum allows for valuable peer support and discussion. Social workers have direct access to medical advice from the CIC Health Team. The nurses also have the advantage of being able to discuss individual cases with the child's social worker as they are based within their team and can attend strategy meetings when required. Close joint working between the Health Team and the Head of Delivery of Corporate Parenting is well embedded promoting joint discussion and liaison through the Health and Social Care Forum to promote the health needs of children in the care of Milton Keynes Local Authority. The Milton Keynes Safeguarding Team including Milton-Keynes Children's Social Care (MK-CSC), the Police Child Abuse Unit, Schools and all other partnership agencies work closely together assessing risk and quickly noticing warning signs relating to safeguarding and identifying children at risk 3.3 Governance and Reporting Arrangements: CNWL-MK is a member of the Milton Keynes Children and Family Partnership and the Milton Keynes Safeguarding Board. There is a strong and consistent leadership commitment to ensure the health needs of children in care are being met. The Associate Director of Children's Health Services is the lead for safeguarding and for Children In Care. This promotes consistency and joint working across fundamental key areas within children's health services. CNWL Divisional Safeguarding Governance sub-group: The governance arrangements consist of a joint adult and children Divisional Safeguarding Governance sub-group which meets on a quarterly basis and is chaired by CNWL-MK Divisional Nursing Director. The group reports to the CNWL Board via the Divisional Quality Forum and provides assurance to the Trust Quarterly Safeguarding Group Meeting. The purpose of the sub group is to monitor safeguarding activity in the division, approve and ratify relevant documents and papers, share lessons learnt and assess, review and monitor safeguarding risks for the division. This remit includes ensuring that the division complies with the CIC agenda. The performance of IHAs and RHAs is also reported monthly on a Milton Keynes CCG Safeguarding Dashboard which is reviewed by the 11 Page 460 of 490

136 sub group and submitted to the MK-CCG on a quarterly basis. This process ensures practice is monitored, statutory timeframes are being achieved and any potential difficulties hindering this highlighted. Corporate Parenting Panel The Corporate Parenting Panel (CPP} is an all-party council members panel whose purpose is to act as parent to all the children and young people who are in the care of Milton Keynes Council and to ensure that the Council's and its partner agencies deliver on its pledge to children in care. The CPP raises awareness of the needs of children in care across the council and its partners and seeks to encourage the development of local resources to meet the needs of children in care. The CPP panel meets 5 times a year and will call on officers and partners to provide information and reports on progress, in accord with its annual work plan in including those relating to meeting the Health needs. The CPP itself report on an annual basis to the CYP Select Committee, Full Council and Children and Family partnership. 4 Performance Indicators 4.1 National Targets/Statutory requirements: Milton Keynes Local Authority sends statutory statistics to the department of health and education (DfE}. DfE will publish their first national statistical release in September Statistics compiled and reported on for children in care are: The number of Initial Health Assessments completed within 28 days of the child/young person coming into care. The number of Review Health Assessments completed every 6 months for children below 5 years of age. The number of Review Health Assessments completed on an annual basis for all children/young people 5 year's up to 18 years of age. The number of children below the age of 5 years with developmental check completed on a 6 monthly basis. The number of children registered with a dentist. The number of children/young people fully immunised in line with the national immunisation schedule. The number of children /young people between the ages of 4 years and 17 years with an SDQ completed. 5 CIC Team Clinical Activity Relating to Health Assessments for CIC: The Local Authority (LA} is responsible for ensuring that arrangements are in place to carry out all health assessments within the statutory timescales. The CIC health team is responsible for the completion of statutory health assessments. Both agencies work closely together to ensure every child has a timely and up to date assessment. Milton Keynes is a unitary authority with one hospital and one community health provider CNWL-MK. This has the advantage of the community paediatric team using the same medical records system as the hospital, therefore not experiencing the frustration experienced by health providers in other local authorities where there are multiple medical record systems leading to gaps in medical information. The CIC Nurses input health assessment data onto the council electronic recording system LCS- Liquid Logic. Specific data is recorded to monitor health assessment performance and ensure children's 12 Page 461 of 490

137 health needs are effectively outcomed. Close and timely communication with all health and relevant professionals is crucial and as such a full copy of the health assessment is also scanned onto the hospital electronic record system (EDM} if a child is under the care of any specialist health provision. The full assessment is also scanned to the community health electronic record system Systmone as well as to LCS for direct access by the social care team. We also ensure a copy is sent to the child/young person's GP as central record holder. A copy of the health care plan is sent to carers and the young person themselves if age appropriate. 5.1 Initial Health Assessment (IHA) Process: Assessment Clinics exclusively for our children in care have run on a Saturday morning and have been based at the Children's Development Centre at Milton Keynes Hospital. This reporting year double clinics have increased to meet the demand of the increase in CIC and clinics are also now being run midweek. All Initial Health Assessments are completed by the Community Paediatric Team. The first assessment should be undertaken by a registered medical practitioner in accordance with the Children Act (Miscellaneous Amendments} (England} Regulations The framework used for health assessment completion is the British Association for Adoption and Fostering (BAAF} electronic form. In Milton Keynes the community paediatric team has seen all children below the age of 5 for their statutory 6 monthly reviews. This is in recognition of the complexity of medical conditions that could arise in the younger age group. This also has the advantage that should an adoption medical be required a separate appointment is not required, reducing the frequency of medical appointments. The health assessment should not be seen as an isolated event but part of a continuous process reviewing and monitoring the health needs of every child and young person in care. Initial Health Assessments completed in 28 day statutory timescale: Initial Health Assessments completed in ZS day statutory timescale No. of IHAs due in month No. of IHAs completed in month % completed within timescale ':>I '> "' <O <O <O <O \) '\ '\ '\ r:,"> c;:,">' c;:,">' c;:,"> "'"','V, "'"'._,e"' _ 0()--0 e \"'<:' "'"' e<"', <:"'"C <:"'V "?-"'. '!'>"' ">"' '<) "'»"'.J;-. "'"' 0 <::>"'"' '<"' "'"' <5' "'"' Graph 4: This highlights number of Initial Health Assessments due each month following admission into care. Total due: Page 462 of 490

138 Number completed within 28 calendar days statutory timescale: 108= 62% This equates to a 3% decrease as compared to last year's total of 65% Factors impacting on delay of 66 cases: Consent not received in reasonable timescale: (average used over 7 days after CIC status) Impacting on 28 cases Out of area request over which we have no control: Impacting on 4 cases Placement moves: Impacting on 8 cases Total DNA appointment's offered: Impacting on 3 cases Carers unable to attend agreed appointment: Impacting on 2 cases Baby/child/young person in hospital at time of appointment: 4 ICO required: 4 No notification of when CIC status commenced: 8 Young person missing from care: 3 Capacity of clinic: 5 Analysis of delay: It should be noted there is a significant increase in the cohort of children entering and leaving the care system in the last reporting year. (See section 2.3}. Some children are made CIC status for safeguarding reasons and then leave care again before there is an opportunity to have an IHA. It should also be noted cases can be affected by more than one factor impacting on the overall delay. There have been some highly complex cases; one involved a family of 3 siblings, where the local authority had obtained an Interim Care Order through the courts. These cases were known to health and as such,an impact on timeliness was predicted. Obtaining consent remains the highest factor in delay. The complexity of individual cases and additional pressures affecting obtaining consent is recognised, such as refusal of parental/young person engagement. However, this would not account for the significant figures affected due to late consent. In the month of November out of 13 I HAs due, only four were completed in timescale. In two cases consent was not obtained until day Page 463 of 490

139 In the month of December, in one particular case consent was not obtained until day 42, despite repeating escalation and the health team going directly to the SW on two occasions. These levels of delay must be avoided. In the month of January out of 11 IHAs due, only one was completed in timescale. In nine cases consents incurred excessive delay and in nine cases, consent was not obtained until day Reviewing the process of obtaining consent promptly has been a core part of our work through the year. There were a total of 12 unaccompanied asylum seekers who required a process of age assessment. This can be a lengthy process and can lead to delay in progressing I HA. There were a total of eight out of area requests for Milton Keynes children over which we have little control. When a request for completion has gone to a different local authority because of geographical distance we have limited influence of timescale. Placement moves in complex cases are sometimes necessary for the child part way through the process. This will add to delay but is unavoidable. We must recognise every child's needs are assessed fully by MK-CSC and placement will only change after careful consideration. There were a total of 3 young people who missed their booked appointment. 2 related to carers not bringing them as agreed, 1 was a young person who required a mental health assessment and was subsequently admitted to a specialist unit. In five cases,capacity of clinic was an issue due to demand, and this took the timescale just outside the 28 days. CIC Nurse went to see one young person in placement due to the complexity of her presentation, which meant she was unable to attend an assessment in clinic. Consideration of how to complete an effective assessment must be given in individual cases, particularly of young people hard to engage. The complexity of this case was known by the Designated Doctor. IHAs are all quality assured by the Designated Doctor. There is a robust process where Health Administration notifies the Named Nurse CIC when appointments are missed. The Social Worker of that case is then informed. Obtaining parental consent for the Initial Health Assessment: In order to meet statutory timescales, co-ordinate,complete and process assessments, we aimed to have paperwork, including parental consent received from the SW for the assessment within 3 days of CIC status. The responsibility of obtaining consent and sending all paperwork required for the Consultant Paediatrician to complete an IHA for a child brought into care, lies with the local authority. The assessment cannot proceed without written consent. In reality, this is a tight timescale and does not take into account loss of 2 days over weekends or bank holidays. If consent is not received from the social worker within 7 days, protocol is that cases are escalated to Management. This ensures health aim for completion within the statutory timescale of 28 days to the best of our ability. There is an agreed target between MK-CSC and health for completion of Initial Health Assessments within a timeframe of 25 days from health receiving consent. This was in recognition that the health team do not have control over gaining consent from the parent. Quarterly percentage of consent obtained within 3 days of becoming a looked after child: 15 Page 464 of 490

140 Consent received from SW within 3 days of CIC status- percentage per quarter: Ql Q2 Q3 Q4 10 out of 35 20% 32% 28.6% 24% This equates to a total annual percentage of 26% and is an improvement on last year's total annual percentage of 9%. An additional problem relating to the remaining cases being seen in time scale was the extensive delay which affected numerous cases. Initial Health Assessments completion within 25 days of receiving consent: Initial Health Assessments completion within 25 days of receiving consent No. of I HAs due in month following admission into care No. of I HAs curupleled wilhin 25 ddys of r eleiplof cuuseul % of assessments completed within 25 days of receipt of consent Graph 5: Number of IHA's due monthly following receipt of consent and number of IHA's which were completed within 25 days of receipt of consent, including monthly percentage: April pt March 31't2017 Due:170. Completed: 136 = 80% Factors impacting on delay of 34cases: Out of area request over which we have no control 10 Baby/child in hospital 3 Just outside timescale-day 29/30 8 Carer missed appointment booked 2 Young person declined 1 Child best interest 1 16 Page 465 of 490

141 Child moved placement day before appointment Appointment booked but young person went missing from care-(subsequently re-booked} 2 2 Clinic capacity affected cases 3 Request delayed from CSC end,in error 3 Analysis of factors affecting delay: Initial Health Assessments completed within 25 days of receiving consent: Of the IHAs due in the month following receipt of consent, 136 were completed in the 25 day timescale equating to a percentage of 80%. On analysing the cause of delay from a health provision perspective it should be noted multiple factors affecting delay are sometimes identified. The highest cause of delay in 10 cases was 'Out of Area' requests over which we have limited control. 2 related to highly complex cases and the children required had rapid placement moves to ensure their needs were fully met. The remaining causes of delay are outlined in the above table. Sometimes young people do go 'missing' from care and in all cases they are located. The two young people highlighted above, did subsequently attend their appointment. Social workers work hard with young people to engage them in the process. We are also respectful if the young person chooses not to have an assessment. Only one young person chose not to attend. Clinic capacity has been affected but only affected 3 cases. Due to the increase in numbers of children and young people requiring health assessments, clinics have been double and have also been arranged mid-week when needed. 17 Page 466 of 490

142 Actions by health & CSC to monitor and improve practice: 1} Joint work commenced between health,ccg and MK-CSC on the development of 'Consent to Placement and Medical Assessment form'. The benefit of this is twofold: It enables the SW to obtain parental consent for the statutory health assessments to be carried out at the same time as parental consent to Section 20 when a child/young person is brought into care. This reduces the need for delay in what is a highly stressful situation. In cases of Interim Care Orders (ICO} and Full Care Orders (FCO} the SW can give consent. It ensures parents have clarity of what is required as a statutory duty of care at the point of CIC status and that they are made aware of the reasons the assessment is required. They can then recognise our joint commitment to their child between health and CSC to ensure all their child's health needs are assessed and monitored while in the care of the local authority. 2} A monthly analysis of delay is compiled by the Named Nurse to track the cause of all delayed cases. A report is sent to Head of Service Delivery, Head of Corporate Parenting and Team Manager of Corporate Parenting. This is so that any possible performance issues can be jointly addressed. In addition to in the coming year the analysis will also be sent to the Service Director- children and families. 3} requests for consent and the required paperwork is sent to the allocated SW immediately the child/young person is made CIC. 4} liaison with the Safeguarding Team to notify health immediately a child/young person is madecic. Preciously health was reliant on 'LCS' notifying us a child had been brought into care. Evidence showed this was not a robust method of notification. 5} Performance is reviewed at each Health and Social Care Forum. Actions if required relating to consent and paperwork process can be cascaded to teams. 6} Training has taken place through the year across the SW teams. This was to ensure all are up to date with their statutory responsibilities when bringing a child into care. 7} BAAF assessment paperwork has been updated. This was already in process and is in line with recommendations made by the Care Quality Commission (CQC}. The assessment paperwork has increased to capture robust information from all health professionals, which takes additional time to collate from across health systems. Nurses have full access to Systm1; assessments include a health promotion section and over all compiling the assessment in a more lengthy process. An assessment for one complex case can take on average up to 6/7 hours to compile. This includes travel, seeing the child/young person, gathering multi-professionals views for a holistic overview and writing the report. 8} Business support from MK-CSC has been reviewed and hours increased: The complexity of co-ordination for CIC Business Support and recommendations is well evidenced. The Intercollegiate Role Framework Guidance for Children In Care (2015} advises on the complexity of co-ordination across services and different electronic systems and advises the need for this to be a dedicated role. Meetings took place on three occasions between health and CSC to review the admin 18 Page 467 of 490

143 requirements,procedures and allocated hours. The business support role has been increased to a full time position from esc. Review Health Assessment Process Annual Review Health Assessments for children and young people 5-18 years of age are completed by the CIC Nurse. This role has significant advantages for the children and young people in the care of Milton Keynes Authority. One key area being that review health assessments are completed by the same nurse therefore promoting continuity for the child/young person. This is our Specialist Nurse's 7th Year working within the MK-CSC Team. Consistent knowledge of the health and wellbeing of the child through their time in care is highly valuable in the assessment process for the child/young person and for their carers. The child/young person can be seen either at home, at school or at an alternative suitable venue of their choice. Liaison takes place with the child/young person's foster carer so they can be involved as appropriate in the process. Health assessments are usually requested to be completed outside school hours so as not to interfere with education. Such appointments are offered after school and the Specialist Nurse can also offer to see young people on a Saturday on occasion if needed. Review Health Assessments completed within statutory timescale: Review Health Assessmentscompleted within statutory timescale No. of RHAs due in month No.of RHAs completed in month % completed within timescale Graph 6: Number of Review Health Assessments due completion each month and how many were completed within timescale: Aprill't March 31't Page 468 of 490

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