Organisation submitting example
Portsmouth City Council & Kingsway House Adult Substance Misuse Service
Local authority/local area:
Portsmouth City Council
The context and rationale
Staff from an adult substance misuse service have been supported to ensure needs for the whole family have been identified sooner. This has been achieved in following ways:
• Reviewing internal systems to ensure their processes identified children of substance misusing parents
• Redesign of a specialist assessment tool to identify risk factors for children who have substance misusing parents
• Staff and management training and ongoing support to undertake high quality assessments (including specialist and Common Assessments), to increase confidence in asking questions about other family members and to undertake the lead professional role to ensure the needs for young people were identified.
• Increased awareness of interagency working
It had been acknowledged between agencies across Portsmouth, that for some families previous interventions and support had not been sustained long term and we were challenged to develop new and innovative approaches to both engage with families and influence their contribution to local neighbourhoods, this included raising their aspirations.
In September 2009, based on research and evaluation of the national Think Family Pathfinders, consultation with services within Portsmouth, and with agreement from the Strategic Directors Board a theme based model was chosen for the local pilot of the Think Family Initiative to be developed with a mapping exercise completed to identify families most known to agencies/services which are experiencing two or more risk factors, thus making them complex families.
The findings from the mapping exercise identified the three main risk factors affecting families were substance misuse, mental health and domestic abuse. These are now known as the ‘toxic trio’, due to neither one existing in isolation, thus creating a toxic environment within which a child or young person may have to live.
Following further research into services providing support around substance misuse, mental health and domestic abuse, Kingsway House Adult Substance Misuse Service was identified as being best placed to take roll out the Think Family Pilot. It was agreed between Portsmouth City Council and Kingsway House that the pilot would focus on the theme of Parental Substance Misuse. Kingsway House is a ‘Tier 3’ service, which means the adults who engage with this service have complex needs associated with their drug and/or alcohol misuse. For the parents who access this service, this may mean their substance misuse can reduce the capacity for effective parenting. Further more, if a drug or alcohol service user is a parent, the outcome of their treatment is likely to be affected (positively or negatively) by the demands being placed on them in caring for their children. Together we identified that failing to recognise this and seek any necessary support from parenting and family services could put both the service user’s outcomes and those of their children at risk.
It was agreed that the pilot would seek to ensure that Practitioners do not do more, but do things differently, thus there should be no need for more resources. This would then provide an opportunity to build on existing resources and practices to improve delivery of services for families, with a view to rolling out this initiative across services citywide.
In April 2010, the Think Family Development Officer met with the Service Manager for Adult Substance Misuse, to agree the roll out of Think Family Pilot at Kingsway House. This was then discussed further with both the Clinical Manager and Service Coordinator, for Parents who misuse substances, to agree a plan of what work needed to be done prior to the launch of the pilot. Around the same time a Think Family Task and Finish Group was developed and made up of up to 30 different agencies from across both adults and childrens services to share what worked currently in practice, what the gaps were and to further develop the implementation of the initiative across the wider area.
In September 2010, the Think Family Development Officer presented the Think Family way of working to the team at Kingsway House. Kingsway House had already identified gaps within their own service and were working towards addressing them.
Practitioners identified that:
• they needed more support/learning around safeguarding children and how to identify and address issues raised at the earliest opportunity,
• they did not know what to do if their concerns were not high enough risk for Social Care intervention.
• Needed guidance through policies, procedures or training for safeguarding
• they needed to develop their skills of asking questions around other family members,
• they needed to better understand what to do with information once they received this
• they needed to develop their learning and skills to work more holistically with their clients,
• needed a more consistent approach to client home visits
• completion of Portsmouths Pregnancy Referral Awareness Meeting/Substance Awareness Meeting (PRAM/SAM) risk assessments were inconsistent and not undertaken as standard practice and no central place record/collate any that were completed:
Two learning sessions were delivered pre pilot addressing practitioners fears and anxieties, hopes for developing Think Family, What is Safeguarding Children, developing a stepped process/pathway, agreeing with the team when the Common Assessment Framework (CAF) would be triggered, when a Pregnancy Referral Awareness Meeting/Substance Awareness Meeting (PRAM/SAM) risk assessments would be undertaken and home visiting.
The pilot was launched on January 3rd 2011. Three practitioners were initially chosen to act as Think Family Champions within the service to support their colleagues with the implementation of this approach.
Monthly group supervisions were held to support these Think Family Champions as well as attendance by Team Manager, Parental Substance Misuse Coordinator, Think Family Development Officer and Workforce Development Officer, at team meetings. These were fundamental for practitioners to discuss their anxieties or achievements as they worked through Think Family approach and three case studies were recorded to highlight this shift in practitioners thinking.
Two further learning/workforce development sessions were delivered to the whole team supporting the change management process and consisted of discussion around processes, practicalities, next steps, what is working well and why?, what are the benefits to client/child, what are the challenges and what are the training/learning needs to take this work forward.
Although three Think Family Champions were initially chosen to support the implementation, it quickly became evident that the rest of the team had begun to see the potential benefits this whole family way of working could bring to their clients and their families and a rapid change in the way the team began to work was clear to see.
Alongside the pilot the Workforce Development Officer and the Service Coordinator of Parental Substance Misuse, ran two focus groups; one with parents who had been through the service the other with practitioners from a wide range of services. This was to identify the differences between the perspectives of parents as service users on what worked well and what could be done better, compared to services perspective of what the service user needs. This identified that parent service users wants and needs were emotionally based whereas the services they approached for support dealt with the service users on a very pragmatic level, thus missing the opportunity to really support these parents and their families effectively.
The information gathered from these focus groups, informed the way in which the pilot would be rolled out and identified what both practitioners and services as a whole need to be taking into consideration when undertaking good quality assessments.
This shift in the way the service has begun identified a need to work more closely with other services. Cranstoun who are the ‘Triage’ who refer clients into Kingsway House have now been included in Think Family discussions and attended the last learning session at Kingsway House in May. Now Cranstoun understand the need for identifying parents/carers and any issues around their children or other family members in need of support at the earliest opportunity within their service before referring to Kingsway House. Though this has been contentious the two services have developed a clear process of Cranstoun completing the front page of the PRAM/SAM when children are involved and include this with the referral to Kingsway House for practitioners there to continue a full assessment.
Referral details can be viewed here.
Achievements so far
The overall outcomes agreed for the pilot were:
• Improved safeguarding and promoting the welfare of children and young people whose health or development may be being impaired as a consequence of parental substance misuse
• To keep the family together
• To reduce inappropriate referrals to Childrens Social Care
• To ensure Think Family initiative is embedded within practice and service specification
The measures we wanted to achieve with this pilot were:
• Consistent PRAM/SAM risk assessments carried out within the first 3 contacts.
• Consistent recording and collation of PRAM/SAMs.
• Consistent Home Visits as standard practice.
• Increased use of CAF
• Increased attendances at TACs
• Increased integrated working
Evidence collected so far:
• All users are now asked if they are parents/carers at point of Triage which is ratified at first appointment at Kingsway House.
• Pregnancy Referral Awareness Meeting/Substance Awareness Meeting (PRAM/SAM) risk assessments are now undertaken at the first appointment if appropriate for client.
• PRAM/SAM assessments are carried out during Home Visits within the first three contacts with a new client, who has been identified as having caring responsibilities for child/ren.
• Where a PRAM/SAM assessment lead to the need for a CAF, practitioners are now initiating and/or completing CAFs with the support from either their manager or a worker from another agency.
• There is now improved joint working between Kingsway House and children’s services, providing an integrated approach and this has been evidence also by the increased attendance of practitioners at TAFs (Team around the Family), who are now able to see the benefit of effective integrated working and a clear agreed action plan for the family.
• PRAM/SAM and CAF assessments are now being recorded consistently. Client data is now recorded through “Nebula”, which now allows much more detailed information to be collated.
12 Kingsway House Practitioners were sent a questionnaire to try and identify if the shift in practice was reflected in a reduction in referrals to social care. 8 Practitioners responded stating that they as a group worked with -
? 123 clients and their families between January 2011 and June 2011, during this period –
? 36 of these families were already known to social care when the 8 practitioners took them onto their caseload
? Of the remaining 87 families, 7 were referred to Children & Families Social Care (2 of these were allocated), meaning 5 were inappropriately referred. 11 further families were supported by practitioners and other agencies following contacts to social care for advice and next steps. 8 responses proved helpful, 3 responses not known.
? 69 of the 87 families had no involvement with social care.
Organisational and/or cultural change, and other developments alongside the pilot can be viewed here.
The main barriers and challenges at the beginning of implementation was getting strategic buy in at the initial stages. Other challenges have been:
• working with one specific service, who is accountable to a huge organisation and ensuring that all stakeholders were involved and updated with the development of the pilot and that outcomes were shared and agreed.
• changing policies within other services either directly, or indirectly involved with the pilot, but who will need to improve their policies and procedures to reflect their commitment to working in a Think Family way and sustain long term embedding of practice.
There were 4 main people involved in implementation of the pilot, Think Family Development Officer, Parental Substance Misuse Coordinator and 2 Workforce Development Officers.
Considering time spent developing the pilot, designing training, delivering training, delivering supervision and workshops, the overall cost in man hours is approximately £3100, this however does not include time spent on administrative duties, or working collateral to support the pilot, or the time of the practitioners attending training.
Learning from experience:
I would suggest to any other area thinking of implementing this way of working, to develop a team of people, it could even consist of just 3 – 4 people, preferably from Adult Mental Health, Childrens Social Care, Workforce Development and a Researcher/Business Development person to monitor performance and review on both societal and economical impacts achieved.
Holding a Think Family Conference in the early days of this role would have been beneficial to spread the word across many services in the city and to enable more buy in to develop this work further. I did develop a Think Family Task and Finish Group made up of both managers and practitioners across both adults and childrens services this was useful initially in sharing ideas about how to implement think family, but later the group reduced in size due to Think Family becoming more service specific, this again could have been prevented had there been a Think Family team ie more than one resource, to move this work forward more effectively across more services in the city.
Key leadership behaviour characteristics
The following core behaviours have been identified as part of successful elements of leadership (see National College for Leadership of Schools and Children’s Services/C4EO (2011). Resourceful leadership: how directors of children’s services improve outcomes for children. Full report. Nottingham: NCSL see http://www.nationalcollege.org.uk/docinfo?id=144732&filename=resourceful-leadership-dcs.pdf).
Portsmouth identified the following behaviours as key to the transformation of their service.
Openness to possibilities – supporting staff to work better across agencies and client groups introduced risks but resulted in definitive improved outcomes for parents and young people.
Demonstrating a belief in team and people – empowering and building confidence at both operational and manager level was crucial. Before the pilot began good holistic practice was found to be due to exceptional staff who chose to develop their own practice as opposed to being led by policies and procedures and
Personal resilience and tenacity – empowering staff to build their confidence and skills in asking different questions. Staff were already able to answer difficult and challenging questions but needed permission to explore issues other than substance misuse.
The ability to create and sustain commitment across a system – while the majority of support focussed on operational staff and management it was crucial to secure buy in from both Children and Adult strategic boards. This was achieved by developing clear lines of responsibility between operational and strategic practice.
Focusing on results – primarily this focussed on outcomes for young people as opposed to their parents/carers.
The ability to simplify – new systems had to be seen as clearly beneficial to clients and their families whilst being manageable to the staff working within them.
The ability to learn continuously – emphasise was made throughout the pilot that learning is a continuous process and that ongoing support (via training, supervision, agency support, research in practice etc) needed to be embedded. This is one of the new priorities for Portsmouth Children’s Trust Board.
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