Multi-Agency Framework for Children with Additional Needs in Bridgend, Study notes of Communication

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Integrated Working

Framework

for meeting the needs of children and

young people and their families

Integrated Working Framework

Contents:

1. Introduction 3
2. What is integrated working? 5
3. Our shared values 6
4. Principles for integrated working 6
5. Identification of needs and services by locality 7
6. Common language and terms 13
7. Communication and information sharing 14
8. Assessment, recording and monitoring of needs 15
9. Team Around the Child and Multi-agency panels 17
10. Connecting Families 18
11. Operational model(s) for integrated working 19
12. Management and governance 21
13. Planning 22
14. Commissioning 23
15. Funding and resources 25
16. Quality assurance (Monitoring and Evaluation) 27
17. Appendices 28

Appendix A: Data on the 5 dimensions of need shown by locality Appendix B: Meeting needs through integrated working - a conceptual model Appendix C: Agencies and potential roles in an integrated child and family support approach Appendix D: Speaking the same language on integrated working Appendix E: Related strategies and plans.

future in a financially challenging environment. It is clear to everyone that the status quo is not an option. This vision for primary and community services has at its heart improved outcomes for the citizen, more effective and efficient ways of working within the NHS and with partners$

The development of this framework also links closely to other projects in Bridgend Council’s Supporting Vulnerable Children 2 Programme (SVC2) which includes the Connecting Families project, a project in each of the three localities (community networks) in Bridgend County to establish multi-agency teams and community hubs, an ICT project to facilitate information sharing and integrated working, a project to improve the lives of looked after children and one to redesign residential provision.

There is a strong drive in Bridgend to develop more integrated working in the field of Adult Health and Social Care and this programme is being aligned with the Supporting Vulnerable Children (2) programme to share developments where possible and make best use of resources to avoid duplication of effort.

The framework relies on certain givens which have been agreed by all partners to the Children and Young People Partnership. In the 2011 CYP Plan, the 6 broad outcomes which we all wish to see are set out in the shared vision:

It is intended that children and young people will:

1. learn and achieve
2. participate and enjoy
3. give and receive respect
4. be healthy
5. be safe
6. be confident and self-reliant

This framework is designed to ensure that each child in need i.e. one for whom some or all of the 6 outcomes will not be or are not being met, has appropriate support. Such support should not be prone to frequent and unsettling change but be from providers of services with whom the child and the child’s family can identify and build a relationship. The forms of working proposed in this framework are also geared to reducing the number of children and young people who require that more intensive level of support provided by a team around the child. Whatever the level of need, therefore, integrated working practices must ensure that:

• support is designed around the needs, progress and development of individual children;
• there is a strong emphasis on prevention and early intervention, turning this from an ambition into actual practice;
• where universal services exist e.g. health visiting, their effectiveness is not diminished but helps to direct intervention to where the real needs are; and
• practitioners reconfigure their services to reflect the particular circumstances and needs of different groups of children and communities and offer children and young people a seamless service.

2. What is integrated working?

If the concept of integrated working, across different sectors and agencies but also within sectors, is to be progressed, there is a need to arrive at a common understanding of what is meant by integrated working, how that might be articulated in broad operational terms of multi-agency working and what principles should underpin its development. The drive towards better collaboration between agencies and therefore a more coherent and satisfying experience for service users is underpinned by the Local Government (Wales) Measure 2009 and more recently by the Families First initiative, the latter replacing Cymorth in 2012 as the vehicle for taking forward the whole child and family centred approach. Other national guidance or requirements, such as the recommendations from the Health Visiting Review by Welsh Government, will need to be taken into account when determining the shape of any integrated working arrangements.

Integrated working, for the purposes of this framework, is defined as:

a system and a culture of partner organisations working together with shared values, common goals and agreed priorities to bring about change for the better in the lives of children and young people.

This is a broad definition and does not prejudge what the model or models of service delivery will look like. Integration can take many forms along a wide continuum of practice. To arrive at an appropriate and agreed model or models in Bridgend will require knowledge of the many aspects of integrated working, including data management, common assessment frameworks, extended services and multi-agency locality team building. It will require close working relationships with decision makers in each organisation, managers and front-line staff. The engagement of statutory and non-statutory partners is essential, including the participation of children, young people and families. Integrated working will require commitment from all partners to sign up to a shared set of values and principles. It is also necessary to be clear on the needs which services must seek to meet, how those needs are assessed and recorded, the language and means we use to share our knowledge, how referrals will work, what will constitute a multi-agency team and how it will operate. Underpinning these will be the organisational and resourcing factors to ensure integrated working is sustainable, efficient and effective i.e. proper governance arrangements, a comprehensive and co-ordinated approach to

i) collaborate to make most effective use of limited resources, pooling budgets where appropriate.

In managing the business of multi-agency working, partners will: j) accept that, without compromising statutory obligations, collaboration may mean giving up some things for the greater good and this translates into positive gains for children and young people; k) safeguard the professionalism (e.g. maintaining professional standards, observing supervision requirements) of those working in a multi-agency setting; l) understand that multi-agency working needs to be geared to the different tiers of need so that multi-agency community (MAC) teams are deployed to defined localities to address the lower tiers of need and they are supported by staff managed centrally when low incidence or higher tier needs cannot be met by the MAC team; m) work towards establishing common or compatible databases which will enable the sharing of information; n) develop agreed means of communication, information sharing protocols and secure practices to facilitate effective multi-agency working; o) invest in workforce development and a programme of collaborative training and development to realise the shared vision and more specific objectives; p) work to the priorities as set out in the CYPP Plan and address any emerging priorities; q) support governance arrangements which allow partner agencies, children and young people and their families to play a part in decision- making; r) agree on robust team structures and working practices with clear lines of accountability.

5. Identification of needs and services by locality

Bridgend’s 4-5-6 model sets out 4 tiers of need, 5 dimensions of need and the 6 outcomes which describe how children and young people would think, feel and act in an ideal world. In mapping needs and the services which seek to meet those needs, the following categories have been applied where it has been possible to do so:

4 tiers of need Tier 1: Basic Tier 2: Additional Tier 3: Complex Tier 4: Critical

5 dimensions of need : Social : Physical

: Emotional : Cultural : Learning

6 outcomes It is intended that children and young people will:

1. learn and achieve
2. participate and enjoy
3. give and receive respect
4. be healthy
5. be safe
6. be confident and self-reliant

The model is intended to support integrated working by: i. providing a common language which is widely understood and not service specific; ii. defining the needs of children and young people in ways which relate to their lives rather than service provision; iii. establishing agreed tiers of need so that it is clear when a child has crossed a particular threshold and requires a different level of support; iv. providing descriptions of what an unmet need looks like in the life of a child; v. giving pointers to the services which can help a child who has unmet needs; vi. defining the outcomes for children and young people in terms of how their lives change for the better

If there is to be a shared understanding of needs, a programme of training in the model would have to form part of the workforce development plan.

The localities are the three agreed by the Local Service Board and which now form the basis for planning across a range of services including the Police, Health, third sector providers, Housing, Safeguarding and Family Support, Education Inclusion, Education Access, Adult Social Care, Adult Learning, Healthy Living and schools. Each locality will be served by a multi-agency community team (MAC team) working from a community hub. The map below shows the three localities and the possible locations for either 3 or 4 such hubs.

The North Locality is essentially the Llynfi Valley, Garw Valley, Ogmore Valley and Valleys Gateway area (Aberkenfig across to Bryncethin).

The East Locality is the Bridgend and Pencoed areas.

The West Locality is the Cefn Cribbwr, Mynydd Cynffig, Pyle, Corneli and Porthcawl areas.

Each hub would have “satellites” to serve communities which could not easily access the community hub. The satellite would offer a facility from which MAC team members and members of county-wide Resource teams could engage with children and young people and families. The hubs would offer a comprehensive range of services delivered by co-located staff working to common principles, shared outcomes and shared approaches to assessment, recording and monitoring.

The map below, showing the deprivation rankings by ward, indicates that the higher levels of disadvantage are generally to be found in the North but there are also significant pockets in the West and East too.

Bridgend County

showing Wards and

Areas of Multiple

Deprivation

Looking at the total population of children and young people in each of the three localities, it can be seen that there are demographic variations by both area and age group. The incidence of need, however, may vary with type and severity of need and this will be a critical factor in determining the level of resource deployed to each area.

Locality Population of children and young people 0-24 in BCBC

% of children and young people 0-24 in BCBC

% of BCBC population

North 14898 38% 11% East 16277 41% 12% West 8431 21% 6% Total 39, Source ONS Mid year Ward estimates 2009, Population Age 0 – 24, BCBC Total Population 134197

Locality Population 0-19 % of children and young people 0- 19 in BCBC

% of total BCBC population

North 12,002 38% 9% East 13,060 41% 10% West 6879 21% 5% Total 31, Source: ONS 2010 Ward Population Estimates for England and Wales, mid- (experimental statistics), Population Age 0 –19 31,941, BCBC Total Population 134,

Locality All Ages 0-4 5-9 10-14 15-19 0- North 49306 2985 2872 3038 3107 12002 East 53795 3297 3166 3283 3314 13060 West 31096 1599 1583 1827 1870 6879 Source: ONS 2010 Ward Population Estimates for England and Wales, mid- (experimental statistics), Population Age 0 –19 31,941, BCBC Total Population 134,

Locality School Population (a) aged 3-11 (b) aged 11- 19

% of school population (a) aged 3-11 (b) aged 11- 19 North (a) 4590 (b) 3342 (a) 37.65% (b) 34.32% East (a) 4834 (b) 3812 (a) 39.66% (b) 39.14% West (a) 2517 (b) 2131 (a) 20.65% (b) 21.88% Out of County (a) 142 (b) 398 (a) 1.16% (b) 4.09% Unmatched (a) 107 (b) 56 (a) 0.88% (b) 0.58% Source: PLASC 2010, Population Age 3-11 12190 (Primary) 11-19 9739 (Secondary) by pupil residence, BCBC Total Population 134197

Appendix A sets out a range of data broken down into the 3 localities and offers a snapshot of need at a point in time. The indicators of need are, in some cases, no more than indicative since proxies for need have to be used in the absence of quantifiable data on the need e.g. the number of children on school action for Additional Learning Needs (ALN) does not necessarily imply

of Bridgecards issued to young people suggests that usage of sports and leisure facilities is far higher in the East than the North or West. The number of racially motivated incidents is at such a low level that the figures are not statistically valid.

Learning needs: Outcomes for learners at each of key stages 2, 3, 4 and 5 are indicative of the success or failure in achieving educational potential. There is a very stark contrast between the performance of pupils and students in the North at key stages 2 and 3 with their performance at key stages 4 and 5; the latter two stages showing much poorer results than the former. Although the comparison of performance is for one year and therefore the different cohorts may well have different levels of ability, the variation is so large as to be significant. This interpretation gains credence when the North’s figures are set against those of the East and West. Performance in the East and West is significantly below that of the North at key stages 2 and 3, and significantly above at key stages 4 and 5. The strong implication is that pupils in the North fail to improve at the same pace as those in the East and West after the age of 14. Across the whole school population, there is a much lower proportion of pupils with poor attendance in the East, the highest being in the North. The highest rate of fixed-term exclusions is in the East. The North has the highest number and highest proportion of pupils on the ALN register at the school action level, whereas those with greater needs, at school action plus, are evenly spread across the populations in each of the three localities.

6. Common language and terms

Successful integrated working will require different professionals and groups of staff to develop a common language allowing time to explore difference in language and culture. Other local authorities that have adopted integrated service models have found it difficult to progress until they have developed a common understanding of key terms, including the actual definition of integrated working. Time spent building a real shared understanding of key terms and definitions will provide a strong foundation for joint working. It is through language that we understand the real world and without a common language, different services will not understand each other or be able to work together effectively. Without a common language there is a danger that misunderstandings will undermine effective communication and collaboration, no matter how good our policies and systems are. Inconsistencies in the use of terms can also reinforce some of the cultural obstacles likely to be encountered as organisations and services in Bridgend become more integrated.

The 4-5-6 Model has as one its aims the ambition to “provide a common language which is widely understood and not service specific”. The Model offers definitions of the 4 tiers of need (Basic, Additional, Complex and Critical), 5 dimensions of need (Social, Physical, Emotional, Cultural and Learning needs) and 6 outcomes which are expressed in terms of change for the better in the life of the child (listed on page 4 of the Introduction in this framework). The fact that the definitions of need and the accompanying signs

of unmet needs for each dimension are not written from any one professional’s standpoint, means that they should be widely accessible.

For a compendium of terms and their definitions, refer to Appendix D.

7. Communication and information sharing

The Council’s Supporting Vulnerable Children 2 (SVC2) programme will rely on highly effective communication and information sharing systems. Within the Children’s Directorate, the project to allow information to be shared via a portal between the 3 main databases (Impulse – pupil data warehouse; Draig

• social services case management system; Tribal – SEN database) will be fully operational in the summer of 2011. The Connecting Families project will have an information officer in post also by the summer of 2011. These are steps towards what will be needed for the full implementation of SVC2.

Agencies working in a truly integrated way must have access to the same data which gives a picture of the whole child. The 4-5-6 model, if adopted, could provide this without compromising the professional integrity of individual agencies’ methodologies and data security. This could also serve as a portal between databases other than those already linked within the Children’s Directorate, if that were appropriate. The Integrated Information Systems project is due to launch in the Spring 2011 and, in fulfilling its aims, will complement and support the Integrated Working Framework.

The Integrated Information Systems project seeks to co-ordinate and, where possible, integrate data sets and the systems which generate the data. In particular, it is important that the project results in:

a. accurate and up-to-date information on individuals, families and populations; b. early identification of children and young people’s needs; c. a comprehensive, accessible and robust information service for managers and front-line workers which will track and measure the effectiveness of support and interventions, quality assurance processes and inform strategic planning; d. systems and processes which have integrity, are reliable and cost effective.

To make these aims a reality it will be necessary to test current information sharing protocols and revise them as appropriate, to have data protection measures in place, which conform to the Data Protection Act 1998 and Code of Connection (Co-Co) regulations, and to develop Sharepoint or a similar e- mechanism for sharing information. The necessary consents from children and young people and family members must also be in place before information is shared between professionals. As importantly, partners must agree on how the data is to be used to best effect by practitioners, managers and strategic planners and what resource is required to make that happen. Knowledge management must be integrated and coherent as far as is

The two approaches seen in the 4-5-6 model and the Common Assessment Framework are not mutually exclusive. What they offer is complementary to the process of information gathering and sharing which can provide a better picture of children and young people who are becoming causes of concern and moving from Tier 1, where basic needs are being met, into Tier 2 where they have unmet and therefore additional needs.

The principles, as set out below, for developing a more integrated approach for assessing, recording, sharing and tracking needs will inform further work on the operational means of achieving the end goal of having a system which alerts services to unmet needs and brings swift and appropriate support to prevent problems escalating to Tiers 3 and 4. To this end any such system must:

• focus on the needs and strengths of the child/young person and her/his family;
• flag potential and actual child protection issues at the earliest opportunity;
• allow for early identification of issues e.g. by checking how a child/young person measures up against the 6 outcomes in a quick overview;
• provide a clear picture of the child/young person’s unmet needs i.e. the sorts of need which are not being met and how far they are not being met;
• offer an assessment of the parent/carers’ capacity to meet needs;
• offer an assessment of the family context and environment;
• employ commonly understood terminology that is also accessible to the lay reader, including the children and young people and the family;
• be easy to complete;
• be in an electronic format;
• demonstrate that the necessary consents have been obtained for sharing information;
• be accessible via the web to different authorised agencies with proper Co-Co compliant security measures and information sharing protocols in place;
• contain accurate and validated contextualising data such as name, date of birth, address(es), siblings;
• complement and allow for straightforward transfer of data into other, more detailed assessment mechanisms e.g. ICS for initial and core assessments by SFS;
• include names of all agencies, and their contact details, involved with the child/young person/family;
• provide a summary but dynamic record of contacts with the child/young person/family;
• specify the support being offered to the child/young person/family and name the key worker.

As a generic assessment, any early means of identifying and recording unmet needs would be distinct from specialist assessments which:

• have a much more specific purpose (for example, assessments under section 17 of the Children Act 1989, where the main purpose is to determine whether a child or young person is a ‘child in need’; whether the child, young person or family requires services; or Onset where the main purpose is to assess the child or young person’s risk of offending);
• are undertaken by staff from a particular service or sector (e.g., criminal justice)
• are usually undertaken only by staff of a particular occupational or professional group (e.g. social worker, educational psychologist).

9. Team Around the Child and Multi-agency panels

The Team Around the Child (TAC) approach is central to the effectiveness of many integrated working arrangements. TAC supports particular elements of good professional practice in joined-up working, information sharing and early intervention. The TAC is a model of service delivery that usually involves:

• a joined-up, common assessment;
• a lead professional to coordinate the work;
• the child / young person and family at the centre of the process;
• a flexible multi-agency team that will change as needs change;
• coordination at the point of delivery;
• a TAC support plan to meet the needs of the child / young person;
• regular meetings to which the child / young person and families are invited to attend.

The Inclusion Service has developed a version of this in the TAPPAS model (Team Around the Pupil, Parent and School) within the context of a drive to meet additional learning needs more effectively.

The aim of a common assessment is to identify vulnerable children earlier, ideally when still at Tier 1, and share information with the consent of parents/carers so that the strengths and needs of a child or young person can be met more accurately. There are many operational implications arising from a TAC approach and use of a common assessment of need e.g.

• how TAC meetings use an initial assessment of needs;
• how a package of multi agency support would be designed to address a child or family’s unmet needs;
• what the role of a key worker or lead professional might be in managing a case.

The Team Around the Child brings together organisations which work with potentially vulnerable children and their families to provide help and support through the agreement of a multi agency plan and the allocation of a key worker. A multi agency plan for children and young people who have additional needs that cannot be met by a single agency is devised and the

The BLSB and the BLSB Delivery Board will form the top level of governance for this project. The project will report progress to BCBC’s Programme Management Board within the project portfolio of the Children’s Directorate Supporting Vulnerable Children 2 Programme.

Connecting Families will be a model of integrated working which is designed to meet, predominantly, the very complex needs of particular families throughout Bridgend County. The team will be specifically constituted to meet these high-end needs but will also deliver a range supports and interventions to family members who may not be categorised as high demand. As Connecting Families and the MAC teams evolve, cases may be referred on to Connecting Families when the interventions by the MAC teams are insufficient to address the issues at Tier 2 or Tier 2/3. When the Connecting Families team has met the objectives for a particular family, they may be referred to a MAC team for continued support. The Information Officer within Connecting Families will need to liaise closely with the Knowledge Management staff supporting the MAC teams.

11. Operational model(s) for integrated working

There are many different configurations of multi-agency teams depending on the needs of children and young people and their families, the size and nature of the area they serve and the resources at the disposal of the agencies to commit to a multi-agency team. It is unlikely to be the case that each MAC team in Bridgend County will have exactly the same composition though there would be elements common to all.

The conceptual model in Appendix B indicates the functions which can be carried out through integrated working, the client or target group and the three categories of support which would be available in each locality (MAC team, ‘Resource Team’ and ‘Other’). The level of involvement with or dedication to a team will vary but members of the actual multi-agency community (MAC) team, whatever their expertise and type of support they offer would be part of the core provision within that team, ideally co-located. Resource team support is where a worker would be linked to a MAC team but operate from a central resource and may cover more than one locality. Other support describes potential services which can be commissioned to make provision that is not available from the MAC or Resource teams.

The partnership roles of agencies contributing to integrated working, whether they provide capacity in the actual MAC teams or not, are to be found in Appendix C. This is not an exhaustive list, but a fuller directory of services is being developed by the CYPP and this would provide an up-to-date directory of support services available to meet needs in Bridgend County.

While the precise constitution of any one MAC team might vary, MAC teams addressing mainly tier 1 and 2 needs through integrated working could typically include one or more of:

• Health visitor

• Primary mental health team
• Community/school liaison police officer / PCSO
• Social worker
• Education welfare officer
• Family support worker (local authority/voluntary sector)
• Youth worker
• Pre-Vent worker
• Housing officer
• Inclusion service (TAPPAS - Behaviour support etc)
• Educational Psychologist

The role of school-based staff, including the School nurse, and their relationship to the MAC team would need closer definition as working arrangements are determined. This relationship may depend to some extent on how far a MAC team is based in a school if it were to form a community hub or satellite to a hub. Also, if a Team Around the Child was set up for a particular child, and the needs of the child were significantly around learning, then the school staff would very properly be part of the TAC for that child. School staff would usually be well placed to complete an early assessment of need and/or initiate an early assessment of need.

Where Flying Start provision is in place, the relationship between a MAC team and the Flying Start team would need clarifying. That relationship could range from the sharing of information on families to establishing Flying Start as an integral but distinct element of a MAC team.

Practitioners in Resource teams would provide additional support to meet some of the lower incidence needs at tier 2 and above and could include:

• Drug and Alcohol support agencies
• CAMHS
• Youth Service
• Family planning
• Parenting services
• Family Information Service
• School and Community counsellors
• Referred services e.g. SaLT, Therapies
• Adult Mental Health Team CPN
• Benefits
• Day care support
• Want to work
• Bridges into work
• Careers service
• Job Centre Plus
• Language and Play
• Number and Play

Other providers commissioned to give support, even as members of the MAC team, might include: