The Scottish Government

« Previous | Contents | Next »

Listen

CHAPTER 3: Key outcomes for people who use services

Outcomes for adults, carers, children and families who use services

The social work division performed to an adequate standard in delivering positive outcomes - with strengths just outweighing weaknesses.

We define outcomes as the direct benefits to people's lives from the services they receive. People who use services whom we surveyed were mainly positive about the differences these had made to their lives. Adults with mental health problems were particularly positive. However, some families with children with disabilities had to wait a considerable time before a service was provided. Seventy adults with a learning disability were still resident with a single care service. There were a number of service users with critical needs who were placed on a waiting list, rather than being provided with a service.

Carers were generally positive about the services provided to the people they cared for, but less so about those provided for themselves.

The division collected some outcome information, but this was limited. It was taking action to address this.

The information showed good performance around educational attainment and throughcare and aftercare services for care leavers. Performance information in relation to mental health service users was also good.

Permanency planning for some children was not happening fast enough.

More needed to be done to modernise services and improve outcomes for older people and adults with learning disabilities.

Measuring outcomes

In common with most local authorities Midlothian's social work division did not yet routinely measure outcomes for all care groups. They were collecting some performance information and were one of the local authorities involved in piloting outcome measures for community care including UDSET (User Defined Service Evaluation Toolkit). This is a national programme designed at improving the focus on, and measurement of outcomes for service users and carers.

Although not yet fully embedded, we met a range of staff who understood the need to define positive outcome objectives and to monitor progress in meeting these. A client relations officer was in post. A new management information system called 'framework i' which the division had commissioned in order to improve its ability to measure outcomes as a key objective was due to be introduced. The existing system was limited in the outcome performance data which it could provide.

Views of people who use services and carers

Most service users who responded to our survey agreed that social work services had helped them to feel safer (82%) and to lead a more independent life (84%).

Less than half (49%) agreed that social work services had helped them feel part of the community. This was the lowest result in inspections to date, although this result is directly influenced by the profile of respondents to the survey and their needs.

The findings of our carers' survey were broadly comparable with the other 20 local authorities inspected to date. They were more positive about the impact of social work services on the person they cared for than on the outcomes for themselves. For example, the majority of respondents agreed social work services had resulted in an improved quality of life for the person they cared for (69%), had helped them feel safer (59%) and to lead a more independent life (52%). However, less than half (48%) agreed that they felt valued and supported as a carer, and that they were helped to have time for family work and other commitments (36%).

We undertook a survey of partners and stakeholders and received 19 responses. 61% of respondents agreed that overall the social work division provided good outcomes for people who use services and their carers. None disagreed and 39% neither agreed nor disagreed.

File reading analysis

Overall the findings of our analysis of case files for key outcomes were positive and were either higher than, or in line with, the average in inspections to date. In particular:

• In almost all (90%) of the case files where there was a care plan, there was evidence that its objectives had been or were in the process of being achieved;
• In most of the files (82%) there was evidence that the individual had been helped to access mainstream services;
• In the majority (66%) of files there was evidence that the individual's circumstances had improved; and
• In most (83%) of the files changes in dependency were found to be in keeping with the needs of the service users.

Services for children and families

Children in need

Midlothian had established integration teams within the education and communities division. These teams played an important role in ensuring that universal services intervened in children's lives at the right time and level. The teams included staff who were qualified social workers.

Midlothian had a partnership with Children 1st to support young carers. We met with a small group of young carers who said they found it helped them to be able to talk to other young people about being a young carer. This initiative had moved away from traditional youth activities to a more therapeutic approach.

Children with disabilities

We saw little outcome-related performance information about children with disabilities. Information submitted by the council for the national performance indicators indicated that it performed well in 2006-07 in the provision of respite (short breaks) for families of children, on both an overnight and daytime basis:

• Midlothian Council was ranked 1st out of 31 local authorities on the total overnight respite nights provided for children. The 2006-07 figure was 139.6 nights per 1,000 population.
• Midlothian Council was ranked 3rd out of 31 local authorities on the total daytime respite hours provided for children. The 2006-07 figure was 1599.9 hours per 1,000 population.

However, we were advised by the division that the data used for this purpose did not distinguish between children with disabilities and other children.

Child protection

As at March 2007, Midlothian Council had 80 children on the child protection register which, at a rate of 5.1 per 1,000 population, was significantly above the national rate of 2.8 per 1,000. This was an increase of 30 children from the previous year.

In 2006, HMIE (Her Majesty's Inspectorate of Education) completed a joint inspection of services to protect children in the Midlothian area. Many of its findings were critical, including those in respect of outcomes which were either evaluated as weak, or as in the case of 'children's needs are met' as being unsatisfactory.

Following the publication of the Midlothian child protection joint inspection report in February 2007, SWIA conducted an analysis of social work case files in Midlothian in March 2007 to provide an indication of both strengths and areas for improvement. The report highlighted the need for improvement in a number of areas, notably:

• management of unallocated cases
• assessment and care management
• assessment and management of risk

These findings applied to both community care and children and families services.

An action plan was provided by the council in respect of the more serious issues of risk assessment and risk management. The outcomes of the action plan and the other issues are addressed in Chapter 5.

After the 2006 HMIE inspection the council drew up an improvement plan which had since been the focus of considerable activity. HMIE undertook a follow-through inspection in December 2007 ⁹. The report of this said 'services were working well together to improve outcomes for children'. Amongst other things:

• steps had been taken to ensure all children on the child protection register had an allocated social worker;
• an independent chair person for case conferences had been appointed;
• child protection plans were clearer; and
• there was a more consistent approach to the assessment of progress in implementing the child protection plan.

We read a number of child protection files as part of our 2008 file reading exercise. In some cases we questioned why concerns about children which should have been discussed by means of a multi-agency IRD (Inter-Agency Referral Discussion) had not been. As a result, the division decided to introduce the random sampling of referrals where the decision had been taken not to have an IRD to check that decisions were appropriate.

Managers told us that the arrival of a significant number of inexperienced staff and a tendency to 'play safe' had been key factors in the increased number of children on the child protection register in 2007. By the time of our inspection the number of children on the child protection register was reported as being 66.

Looked after children (at home and accommodated)

As at March 2007, the proportion of looked after children in Midlothian was higher that the average for Scotland (1.6 % of the population 18 years and younger compared to 1.3%). Midlothian's figures had been consistently above the national average for the previous five years.

In 2006-07, there were 209 children who started to be looked after and 185 who ceased being looked after. The accommodation types were in line with the national picture with 87% in a community setting and 13% in residential care.

Of the 201 children looked after away from home on 31 March 2007, 74% had been in placement for 1 year or more and 24% had three or more placements. For Scotland the figures were 72% and 29% respectively.

We saw that the social work division had noted in late 2005 that it had a disproportionately high number of children and young people who were looked after and accommodated (including a high number of young people placed in residential schools outwith the authority) and had taken a range of actions, including:

• the establishment of a Multi-Agency Resource Group ( MARG);
• a focus on ensuring that care plans were reviewed; and
• a joint project with Children 1st to ensure the systematic use of family group conferencing.

By the end of 2007 the total number of looked after and accommodated children and young people had dropped from 163 to 125 ¹⁰. This was at a time when the trend nationally had been rising. The number of children and young people placed in residential schools outwith Midlothian fell by two thirds, whilst the number in kinship care doubled from 42 to 87. This meant that almost a quarter of looked after children in Midlothian were in kinship care placements which was double the national average. We comment later in the report on kinship care arrangements.

In 2006-07 ¹¹, 54% of all care leavers in Midlothian obtained at least one qualification at SCQF level 3 or above which was just greater than Scotland's total of 52%. Encouragingly this represented an increase of 23 percentage points on the previous year, including a 9% increase for care leavers away from home.

Performance in respect of qualifications in maths and English was not as good. Overall, 29% of all care leavers in 2006-07 obtained these qualifications at SCQF level 3 which was below the Scottish average of 34%. Whilst the position for leavers from care at home was above the national average (28% for Midlothian compared with 26% nationally), the position was significantly below in relation to leavers from care away from home (29%) for Midlothian, compared to the Scotland total of 45%.

The number of young people to whom this performance data applies is small which means that year-on-year fluctuations can be significant. However, the impact of poor educational attainment for an individual young person can be considerable. We saw evidence of effort being made to improve the educational experience and attainment of looked after children.

Adoption and fostering services

The Care Commission undertook inspections of the council's fostering and adoption services in January 2008. There were almost 80 children in foster care at this time and the inspection found most of them had experienced changes of social worker. Many of these workers were inexperienced in this area of work. Both staff and carers were concerned at the uncertainties this caused and there was evidence that planning for children had suffered as a result.

Front line staff told us that there were children in foster care who did not have an allocated social worker. During a focus group, foster carers all said that planning took too long and a number cited examples of delays in permanency plans either been prepared and/or implemented. Senior managers told us that they would continue to monitor and act to improve the situation.

Midlothian, due to its small size, was not able to provide the full range of adoption services directly. Most of its adoption work was contracted to a local voluntary organisation: the Scottish Adoption Association. The Care Commission's inspection included two requirements and 11 recommendations amongst which was the need for adoptive families to receive support to ensure the future of their adopted children was secured.

Throughcare and aftercare services

Corporate parenting ¹² requires all services in the local authority to work together for the good of the child. The social work division performed reasonably well in this.

In 2006-07, there were 35 care leavers in Midlothian. All of them had a pathway plan and a pathway co-ordinator. This was twice the national average. Similarly, they were all still in touch with the service which compared to 88% nationally.

We held a focus group with a number of young people who were involved with the throughcare and aftercare team. They all spoke positively about the support they received. Some of them expressed frustration about the lack of appropriate accommodation for care leavers which we return to later in the report. The team had no waiting list of young people due to leave care within the following six months.

The team worked in close partnership with Careers Scotland who provided specialist support to these young people. The throughcare and aftercare team said that this played an important part in the council's strong performance against the national indicators. Fifty five per cent of young people involved with the throughcare and aftercare service were in employment, education or training (Scotland 38%).

Youth justice

The number of young people referred to the children's reporter on offence grounds had increased between 2003-04 and 2006-07 from 2.0% to 2.9% of the population aged 8-16 years. The national percentage had held steady at around 3.0%.

There were 30 young people defined as persistent young offenders in 2006-07, equal to 0.32% of the relevant population. This was higher than the overall Scotland figure of 0.26%. The number in Midlothian had grown year on year from 15 young people in 2003-04 and the national target to reduce persistent young offenders by 10% in 2005-06 ¹³ had not been met. The number of persistent young offenders had peaked at 37 in April 2007 and had fallen to 29 by March 2008. Managers told us that Midlothian aimed to retain 16 year old young offenders on supervision in order to divert them from the adult criminal justice system.

Community care services

Older people's services

As at March 2007, there were 13 care homes for older people in Midlothian of which three were directly managed by the local authority. The Care Commission had taken no statutory enforcement action against any of these establishments during the previous three years.

In 2005-06, Midlothian financially supported 470 older people in care homes. This was equal to 37.5 per 1,000 older people and was less than the Scotland average of 38.2 per 1,000 population. Midlothian had moved over the preceding four years from a position where it had been above the national average. Between March 2000 and March 2007, there had been a 6.2% reduction in the number of care home places for older people. This was a larger reduction than nationally (decrease of 4.9%). At March 2007, there were 46.5 care home places per 1,000 population, compared to the Scotland wide position of 44.5 care home places per 1,000 population.

In 2006, there were 49 older people attending registered day care services run by the council in Midlothian. This was equal to 3.9% per 1,000 population and was well below the Scotland figure of 14.3 per 1,000 population. With only having 0.8 day care places per 1,000 population, Midlothian was also well below the national average of 8.8 places per 1,000 population. However a best value report on day care showed the availability of a further 205 day care places and 155 lunch club places, 325 of which were supported by the social work division through direct funding.

Staff told us there was a great deal of unmet demand for day care with average waiting times of a year. We heard from managers that a lot of funding for grants to voluntary organisations was used to purchase day care. This was for places not registered with the Care Commission. They also informed us that gaps in day care, including for older people with dementia, were being dealt with as part of a day services review. We saw no specific outcome data for older people with dementia.

In terms of respite for older people, Midlothian was ranked 6th out of 29 local authorities on the total daytime respite hours provided. It was ranked 16th out of 31 local authorities for overnight respite.

Home care is one of the key services for older people. As of September 2006, 970 older people were receiving home care provided or purchased by the council. This was equal to 76.7 per 1,000 population (65%) which was well above the national figure of 68.2 per thousand. The council was ranked 14 out of 31 local authorities on the total hours of home care provided as a rate per 1,000 population.

In 2006-07, Midlothian was ranked 20th out of 31 local authorities on the number of home care clients aged 65+ as a percentage of clients (24.8%) receiving care in the evenings or overnight. It was ranked 27th (45.1% of clients) out of 31 local authorities for care at weekends.

At 16.7%, Midlothian was in line with the national average for the proportion of older people receiving intensive home care (10 hours or more) and also for the proportion of home care as a percentage of long term care (29%).

We heard mixed views from service users about the quality of the home care service they received. We heard more positive comments about the council's own home care service than the service it purchased from the independent sector. However, most said there were too many different staff involved in providing their care.

The proportion of older people receiving less than 10 hours of home care per week was significantly above the national average (60.6% compared to 51.7%). Whilst a few hours of home care can play an important role in supporting older people to remain at home, we noted that this generous provision was taking place at a time of considerable pressure on the community care budget. This meant that the funding could not be released for people with high priority needs.

This was also at a time when some service users with critical needs were being placed on a waiting list for services, including home care. We saw there were about 30 people each month waiting for care package funding during the early part of 2008. We attended the weekly resource panel and were concerned to note that 12 people with critical needs were placed on a waiting list rather than being provided with a service or receiving the assessed level of service.

The Scottish Government gathers information from local authorities and the NHS about how effectively they work in partnership to deliver aspects of community care. In the relevant reporting period, the system for doing this was the joint performance and assessment framework ( JPIAF). In 2006-07, the overall performance of Midlothian Council and NHS Lothian partnership was assessed as making 'steady progress'.

However, it concluded that the balance of care was moving in the wrong direction and needed to be reversed. For its local improvement targets ( LITS) the partnership was evaluated as meeting or being close to meeting its targets. More specifically it was evaluated as:

• reducing emergency admissions - fell well short of target. The target was 489, but there were 579 emergency admissions (the baseline in 2005 was 515);
• intensive home care - more than met target and exceeded the national target;
• delayed discharge - fell short of target. This had risen from 0 to 6 delayed discharges ¹⁴;
• rapid response - met or was close to meeting target, although target was not seen as particularly stretching; and
• better support of carers - fell short of targets. Although targets for assessment were met, targets for respite fell well short.

In order to address delayed discharge and emergency admissions, a rapid response service had recently been established. Although this service was late in being introduced compared to other areas, it was an important development as was telecare and the home care restructuring. Managers told us that there were no delayed discharges in April 2008. The Community Health Partnership ( CHP) general manager told us there was one delayed discharge at the time of our inspection.

The partnership was evaluated as making steady progress on JPIAF 6 which considers the timescale from the point of referral to the first delivery of service. The average was 27 days which was 'a significant reduction' on 2005-06. However, it was still above the national average of 22 days.

Learning disability services

We go into more detail later in this report about the development of services for adults with learning disabilities and whether adequate funding had been identified to enable learning disability services to be modernised as planned. This would impact on outcomes for individual adults with a learning disability.

The majority of the outcome data for adults with learning disabilities in Midlothian was below the national average. For example in 2007:

• 23% of adults with learning disabilities had a personal life plan (Scotland 32%);
• 6% used the services of a local area co-ordinator (Scotland 13%);
• 3% had an independent advocate (Scotland 12%); and
• 12% lived in their own tenancy (Scotland 33%).

More positively, 18% of adults with learning disabilities had employment opportunities (Scotland 16%) and the percentage attending a day centre five days a week ¹⁵ was well below the national average (8% and 25% respectively). Twenty seven per cent of adults with learning disabilities had alternative day opportunities (the same as the national average). We also saw that the division was committed to person centred planning and an 'in control' ¹⁶ pilot was underway.

An adult carer scheme had also been established which enabled adults with learning disabilities (and older people) to spend a couple of days per week in the homes of approved carers. At the time of our inspection there were eight carers providing 45 placements. In 2007, 9% of adults with learning disabilities had community respite (Scotland average was 8%).

Physical disability services

We found little information about outcomes for people with physical disabilities.

Day care places for adults with physical disabilities were purchased from the City of Edinburgh. There was a local area co-ordinator in Midlothian who provided support in this service area, something which the national guidance on local area co-ordination had identified as an example of good practice.

First line managers told us that arrangements for occupational therapy assessments worked well. They said that although there was a waiting list for assessment, this was fairly small (25 people) with an average waiting time for assessment of six to seven weeks. We saw the division had management information that monitored this and that the waiting list had been reduced. Comment was also made that small items of equipment were provided quickly through the joint equipment store, but there could be long delays in the completion of major adaptations.

We held a focus group with service users, some who had complex needs are were in receipt of large care packages. Overall this group was positive about services.

Adult protection

We were impressed with the progress the social work division and its partners had made with adult protection. The council showed its commitment to adult protection by appointing an adult protection officer. In 2007, the social work division had 60 adult protection referrals. Seventeen of these referrals (28%) progressed to the stage of an adult protection case conference. In January to April 2008, the social work division had 29 adult protection referrals. 12 (42%) progressed to the stage of an adult protection case conference.

Mental health services

The implementation of the Midlothian mental health strategy commenced in 2007 with a community model of care as its key feature. As part of its strategy, we found that Midlothian was making significant attempts to measure service outcomes for this care group. As we state later in this report, we heard many positive comments about the quality of mental health services. In SWIA's inspection reports to date, a common theme had been the lack of outcomes information for people with mental health problems. However the outcomes data we saw, although still relatively new and still with a number of gaps, had started to provide some evidence to support this:

• admissions to psychiatric hospital fell in 2006-07 from 262 to 241 ¹⁷;
• the number of mental health in-patient beds had been reduced from 19 to eight. In practice only six of these beds were being used ¹⁸;
• average stay in hospital was down to eight days in 2007 from 16 in 2005 ¹⁹; and
• local improvement targets had been developed which were linked to national outcomes. They also clearly defined in what ways service should impact positively on service user's mental health and life expectancy.

Sensory Impairment services

In contrast to mental health services, we found no information about outcomes for people with a sensory impairment. A Lothian wide joint physical and complex disability strategy had been produced in 2007 which included sensory impairment services. However, it contained no outcomes performance data.

Substance misuse services

The MDAAT (Midlothian drug and alcohol action team) had commissioned a survey which involved interviews with 50 substance misuse service users. This found that people who misused drugs had to wait much longer to receive a service (40% had to wait more than four months) than people who misused alcohol (more than half waited less than four weeks).

A multi-agency substance misuse screening group was established in 2007 to consider the needs of children living with parents with problem substance misuse. There were 314 children in Midlothian whose parents were involved with substance misuse in 2007-08. Of these children 167 were living with a parent with problem substance misuse. We cover the working of this group in Chapter 5.

Personalisation of services and direct payments

In 2007, 29 people in Midlothian received direct payments. This was equal to 3.7 per 10,000 population which was less than the Scottish average of 4.5 per 10,000 population. The proportion of Midlothian service users in receipt of direct payments had been below the national average for the previous five years. Managers told us that there had, until recently, been insufficient resources to promote these.

Adults with physical disabilities were the largest group of direct payment recipients. We saw that the division had a stated commitment to personalisation. We saw evidence of efforts being made to develop personalisation. For example:

• a direct payments officer had been appointed in 2006 and the number of people receiving payments had risen to 35 by January 2008;
• the average value of direct payments in 2007 was £36,000 which was double the national average; and
• the number of people with person centred plans had increased to 140.

Care Commission

Midlothian Council had signed a Memorandum of Understanding in March 2008 with the Care Commission. This allows the Commission to share information relevant to protecting people.

« Previous | Contents | Next »