Scottish Government

Growing Support

2 What supports do familes get?

Agency and professional perceptions of vulnerability
How do local authorities assess vulnerable families with children in need?
What support is being provided to meet needs and reduce risk?
Health visitors
Special health services for adults and children
Support from social work services
Voluntary sector support
Children with disabilities - a poor service
A continum of support?

1. We found that there was a high degree of consensus between agencies and professionals about what makes children and families vulnerable. There was far less consistency about when and how professionals and agencies should intervene with individual families.

2. Most practitioners and managers in health and social work services agreed that vulnerable families needed particular help to access and engage with universal services such as health and education and also needed specific services which tackled their particular problems. Most saw the responsibility for enabling these families to have better access to universal services as lying elsewhere. Social work services argued that health and education agencies needed to work harder to ensure that their services were more attractive and accessible to families in difficulty. Health and education agencies suggested that input from social work services could encourage and better enable vulnerable families to engage with mainstream services.

How do local authorities assess vulnerable families with children in need?

3. Each agency in contact with families will carry out some assessment of their situation in order to decide what services to offer. We looked for information about:

• the index child's and family's perceived needs and on what this assessment was based;
• the nature and extent of any perceived risk and how conclusions had been reached; and
• information about the family's social circumstances including family and social relationships and social supports, housing and financial circumstances and their wider environment.

4. One in five cases included evidence of assessment in each of these three areas of need, risk and social circumstances. These were amongst the most well-managed in the sample. Half of these cases displayed major strengths, with many examples of excellent practice. In these cases assessments were based on regular and consistent contact and observation of children and their families (including in some instances contact with extended family members), information from other agencies and a good understanding of the family's social history and each member's personal history. There were examples of cases that included this kind of comprehensive assessment in each of the local authority areas.

5. Only four cases in which assessment had addressed all these areas dropped below satisfactory standards. All four came from one local authority and reflected that authority's difficulty in sustaining support for vulnerable families because effort was focused on child protection and crisis management.

6. There was evidence of assessment of need in two-fifths, 60 (40%) of the case sample. Almost all of these cases concerned families with complex and multiple problems including drugs, alcohol, domestic abuse, parental youth and previous cause for concern. More than two-thirds of these children (21) were named on the Child Protection Register and a similar proportion (19) were looked after. In just over a third of these cases the records indicated that outcomes were already very positive for the child who was well supported either within his or her birth family or protected in alternative family care, usually with grandparents.

7. Assessments of need most often identified mothers' needs for practical and emotional support to combat social isolation, alleviate mental health or relationship problems and low self-esteem, and described children's needs for consistent care. Social workers frequently perceived a need to support parents to parent, for example in setting appropriate boundaries on children's behaviour. Some assessments focused too much on parents' needs and material circumstances rather than assessment of individual children's needs. They overlooked the impact of enduring parental problems on very young children's longer-term welfare. In too many cases the focus of assessment was on immediate stresses within families and tackling practical problems rather than the long-term outcomes for the child. Where families were affected by parental drug or alcohol misuse, there was little information about the extent of misuse, whether adults were thought to be drug or alcohol dependent and whether they were receiving help from specialist treatment or rehabilitation services. We found little attention to the role and contribution of fathers and cohabitees in families.

8. A higher proportion of cases included evidence of assessment of risk to the index child or others in the family. Risk was considered in just under half of the cases reviewed (49%). 51 of these cases concerned children who were or had been named on Child Protection Registers during their first three years, indicating that of the 55 children registered, the local authority had carried out an assessment of risk to the child in 92% of cases. The quality of these assessments varied. In many instances risk assessment was explicit and well evidenced, clearly identified the nature and source of risk, and informed prompt action to safeguard children's welfare. In some cases clear and skilled initial assessment and intervention was evident but this was not sustained after initial crises subsided.

9. Some of the case records did not make sufficiently explicit the nature of the perceived risk, what the consequences of exposure to continued risk might be or the factors that might exacerbate or reduce risk, even in reports and minutes of child protection case conferences. Risks were usually presented in general terms with proposals for action reflecting these, for example 'continued support to mother' rather than specifying what aspects of the family's function needed to be addressed, why and how. In a minority of case records it was not possible to identify either the category of child protection registration or the nature of the perceived risk from the current case file.

10. Parents told us that they knew social workers and other professionals were worried about their child's safety. We found that they were often uncertain about what their social workers thought might happen to their child if the risks were realised. Social workers and their managers told us that they had communicated their concerns about risk clearly to families. Both parents and professionals find discussion of risk to children stressful.

11. Planning and outcomes were significantly better in those cases in which the social worker gave attention to risk and needs. There were indications that the child's safety and welfare had stabilised or improved since intervention in two-thirds of these cases (24/37) and informed monitoring indicated the need for further action in most of the remainder.

12. In two of the local authorities we found evidence of consistent, thorough and careful assessment of risk in response to concerns about a child's welfare. But, despite this good practice in risk assessment, many of these cases displayed significant weaknesses and poorer outcomes because there was insufficient attention to the needs of the child, other children in the family or parents' needs. This resulted in a lack of clear direction in case planning for achieving change and too great a focus on 'monitoring' which families experienced as punitive and unhelpful. In a minority of cases, a focus on child protection enquiries with the emphasis on risk assessment, without timely consideration of the families' own needs or wider circumstances had caused significant distress for parents who were then less willing to make effective use of supports offered.

13. In another local authority the emphasis on supporting families wherever possible on a voluntary basis was not combined with sufficient attention to risk. In two local authorities there was more consistent assessment of both needs and risk and most cases in these authorities reached satisfactory standards.

14. Across both health and social work services in all areas, the assessments almost always related to the mother's ability to parent or protect her children and her needs. Men were largely invisible in the records or in discussion in terms of their contribution to family life and wellbeing, their needs, or in an assessment of the levels of risk they might pose.

15. Most cases included evidence of assessment of the family's social circumstances. This was more often limited to consideration of the family's housing or financial circumstances than available social supports. In almost a quarter of the sample cases assessment was limited to gathering information about the family's social circumstances. In almost all cases in which there was a disabled child there was insufficient assessment of the suitability of the family's housing and financial circumstances and the impact of the child's disability on family life.

16. Social workers made good use of other professionals and agencies to inform their assessments drawing on the skills of, and information from, family centre staff, specialist services, foster carers, and specialist health professionals. There was evidence of good liaison and collaboration with other professionals including health visitors and residential and throughcare staff particularly in assessing the needs of very young mothers, female pregnant drug users, care leavers and their babies.

17. Although the assessments drew on the knowledge and expertise of others, they were frequently too narrowly focused. In those cases which included attention to two out of the three areas of assessment (risk, needs and circumstances), there was most commonly attention to 'risk and circumstances', followed by 'needs and circumstances'. Attention to both 'risk' and 'need' was less likely. This reflected the route of, and reasons for, a referral. When referred for child protection investigations, needs not immediately related to the perceived risk were rarely identified and, where risk could not be established, services ceased contact.

18. Focusing on the parent and/or the child as separate entities, both health and social work professionals often overlooked the quality of parental interaction with very young children leading to under recognition of behaviours which may lead to emotional abuse or neglect, and failure to thrive.

19. The assessments were also often too narrowly focused in other respects. For example, consistent and sustained support for young mothers who had previously been looked after was evident across all the fieldwork sites. The assessment and support provided by aftercare workers generally focused on these young women's needs with insufficient attention being given to the needs of their very young children. Little attention was also given to young women's needs as young and vulnerable parents. In contrast, children's social workers in touch with these young parents too often focused on the safety and welfare of their young children without fully assessing and meeting the needs of the young mothers and were perceived as threatening or unsympathetic by the young people.

20. In the small number of cases concerning families from minority ethnic communities there was insufficient analysis of the impact of ethnicity or racism on family problems and implications for how these might be resolved. Social workers tried hard to have regard to considerations of ethnicity, culture and religion, but in all areas they needed more information and advice to support their efforts, although some local authorities were making good efforts.

21. In a small number of cases (17) there was no assessment of the child or individual family members. In four cases in one local authority this was because the sole support provided to the family was group work for the mother. Although there was evidence that parents valued this input, and maintained regular attendance and commitment, recording of individual intervention was limited and there was little or no information about the child. Links between the voluntary agency providing support to parents and the statutory services in touch with the family were poor.

22. In another case although there was no information about the child or family on the case file, the local authority had provided funding for a service in response to the assessment and request of another agency, promptly, and to evident benefit to the children and family. Reliance on the assessment of other professionals in allocating a service was rare and we found evidence of considerable duplication in assessment. In the remainder of these cases there was no information and little evidence of progress or improvement in the child's circumstances. In some cases problems or concerns remained unchanged over time, or there was insufficient information recorded in the case record to assess the impact of contact with the department.

23. We found examples of skilled, comprehensive and well recorded assessments by local authority social workers. Too many cases fell short of this standard, focusing on immediate risks to children's safety or family problems. There was little evidence of a consistent approach to assessment in any of the local authorities we visited, other than a focus on risk at the expense of needs. One local authority was beginning to pilot a local framework in some areas, and although this looked promising, most of the examples we found were incomplete.

What support is being provided to meet needs and reduce risk?

24. Midwives provide the bulk of ante-natal care and support for families in the immediate post-natal period, generally for the 10 days after birth. Support is offered through attendance at clinics, home visits and parenting classes.

25. We spoke to midwives individually and in groups about their role in supporting the most vulnerable families. Most perceived themselves as offering the same service to all new parents and some suggested that all mothers of new-born babies are vulnerable to some degree. As with other professionals there was broad agreement about the range of factors which make particular groups of mothers and their children at increased risk of early problems with care and bonding. Often these are associated with poorer take up of midwives' advice and support.

26. There was far less consensus about whether the midwife has a role in identifying particularly vulnerable families and offering extra help to them. Midwives did not necessarily provide more input to these families and said that their core training did not specifically address the needs of vulnerable families. For example, although many victims of domestic abuse report assault during pregnancy, midwives said they did not receive advice about the impact of domestic abuse on families and children. Some practitioners had had occasional study days but there is no consistent programme of post-qualifying training tackling related risk factors in families which affect child welfare. One midwife said that if she was concerned about the social circumstances of a mother or baby she would convene a case conference. One of her colleagues said that she would feel uncomfortable doing this and yet another clinic-based midwife advised that she would find it impossible to ask all pregnant mothers whether they had suffered domestic abuse.

I'm really there as a midwife. It's the role of other agencies to provide support, ours to refer on. For example, families will often need financial help, or help with housing problems - I would pass this on to the Health Visitor.

27. Practitioners working in specialist settings or areas of multiple disadvantage were more confident than their colleagues in more affluent areas about combining support for parents during pregnancy with assessment of potential risk to their unborn or new-born baby. These routinely participated in inter-agency work to promote and protect the welfare of the babies in families where risk was evident. Many midwives were anxious about involving social workers, fearing that removal of children would be the most likely option. Although separation may occur in a minority of cases the vast majority of children in need are supported by local authorities at home. But many were inclined to the view of one practitioner on inter-agency collaboration:

I hate it - I feel it's such a responsibility, like a jury. Is my contribution helping to separate this mother and baby?

28. In Edinburgh one LHCC had recently established a 'midwifery forum' to promote a more strategic approach to ante-natal care and foster good relationships with local Health Visitors. As targeted programmes have had poor attendance and been unsuccessful the LHCC's objective is to enhance take up and delivery of universal maternity services by vulnerable families.

Health visitors

29. The key contact with health services for the families in our review sample was with their health visitor. Most of these families had a designated health visitor although levels of contact varied widely from weekly in some instances to very limited contact in others. Health visitors undertook careful surveillance of young children's growth and development and provided emotional support for mothers. They were ideally placed to identify family stresses and early health or parenting problems. Health visitors were in close contact with local child care resources and provided early referral to day care services when they perceived parents under stress.

30. Whilst every child potentially has access to a named health visitor, in many cases contact with a family may be very limited or not necessary. For some the input is more important. Like midwives, health visitors did not have a clear sense of the extent of their responsibilities towards vulnerable families and practice varied widely according to the demography of the area in which the practitioner worked, their experience and confidence and perceived support from colleagues and management. In one area pre-school education services expressed concern that the stress on meeting minimum requirements for all meant that health visitors' regular contact with a vulnerable family in the first year of life tails away. There may be no contact with a child at all, if parents do not present for periodic developmental checks, until the child is ready to begin pre-school education, by which time behavioural difficulties are often more entrenched.

31. We found a range of initiatives designed to help vulnerable children including:

• the development of specialist expertise in working with vulnerable families;
• special clinics, programmes and group work activities;
• structured, monitored, targeted and evaluated health visiting through the 'Barker Integrated Urban Model'; and
• multi-disciplinary teams and co-location of health visitors in children's centres.

32. Although we found examples of excellent support for children and families within the range of health services we visited, the majority of health care was reactive. Preventative work by health services was focused on universal health surveillance and general health promotion advice. It took little account of the difficulties that vulnerable families may have in following the comprehensive and sensible advice offered. We concluded that health visitors' contact with parents and children needs more careful focus to avoid duplication, superfluous surveillance and achieve maximum impact. A greater focus on health promotion and direct work with parents rather than routine health surveillance would better meet the needs of vulnerable families.

Specialist health services for adults and children, for example, drugs and mental health services

33. Other than that of midwives and health visitors, most contact with other health services centred around diagnosis and treatment of the individual patient. Specialist services rarely considered the family's wider circumstances unless there was evident immediate risk to a child, for example of physical injury.

34. Links with specialist services for children were less than effective across all authorities, particularly in those cases where families' social circumstances were perceived to underpin the child(ren)'s problems. Social workers, managers and education staff perceived psychological or child mental health services as not readily accessible, with lengthy waiting lists, inflexible appointment-based systems, and families discharged quickly if they failed to attend appointments. We found examples of specialists refusing referrals when children's home circumstances were unstable or uncertain, or when parents were deemed unwilling to engage or unlikely to work co-operatively. In some cases where the local authority had referred a child for support the response had been that as the family circumstances made the child's prognosis poor, there was no point intervening.

Support from social work services

35. Most of the families in our sample had an allocated social worker working with them. Social workers carried out assessments of families' situations and made referrals to other services such as family or child care centres. In the most well-managed cases social workers provided considerable practical and emotional support for parents through counselling, advocacy and providing access to goods and money. There was little emphasis in each local authority on social workers' direct work with families or counselling for parents, although there were excellent examples of this being offered or arranged in more complex cases, particularly those involving children's removal. Most allocated social workers attempted to provide some counselling around conflict in family relationships but more commonly monitored children's development alongside health visitors and nursery staff and relied on other staff or agencies to offer remedial or therapeutic input. In a minority of cases in each local authority there was evidence of skilled engagement with families and systematic family counselling. Where there was more than one child in a family the needs of the youngest, particularly pre-lingual, children were likely to be overlooked in the need to deal with pressing crises presented by older children.

36. Local authorities provided families with a great deal of material and financial help. Social workers arranged help with holiday costs for families under stress, purchase or loans of some childcare equipment, basic furniture, bedding and clothing, and administered small grants and crisis payments to some families without immediate resources. They applied to charities on families' behalf and arranged subsidised child care or respite services.

37. Many social workers made good use of specialist services with appropriate referral to local child and adolescent mental health services, adult psychiatric or specialist substance misuse services in relevant cases. They kept in close touch with other services, particularly housing and benefits agencies, and were powerful advocates for their clients. However, there were lengthy delays in access to specialist services for families. Local authorities funded residential placements for adults with addiction problems, sometimes with their children.

38. Family support workers, family aides or home carers offered practical advice and support to parents with parenting and household management and sometimes offered respite by looking after children at home and taking them to school or on outings. These staff also played a part in monitoring children's development. One local authority had developed a local programme to promote good parenting skills through delivering a series of sessions on knowledge of child development and how to respond to children's behaviour positively. Some children's centre staff and social workers had been trained to provide the programme with the involvement of the local voluntary sector family centre.

39. Out of Hours or emergency services played a key part in dealing with crisis referrals. They were quick to respond despite the constraints and difficulties in working when other services and resources were unavailable. In these circumstances they had no alternative but to spend time talking directly with families to understand their immediate circumstances and problems. In one local authority social work staff and users told us that new contractual arrangements for out of hours services with a consortium servicing a number of neighbouring authorities had eroded the service which had become less responsive, relying on telephone contact rather than visiting families in crisis. Another planned to move from joint arrangements with another authority to a more local arrangement to tackle this kind of problem. Rural authorities have particular challenges in providing out of hours services across large areas but the quality of the response appeared generally good.

40. Out of Hours staff in all the local authorities were skilled and experienced. They gathered a great deal of information and offered good professional insights into the supports needed. This contact was often extremely important in setting the context for the families' further contact with daytime services. Some families made regular use of the Out of Hours services for advice and support. This model of intervention in which a prompt and reasonably robust assessment is formulated on the basis of urgent family contact should be more common in daytime responses to initial referrals.

41. Many of the children using day care or nursery placements had siblings in nurseries, or had home care. Most of these cases did not demonstrate expected benefits as social work contact reduced proportionally and there was reliance on these staff to monitor and support the family with little direction or measurement of outcomes.

42. Family centres or their equivalent brought together a range of practical, material and emotional supports for parents usually underpinned by some form of child care. We found examples of family centres providing group work with children and adults (often with crèche facilities), drama workshops for young people, a venue and sometimes supervision for parents' contact with children in care and a great deal of individual counselling for parents in centres and through home visiting. Some families had received consistent support from their local family centre over some years and these seemed able to engage even isolated and unwilling parents well. In some areas of Glasgow a discrete, community-based support service, run by the social work department but at arm's length from the local area team, provided emotional and practical support for families in difficulty, from a local base and using other community meeting facilities. Families found contact with this service very helpful and described this kind of support as less stigmatising.

43. When older children presented behavioural problems and proved difficult for parents to manage, local authorities provided respite services. Child care centres provide excellent advice and direct support for parents on setting appropriate boundaries, consistent routines, physical development and nutrition. Parents reported that they learned a great deal from following the examples set by child care staff. We found less evidence of sustained work with parents and their children on emotional development, play or developing independence and identity.

44. Support workers in the Throughcare team supported young people towards independent living by assessing their knowledge and skills in managing a tenancy, assisting them with housing, benefit and grant applications and liaising with other agencies on their behalf. There was little evidence of information sharing with field social workers or other relevant professionals.

Voluntary sector support

45. In each local authority area voluntary sector services played an important part in assessment and support for families. They offered home visiting services, parents' support groups, child care and play sessions with parents, advice, advocacy and emotional support for young homeless people or people leaving local authority care, and specialist assessment of families with complex needs for the local authority. In some areas they provided a venue and supervised contact sessions for parents with children in foster care or in extended family placements.

46. In one local authority the voluntary sector provided most non-statutory support services, with social work services working with children under supervision or on the Child Protection Register or with complex needs. Support for families with younger children was delivered by a national voluntary organisation from a centrally-located family centre, with outreach and project staff working in outlying rural areas. Families were very positive about the quality of both the premises and support. The voluntary sector service was working with a less (but still) disadvantaged group of families and focusing on secondary prevention. The local authority and the voluntary organisation had worked hard to establish a robust strategic partnership which was bearing fruit in new developments and more creative approaches to local problems of scale and rural isolation.

Children with disabilities - a poor service

47. Within the sample of families there was a small number of children who had physical or learning disabilities or sensory impairment. The majority of cases involving disabled children were managed poorly. There were lengthy delays in responding to referrals, making decisions and between contacts. The impact of the disability on the family as a whole was not taken into account in planning and carers' needs were not consistently assessed. Singleton specialist social workers attached to local authority children and families teams were assigned all assessment of children with disabilities. They reported that their tasks centred around co-ordination of community care packages or future needs assessments with little scope for ongoing direct work with children or families. Health and education services reported that social work services were difficult and slow to obtain in the absence of an allocated social worker. Disabled children appeared to have little priority.

A continuum of support?

48. Health services argued that they needed better direct access to some of the resources and supports currently controlled by social work departments. They wanted to access support staff such as family aides to undertake intensive teaching of parenting skills and household management without reliance on social work referral and assessment. They perceived the threshold for access to this kind of support as currently too high.

49. We found that unless there was an inter-agency child protection plan or supervision plan in place support for families was poorly co-ordinated. There were examples of social work services providing a 'link social worker', a social worker designated to attend regular meetings with other agencies or services to foster better communication. These link social workers were not empowered to take decisions on allocation of resources and took information back to their own service for case allocation and resource decisions. All agencies agreed that there was a need for better communication and co-ordination between services but saw this as a need for change in systems of communication rather than changing their own practice.