Getting It Right For Every Child Learning Partner. Business process mapping

Transcription

1 Getting It Right For Every Child Learning Partner Business process mapping

2 2 Social Work- Children and Families In order to effectively analyse the processes within children and families social work in North and South Lanarkshire and identify the positioning of the Getting it right for every child core components within this process (please see National Practice Guide), the Getting it right resource team facilitated a session with social workers and their front line managers in North Lanarkshire, followed by another session in South Lanarkshire. The purpose of the business process mapping event was to give practitioners the opportunity to influence the Lanarkshire practice guide which will describe the use of the core components. Practitioners were also invited to comment upon and add to the business process map created by their senior managers at the two-day event, held by the resource team in February. All of these maps formed the basis of the practitioner sessions. The value of involving practitioners was further emphasised by the learning received from one of the domestic abuse pathfinders which identified that what practitioners do on a day to day basis may differ from what their managers believe is happening. The value in capturing both versions of the mapping is evident. Each session covered different aspects of practice as well as some commonalities. I have tried to highlight the commonalities between the two services while representing the individual flavour of each session.

3 3 ATTENDANCE (both) In North Lanarkshire, staff were requested to attend through the service manager for children and families who contacted the six locality social work managers who in turn identified practitioners to attend the event. All localities were represented, and across the six localities there was a mix of grades present, including senior social workers, social workers and support workers. Overall, twelve people attended with the breakdown in grade as follows: three senior social workers; five social workers and three social work assistants/ grade 9. In South Lanarkshire, permission for staff to attend was given by the children and families services manager who also provided administrative support. The administrator contacted staff on the team s behalf and ensured an equitable mix of people from each locality, including workers in ICS and family centres. In total, twelve people attended with the breakdown in grade as follows: four team leaders; five social workers and three family support workers. As above, the participants were given the business process maps completed at the February two-day event. CORE COMPONENT: REQUEST FOR ASSISTANCE (NL) The first matter to be discussed was the source of information (referrals or requests for assistance) and who may pass information to the social work department for action. Practitioners in North Lanarkshire identified that information came from the following agencies: Education Health (public health nurses; midwives; school nurse; school doctors; GP; NHS 24; hospital A & E; addiction services; CAHMS; adult mental health teams; hospital paediatrics (Wishaw and Yorkhill) Police (domestic abuse unit, family protection unit, community police officers, campus police officers) Housing and tenancy support services (including antisocial task force) Justice services Voluntary sector Other social work departments (both within the authority and externally) Reporter Community learning and development (youth clubs). The general public and self referrals were other sources of information. Information was passed on in a number of ways via telephone calls, s, letters both anonymous and otherwise, current agency referral forms people presenting at the office and formal child protection paperwork. On many occasions information was passed on in more than one manner, for instance a phone call may be followed up with a written referral. (SL) In South Lanarkshire consideration was given to the continuing prevalence of single IT systems and how this did not support the practice of information sharing. HOTSPOTS There was also some discussion in North Lanarkshire about agencies or professionals making reluctant referrals in that they wanted to pass information on for action but were unwilling to attach their name to the information.there was a discussion about encouraging some professionals within other agencies to take responsibility for the referrals they make. (NL) CORE COMPONENT: It was discussed with staff from North Lanarkshire that the role of the Named Person/Lead Professional very much challenges the culture of referring on as it maintains responsibility with these roles. Also a change of language from referral form to request for assistance emphasises that responsibility is not passed on with a concern for a child. (NL) HOTSPOTS Participants from both local authorities discussed that information is at times erroneously passed on under the auspices of child protection, when in fact the matter is a childcare concern and that this impacts on the workload of a team. In South Lanarkshire, participants felt that this was an issue that could be resolved through training and that misunderstanding occurred,

4 4 often as a result of differing thresholds. In terms of Getting it right for every child, participants felt that this practice issue often prompted an inappropriate response to a child s needs that was not proportionate. (BOTH) In terms of increasing teams workloads, one senior social worker in North Lanarkshire commented that as soon as information is received under child protection that this was automatically recorded and investigated as such, until an assessment can re-prioritise it. This led to a discussion about the possibility of differing recording practices within teams. One senior social worker felt that at times there was not a great deal of clarity between child protection and child welfare cases which social work and public health nurses were accustomed to. And this led to thresholds being considered. (NL) CORE COMPONENT: Request for Assistance/use of well-being indicators. The possibility of creating a structure around how information is gathered and passed on was considered by staff in North Lanarkshire and it was generally agreed by the practitioners present that the well-being indicators would be a useful tool for structuring information. Further discussion highlighted that practitioners thought that the structure of well-being may be useful for supporting staff within other agencies to clarify the difference between child protection and child welfare and to support an analysis of information from the outset. It was agreed that information passed on from other agencies erroneously under the auspices of child protection could often be understood, as people may be fearful of the consequences for a child if there was no response. It was thought there may be a lack of confidence in making an assessment and that these issues could be addressed by multi-agency training. (NL) GOOD PRACTICE: one of the senior social workers in North Lanarkshire advised that in his locality head teachers were encouraged to phone a senior social worker with any concerns that they believed to be within the child protection arena before submitting a standard circular 57, as this education child protection form automatically prompts a referral to the Reporter. By encouraging these phone a friend discussions, the head teacher and senior social worker agreed whether to proceed under a child care or child protection framework. Where the matter was child protection it agreed to proceed under these terms. In either case a quicker response to the needs of the child was achieved. However it was identified that in smaller localities there may be greater capacity to build these relationships of trust with colleagues in other agencies. (NL) In South Lanarkshire it was identified that the current practice of meeting with midwifery staff to discuss women with identified vulnerabilities in pregnancy was effective (this practice happens across both LAs as it supported the joint identification of appropriate requests for assistance (SL)) PATHWAYS Reception Services to Children and Families social work Practitioners in North Lanarkshire identified the variety of pathways which children whose information was passed onto the social work department could be subject to. It was generally agreed across the authority that if a child did not have an allocated social worker that staff in reception services would receive the information and undertake any further information gathering and initial analysis. In the case of a child having an allocated worker the information was generally passed to the worker for action. (NL) However while this would be the standard model across the authority, it was identified that there are often local variations to this. In one locality if the case was closed or unallocated, the matter would be dealt with by reception services, while in another locality either the reception services staff or children and families duty worker may receive the initial information. It was identified that in most localities relationships with workers in other agencies often resulted in staff taking a referral because another professional had phoned for advice. It was felt that to rigidly adhere to standard procedures may be detrimental to the welfare of children in some localities. (NL) GOOD PRACTICE: it was considered by staff in North Lanarkshire that as Getting it right became more embedded in practice that these trusting relationships between professionals may increase. One senior social worker commented that it was the duty of social work to respond to the needs of a child and that children should be protected before any referral pathway is protected. (NL) HOTSPOTS: Advising the outcome of a referral It was agreed by practitioners in North Lanarkshire that social work as an agency could generally improve their responses to other agencies and it was agreed that this could be included in the practice guidance. It was also discussed that when agencies require feedback, they should also be proactive about pursuing this.

5 5 THE ROLE OF JATS OR MASTS It was advised by North Lanarkshire participants that existing JATS are populated by social work staff in a variety of ways, some through staff identifying an interest, some by senior social workers. There was no standard means across the authority of identifying social work representatives to attend a JAT. However it was felt that multi-agency meetings led to earlier intervention and practitioners welcomed this approach. The example was given of the role of JATS in Cumbernauld in reducing referrals to the Reporter. This contrasted with the experience of some social work staff in South Lanarkshire who felt that the role of the JAT was to agree a referral to the Reporter as an initial action point, rather than consider appropriate single or multi-agency interventions first. However multi-agency meetings were again welcomed as it was felt that they often flagged up the involvement of other agencies previously unknown, for example, a recent MAPPA meeting highlighted for one worker the significant involvement of criminal justice services. (BOTH) Practitioners in South Lanarkshire considered the number of meetings which social workers facilitate within their role as lead agency/professional which is not reflected in the business map. They considered the time implications for workers of these meetings. While formal multi-agency meetings such as GOPR, children s hearings, JATS, CP were considered it was suggested there was a layer of meetings below these which also demanded time and reflected both single and multi agency working. For instance, these could range from attending the area resource group to supporting a family to attend a meeting to return a child to school after an exclusion, attending a child and family clinic, supporting a family to attend an internal or external resource for a service by accompanying them to the referral meeting or initial session. These meetings were referred to as liaison meetings which generally supported or enhanced the work of other agencies. (SL) CORE COMPONENT: INTEGRATED ASSESSMENT Staff were familiar with the My World Triangle and were using it in practice with children and families, although this was not part of the paperwork they were using yet. One worker in North Lanarkshire gave an example of using it to complete a court report which they felt reflected the views of the young person much more thoroughly. It was felt it would be useful to have these tools on the intranet. As one worker had recently worked in East Ayrshire, the practicalities of completing an Integrated Assessment were discussed. It was identified that an Integrated Assessment is not a risk assessment (this is a CP1) and that following a CP1 an integrated assessment may be completed as part of the ongoing work plan, ie through the need for a parenting capacity assessment. It was discussed that the analysis of information should be a joint activity although some workers commented that some professionals from other agencies are not accustomed to undertaking assessments. Due to time restraints it was not possible to discuss, planning, intervention and review with practitioners from North Lanarkshire. A further date was suggested but this was not taken up by the workers who had attended the first meeting.

6 6 GENERAL PRACTICE ISSUES AS DESCRIBED BY PARTICIPANTS OVER THE 2 SESSIONS Guidance required re taking client records to home visits Real difficulties with some records being available for immunisation clinics and/or other immunisations i.e. Hep B, influenza Guidance on what is written in work diary Role and responsibility of team leader when notified of a domestic abuse incident therefore differing practice for PH teams to follow and different service given to child, young person and family There is a PHN working in one CHP specifically with domestic abuse victims Generally PHN s report that they don t know people and communities the way they used to Understanding of what HPI is for not always clear to staff within NHS and outwith in other agencies, therefore HV not receiving all information that would help accuracy of HPI Corporate working has contributed to the above Is there a minimum number of home visits per day? Is it possible? Lack of administration/clerical assistance within public health teams What has happened to framework of nursing for schools Brief interventions further discussion required re how much this has impacted core work Consistent practice re working with GP practices some continue to work to an attached model Both CHPs have different protocols and practice

7 7 BUSINESS PROCESS MAPPING DAY 1 SOCIAL WORK- CHILDREN AND FAMILIES & PUBLIC HEALTH In order to effectively analyse the processes within social work (children and families) and public health nursing the Getting it right resource team facilitated two sessions with the two single agency groups, with an additional session organised for the month of July. The purpose of the business process mapping event (described above) was to give practitioners the opportunity to influence the practice guide for use of the core components and comment and add to the business process mapping created by their senior managers at the two-day event these maps were shared at the sessions. The value of involving practitioners was further emphasised by the learning received from one of the domestic abuse pathfinders who identified that what practitioners do on a day to day basis may differ from what their managers believe is happening. The value in capturing both versions of the mapping is evident. Public health team mapping session The benefit of conducting this piece of work is that it has given the resource team and the practitioners a description of how public health nurses work and how the service is delivered. The attendees engaged with the process and commented that having the opportunity to walk through their every day experiences helped to trigger and highlight areas that have contributed to the way they deliver the public health nursing service making it easier to identify what works well and what requires to be improved. At t e n d a n c e Within NHS Lanarkshire public health teams, the ten localities had representation from qualified public health nurses, public health practice teachers and public health team leaders. There was also representation from practice development and the child protection team twelve representatives in total. This report has been broken down, where possible into sections, attempting to illustrate and track one of the core pieces of work of a public health nurse.

8 8 The notification of the birth of baby through to primary school entry The Process Part 1 st Notification of pregnancy through to infant aged sixteen weeks 1. Public health nurse receiving notification of an expectant mother Midwifery services commence a perinatal mental health assessment at booking visit HOT SPOTS ANTE-NATAL PERIOD Some localities have not received the perinatal mental health assessment since the introduction of the national midwifery record (SWIMR) however staff believe that the assessment is now being reintroduced by midwifery colleagues Interventions planned as need identified from assessment Little or no public health input at locality antenatal clinics If further interventions required, midwife (either community or hospital based) contacts the public health nurse for discussion The perinatal mental health tool is passed to the public health nurse after booking in visit Some areas have a meeting (monthly) where potentially vulnerable infants are discussed and care management co-ordinated attendance can vary from public health, midwife, social work and addictions all in attendance to a combination of these. Public health input at parentcraft, breastfeeding classes varied Collation and filing of any antenatal records/ information not consistent within public health teams for two reasons: standard of information received varies and no guideline available for public health teams to follow a standard No standard available for the vulnerable infant meeting.

9 9 2. Public health nurse receiving notification of birth of infant Midwifery service notifies public health nurse of new birth between 10 and 14 days of infant s birth The public health nurse adds to the data already received antenatally. Continues to build and add to the midwifery assessment. Assesses child and family; strengths/challenges/parenting capacity Best practice of birth handover is where midwife has face to face contact with the public health nurse to give the handover of the birth notification, mothers health, infant feeding forms and all other relevant information. HOT SPOTS BIRTH NOTIFICATION PERIOD Handover to public health nurse by midwife varies. No consistent method of passing this information between the two professions Least helpful is where the notification sheet (known as pink slip ) and infant feeding form is left in mother s home and public health nurse advised of the information by telephone message Public health nurses have now developed an in house form different in each locality if not team to necessitate the gathering of the information passed to them via telephone or answer machine no standard available within NHSL the hospital midwifery service Delayed assessment of infant and mother can occur if public health nurse has no notification given can occur most often when infant discharged from hospital and not via community midwife Cambuslang and Rutherglen and Northern Corridor public health teams have newly joined NHS Lanarkshire and are still working alongside the midwifery service attached to Greater Glasgow and Clyde. They also continue to be GP attached GP practice does not always receive the notification timeously Public health team alignment to GP practice has resulted in some teams aligning to up to four or five separate GP practices not all of these GP practices being based in the one centre. * NOTE as a result of the NHS Lanarkshire community nursing review all public health teams are GP aligned no longer GP attached. The public health teams have developed a system to ensure communication systems do not fail between GP and themselves and each GP practice is assigned a named public health nurse. 3. Primary birth visit to family by public health nurse days Public health nurse contacts family usually mother to introduce self and arranged suitable time for visit (known as first visit ) All paperwork available for public health nurse to take to visit should be contained within the public health nurse record Assessment process continues to build upon all previous information and assessments available (midwifery, vulnerable infants forum, GP, addictions, learning disability, social work, siblings records) family may also be already known to public health nurse The public health nurse continues to assess and between six and sixteen weeks assigns a health plan indicator (HPI), in discussion with parent/carer this is in line with Hall 4 recommendations. The categories of HPI are: Core, Additional, Intensive Agreement made between public health nurse and parent/carer re frequency of contact visits most public health nurses prefer to visit at home until infant reaches age of six weeks all dependent on continuing assessment and sharing of that assessment findings between public health nurse and parent/carer *Some areas now using well-being indicators to assist assessment and also discussing this with parent/carer those using well-being report that it adequately identifies the needs of the child If infant discharged from hospital the public health nurse not always informed by Some areas give health promotion advice, leaflets on various issues, Bookstart

10 10 Some areas ask parent/carer to use Ready Steady Baby as main reference book Childsmile referral made HOTSPOTS PRIMARY VISIT Public health record often arrives without all information required Public holidays appear to delay the delivery and arrival of the public health record Public health nurses report no standard on how to complete first visit record Public health nurses report concerns re varied knowledge of child development, parenting, attachment The records are not sent from a centralised unit there are three areas and there appears no overlap or communication between the three although locally the administration team at these bases do try to accommodate requests again this can result in variation in information contained within the record giving an inconsistent standard of care and incorrect use of protocols e.g some localities have the information sharing protocol (ISP) inserted into the record, some have the Edinburgh Post Natal Depression form Public health nurses require clarity re use of and interpretation of HPIs Public health nurses require clarification re use of and interpretation of Information Sharing Protocol There is confusion re formal notification of change of the HPI there are two forms (identified as lilac and green forms) and clarity required re consistency of use Use of these forms help inform a centralised system that, if used properly, can give an indication of workload and resource public health nurses concerned that inaccuracies in the use of the forms are not assisting them in providing a clearer analysis to line manager Some public health teams work corporately, some work geographically, others do not Practice varies on how public health nurses assign themselves the new birth visit some are allocated the families by team leader, some work in rotation, some work as almost still GP attached, some ad hoc, where family already known it is usual for that public health nurse to continue with new sibling a few other concerns were noted by practitioners

11 11 Practice varies where the family have newly moved into area and have perhaps not yet either registered with a GP or have not been assigned a GP by the general practitioner service Similarly, practice varies for families newly homeless no consistent standard available No consistent practice for looked after infants and looked after and accommodated infants often depends if the carer is registered with a local GP and if the child and family social work team are within the locality Some of the assessment tools require clarity e.g. the profile of significant factors and NHS single agency assessment (public health staff have recently had training on assessment and the use of well-being indicators) 4. Review visits to family by public health nurse 3 16 weeks Agreement between public health nurse and carer re frequency of visits The public health nurse continues with the assessment process, continuing to add/ make decisions regarding programme of care by information gathering and analysis of assessments made Infant is called for six week child health assessment carried out by a medical doctor either the GP (with extra training) or community paediatrician The six week assessment form is given to the public health nurse for insertion of HPI HPI should be assigned by the public health nurse by 16 weeks Infant is called for primary immunisation schedule first immunisation offered at eight weeks of age HOT SPOTS REVIEW VISITS, ASSESSMENT AND IMMUNISATIONS, PRACTICE ISSUES, CLINICAL SUPERVISION Analytical skills of public health nurses varied all report that they would like further training if possible Where clinical supervision has been established, staff felt more able to talk through the case resulting in clearer analysis The child health assessment (CHS) at six weeks of age has been described as a disaster by some public health nurses no consistency in some cases, incomplete forms returned by the assessing doctor and the following concerns have been noted as hot spots within the CHS: Information such as centile charts, feeding status not completed Guidance required on what information/ health promotion material to be given at primary visit. Health promotion programme based on Hall 4 recommendations commenced Mother has first and second screenings for postnatal depression Parents advised of expected development of their child If the allocation of HPI has to be accurately made, the public health nurse, in some cases, does not have all information available to do this professionally and accurately Public health nurses report that in some localities they have no input at all at the six week assessment Contact details of the public health team reinforced Invited to participate in local health promotion clinic offered by that team In some teams a public health staff nurse continues with the home contact visit Previously infants were called to an assessment clinic that was staffed by a community paediatrician, public health nurse presently these clinics have almost all been replaced by a GP assessing the infant within the GP practice time or at the mother s post natal check.

12 12 *In some areas the GP practice facilitates a stand alone assessment clinic with public health nurse involvement No Parent Held Child Health Record (PHCHR) available for parents in Lanarkshire Parents' views have not been fully sought re the changes to the programme public health nurses feel this has contributed to the challenge of attempting to involve parents more in their understanding of the development of their child. Interpretation of Hall 4 for the ongoing input to assessment process requires clarification some public health nurses report that they are going to assess a child at two years is this to be consistent practice throughout NHS Lanarkshire. Not always clear that our partner agencies have been fully involved in the work of Hall 4 e.g. where an infant has received a supported application and attending nursery there are gaps in the communication process between education and public health Clinical supervision availability to practitioners varies Role clarity TL/CPT/HV/Staff nurse/ Skill mix/practice nurses/clinical support workers Resources within the teams to attend/ participate fully with job satisfaction MARAC/multi-agency meetings/ breastfeeding groups/peri-natal mental health At any review visit practitioners hope that parenting strategy will help inform practice e.g. offering baby massage to all. 5. Twelve sixteen weeks Infant continues primary immunisation Some areas have implemented Hall 4 health promotion clinics to run alongside immunisation clinics Home visits by most areas for post natal depression screening continues usually around 14 weeks North localities instigate home safety referral to Wise group R & C Wise group give carers referral for their completion All areas try to have the HPI completed at this stage use various tools to assist In some areas parents or carers advised by PHN of public health team contact At contact either home or clinic weaning/dental care/feeding cup/bookstart given HOT SPOTS WEEKS CONTACT Which grade conducts PND questionnaire Varied skills of those who contribute to HPI (some staff nurses complete second EPDS, give weaning advice, not all)

13 13 ISP clear guidance re completing this when referring for home safety Some practitioners concerns re the various tools used to assess vulnerability Do practitioners, get the time to really know client to allocate accurately the HPI Some areas advising parents/carers of HPI allocation Some areas have the Band 5 take over at six weeks Some areas band 5s review child development at six months Inequity of work allocated to band 5s across NHSL Hepatitis B immunisation requires guidance as to who administers and ensuring infant recalled via SIRS (and subsequent collection of bloods) All report less contact time with clients asked question Is this due to Lanarkshire CNR? I m not seeing the children and family I know I should Not all working corporately and therefore no complete knowledge of all clients some have worked corporately in the past and didn t feel it worked Require guidance re what health promotional materials given at this time 6. Ongoing input as per Hall 4 Contact with child and family dependant on allocated HPI and information received If child allocated additional/ intensive this triggers a fuller assessment Single Agency Assessment implemented some using GIRFEC practice model. 7. Contact at one year Immunisation contact between 12 months and 14 months in some areas Band 5 s and in some Band 6 Some areas note two defaulted immunisations and then contact parent/carer Some areas telephone and invite parent/carer to yearly health promotion clinic health promotion material given and discussed at this contact HOT SPOTS CONTACT AT ONE YEAR Guidance re noting and contacting immunisation DNAs and adjusting HPI Who does follow up to those who DNA SIRS system unable to recall Common practice to circle 2 on the SIRS form Rural areas have different issues re contacting DNAs Require guidance on what health promotion material given at this contact Practitioners feel that universal programme not communicated and defined well enough Some areas conducted a questionnaire asking parents/carers to help introduce the newly structured Hall 4 clinic also gave some guidelines to parents re attendance at these clinics this system has been reviewed recently and can be seen as ticking the boxes from a health promotion aspect Band 6 staff do not feel as involved with infants at this stage and have concerns that assessment may not be as thorough.

14 14 8. Two-year contact HPI updated/reviewed Some teams have a system that ensures the team leader has knowledge of all changes of HPI Some teams call all core children by telephone to enquire re child s development Some teams do not contact any core children Some areas call additional children to clinic Some areas have reinstated the universal two-yearold contact Some teams have joint visit with local nursery staff if supported application received and discuss application with parent/carer assessment skills of Band 6 staff require review Point made that many staff do not have contact with those children developing along the normal milestones and therefore this somehow skews or lowers thresholds If child has supported application nursery place, liaison between nursery and public health team can be inconsistent Nursery staff report varying levels of quality of referral from public health teams consistency and guidance required Some nursery clusters do not invite a public health nurse team leader to sit on nursery panel working primarily with schools and they are given information on these children HOT SPOTS THREE-YEAR PRE-SCHOOL Communication between education and public health Parents/carers can be under impression that health visitor no longer has any input to their child Those children in pre-school year not visible to public health team Not always aware if child has taken up a place at nursery No system for calling for CHS review for child in Primary 1 Some team leaders represent public health teams at the local nursery panel meeting HOT SPOTS TWO YEAR CONTACT Developmental delay not being noted at two years Some teams have most of children already on additional or intensive and therefore contact for review some may have been on additional or intensive since birth, but have had less input than is advised No consistent practice for two-year contact 9. Three-year pre-school contact Primary immunisation schedule completed usually by 48 months DNA s treated as at one year No set contact with core children and most areas only have contact with these children if contacted by parent/carer or opportunistically Most core children take up place at nursery if place available Additional and intensive children will be kept on the caseload of the public health nurse Increasing caseload of children within additional/intensive caseload and little input given at present resources. 10. Pre-school school There was a general feeling within the session that the transition from pre-school to school needs further discussion as in some localities there are public health nurses with a responsibility for schools and none of these colleagues were represented at this session. However, there is a practice session arranged by the Associate Director of Nursing Public Health which will hopefully be able to map this process. Practitioners suggest that developmental In some areas there are public health nurses