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CHAPTER 5 Delivery of key processes

Overall, we found the delivery of key processes was adequate, with strengths just outweighing weaknesses.

Analysis of the key processes in children's services and adult social care was complex.

We found many examples of good multi-disciplinary working by children's services and adult social care staff.

There were a number of areas of service that needed to improve. The access/short-term teams in children's services and adult social care did not function properly. They struggled to take on new work because they could not pass on work to the long-term teams.

Senior managers in children's services and adult social care agreed there were unacceptable levels of unallocated work.

Access to services

Information about services

We found there had been a lot of work to develop and update information about social work services. Children's services provided more information than adult social care. The business support unit had commissioned a review of information leaflets for adult social care.

We found the on-line directory of children's services was very user friendly. The site linked enquiries about substance misuse to local services and national organisations providing help lines.

The council could provide interpreters for non-English speakers. The minority ethnic population was relatively small. Written information about council services was available in Bosnian, Polish, Urdu and Cantonese. Written information was available in Braille or large print and on audio tape. Lip readers and signers were available.

Initial contact with services

Children's services and adult social care were restructured in 2006. Each service reviewed the new arrangements after six months. The duty systems were changed again after the reviews.

Children's services

Children's services had short-term and long-term practice teams. The short-term team took cases for up to 12 weeks. Workers did duty on a rota. Staff had mobile phones and personalised answer machine messages to make them easier to contact. There were an average of 128 duty referrals per month, half of which were by telephone. Staff told us that the office move to a remote business park did not disadvantage the public as there had been few (12%) personal callers at the old locations.

Administrative staff in the children's services office said they were asked to cover reception duty with little or no knowledge of some services.

Adult social care

Adult social care had tried the short-term team (access) and long-term team model (complex care). They reviewed the model and made changes. A contact and response service was developed for new referrals. This was part of the access service. The access service got around 2800 telephone calls per month and this was the main referral route. Five to fifteen per cent of calls were unanswered. They were only able to keep two lines open out of a possible seven, even though they had an agency telephonist. Managers knew about the concerns of front line staff about this. They also said they had trouble contacting colleagues.

Out-of-hours service

The emergency social work service based in Edinburgh provided the out-of-hours service. East Lothian had a crisis response service based in a care home. The council was reviewing its arrangements for out-of-hours cover. Midlothian and Scottish Borders councils were included in the review.

HMIe's child protection inspection found that the police call centre and the emergency social work service made sure a professional worker could always be contacted by anyone who had a concern about a child.

There were planned changes to mental health services to provide a response to both urgent and non-urgent referrals between 9 am and midnight. The council was working with NHS Lothian to develop a 24-hour, seven-day-a-week community alarm and telecare service.

Day-to-day planning and resource allocation

Children's services

Every child registered on the child protection register had an allocated social worker. The short-term team had had an increase in child protection referrals. This had resulted in an increase in caseloads. The short-term team had a limit of 12 weeks for how long it could hold a case before passing the case on. The team was keeping cases for over 12 weeks. This was because the cases needed a level of work that the long-term team could not provide.

In a recent pilot development, a multi-agency screening group had been set up to screen police juvenile liaison officer ( JLO) non-offence referrals. We observed a meeting where many of the referrals were appropriately taken by partner agencies or other council services.

A similar screening group had just been introduced in youth justice for offence-related JLO referrals. The purpose of this group was to make sure there was an appropriate response to low level offending without involving the children's reporter. It had not been possible to join this group with the officer group for persistent offenders.

Management information systems about referrals and caseload activity were better in children's services than in adult social care. Workload management was based on supervision of individual staff. Children's services and adult social care did not have a specific workload management system.

Adult social care

The developments which had taken place in adult social care since the restructuring in 2006 were considerable. These changes were made to make better use of resources.

Service managers could allocate care services in urgent circumstances but this needed to be ratified by the resource panel. This was introduced in 2004. All requests for funded support or residential care had to go to this panel that met weekly. Managers thought the resource panel was necessary for gate-keeping and for control of the budget. They also thought it helped social work staff to prioritise who needed care and what care they needed. Adult social care eligibility criteria was introduced in 2005.

Workers had mixed views about the resource panel. Some thought it was burdensome. Applications were often sent back for information that workers felt was already there. This caused delays. The reasons for decisions were not always clear or consistent. Managers knew there were some tensions around the operation of the panel. They had offered staff the opportunity to attend, but few had done so.

Eligibility criteria

In June 2005 the council decided only adults who had critical or substantial needs should get a service from adult social care. People with moderate or low needs were to be sent to other services.

Eligibility criteria for adult social care

Critical: The risk of major harm/danger to a person or major risks to independence.

Substantial: The risk of significant impairment to the health and wellbeing of a person or significant risk to independence.

Moderate: The risk of some impairment to the health and wellbeing of a person or some risk to independence.

Low: Promoting a person's quality of life or low risk to independence.

Eligibility criteria for children's services

Low: There is not an immediate or foreseeable risk of the child suffering harm or impaired health and development, but the provision of social work services would significantly improve the child and family's life chances and quality of life.

Moderate: There is some risk of impairment to health and development. Without social work intervention there will be a risk of family breakdown or of harm befalling the child.

Substantial: There is a significant risk of the child suffering ill health or impaired development. There is a significant risk of family breakdown, or the child is already accommodated and there is a significant risk of placement breakdown. The child and family may be in need of intensive support and this might include respite care or daytime care.

Critical: There is a risk of major harm to children, or the child is in need of care and or protection, or the child poses a danger to others. The child has been assessed as needing to be accommodated away from home or closely supervised at home.

Only children and families with critical or substantial needs got a service from children's services. This meant there was a waiting list for some services.

We were concerned that children meeting the 'moderate' criteria for eligibility could have substantial risk factors yet get no service. We think that a child assessed as moderate rather than 'substantial' or 'critical' in terms of need would likely have significant protective factors that meant the risk was not of a higher order. As the criteria stand, these factors are insufficiently explicit to give good guidance to staff making crucial decisions. We found no evidence that people below substantial or critical in eligibility got support to get other services. Staff told us that it was common for someone not to get a service, only to return in worse circumstances a few months later. Then they got a service.

Recommendation 2
Education and children's services and adult social care should review the application of the eligibility criteria for their services.

Recommendation 3
Children's services and adult social care should make sure that people who are assessed as below the threshold for social work intervention get some help to get appropriate alternative services.

Unallocated work in July 2007

Children's service's figures showed that 233 children in need did not have an allocated worker. Some of these children may have been in the process of being assessed.

There were 11 looked after and accommodated children who did not have an allocated social worker. Senior managers agreed that this was unacceptable.

Recommendation 4
All looked after and accommodated children should have a named allocated social worker.

There were 36 families of children with disabilities that were waiting to get a social worker. Some of the children with disabilities were getting other council services.

The number of unallocated cases in adult social care was unacceptable. The head of adult social care and the director of community services acknowledged this. In adult social care there were 494 people on the waiting lists. The figures combined those waiting for social work, an occupational therapy and a community care assessment. Eight of these people were waiting for both a comprehensive and supplementary assessment. One-hundred-and-forty-five people were getting service but were waiting for an assessment or reallocation. There were no unallocated adult protection cases.

The older people access service had 241 people waiting for a comprehensive assessment, 79 people waiting for a simple assessment and 23 people waiting for a supplementary assessment. Complex care had 5 people waiting for reallocation and 3 people waiting for a comprehensive assessment.

Some service users did not get an allocated social worker when their case was transferred to the complex care team. These were people who had been assessed, and who had a care package in place. The service user could make contact if there was a change or a crisis.

Discharge response team

The discharge response team helped people who came out of hospital.

In 2006 the team got around 98 referrals per month. One-third of the people referred just needed equipment. Almost two-thirds of the people needed a care package. The team had reduced the delayed discharge figures but this progress had not been sustained. The team was not able to reduce repeated admissions to hospital because it concentrated on preventing delayed discharge.

Occupational therapy services

The occupational therapy service had a waiting list for equipment and adaptations. The service was doing a review. The purpose of this was to try to improve performance and change staff resources to meet service user's needs better. There had been initiatives to reduce waiting lists, particularly in the simple assessment service (32 referrals per month). These initiatives had included driver technicians helping to install equipment. Evaluation showed very high levels of customer satisfaction with this service. They had to stop this pilot service as they did not have enough staff.

Assessment and case management

Assessment

Our file reading exercise found that 93% of files contained an assessment. The majority of service users who responded to our survey said that they had seen a copy of their assessment. We judged the quality of the most recent assessment to be good or very good in 69% of cases.

The single shared assessment tool used was Carenap. We found from our file reading that health staff did not act as lead assessors. Historically, health and social work staff used the e-assess stand-alone system to record assessments. The introduction of Carenap meant double recording of assessments for care managers. This was unsatisfactory. There was an IT compatibility problem. There were problems getting health staff to use Carenap. An officer had been appointed to sort this out (funded by the joint improvement team).

Managers in the access service were dealing with staff concerns that Carenap was burdensome in less complex cases. They were developing a shortened version of Carenap. Staff in complex care and mental health used a person-centred planning tool. Some staff felt this did not fit younger service users as well as it did for older service users.

Our file reading and survey results showed the following:

• Risk assessment pro formas had been introduced without training for staff or supporting documentation. This lead to low levels of completion.
• Staff thought assessment procedures involved duplication of information.
• Independent sector providers said many assessments they got had limited information about the service user. They rarely included the Carenap.
• Agencies that supported carers and young carers were not given carers assessments.

Children's services had an integrated staged assessment framework based on the triangle of needs. ¹⁰ Education and health staff were involved in the assessment process. Staff liked the initial assessment pro forma and action planning tool.

Scottish Children's Reporters' Administration ( SCRA)

In 2005-06, 55% of East Lothian's reports to SCRA were submitted within the target timescale of 20 days, significantly better than the Scottish average of 36%. Figures for the previous two years were also better than the Scottish average and performance had improved over the three-year period. However, the figure for 2006-07 (48%) showed a dip in performance, although it was still substantially better than the Scottish figure (33%).

The children's reporter was satisfied with the good quality of the reports produced by social workers and was confident that action plans would be followed through.

A specialist team to support children and families affected by disability had been planned for some time. This would increase capacity to do assessments of the needs of children with disabilities (section 23 assessments). Children's services staff acknowledged this was an under-developed area.

At the time of our inspection 39 children were registered on the child protection register. Twenty-nine of these children were registered because of the effect of parental substance misuse. We found there was good information exchange between children's services and criminal justice. Communication between children's services and the rest of adult social care was not so good. Managers were trying to deal with this.

Case recording

Our file reading found that 66% of records were continuous but any gaps were usually justified. The level of recording was in keeping with the needs of the service user in 83% of cases.

We found the file structure was confusing. Some files we looked at were hard to follow. Some of the information was not filed in the right place.

We found that many workers recorded in long hand rather than use the electronic Carefirst system. Some file entries were not legible. Administrative staff said it was hard to get social workers to follow electronic file handling procedures. This gave them extra work tracing files and tracking their status.

Case management

The results for children's services files were better than those for adult social care in a number of areas. These included the following:

For the most part this good performance by children's services was confirmed in our fieldwork. We observed looked after children reviews chaired by the part-time reviewing officer. The atmosphere created by the chair helped the family to have their say. Advocacy workers were well briefed by families and were included in meetings. Families told us they found the process was fair overall, although they felt that negative reports were given "more air-time" than positive ones. We thought that a voluntary agency doing parenting assessments was a good development. We saw good involvement from psychological services in a case where the parents had learning disabilities. We felt this made sure the parents were not disadvantaged.

The children's services reviewing team was developing a database to improve its information systems. They hoped the database would make sure that permanency was considered for all children after they had been accommodated for six months.

Family group conferencing was quite well used. We saw evidence of this from file reading and fieldwork. We observed a meeting where social work was criticised by family members for not doing things they agreed to do at the previous meeting.

Children's services, adult social care and their partners were developing a transitions protocol. The Lothian transitions protocol was used at the time of our inspection.

Partner agencies providing child care services were satisfied with the quality of the referral information they got from children's services.

In adult social care a standard letter was sent to service users where initial screening indicated that they were eligible for services. It was vague about when people could expect the service to contact them. We also heard from service users that there was not always a hand-over meeting to explain that they were being transferred to complex care. It was only when they made contact that they found their case had been transferred and their case was open but unallocated.

Partner agencies told us that the quality of the referral information they got from adult social care was not good and that reviewing of care was assumed to be their responsibility. They said there was no input from adult social care. Agencies that supported adult and young carers told us that carers assessments were not shared with them.

Adult social care staff told us that after the three-month review there were no further reviews of service users who lived in care homes. Adult social care needed to decide what resources would be required to meet the terms of the national home care contract.

Recommendation 5
The council should comply with the reviewing requirements of the national care home contract.

Risk management and accountability

At our file reading, 14 out of the 17 relevant children's files had an up-to-date risk assessment, but only 2 of the 12 adult files had one.

The single shared assessment tool used in adult social care had a section on risk assessment but this was often left blank. A separate risk assessment tool was devised and introduced by management but our file reading revealed that this was also left blank. Adult social care staff told us that the form had been introduced without training.

Children's services had done a broad consultation exercise on risk assessment. There was agreement to have a stand-alone risk assessment tool.

Foster care

Some foster carers told us that social workers sometimes left them to cope with serious risk. One gave an example of supervising contact between accommodated children and their parents. The parent's behaviour was difficult and volatile. We got corroborative evidence from our file reading. We read a case file where a father had been extremely threatening to social work staff. The social worker later asked a number of people, including a foster carer, to supervise access between this father and his children. The social worker did not mention the risks when they tried to get someone else to supervise the access. There was no risk assessment on file. Managers did finally get involved and the matter was handled better.

Recommendation 6
Children's services should make sure that foster carers are not exposed to unacceptable risks. Risk assessments should be done where appropriate.

Child protection

We found the appointment of a child protection manager had improved child protection practice. Staff expressed confidence in the current procedures. We saw good practice at case conferences. We found a strong commitment to continuous improvement from all of the partners. There was an integrated services manager (the post was jointly funded by the local authority and health). This individual helped front line health staff to understand their responsibilities in child protection cases. There were regular multi-agency practitioner days and a jointly agreed training programme. Training in adult protection was to be linked with this.

We read a number of files for children affected by substance misuse. We were concerned about the lack of communication between substance misuse workers and children's services workers. The HMIe's child protection inspection report (2007) also said this was an issue.

Another concern was that social workers assessments of the level of parental drug misuse were based only on what the parents said. The parents tended to play down the amount and frequency of their drug taking. There was no assessment from a suitably qualified worker about the parent's drug misuse.

Recommendation 7
In child protection and child care cases children's services and their partners should make sure substance misuse workers and children's services workers work together and communicate properly. Children's services staff should always get an assessment from a suitably qualified worker about the level of the parents' drug misuse. These assessments should be updated as appropriate.

Adult protection

In 2006 the council hosted multi-agency training to launch the adult protection guidance. Voluntary sector partners said this had been an excellent event. The council was going to join forces with Midlothian Council later in 2007 to do more adult protection training.

In 2006 East Lothian was one of the first Scottish councils to establish an adult protection committee.

We learned from a number of sources that professional discussion meetings were the initial response to adult protection concerns. We were told that often there was no progression to an adult protection case conference. Senior managers told us this was to " avoid escalation". We were concerned that this practice could lead to adults at risk not being protected.

Recommendation 8
Adult social care and their partners should stop having formal "professional discussion meetings" as an alternative to an adult protection case conference. An initial adult protection case conference should be held under the adult protection procedure.

Partnership with people who use our services and their carers

Children's services

The HMIe report of 2007 said children's services were not sufficiently child centred. Steps had been taken to try to change this. For example children's services had done a pilot study on how to involve service users in decision making. It used viewpoint, a computer programme designed to help find out the views of young people and their carers.

We noted that remit of the children's rights officer was wide and included aspects of quality assurance, such as doing exit interviews. We saw no evidence that this information was being used to improve outcomes for children. Children's services staff agreed they needed to do better at involving children in service planning. They planned to have an inter-agency consumer involvement post by autumn 2007.

Children's services felt it involved children and family members in their own reviews. It helped children to see electronic information about them, such as care plans. We saw evidence of this at a child protection case conference. The chair made sure information was given out in advance and family carers were fully involved in discussions. We learned that looked after children were involved in the development of information leaflets for young people in care and leaving care. We learned of plans to send questionnaires to parents after initial child protection case conferences. The Who Cares worker planned to complete these with parents after the review case conference.

Financial allowances for kinship care were restricted or not paid at all. This was due to budget constraints.

Adult social care

We saw a good example of a service user and their family being fully involved in a review to discuss the service user's future living arrangements. Staff said that service users were directly involved in the assessment and care planning process and they got a copy of their care plan. A number of service users we met said they did not have a copy of their (adult social care) care plan. They did have care plans from independent sector providers.

Some staff had got training from the national development team on assessments that are focused on outcomes. Adult social care acknowledged it needed to develop a better way to get service user feedback.

We met carers in various settings. Their biggest issue was a lack of communication about:

• new structures
• staffing changes
• the content of assessment reports going to the resource panel and the appeals process.

Inclusion, equality and fairness in service delivery

Six out of 15 respondents to our stakeholder survey thought that adult social care and children's services worked hard to engage with people in hard to reach groups. A further seven respondents neither agreed nor disagreed with this statement. Eleven out of seventeen respondents agreed that adult social care and children's services promoted equality and diversity.

Children's services

Children's services had produced a 'vision and values' poster and a poster and media campaign to promote local area co-ordination for children with disabilities and their families. The children's services charter had some good principles.

We found some evidence that children in foster care were unable to get an advocate. This deficit should be addressed.

Some fieldwork staff said children with disabilities were a low priority. Staff were positive about the plan to develop a specific service for children with disabilities. Vulnerable children from rural primary schools were helped to make the transition to a large secondary school.

There was a social work link person for traveller families.

Adult social care

A council report (2003) identified shortfalls in the provision of some advocacy services. We found evidence that advocacy services had improved since 2003.

Multi-disciplinary working

A senior manager told us, "There is a strong culture of constructive multi-disciplinary working within children's services and adult social care and externally with health, police, and the independent sector".

Eight out of 15 respondents to our stakeholder questionnaire agreed that planning structures engaged all major stakeholders. Stakeholders were generally pleased with the extent of multi-disciplinary working in children's services though they felt that education could involve themselves a bit more.

Staff questionnaire results showed 67% of staff who responded, said their team had a good working relationship with education. Results also showed good relations with health (74% of respondents). Fifty-five per cent of staff who responded to our survey said their team had a good working relationship with the housing service. This figure was comparable with other inspected authorities but at the lower end of the scale.

Children's services

The 2007 HMIe inspection of services to protect children and young people found that agencies worked well together to identify and intervene if there were immediate risks to children. Staff were clear about roles and responsibilities. There was good joint training.

Children's services staff met every two months with the children's reporter and the chair of the children's panel. The reporter said teachers usually attended children's hearings. There had been joint appointments to specialist nursing posts to support children with complex needs and children at transition points.

We also saw a weekly gate-keeping meeting attended by the integration team manager and a manager from education services. We found good working relationships. There was a limited health contribution to this group and the multi-agency resource group to consider children's placements. For example, the looked after children's nurse did not attend the gate-keeping meeting, though issues about children's health needs were discussed. Children's services and their health partners should make sure health staff go to relevant meetings about children.

Adult social care

Home care staff said they had good working relationships with private agency staff and that there were several shared-care cases.

Adult social care workers said that there were clear protocols on information-sharing. We heard that health needed to do more single shared assessments. We heard from a group of service users that once care packages had started up, adult social care and health staff worked well together.

Adult social care staff told us that working relationships with health were good but that there were problems getting physiotherapy for people who needed it.

In mental health services, staff said there were good working relationships between adult social care and community psychiatric nurses. Problems sometimes happened when ward staff did not involve adult social care staff or follow discharge planning procedures. Adult social care and their health partners should make sure hospital ward staff follow the discharge planning procedure.

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