The Scottish Government

Listen

ISBN

0 7559 1138 5 (Web only publication)

This document is also available in pdf format (224k)

Contents

Chapter 1: Introduction
Chapter 2: The content and process of assessment
The process of an Integrated Assessment
Content of an integrated assessment
biographical details
chronology
record of assessment of information
assessment and analysis
action plan
monitoring, review and lead professional arrangements, which include transition planning
information & communication technology ( ICT) and the integrated assessment framework
Chapter 3: Implementing an integrated assessment framework
prerequisites for managing change
principles of an implementation strategy
elements of an implementation
Annex A Glossary of terms
Annex B Membership of assessment working group

Chapter 1: Introduction

1. This paper is the first in a series of supporting documents that together set out the rationale for an Integrated Assessment, Planning and Recording Framework, as outlined in Section 3 of Getting it right for every child, a series of 3 consultation papers.

These supporting papers originated from the work of the Assessment Working group - a multi-disciplinary group of practitioners, managers and officials involved in children's services. The papers are as follows:

• Paper 1: Supporting document: this paper sets out the process and content of assessment within an integrated framework, to outline some of the processes involved in preparing organisations for change and to provide details of the key elements of an implementation strategy
• Paper 2: Mapping template: this has been developed to assist national and local planners, developers and practitioners to match materials that are currently used or are in the process of being designed against the requirements of the IAF. This will ensure that the existing multiplicity of assessment tools and materials are streamlined and move towards a more standardised approach that is adopted across Scotland.
• Paper 3: Case Studies: the aim of the children's histories is to facilitate the process of local discussion to: develop a shared understanding about the principles and concepts underpinning the IAF; explore 'how it might work' locally, and review what might be different under the Framework, what is in place to support its implementation and what needs to change

2. The Scottish Executive sees the Integrated Assessment. Planning and Recording Framework as providing one of the building blocks for the wider range of policy developments moving towards greater integration of children's services. It will underpin the Education (Additional Support for Learning) Act 2004, the Children's Hearing system, Youth Justice, the inclusion agenda, The Child Protection Reform Programme, Hidden Harm and other initiatives contained within Annexes D and E of the Integrated Children's Services Planning 2005-2008 Guidance.

3. Parents and professionals are continuously engaged in assessment in their interactions with children. From the birth of a child, parents and professionals draw on information to judge the most appropriate responses to needs and behaviour. Every action should be supported by assessment that suits the situation, however brief, simple or informal. The IAF provides guidance on the content and process of assessment when agencies are seeking to ensure that children and young people receive the services they need, tailored to their individual circumstances, at the earliest opportunity.

4. Assessment needs to take account of all influences on a child's life and should be rooted in understandings of child development. Assessment involves systematic analysis and evaluation, recognition of alternative explanations and interpretations for the purpose of planning. All those who are significant in a child or young person's life should reflect on and review what is known about them and their circumstances before planning the most appropriate action. The aim is to support assessment and action, which respects rights and needs, seeking the earliest, most effective and least intrusive responses.

5. In order to manage successful change, an organisation must have a clear understanding of its current structures and processes and a clear vision of its goals. This will help to identify the steps needed to promote, implement and manage change, and to shape the long term strategy required to support the Integrated Assessment, Planning and Recording Framework.

Chapter 2: The Content and Process of Assessment

6. Collecting, recording and sharing information is part of the daily practice of professionals working across Children's Services. Information is gathered and recorded as soon as a child is born; first by a midwife and then by a child's health visitor. The health visitor has responsibility for routinely updating a child's health record with details of immunisations, illness, treatments and other information.

7. Once a child begins school, responsibility for updating the information is transferred to the school nurse or to designated education staff in nurseries, primary and secondary schools. The school also initiates an educational record that follows the child through school. This includes reports and assessments, achievements and results from each year plus other relevant information that needs to be collected, such as attendance and absences. When a child or young person registers with a GP, health information is brought together to form a medical record that is added to throughout their life and moves with the child or young person.

8. The aim of assessment is to bring together and analyse relevant information to guide appropriate action. A variety of records are kept on all children, by different agencies, in different places. In many cases, these will already meet the requirements set out below.

9. Developing technologies, within initiatives such as eCare, will allow these records to be brought together in a common format, which will be accessible to the child and family, added to as the child grows and develops. This record will be able to draw together relevant information from health, education, social work and other services.

The process of an Integrated Assessment

10. The process of assessment involves planning the processes of gathering, recording and assessing information and identifying the relevant people or agencies to include. Information is analysed and restructured into a balanced account or overview of what needs to change for this child. Alternative explanations and differences of opinion and judgement are also noted. Facts and evidence will be clearly distinguished from opinion. Analysis provides the basis for identifying appropriate actions and plans to meet the child's needs.

11. Children, young people and their families (and significant others) will be fully involved in the process of assessment and their views and wishes and priorities evidenced and recorded. It is important to consider the most effective means of communication with the child or young person and to take account of observations of the child or young person's behaviour, interactions and relationships.

12. It is clear from research and practice that very young children are capable of expressing their reactions and wishes; this might include exploring verbal communication or other means such as play or drawing, makaton and sign language to understand the child or young person's views or reactions to events and concerns. These must be recorded and taken into account. Parent's or carer's accounts of a situation, the needs of a child or young person and what support is needed should also be understood and recorded. Differences of opinion on the significance and accuracy of information between professions or between professionals and family members might be expressed. Sources of information should always be identified and fact distinguished from opinion and different types of information differentiated.

"You want to decide who should know things about you. You want to keep control of what's written about you." (Young people in consultation, 2004)

"Respect, respect, respect!"

Content of an integrated assessment

13. The content of assessment includes:

• A core set of biographical details or person details for the child. These details can be shared across all agencies and professionals working with the child and family, either because there is consent or a concern.
• A chronology of significant achievements, developments, events and changes in a child's life, as well as a record of contact and action is already recorded by professionals working with children. The chronological account will be collated to a common format, allowing information to be recorded once for several purposes. Appropriate software will avoid additional burdens in record keeping.
• Record of assessment information. Assessment will be based on the evidence available. In order to assess the child's needs, appropriate information will be gathered about the child's life and experience relating to the main headings of the assessment triangle. What is already known and recorded will be brought together and any necessary additional information gathered.
• An action plan resulting from the assessment and analysis will be agreed. This will be structured and purposeful, with agreement about methods of achieving change for the child, and any services to be provided in order to meet the needs of the child. It will identify the responsible key worker/s and agencies, and agree timescales.
• A review date and method of updating the plan will be included. This review will evaluate whether the action plan has achieved the planned outcomes within agreed timescales and, if necessary, agree changes to the plan.

Biographical details

14. Specified limited data (listed below) will be compiled for all children. This will be derived from information that is collected initially from data recorded in the maternity and Scottish birth records. Some details will be collated at a later point. The task of staff will be to confirm that the details are correct or to update them. Much of the data is collected currently but the data listed below should be collected consistently using common language with agreed definitions. A minimal set of standards for recording a person's details has been developed jointly between the Scottish Executive's Social Care Data Standards Project ( SCDS2) and the NHS Scotland National Clinical Datasets Development Programme ( NCDDP) and is in the process of being adopted by the NHS. Adopting this will in turn ensure that person centred information can be easily shared and understood across agency boundaries and that duplication in recording information is kept to a minimum.

Person details and definitions

Name	An ordered sequence of person name elements such as title, forename(s) and family name
Birth Date	The date on which a person was born or is officially deemed to have been born, as recorded on the Birth Certificate.
Unique Person Identifier	Number which can be used as a common reference number across information systems to identify an individual or an individual's records
Gender	This is a factual statement, as far as is known, about gender (sex) of the person at birth. However, gender can be changed and a statement by the individual about their gender (sex) should be recorded.
Ethnicity	A statement made by the service user about their current ethnic group
Religion	A statement made by the service user about their current religious affiliation/ faith Community.
First Language	First language is 'the language normally spoken at home'
Preferred Language	This item is defined as the person's language of preference and may differ from first language (as defined as the language spoken at home) and is required for effective communication with the person.
Interpreter Required	Indication of requirement for assistance to communicate in English
Cultural Issues	Information about habits, beliefs, social conventions and customs, family structure, Ceremonies, dress, diet, health issues etc.
Preferred communication method	The method of communication used by the person to make themselves understood
Home Address	(Start Date) Normal Domicile address. The Address where the Child has resided the majority of the time and where a recognised carer for the child also lives.
Previous Address	(Start and End Dates). Any residences where the child has lived prior to where they are living now.
Current Address	(Start Date) The address where the child is staying at the present time
Contact Details	Details such as telephone numbers and e-mail addresses where a child or others associated with the child can be contacted
Educational Establishment attended	The Educational establishment where the child is currently enrolled. This could be a nursery, school, further education collage, or project
Previous Education	The Educational establishment where the child was previously enrolled.
Establishment attended	This could be a nursery, school, further education collage, or project
Child has a Disability	Most children whose needs fall within this category will have a medically diagnosed condition such as cerebral palsy, autism, or Downs Syndrome. However, there are some conditions where there is uncertainty or controversy about whether it is appropriate to regard them as intrinsic to the child. Currently the cause of "attention deficit hyperactivity disorder" is in dispute. For these purposes, however, if the main reason why agencies are involved is because the child is thought to have this disorder, then details should be recorded. Children who have been diagnosed as suffering from a psychiatric illness should also be recorded. The use of the term "disability" here embraces any illness or impairment that causes the disability. Although the majority of the children included in this category will be permanently disabled, this does not have to be the case. A child requiring care during the course of recovery from a disabling illness, or whose prognosis is uncertain, should be recorded
Child affected by Disability of Carer or Family Member	A child affected by the disability of another family member that impacts on the child's care. This includes permanent and temporary disability of a family member that results in the need for additional support with the care of the child due to their parents/carer's disability, illness or mental illness. These children may or may not be directly involved in the care of their parent(s). The key to recording this category is that the parent or carer has a diagnosable medical condition that is primary in requiring additional support with Child Care and there is insufficient or no compensatory help available other than through additional services. The medical conditions include seriously disabling mental illness (including personality disorders). Children who are in need because their parent or parents have learning disabilities that require additional support with child care should be included along with "young carers" who take on caring responsibilities for disabled or chronically ill parents
Legal Status	There are two reasons for attaching a legal status to a child: the first of these will be when the child formally becomes subject to an order, requirement or warrant from either a Sheriff Court or a Children's Hearing. The second defines the statutory basis for providing services to a child and/or their family. The legal status may change over time as a child progresses through the care System
Reporter's Administration involvement	Those children who are currently involved with the Reporters Administration and are subject to Supervision requirements or are subject to a warrant. Children who have had an initial hearing and have been referred to the Sheriff Court awaiting a proof hearing should also be recorded
Associated People	Associated people are the people who have a significant involvement or relationship with the person ( e.g. main carer, next of kin, relatives, emergency contact etc)
Sibling Details	Included in this category are those siblings related to the subject child through having one common parent linking them through birth or having being adopted into a family where the children in that family are linked to the adoptive parents through birth.
Other children living in the same household
G.P Details
Associated Professionals	Associated professionals are the people who are already involved with the person in a professional capacity e.g. social worker, occupational therapist etc
Child Protection Details	Current and Previous Child Protection Registration(s) Child Protection Registrations are used as an indicator to highlight that a child has been assessed as being at risk from their environment or another person. Child protection registration categories describe the risk factors associated with that child

Chronology

15. The purpose of a chronology is to document systematically achievements, events, developments and changes in a child's life, so that the pattern and impact of events on the child over time may be observed and responded to.

16. A chronology is important because it records the circumstances and experience of the child and milestones in the child's life, such as the date the child takes his or her first step unaided or the day the child first starts school. These are positive events to be celebrated by a family and which are usually easily remembered or recalled. Other significant experiences may be less positive but are an important influence on the life of the child, such as the break up of the parent's marriage, or a serious illness of a parent or sibling requiring a stay in hospital. This needs to be recorded as a chronology to identify at a glance the key patterns indicating needs, risks and services provided.

17. Each agency working with children will build chronologies over time. As part of implementation, local agencies will need to agree common formats. This will be in a format that enables records to be merged when it is appropriate for a multi-agency assessment or review. This will ensure that evidence of achievements, developments, patterns of need or risk is fully documented and accessible for scrutiny and change by the child or young person, family, carers and professionals involved.

18. Being able to share a chronology with the child and family as well as other professionals will often mean that certain patterns emerge that would not otherwise. For example, a series of missed appointments with one agency may not appear to be important, but if the same pattern emerges for all the key agencies involved this can become an important indicator or risk factor that needs to be addressed. Sharing this information can also have the converse result, it may emerge that one agency has been having regular contact with the child and can confirm that all is well, or parents can provide vital information that has until then been omitted. For families, the ability to have a summarised account of the child's journey from birth will enable them to make sense of the multitude of information that accumulates over the years. For the child, it will provide useful information at key transition points in life, such as when moving from primary to secondary school, ensuring significant events and experiences are not lost or forgotten. For some children who have frequent moves, this "life story" material will be valued, as busy and changing lives often mean information can be mislaid.

Content of a Chronology

19. A list of the information that might be recorded in a chronology is suggested below; but is not exhaustive. Incidents, events or experiences important to a particular child or young person will differ depending on the age of the child e.g. baby or young person, lifestyle, their relationships with family and peers, and their environment.

Significant changes to a child or young person's life	This includes: Household/family composition (such as separation/divorce/new member of the family, births and deaths) Place and nature of residence ( home/family/respite/foster care) Social and material circumstances (employment/income, housing etc) Significant events or issues in relation to health, education and general development
Contact with agencies	This might include: Medical consultations, reviews of school progress or behaviour, meetings with parents - if the child does not live at home, case conferences, Hearings, Looked After Children Reviews, multi-agency professional meetings Referrals for service, requests for a coordinated support plan Period of involvement of other services
Where appropriate, changes to legal status	Such as: Legal status (supervision requirement, adoption) Legal status of other family members, such as siblings
Family and social relationships	For some children it may be necessary to record the following: Interactions between family members, evidence of attachment; positive engagements and guidance; disagreements, family hostilities, violence and so on Significant reports or expressions of concern from other people such as family members, members of the public, neighbours or other agencies, such as the police, voluntary organisations

Who should compile a chronology?

20. All practitioners currently have a responsibility to keep case-records/contact sheets in various formats. Agencies should ensure that this information is held in a form that enables it to be swiftly collated into a contribution to an integrated record when it is required.

21. It is important that any professional in contact with a child or his/her family should record facts and evidence as they discover them. A health visitor on a home visit may observe a change in the mother that may traditionally be seen to 'be more relevant to another service or professional'. Similarly, a social worker may be told about an illness of a family member. A chronology of significant information needs to be seen to be the responsibility of any professional in contact with the child, and not just the province of the perceived lead worker.

22. The type of information collected through a chronology should be common for all practitioners working with a child or young person. This means that some information may be collected more than once by each agency. However, for agencies that need to work in partnership, an aim of the IAF is to minimise this duplication and allow for information to be exchanged appropriately. This needs to be considered as part of the planning process when undertaking assessment.

How does a chronology differ from a contact record ?

23. For those children and families referred for support or a service, information is gathered and recorded. This is commonly called a Record of Contact or Contact Record or clinical notes. This collates information and records the overall contact with that particular agency. It will include the date the child was first seen or was referred, it will record all subsequent contacts with that agency and a brief description of the outcome. This record can be very helpful in understanding what services have been offered at different stages in a child's life. For example:

• the date of a child protection investigation took place;
• the date the child or young person moved from living with one parent to another.

24. Significant information of this kind, contained within the contact record can usefully be summarised and marked for electronic transfer to the chronology.

Record of assessment information

25. Information about the child's life and experience will be recorded under the three headings of the assessment triangle:

• How the child/young person grows and develops
• What the child needs from people who look after her or him
• The child's wider world

26. The approach of the IAF is child centred and takes account of the child's perspective (see Figure 1). It draws on the Framework for the Assessment of Children in Need (Department of Health, Department of Education and Skills and Home Office 2000).

27. As stated in An Integrated Assessment, Planning and Recording Framework Consultation document, the framework for assessment is applicable to all children and young people ¹ and can be used to guide any assessment that takes place routinely within education and health as part of existing universal services. The same framework can also be used in an expanded or elaborated version where enduring needs or risks have been identified, and where more than one agency will be involved over time. It is important to emphasis that there will be different levels of detail proportionate to the circumstances of the child or young person.

28. All professionals working with children or young people should have regard to all aspects of a child's life, development and needs and what is required for all children to have the opportunity to fulfil their potential. The Assessment triangle ( Fig 1) represents a range of these aspects.

Figure 1
The Assessment Triangle

How the child/young person grows and develops

29. In order to understand fully how a child or young person is growing and developing it is important to consider all aspects of a child's/young person's life, including their health, education, developing social skills, confidence and independence, and the ability to form appropriate relationships.

Being healthy This includes full information about all aspects of a child's health and development, relevant to age and stage. Developmental milestones, major illnesses, hospital admissions, any impairments, disabilities, conditions affecting development and health. Health care, including nutrition, exercise, physical and mental health issues, sexual health, substance abuse. Information routinely collected by health services will connect with this. Learning and achieving This includes cognitive development from birth, learning achievements and the skills and interests which can be nurtured. Additional support needs. Achievements in leisure, hobbies, sport. Who takes account of the unique abilities and needs of this child? Learning plans and other educational records will connect here. Being able to communicate This includes development of language and communication. Being in touch with others. Ability to express thoughts, feelings and needs. What is the child's/young person's preferred language or method of communication. Are there particular people with whom the child communicates? Are aids to communication required? Confidence in who I am Child's/young person's temperament and characteristics. Nature and quality of early and current attachments. Emotional and behavioural development. Resilience, self esteem. Ability to take pride in achievements. Confidence in managing challenges, opportunities, difficulties appropriate to the age and stage of development. Appreciation of ethnic and cultural background. Sense of identity which is comfortable with gender, sexuality, religious belief. Skills in social presentation. Learning to be responsible Learning appropriate social skills and behaviour. Values; sense of right and wrong. Consideration for others. Ability to understand what is expected and act on it. Key influences on the child's social development at different ages and stages. Becoming independent, looking after myself The gradual acquisition of skills and confidence needed to move from dependence to independence. Early practical skills of feeding, dressing etc. Engaging with learning and other tasks, acquiring skills and competence in social problem solving, getting on well with others, moving to independent living skills and autonomy. What are the effects of any impairment or disability or of social circumstances and how might these be compensated for? Enjoying family and friends Relationships that support, value, encourage and guide the child/young person. Family and wider social networks. Opportunities to make and sustain lasting significant relationships. Encouragement to develop skills in making friends, to take account of the feelings and needs of others and to behave responsibly.

What I need from people who look after me.

30. It is important to build a picture of the ability of the parents or caregivers to understand and meet the needs of children and to respond adequately to them. Family circumstances and histories can have a huge impact on the confidence and ability of parents to look after their children and encourage their progress and development. Other significant relationships will crucially influence opportunities to grow and develop.

"What you want is loving, caring, feeding and close family and friends" (Young people in consultation, 2004)

Everyday care and help This includes day-to-day physical and emotional care, food, clothing and housing. Enabling healthcare and educational opportunities. Meeting the child's changing needs over time, encouraging growth of responsibility and independence. Keeping me safe Keeping the child safe within the home and exercising appropriate guidance and protection outside. Practical care through home safety such as fire-guards and stair gates, hygiene. Protecting from physical, social and emotional dangers such as bullying, anxieties about friendships, domestic problems such as mental health needs, violence, offending behaviour. Taking a responsible interest in child's friends and associates, use of internet, exposure to situations where sexual exploitation or substance misuse may present risks, staying out late or staying away from home. Are there identifiable risk factors? Is the young person knowledgeable about risks and confident about keeping safe? Being there for me Love, emotional warmth, attentiveness and engagement. Who are the people who can be relied on to recognise and respond to the child's/young person's emotional needs? Who are the people with whom the child has a particular bond? Who is of particular significance? Who does the child trust? Is there sufficient emotional security and responsiveness in the child's current caring environment? Play, encouragement, fun Stimulation and encouragement to learn and to enjoy life. Who spends time with the child/young person, communicating, interacting, responding to the child's curiosity, providing an educationally rich environment? Is the child's/young person's progress encouraged by sensitive responses to interests and achievements, involvement in school activities? Is there someone to act as the child's/young person's mentor and champion? Guidance, supporting me to make the right choices Values, guidance and boundaries. Making clear to the child/young person what is expected and why. Are household roles and rules of behaviour appropriate to the age and understanding of the child/young person? Are sanctions constructive and consistent? Are responses to behaviour appropriate, modelling behaviour that represents autonomous, responsible adult expectations. Is the child/young person treated with consideration and respect, encouraged to take social responsibility within a safe and protective environment? Knowing what is going to happen and when Is the child's/young person's life stable and predictable? Are routines and expectations appropriate and helpful to age and stage of development? Are the child's/young person's needs given priority within an environment that expects mutual consideration. Who are the family members and others important to the child/young person? Can the people who look after her or him be relied on to be open and honest about family and household relationships, about wider influences, needs, decisions and to involve the child/young person in matters which affect him or her. Transition issues must be fully explored for the child or young person during times of change. Understanding my family's background and beliefs Family and cultural history; issues of spirituality and faith. Does the child/young person have a good understanding of their own background - their family and extended family relationships and their origins. Is their cultural heritage given due prominence? Do those around the child/young person respect and value diversity?

The child's/young person's wider world

31. Children and their families are influenced and supported by their wider family, the neighbourhood and the social networks within which they live. An account of the family's community and wider world is needed to understand how a child/young person is developing and the opportunities for those who care for the child to respond to their needs. Research shows that this crucial focus is often neglected.

"We need more things to do where we live. We need swimming pools, football pitches, leisure activities which we can afford" (Young people in consultation, 2004)

"We need to be able to go out without gangs of older kids bullying us and giving us hassle." (Young people in consultation, 2004)

Support from family, friends and other people Networks of family and social support. Relationships with grandparents, aunts and uncles, extended family and friends. What supports can they provide? Are there tensions involved in or negative aspects of the family's social networks? Are there problems of lost contact or isolation? Are there reliable, long term networks of support which the child or family can reliably draw on. Who are the significant people in the child's/young person's wider environment? School From pre-school and nursery onwards, the school environment plays a key role. What are the experiences of school and peer networks and relationships? What aspects of the learning environment and opportunities for learning are important to the child/young person? Availability of study support, out of school learning and special interests. Enough money Has the family or young person adequate income to meet day to day needs and any special needs? Have problems of poverty and disadvantage affected opportunities? Is household income managed for the benefit of all? Are there problems of debts? Do benefit entitlements need to be explored? Is income adequate to ensure the child can take part in school and leisure activities and pursue special interests and skills? Comfortable and safe housing Is the accommodation suitable for the needs of the child and family - including adaptations needed to meet special needs. Is it in a safe, well maintained and resourced and child friendly neighbourhood? Have there been frequent moves? Work opportunities for my family Are there local opportunities for training and rewarding work? Cultural and family expectations of work and employment. Supports for the young person's career aspirations and opportunities. Local resources Resources which the child/young person and family can access for leisure, faith, sport, active lifestyle. Projects offering support and guidance at times of stress or transition. Access to and local information about health, childcare, care in the community, specialist services. Belonging Being accepted in the community, feeling included and valued. What are the opportunities for taking part in activities which support social contact and inclusion e.g. playgroups, after school clubs, youth clubs, environmental improvements, parents' and residents' groups, faith groups. Are there local prejudices and tensions affecting the child's or young person's ability to fit in?

Assessment and analysis

32. Assessment is more than a process of gathering information. It is vital that staff take time with the family to analyse and make sense of the information and to come to a view on what the information tells them about the needs of the child and risks to the child's well being, health or safety.

"Parents are expert… they see the whole range of behaviour. they don't just come in and take a snapshot" (Parents in consultation about assessment, 2004)

"Those who assess must know the child" (Parents in consultation about assessment, 2004)

"Some professionals are prepared to give an opinion about a child's behaviour and its causes when they don't know the child" (Parents in consultation about assessment, 2004)

33. As part of the analysis thought needs to be given to the weight assigned to different elements of information. Staff should come to a view and be factual and specific about the evidence to support this, from the assessment information and from the chronology.

34. The assessment should focus on the child needs in order to maximise her or his well being and, when analysing and weighing up the evidence gathered, the process of identifying risk needs to be considered. Therefore, assessments should consider:

Strengths and resilience	Such as: Good health Educational, sporting, artistic, leisure or other achievements Independence, strong sense of self Personal or family experience of overcoming problems/adversity
Protective factors	Such as: Favourable material circumstances and opportunities Strong supportive relationships within or outside family Community and social networks of support Easily accessible childcare and other services Openness about needs and problems Willingness to work collaboratively to meet needs, overcome difficulties
Needs and vulnerabilities including risks to the child or young person	Such as: Long term poverty and disadvantage Parents' ability to provide engagement, warmth, stimulus or guidance Consistent attention to health or educational development Opportunities for supportive peer and social relationships Health problems; disabilities; developmental delay Multiple sources of stress Risks might include previous neglect, abuse, family violence; history of criminal offences; substance misuse; isolation; negative or unstable relationships of carers; frequent changes of accommodation or housing need; number of out of home placements or changes of carers

35. All the information should be analysed and the impact considered of all the factors on the child's needs, development and safety .The support and services that the child or young person require needs to be evaluated. The outcome of analysis and assessment is the action plan.

Action Plan

"Assessment must be followed by coordinated strategies, agreeing the achievements and approaches to be followed in the different environments of the child" (Parents in consultation about assessment, 2004)

36. Action plans must be clearly derived from the systematic assessment and analysis of the information gathered about the child or young person. The action plan may be called a Learning Plan, Care Plan, Child Protection Plan or Coordinated Support Plan, to give just a few examples. It forms the agreed basis for providing support, services and resources to meet the needs of the child/young person.

37. The overarching aim is to achieve one agreed coordinated plan and planning process, which can be used for a variety of purposes, which makes sense to the child/ young person. It should reduce the number of meetings that a child/young person has to attend, and simplify the process for families and professionals.

38. The plan is an output of the assessment process (as is the review of outcomes) and as such will need to take account of the multiplicity of services and professionals who may be involved. For a child/young person with very complex needs, the action plan will need to show considerable detail, with subsidiary plans supporting each objective. Conversely, the plan may be very simple and involve just one service, or a change in delivering a universal service.

39. An effective action plan, will clearly state:

• what action should be taken and
• by whom to improve the child or young person's circumstances
• the reasons for this plan
• timescales
• intended outcome and future review date for the child, young person and, where appropriate, the family.

40. All family members and professionals working with the child/young person will need to ensure that the services planned are appropriate and can be delivered. Details such as how a parent can access a service need to be explored, otherwise the service may not be a practical reality. Transport and day-to-day arrangements will need to be considered from the outset and built into the Plan.

"Labelling must not be part of the process of diagnosis" (Parents in consultation about assessment, 2004)

Main components of an Action plan

41. The main components of an action plan include:

• Date of plan or previous plan
• The name of the assessment co-ordinator (See An Integrated Assessment,Planning and Recording Framework: Consultation document)
• The reasons why the child/young person needs support (or additional support) - why agencies or families believe a child or young person needs an action plan, including any issues of concern to be addressed.
• Details of the resources/services/support offered to the child and family. This will include the services, actions that will take place to meet the needs of the child/young person. It will include actions for the child him/herself, actions for the parent, actions for the carer, and actions for the named professionals involved with the child/young person.
• Details of the outcomes to be achieved with clear timescales and actions needed if particular outcomes are not achieved. Outcomes will also include educational objectives that have been derived from the child's personal learning plan, if the child/young person is of school age. Both short and long term outcomes with timescales for achievement need to be included. Where a child or young person is at risk of abuse or neglect or poses a risk to others, the action plan should identify the minimumrequirements or standards of care, nurture or behaviour to ensure the child is safe or the safety of others is protected.
• A named coordinator will be identified to ensure that the plan is being implemented, to be the key contact with the family - and whom all members of the team will contact, reporting on changes, updates or new information that may emerge. (In many cases this will be the same person as the assessment coordinator)

"There needs to be someone who is powerful enough to ensure it is the child and not the services, which dominate assessment" (Parents in consultation about assessment, 2004)

"The process of integrated assessment needs to be managed, facilitated. Differences of opinion need to be handled" (Parents in consultation about assessment, 2004)

• The names of all the key partners to the plan - professionals delivering the service, as well as parent(s), carer(s) and other family members. Contact details must be included, so that all members of the team are aware of who else is involved with the child or young person, and how they can be contacted.
• The child's views (and those of their parents or carers) about any or all of the action plan
• Compulsory measures - where compulsory measures of supervision are needed, the reasons for this should be recorded within the action plan

"It's important to ensure that those children whose parents find it difficult to access services and other support do not lose out" (Parents in consultation about assessment, 2004)

Monitoring, Review and lead professional arrangements, which include transition planning

42. The assessment coordinator will ensure dates are set for the plan to be reviewed. Some plans need only be reviewed annually ( e.g. Co-ordinated Support plan), whilst others may be reviewed more frequently ( e.g. a Looked After Child's plan needs to be reviewed 6 weeks after a child becomes looked after, then at 3 months and, following that, six monthly intervals). However, professionals need to be aware of, and respond to, new information that may arise and be able to respond flexibly without having to wait until the next review date.

" Do not reassess when the information is already there" (Parents in consultation about assessment, 2004)

43. A summary of the work undertaken in the review period and a review of progress, achievements, and any set backs including any outstanding work need to be incorporated into a review. The Review should have details of

• The name and contact details of the person who is responsible for monitoring progress and how this will be done
• The name and contact details of the person who is responsible for co-ordination, communication and undertaking review arrangements
• Consideration of need for a review and how this will be undertaken (meeting forum, paper, electronically) when this will be undertaken, who should participate and the need for prior assessments or review reports.

43. For those children and young people who face significant changes in the services and environment in which they live - for example moving from one school to another, a change of address involving new agencies or council services, or a move from children's services to adult provision will require careful planning well in advance of the move. All those involved in contributing to the action plan should consider who else should be brought in to the core group to plan for the future, so that the review of the Plan is well informed about what needs to be put in place when the move eventually takes place. Where a child or young person moves without warning, or goes missing, the coordinator is responsible for ensuring that the most recent action plan and assessment information is sent to the receiving areas as soon as possible.

Information & Communication Technology ( ICT) and the Integrated Assessment, Planning and Recording Framework

44. The IAF sets out a framework for all agencies to gather and record information about the children, young people and the families they have contact with. There will be a need for agencies to share different levels of information according to the child or young person's circumstances in order to avoid unnecessary duplication and to avoid families repeating unnecessarily the same information about their child to a variety of professionals in different circumstances. Finally, a more integrated approach to recording information should help prevent children and young people from going missing from universal services.

45. However, there are implications for sharing information and for the continued development of electronic systems to support this activity. It will be necessary to consider the following:

• the mechanisms, nationally and locally, to negotiate a consensus over the balance between information sharing and personal privacy.
• the protocols and policies needed to govern the sharing of information appropriately between agencies.
• identifying the infrastructure required to support information sharing
• the skills necessary amongst staff, children and carers to maximise the potential of IT and sharing information
• a review of data currently collected and how this is aggregated to meet the requirements for individual case management, for the strategic direction of each agency and for the Scottish Executive

46. Although, ICT has an important role to play in supporting the exchange of information between professionals, it is not the whole story. Information is often shared effectively between practitioners, children, young people and their families through current formal and informal processes. Developments in ICT need to be a platform for current information sharing, rather than the sole means of carrying it out. Therefore, different levels to information- sharing are envisaged:

• At its simplest level, practitioners need be able to check the accuracy of basic information recorded about a child or young person such as demographics or personal details
• The next level of information sharing is to identify key staff currently involved with the child
• The next level is for practitioners to be able to check whether the details of a relevant or current assessment is available.
• Finally, the system would enable those with legitimate responsibility to access and print information held by other agencies. This will include multi-agency assessment and service information as well as an event chronology and may also include alerts and messages shared on a multi-agency basis. This can then be used to inform assessments, reviews and reports required to meet the changing needs of the child.

47. This approach should support a sensitive and flexible approach to the sharing of various levels of information about children. It should be governed by either child/parental consent or by circumstances that legitimately must override this.

48. The Scottish Executive's eCare Programme is enabling and supporting local partnerships to develop electronic, multi-agency assessments and service records for children who receive support or services from those partnership bodies. Current partnerships are based in Aberdeen, Dumfries and Galloway, Glasgow and Lanarkshire and are implementing a series of local 'multi agency stores' with agreed standard national datasets. The stores act as a repository for consented data about an individual. Each agency sends its own information via an adaptor or web services to the store where it is held and viewed by other agencies. It should be noted that information is only sent to the store; information from the records of one agency systems is not stored on the systems of other agencies.

49. It is anticipated that these local stores will be able to exchange information on a national basis.
The Social Care Data Standards Project is working with eCare to produce agreed standard data definitions to support information sharing between people and systems across organisational and professional boundaries. Each individual organisation will continue to use its own IT systems to participate in the process. This makes the transition to the eCare system simpler as it will be incorporated into existing working practices. Where such flexibility does not exist, or where no system is in place, the eCare Programme has developed its own crown copyright product called e CART (electronic care assessment recording tool) which can be used as a stand alone application or incorporated into existing systems giving every user, regardless of their own operating environment, the ability to participate in the process electronically.

Chapter 3: Implementing an Integrated Assessment Framework

Prerequisites for implementation and managing change

50. Any strategy for managing change or implementing the Integrated Assessment Framework needs to take account of the evaluation of the implementation of a number of initiatives both nationally and locally across the UK. This includes the preliminary findings from the pilots of implementing integrated assessments in Ayrshire, West Lothian and Glasgow, the eCare pilot projects in pan-Grampian, Glasgow, Dumfries and Galloway, and Lanarkshire, the experience of implementing Looking After Children across the UK, and the Assessment Framework for Children in Need and their Families in the Community and Information Sharing and Assessment (formerly Identification, Referral and Tracking) in England (Department for Education and Skills 2004).

51. A clear message from all these initiatives is the importance of developing clear strategic plans for the management of change and the necessary supports for this process. The IAF is central to the Scottish Executive's commitment to the integration of all services for children and families. It is essential that the work undertaken to support the Framework connects with all aspects of the integration agenda. Those planning to implement an Integrated Assessment, Planning and Recording Framework will need to consider the following:

• Planning for change is essential. The focus of change required is broader than internal changes within agencies; it includes structures, processes and attitudinal change. Experience from the eCare projects has shown that time needs to be built into any plan for change to consider what is in place in the organisation and what needs to change. If this does not happen, successful implementation will be seriously hampered.
• A child centred approach and value base needs to be shared across agencies rather than simply within each agency. This will also involve a review of the way agencies support the active participation by and involvement of children, young people and their families. Implementation will be hampered if this is approach is not understood by agencies.
• Training is essential to increasing awareness of all professionals, in all organisations at all levels and to begin to change attitudes. This will include training for those with support functions, and administrative and managerial functions as well as front line staff.
• Information-sharing and electronic systems; issues of data sharing, privacy, confidentiality and access will need to be acknowledged and joint solutions agreed.
• Commitment and ownership within and across agencies must be in place as well as within each organisation at all levels from front line staff to senior managers. Senior management must be fully engaged with the process of change and be determined that change is integrated into mainstream practice and policy. Furthermore, previous experience of implementing initiatives such as Looking After Children in Scotland highlights the important role of first line managers in supporting staff in terms of change.
• Quality assurance mechanisms based on self-evaluation and external monitoring must be in place to ensure the IAF delivers better services to and outcomes for all children.

Principles of an implementation strategy

52. Key principles that underpin any implementation strategy include:

• Implementation should be supported by an effective communications strategy. Information should be developed in formats easily understood by professionals across agencies, and by parents, carers, children and young people. Communication and consultation are key elements of any implementation strategy. In particular, it is essential to involve and consult appropriately with key stakeholders including parents and children about the principles underpinning an integrated approach and the structure and content of the proposed framework.
• Implementation should have a multi-agency focus.
• The implementation strategy will need to be multi-layered with clearly identified links between a national implementation strategy led by the Scottish Executive and local implementation strategies led by local multi-agency steering groups.
• Implementation needs to be based on a realistic understanding of current practice within each organisation. Any strategy should seek to build on good practice and develop local arrangements that fit the needs of families and service users.
• Implementation requires a wide focus; implementation is not a one-off event, but has long term consequences both for the staff and organisations, that need to be fully understood, so that continuing support will be available for review and development.
• Implementation will involve attitudinal change and changes in working practice.
• Implementation will require collaborative working across the key stakeholders to plan for changes in terms of technology, resources and management structures and to implement the framework at both national and local levels.

Elements of an implementation strategy

53. Local implementation strategies need to consider the following elements:

• Practice needs of local organisations

Practice needs

Such as: Consider whether current inter-agency practice conforms with national guidance and regulations, local policy and procedures, each agency's expectations and identified good practice; Map current business processes: what are the current structures for assessing children and families; how far do these processes support integrated assessments and what needs to change; Establish a service directory with a database giving information about the local statutory services in the area - health, social work, education, the children's Reporter as well as links to relevant voluntary services and relevant databases and sources of information; Consider the current quality assurance mechanisms; and Develop clear operational procedures for the delivery of the an integrated framework in each locality across agencies Develop a local multi-layered training plan that will be a core requirement of the multi-agency strategic training plan. Managers and practitioners from across agencies will require different levels of knowledge about the IAF depending on their roles and responsibilities. Links need to be made with other multi-agency training for those working with children and young people to reduce duplication and encourage a partnership approach to working with children and families. Feedback channels will be necessary for staff, managers and families to report back; implementation may have a particular impact on some areas of practice and highlight areas of strong and weak practice. Coordinate feedback to the national multi-agency steering group.

IT needs

Such as: Assess the extent to which they are compatible with the data and other requirements of the IAF; Identify whether systems can be developed to incorporate the requirements of the IAF or whether new systems will have to be commissioned; Consider the links with eCare and data standards; Identify whether all teams and units are connected to the system and whether there are there sufficient computers for users; Whether the hardware has sufficient capacity to support an integrated framework; How, if there are gaps in current IT provisions, how this will be resolved; Establish the IT skills base of staff and whether further skills need to be developed to use the Integrated Assessment Framework

• Training needs of staff across the agency

Training needs

Such as: Develop a local multi-layered training plan that will be a core requirement of the multi-agency strategic training plan. Managers and practitioners from across agencies will require different levels of knowledge about the IAF depending on their roles and responsibilities. Links need to be made with other multi-agency training for those working with children and young people to reduce duplication and encourage a partnership approach to working with children and families. Feedback channels will be necessary for staff, managers and families to report back; implementation may have a particular impact on some areas of practice and highlight areas of strong and weak practice. Coordinate feedback to the national multi-agency steering group.

Annex A
Glossary of Terms

Action Plan	A coordinated structured plan that agrees methods of achieving change for a child, with timescales, responsibilities and any services that need to be provided in order to meet the child's needs
*Agencies	Organisations in the statutory or voluntary sector where staff, paid or unpaid, work with or have access to children and/or families. This includes, but is not exclusive to, social work, health, education and the police.
Assessment	An ongoing process of gathering information, structuring it and making sense of it, in order to inform decisions about the actions necessary to maximise children's potential.
Assessment co-ordinator	The person who will have overall responsibility for ensuring that the action plan is in place, who is going to do what and by when. They will also chair a meeting to review the Action plan.
Biographical Details	Details about a person such as Name, Address, and Date of Birth etc
*Child	Is a person under 16 years of age. It is also a young person over 16 years of age with special needs who requires help from statutory agencies in order to be protected.
Concern/Worry	An event, or series of events which affects the welfare or happiness of a child that leads to anxiety or unease in the person identifying the child's difficulty.
Chronology	A way to document systematically events, developments and changes in a child's life, so that their impact on the child over time can identify incremental benefits or harm.
ECare	eCare enables secure information-sharing between professionals - such as doctors, nurses, social workers and teachers - in public and voluntary agencies through the use of computers and communication technology.
ICT Systems	Abbreviation for information and communication technology.
Integrated Assessment report	A written report compiling a summarised account of what needs to change for this child/ young person, and should demonstrate the active involvement of the child and parents.
Multi - Disciplinary	Where more than one professional is working together and they belong to different disciplines within the same agency, and/or are from different agencies.
Named lead person	The person who will ensure that the plan is being implemented, to be the key contact with the family - and to whom all members of the team will contact, reporting on changes, updates or new information that may emerge.
*Parents	Includes those who have parental rights as defined in law and those who have care of a child. For example, foster carers and co-habitees.
*Partnership	Where more than one person, group, agency, professional or community are working together and share responsibility for decisions and actions.
*Professionals	Staff who work directly or indirectly with children and/or families and can include, but is not exclusive to, police officers, doctors, nurses, teachers, nursery staff, social workers, therapists, dentists, youth leaders, leisure and recreational workers, housing staff and staff who work in criminal justice, mental health or drug and alcohol services. In many cases the term 'professionals' may mean volunteers in contact with children.
Review Date	The date when the Action Plan will be appraised to determine if agreed outcome measures within agreed timescales have been achieved, and if necessary agree any changes to the plan.
Universal Services	Services that all children will have access to throughout their childhood, i.e. Health and Education Provision.

*Those terms included in the Protection of Children and Young People. Framework for Standards. (2004)

Annex B
Membership of Assessment Working Group

Norma Baldwin	Chair, Professor of Child Care and Protection
Peter Ashe	Information Consultant, NHS National Services Scotland
John Bissett	ASN Division, SEED
Anna Boni	Educational Psychologist, City of Edinburgh
Isabel Denholm	Children's Services Manager, Barnardos, Scotland
Christine Gilmour	Health Visitor, Highland PCT
Hilary Hood	Speech and Language Therapy Manager, Tayside
Alex Hunter	Children and Families Division, SEED
Andrew Keir	Social Care Data Standards project
Neil MacKechnie	Education and Cultural Services, West Dunbartonshire Council
Maureen Mathieson	ASN Division, SEED
Murray McVicar	eCare Childrens Services Coordinator, SEHD
Susan Orr	eCare project, Glasgow Council
Vijay Patel	Children and Families Division, SEED
Noreen Philips	ASN Division, SEHD
Michael Proctor	Primary Care Division, SEHD
Jane Scott	Centre for Child & Family Research, Loughborough University
Carol Thompson	Childrens Panel Reporter, SCRA
Tim Warren	SWSI, SEED (February-July 2004)
Adrian Williams	Assistant Director Social Work Services, Orkney
Cynthia Wise	Community Nurse, Borders

1 For the purposes of the IAF, the term child or young person embraces those aged
0-18. It also applies to the assessment of the unborn child and extends to those moving from Children's Services into adult provision.