Professionals were “over optimistic and unrealistic” in their assessment of two parents’ capacity to care for their children when the mother became pregnant years after five of their children had been taken into care.

A serious case review into the neglect of two children, ‘Charlie’ and ‘Charlotte’, found problems with the ‘start again’ approach taken in Durham.

Charlie was born in 2007 and Charlotte in 2010. Both remained in the care of their parents from birth but were eventually placed into foster care aged 10 and seven.

The neglect has had a “lasting impact” on their health, including sight problems and tooth decay, due to them missing numerous medical appointments. However, the review said missed medical appointments “were not always recognised as a serious symptom of chronic neglect by professionals”.

In 2001 another local authority had removed five children from the parents’ care because of concerns about severe neglect and physical and sexual abuse.

The family’s history was “the single most important indicator that parents were highly unlikely to ensure that the children’s health needs were met”, it added.

The review said Durham local safeguarding children board should ensure an initial child protection conference was automatically convened when a parent becomes pregnant and there had been a history of care proceedings, “regardless of current family circumstances”. If this was not considered necessary, a “clear rationale, with legal advice” should be provided.

‘Simplistic and unsafe assessment’

An assessment in March 2007 when ‘Charlie’ was 10 days old concluded that “the current situation has been assessed and found to be acceptable in terms of meeting the needs of a child”.

However, the review said that, given what is known about neglect and about the parents’ history, this assessment, said to be carried out over a very short time period was “overly optimistic, simplistic and unsafe”.

An initial assessment had been triggered by a referral from a midwife in October 2006 when the mother became pregnant with ‘Charlie’.

Concerns were identified due to the family history of child protection issues, though an assessment regarding the unborn baby did not include information about historical concerns of sexual abuse.

A decision was made at some point following the March 2007 assessment to manage the case at Child in Need (CIN) level, but these arrangements closed in September 2007, and the review said it was “not clear” how many CIN meetings (if any) took place along with the outcomes and actions.

Within two months of this, ‘Charlie’ had missed his first eye care appointment.

The review said ‘starting again’ might involve an “unfounded assumption that a new baby, or a different partner, presents an opportunity for the family to embark on a more successful period of parenting, without adequate professional reflection about whether the parental capacity to care for the child has in reality changed”.

But such a strategy “prevents workers from having a clear and systematic understanding of a case”, it added.

Historical information

Durham LSCB said it will “ensure that better processes are in place to protect children” where there is a history of care proceedings and a parent becomes pregnant again.

It also said multi-agency protocols would be put in place to “highlight where children are not brought to appointments so that, if necessary, relevant interventions can be made at the earliest stage”.

It added: “The LSCB has agreed that ‘working together’ and tackling ‘neglect’ are Board priorities and actions arising from the serious case review have and continue to be progressed by each agency.”

No consideration of sexual abuse

The review said indicators of potential sexual abuse were “not considered as an ongoing or longstanding concern”, and no overview of reported incidents of sexual abuse was used to inform risk assessments.

During 2008 two of the parents’ older children alleged they had been sexually abused by both parents. Durham children’s social care reviewed the information held by the local authority where the parents had previously lived and the allegations led to a criminal investigation, but no offences were revealed and Durham agencies took no further action.

The fact that no criminal proceedings against the parents took place despite as a result various allegations and investigations “may have influenced decision making and practice,” the review said.

The review recommended Durham LSCB and partners outline to practitioners how the thresholds for evidence in criminal and civil proceedings differ, and what this means for children where physical or sexual abuse is alleged or suspected.

“Specifically there should be a focus on those cases where the evidential threshold for criminal proceedings is not met but the probability of abuse having taken place is high and what this means for decision making and practice.”

It also pointed out that both parents were possibly victims of childhood sexual abuse and exploitation, and that “this can also be an indicator that their own children were more vulnerable to sexual abuse”.

Children’s views not sought

The review said there was “no information to suggest that Charlie and Charlotte were seen on a regular basis independently of their parents”, or that their wishes and feelings were sought.

“It therefore follows that they were unable to contribute to assessments of risk, planning and decision making,” it added.

“However it is important to note that the children had on occasion made disclosures of domestic abuse, alcohol misuse by their parents and of being hungry. This information did not contribute to assessment and decision making and the parents were able to deflect this.”

The review said Durham LSCB and partners should “ensure that practitioners and line managers are able to evidence that children and young people have been listened to and their wishes and feelings have been understood, respected and taken into account in decision making, risk assessment and planning. This should be a core (and clearly recorded) element of all work at Child in Need or Child Protection levels.”

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Gloucestershire council is to increase its budget for vulnerable children by almost 30% as it deals with increased demand for services and the fallout from a poor Ofsted result following a monitoring inspection.

The council will spend an extra £3.9 million on its children’s safeguarding service in 2018-19. Its medium-term financial strategy states this will “ensure it is fit for purpose, supports practitioners in delivering best practice and is market competitive to attract staff”.

This will also “support a revised career structure and allow nationally accepted caseloads for social workers”.

The council will also spend an extra £1.1 million on implementing an improvement plan after Ofsted judged its children’s services to be ‘inadequate’ in 2017. Its total spend on services for vulnerable children will increase by 28.4%, from £57.4 million to £73.7 million.

‘Slow progress’

The news comes as an Ofsted monitoring visit to Gloucestershire, the second since the ‘inadequate’ judgment, found that the pace of change in children’s services “remains too slow”.

Although senior leaders had implemented improvement frameworks supported by “significant financial investment and additional resource”, children in need of help and protection “continue to experience delay at every point of their involvement with children’s services”.

The report said some children remained in situations of unassessed risk for too long, and others experience chronic neglect or continue to be exposed to risk “without effective action being taken to protect them”, particularly those young people experiencing or at risk of sexual exploitation.

Gloucestershire had been successful, though, in recruiting suitably qualified and experienced social workers and managers, and most social workers had “manageable caseloads”.

But in some parts of the service social workers “do not always have the level of skills and experience required to provide effective interventions for children’s complex needs”.

While managerial oversight of practice and staff supervision was regular, managers “are not yet providing staff with sufficient challenge or direction and too often fail to address deficits in practice”.

As part of its improvement plan, Gloucestershire has appointed a new permanent director of children’s services, Chris Spencer, who will take up the role on 5 March. He has held director positions at councils including Redbridge, Hillingdon and Slough.

Councillor Richard Boyles, Gloucestershire’s cabinet member for children and young people, said: “Having a permanent director in place will bring stability to the service and help us to make the changes we need to make sure vulnerable children are protected here in Gloucestershire.”

He said the council’s “biggest concern” was that the pace of improvement was still too slow and that children continued to experience delays.

“We also know social work practice is inconsistent, but we are addressing these concerns.”

Demand pressures

Gloucestershire’s medium-term financial strategy said the council had seen a 17% increase in referrals to children’s social care over the past year and a 35% increase in the number of children subject to a child protection plan.

Its looked-after children population is forecast to reach almost 700 by March. One reason for this is an improvement in practice and assessment from a situation where thresholds have been “poor and inconsistently applied”.

It will use the extra funding to recruit more social workers to manage demand, recruit and retain experienced and qualified social workers through a revised career progression pathway, develop smaller teams to support quality of practice and decision making, and invest in extra administrative support so social workers can focus on direct work with families.

The council will also apply a 2% adult social care precept, which specifically funds adults’ services, to its council tax in 2018-19, on top of a basic 2.49% rise. It will use the increase to meet costs of implementing the Care Act 2014, as well as the impact of demographic changes and cost pressures including the National Living Wage.

The budget said demographic changes “indicated a rising demand for support from people with increasingly complex needs that requires the council to better manage and respond to demand”.

The number of approved mental health rofessionals, the practitioners authorised to carry out Mental Health Act assessments, continues to shrink, research by Community Care shows.

A Freedom of Information request to local authorities also highlights a continuing failure to make the AMHP workforce more professionally diverse by bringing in more non social workers, one of the main reasons for the creation of the role to replace that of the approved social worker (ASW) in 2008.

Community Care received 102 responses from England’s 152 local authorities to its FOI. The number of warranted AMHPs – those qualified and warranted by local authorities to carry out Mental Health Act assessments among other duties – fell by 2.5%, from 2,174 at 1 April 2016 to 2,120 at 30 September 2017, across the 91 councils which supplied data for both dates.

This is a smaller decline than Community Care last reported – of 7% from 2013/14 to 2015/16 across 120 councils – and the latest FOI shows that the situation varies across the country.

From 1 April 2016 to 30 September 2017, 32 councils reported a rise in their number of warranted AMHPs, 42 reported a decrease and the numbers stayed the same in 17. In many cases the changes were minor.

Only one psychologist and nine occupational therapists across the 102 local authorities which responded to Community Care’s FOI are warranted AMHPs, and about 95% are social workers.

Community Care’s special report on AMHPs examines the FOI findings in more detail, including the failure to bring more nurses, occupational therapists and psychologists into the AMHP workforce, and possible solutions.

AMHPs: The picture today

Recruitment and retention

Reports sent by local authorities in response to Community Care’s FOI request also highlight the reasons behind the ongoing challenge of recruitment and retention of AMHPs, including:

• The ageing AMHP workforce and retirements, leading to vacancies;
• Decline in community mental health services, meaning other avenues of support are not fully explored and increasing the pressure on AMHPs;
• Long working days for daytime workers which extend into the evenings due to lack of ambulance availability, delays in ensuring safe conveyancing, a lack of local beds, and more doctors becoming available to attend incidents later in the day;
• AMHPs accumulating a large amount of time off in lieu as demand for assessments and the day-to-day operational challenges involved cannot be managed within core hours;
• The loss of some AMHPs to become independent social workers, due to the amount of work available doing Deprivation of Liberty Safeguards assessments.

AMHP numbers – rises and falls

Community Care highlights the largest rises and biggest drops in AMHP numbers between 1 April 2016 and 30 September 2017 across the local authorities who responded to our Freedom of Information request.

Councils with the largest increases in warranted AMHPs

225% – Bedford

55% – Bexley

40% – Gateshead

31% – East Riding

27% – Middlesborough

Councils with the largest decreases in warranted AMHPs

41% – Somerset

40% – Barking

36% – Medway

33% – Southwark

31% – Cambridgeshire

Almost a decade after the position of approved mental health professional was introduced, the pressures on professionals in the role might never have been greater.

While the number of detentions per year under the Mental Health Act has increased by almost 50% over 10 years, it seems the AMHP workforce continues to shrink, as Community Care’s Freedom of Information request to local authorities shows. 

The number of warranted AMHPs fell by 2.5%, from 2,174 at 1 April 2016 to 2,120 at 30 September 2017, across 91 councils which supplied data to Community Care for both dates.

Our research also highlights a continuing failure to bring more non-social workers to the AMHP workforce.

And with some councils reporting concerns about an ageing workforce and the potential to lose more experienced AMHPs in the next few years, the training and recruitment of more professionals to occupy the role is becoming an increasingly critical issue, as is improving the working conditions of those at risk of suffering stress and burnout.

These developments are taking place in the context of widespread funding pressures, both within AMHP services and among partner agencies, meaning any major and transformative investment in this workforce is unlikely.

The information gap

In comparison to the numbers supplied to Community Care, a workforce report published by NHS Digital this month recorded 1,300 workers with an AMHP qualification across 116 councils which responded to a voluntary request for this information from Skills for Care.

This is about half that estimated by the National AMHP Leads Network. There is the possibility that when asking for the numbers of warranted AMHPs, some could be double counted. AMHPs can be warranted and authorised by more than one local authority, though they can only be approved by one.

Greater impetus to tackle these data problems comes particularly from the chief social worker for adults, Lyn Romeo.

She says: “We need to improve data collection to understand how many AMHPs we have. There’s been a lot more focus on the role in the past 12 months. But there’s still a lot more to do.”

Romeo says the Skills for Care return will be among data used to determine mandatory information collection from local authorities, but this probably won’t start until 2020.

Improving data, not just about the numbers of AMHPs but also their work is vital, says Ruth Allen, chief executive of the British Association of Social Workers.

“Data is power,” she says. “If we really start to look at the level of need, how many staff have you got, it then starts to expose the pressures on referrals.”

Allen says the lack of national data about AMHP activity, with statistics instead focused on local services, means “everything is all about how this or that council provides a service”.

“The upshot is that this quite risky and very pressurised work has stayed a bit off the radar,” she adds. “It has been quite convenient at national level to not know what’s happening.”

The number of Mental Health Act detentions has been the only official indicator of demand on AMHPs, but an  Association of Directors of Adult Social Services (ADASS) survey  in late 2017 aimed to improve the knowledge of overall workload by finding out how many MHA assessments they co-ordinate and details about the referrals they receive.

Social perspectives

One reason for the creation of the AMHP role was to improve the professional diversity of the workforce, by making it possible for mental health and learning disability nurses, occupational therapists and psychologists to train.

The government has commissioned the Social Care Workforce Research Unit at King’s College London to gain a better understanding of why other professionals are near absent from the AMHP workforce.

Its Who wants to be an Approved Mental Health Professional?’  project involved interviews with members of the other professions and a survey of AMHP leads, with initial findings due soon.

Allen says there continues to be a “clearer fit” between the training and expectations of social workers and the AMHP role than for other professionals.

She says some local authorities and AMHPs believe it’s important that the role can “provide a countervailing view to that of health professionals” by focusing more on social than clinical perspectives.

“But there have been some fantastic people coming through to that role [from other professions],” she says.

Then there is the fact that responsibility for the service remains with local authorities, meaning more onus on them, not NHS trusts, to invest in training.

Emad Lilo, vice-chair of the National AMHP Leads Network and social care professional lead at the Mersey Care NHS Trust, says health trusts might question why they should release staff for statutory local authority duties when they’re facing their own severe resource pressures.

“I don’t think there’s a shortage of health staff coming forward and keen to do the role,” he says. “But it needs the support of the employers and funding.

“Largely we saw up to 2014-15 very good nurse recruiting and training. But austerity and cuts are having a major impact.”.

‘Disintegration’

Lilo also points to the effects of ‘disintegration’, where local authorities and trusts are withdrawing from services they were jointly funding and providing, particularly under pooled budget agreements made possible by section 75 of the NHS Act 2006.

One high-profile example was Somerset council’s decision two years ago to end the integration of social workers with Somerset Partnership NHS Trust, an arrangement which had been in place since 1999.

Disintegration, combined with resource pressures on the NHS, might prevent some keen health professionals from joining the AMHP workforce.

Karin Orman, professional practice manager at the Royal College of Occupational Therapists (OTs), says the low number of OTs warranted as AMHPs “does not reflect a lack of appetite but challenges due to structural issues”.

While the statutory duty to provide AMHP services lies with local authorities, most OTs with the relevant skills and experience are employed in the NHS.

“Managers are not releasing staff as there is no statutory obligation to do so and releasing staff for training has cost implications for their service,” Orman adds.

The AMHP role is “embedded in the social disabilities model which is in alignment with our values as a profession”, says Orman. However, she says there has not been a government programme of support to “encourage wider recruitment of professions” to become AMHPs.

The 2007 amendments to the Mental Health Act 1983 also created the role of the Responsible Clinician. This replaced the Responsible Medical Officer role and was opened to professions including social work and occupational therapy.

Allen says this role is at a higher level and is broader than the AMHP. “You see some psychologists moving to that role and smaller numbers of social workers,” she says.

Professor John Taylor, a consultant clinical psychologist and associate director for psychological services at Northumberland, Tyne & Wear NHS Foundation Trust, says the British Psychological Society, through its Mental Health Act advisory group, is focusing on the promotion of registered psychologists as Approved Clinicians.

“We consider the competencies for this role, which includes acting as the responsible clinician for detained patients and those subject to CTOs [community treatment orders] and GOs [guardianship orders], is more commensurate with the training and experience of senior psychologists working in (mental) health settings,” he says.

Training challenges

There are also practical challenges facing many who want to train as AMHPs – following at least two years’ post-qualification experience – not least the time it takes to do the course.

Allen says: “We need a relatively stable workforce and to prepare people to get to the point where they are ready to do training. Their positions need to be backfilled so they can be released to do the training.”

Steve Matthews, an experienced practitioner , highlights the impact of the Care Act 2014 in adding to the workload of local authority adult social care departments, which might mean managers are “reluctant to let staff go on training courses”. Four months of the course is full-time and trainees are not available for normal duties. Once trained and approved by the local authority, they probably won’t be available at least one day a week as they’ll be on the AMHP rota.

Multi-agency working

Pressures on the AMHP workforce are increasing amidst their shrinking numbers.

Experienced AMHPs say delays in receiving police support – not from a lack of willingness but resource pressures – have the potential to place them in more dangerous situations and are increasing anxiety. Ambulances are also taking longer to arrive to take people to hospital, and even when they do, there might not be a bed available for patients who need to be detained, or it could be far away from the local area.

Matthews says: “Cutbacks to police, delays with ambulances and a reduction in beds do make the AMHP role more difficult.”

He says the Mental Health Act code of practice states that different agencies should work together and be able to provide appropriate services and assistance “but it doesn’t necessarily happen”.

Lilo says AMHPs are being “put in a vulnerable position dealing with very distressed people on their own because of diminished support from other agencies who are having to deal with cuts”.

He adds: “I’m still a practising AMHP and have lots of experience but in the last two years I’ve been starting to have a bit of anxiety. There’s a lack of support from the police and ambulance service to convey [patients]. You feel anxious, is something going to go wrong?”

Lilo says there is “no comparison” between the current situation and when he started working as an ASW 20 years ago

“Support from other agencies was more available and accessible. Although we have good working relationships they are tightening it more. And this is a national picture.”

Mental Health Act review

The review of the Mental Health Act, announced last year by Prime Minister Theresa May, might provide an opportunity to push for national reforms to ease pressure on AMHPs.

One of its main objectives is to understand the reasons for rising detention rates, and any recommendations, and subsequent policy and legal changes could impact on AMHPS.

AMHPS are using the review to call for tougher rules concerning the duties of other agencies. In its submission, the ADASS North-West Mental Health Group has suggested the review should consider if the responsibility of the police and ambulance service to support AMHPs should be made statutory and not just be defined in the MHA code of practice.

Ongoing work is focused on the professional status of, and oversight over, AMHPs. The government’s consultation on Social Work England proposes that it would set the criteria for, and approve, AMHP training courses.

A CQC and Department of Health review of the monitoring of AMHP services in 2016 suggested that Social Work England could gain responsibility for developing a national register of AMHPs. though one challenge would be that not all are registered social workers.

These initiatives might positively impact on recruitment and retention, as could Romeo’s intention to put together a workforce development plan for AMHPs in the next year.

But the pressures on the service show no signs of abating and fall directly on the dwindling number of AMHPs available – as well as on those they are trying to protect and provide care for.

Research by Community Care has revealed continuing pressures on the approved mental health professional workforce nationally, including reducing numbers of warranted AMHPs.

The findings have also highlighted the context for, and implications of, these pressures in local areas, after we asked councils for any reports they had prepared which looked at their AMHP workforce. These raised core recruitment and retention issues.

The ageing workforce and imminent retirements

Brent council says three of its AMHPs are approaching retirement, and all have reduced their hours in the past few years in anticipation of this.

Meanwhile, Worcestershire council says its “established and experienced” AMHP workforce provides “significant stability”, but 11 of the 38 AMHPs approved in the county are estimated to be within five years of the earliest local authority retirement age of 60. “It is very difficult to determine accurately what the impact of this will be on the service,” it adds.

Stress and burnout

Halton council says two very experienced AMHPs have withdrawn from the service’s rota because the work was having “a significant effect on their mental health and levels of stress”.

In Oldham, four vacant posts in the council’s AMHP teams are “impacting on the work/life balance of practicing AMHPs due to frequency on rota’s and late working”.

And Nottinghamshire council says pressures on the AMHP service could “lead to a reduction in quality of work and/or the worker experiencing high levels of stress or burnout. This is certain to have an impact on recruitment and retention of AMHPs, which is already challenging”.

Alternative jobs

AMHPs have been reducing the time they spend in the role or leaving the workforce for other social work positions. Wakefield council says people have been leaving to become independent social workers, an “unavoidable consequence” of the amount of work available doing Deprivation of Liberty Safeguards (DoLS) assessments.

Uneven working patterns

Leicestershire council says the majority of Mental Health Act assessments occur after 5.00pm. mainly due to the availability of doctors. Because of this, staff starting shifts at 8.30am had been “regularly working long hours including into the late evening”. However, the introduction of staggered shifts has significantly reduced the level of time off in lieu accumulated by AMHPs.

Local solutions

Association of Directors of Adult Social Services (ADASS) president Margaret Willcox, who made promoting the work of AMHPs a priority for her time leading the association, says challenges with recruitment and retention of AMHPs in some areas of the country are “one symptom of the overall funding crisis facing adult social care”.

She says the ADASS mental health policy network is currently reviewing areas that are having success recruiting and retaining AMHPs, and will look to share this best practice with other regions.

Local solutions to the problems of recruiting and retaining AMHPs are being introduced across the country.

Chief social worker Lyn Romeo’s 2016-17 annual report highlights the example of a new delivery model for the daytime AMHP service launched in Devon in 2015. Small, dedicated AMHP teams replaced the duty rota model, and each locality team became “empowered to define and direct their own work according to local need”.

Kent council responded to the “serious loss” of 26 AMHPs between February 2014 and April 2016 with a “higher than average intake” of trainees in September 2016. By the same time in 2017 it had five newly qualified AMHPs, with another two following in the November, and it currently has five taking AMHP training.

Brent council created a dedicated AMHP team and says given the shortage of AMHPs this is “the only way to deliver a safe statutory service”. It says this “would not necessarily be the ideal model to deliver effective services if there were enough AMHPs to choose a different model”.

Meanwhile, Leicestershire council says its introduction of an AMHP duty hub is “a much more efficient way of responding to referrals” and had reduced the number of times when it had to call in staff who were not on the AMHP rota. “Workers find it supportive of their practice and well-being,” it adds.

Referral hub

Steve Matthews, an experienced practitioner who blogs as The Masked AMHP, highlights the advantages in the area of the country where he works of having a group of practice consultants and team managers responsible for overseeing the AMHP service across a large geographical area.

They triage referrals and prioritise work, while AMHPs from social work and other teams go on a rota to carry out assessments.

“If there’s a hub where referrals are triaged, AMHPs are much less likely to be having to work late and generally we can allocate work so it can be completed during normal working hours.”

He says there can be problems associated with area-based duty provision, as AMHPs can have “completely unprocessed requests coming directly to you which you then have to deal with because you’re on duty”.

But there are advantages to the duty model over that of dedicated AMHPs. “You might be more likely to be burnt out if you are just doing AMHP work all of the time.”

More people are starting local authority adults’ social worker roles than are leaving, and the profession was the only section of the local authority adult social care workforce which increased last year.

The latest government figures on the local authority adult social care workforce reported that the ‘Professional’ job group, comprised of 84% social workers but which includes OTs, was the only group to have reported an increase in jobs – of 200 – from 2016 to 2017.

The number of jobs in this group fell by only 2% from 2011 to 2017, compared to a decrease of almost a third across the whole local authority adult social care workforce. However, compared to the 8% average vacancy rate across all adult social care, the rate for social worker jobs was higher at 10%.

The figures also reported a 3% drop in adults’ social workers’ median pay in real terms from
2012 to 2017, compared to a 1% rise for occupational therapists (OTs).

Local authorities employ around 85% of the estimated 19,000 social worker jobs across the whole adult social care sector, which also includes independent providers and the NHS.

Although the average number of sickness days for social workers and OTs fell from 10.2 to 8.7 between 2016 and 2017, this was still more than double the UK average of 4.3 days per worker.

However, 6% of workers had more than 40 sickness days, and the report said particularly high numbers “may have an impact on the overall mean”.

AMHP numbers lower than expected

For the first time, the report included figures for the number of Approved Mental Health Professionals (AMHP), as part of plans to improve intelligence on this section of the workforce.

Just over three-quarters of councils responded to the voluntary request, reporting a total of 1,300 workers with an AMHP qualification.

However, this is well below figures reported by both the AMHP Leads Network and a Freedom of Information request by Community Care, which found more than 2,900 AMHPs across 120 councils in 2015-16.

Job satisfaction

The report was published soon after a research paper on recruitment and retention in the adult social care workforce which found concerns among social workers about job satisfaction and morale.

The research by the Social Care Workforce Research Unit at King’s College London said while social workers and OTs were a “much smaller group numerically” than care workers working with older people, “the consequences of recruitment and retention problems among these professions can be considerable, for example, in the rate of delayed hospital discharges”.

Social workers participating in the study pointed to the effects on job satisfaction and morale of “work intensification”, the increase in the amount of work to be done in a set amount of time or of reducing the time allowed for completing certain tasks.

Funding pressures had accentuated work intensification in adult social care departments, the report said, with social workers reporting problems with recruiting new workers, staff being asked to take on more roles, experienced workers leaving through voluntary resignation programmes, and a reduction in peer support.

‘Churn’

The study said there appeared to be “high levels of ‘churn’” among local authority social workers and OTs. Their pay levels, while above the National Living Wage, may be “perceived as incommensurate with experience or workload”.

It added: “In this sense, ‘enough pay’ was seen as just one factor influencing turnover that would be traded off against other considerations such as job satisfaction or feeling valued.”

In addition, with no national pay scale for social workers, there were reports that newly qualified workers were leaving for neighbouring authorities where salaries were higher:

Professor Jill Manthorpe, one of the authors, said while much of the focus in recent years had been on the recruitment of social workers, it was also important to look at retention, particularly across the profession rather than just individual jobs.

She said the reasons for ‘churn’ were not necessarily linked to people’s jobs but could be related to housing costs or problems travelling to work, and while “often cast negatively” churn could, for example, be linked to social workers moving for promotion.

“If we want people to be managers and leaders then there will be movement,” she said.

Competition with NHS

The research highlighted issues affecting recruitment and retention in the wider adult social care workforce, notably “unease about the effects of competition with the NHS”, including workers leaving for jobs in the NHS after social care providers had invested in their training.

“Competition with the NHS for occupational therapists is another area that might benefit from further investigation,” it added.

A consultation on the adult social care workforce will be launched soon by the Department of Health and Social Care and Skills for Care. This comes after a report by the National Audit Office criticised the government’s failure to have an up-to-date workforce strategy which took account of major developments in the sector, including the Care Act 2014, and for its lack of oversight of workforce planning in local areas.

A review into the abuse of adults with autism at a home in Somerset run by the National Autistic Society (NAS) has called for an overhaul of the monitoring of out-of-area care placements.

Mendip House, which closed in October 2016 following a highly critical inspection, was part of an NAS ‘campus’ home to adults with severe autism placed by 30 local authorities and clinical commissioning groups from across the UK.

The review by the Somerset Safeguarding Adults Board (SSAB) said Somerset County Council (SCC) “had to invest in an expensive and labour-intensive enquiry because of the lack of rigor and failures of judgement of commissioning professionals”.

“Had the National Autistic Society addressed long standing concerns and the commissioners undertaken essential reviewing and monitoring, the workload of SCC and the Enquiry Team would not have been as extensive,” it added.

The review criticised the failure of the Care Quality Commission (CQC) to identify problems at the home earlier through its inspections.

It drew comparisons between Mendip House and Winterbourne View, the private hospital near Bristol where BBC Panorama exposed abuse of people with autism and learning disabilities.

It said: “There were over 30 different placement authorities across Somerset Court and although concerns were raised with SCC’s safeguarding team about other Somerset Court dwellings on at least four occasions between 2014-2016, not one identified concerns about Mendip House. Five years after the scandal of Winterbourne View Hospital this is remarkable.”

Commissioning failings

The review said commissioners continued to “act as place-hunters rather than agents of individuals with autism or stewards of the public purse with the means to control fee levels”.

It recommended that the Department of Health and Social Care, NHS England and the Local Government Association consult on the regulation of commissioning, including the “expectation that commissioners must notify the host authority of prospective placements”.

The consultation should look at the role of a ‘lead commissioner’ to “assume responsibility for coordination when there are multiple commissioning bodies of a single service”, and “assert a new requirement to discontinue commissioning and registering ‘campus’ models of service provision”.

Somerset council plans to require commissioners of services in the county to fund “essential monitoring and reviewing processes”, fund residents’ access to local health services, particularly community health services, and to identify a lead commissioner.

History of concerns

The review criticised the NAS for failing to share findings from its own investigations with the CQC.

The CQC and a senior NAS manager received allegations of abuse at Mendip House from whistleblowers in November 2014. The outcome of the NAS investigation raised concerns about the staff culture in the home.

In addition, a provider audit in October 2015 identified 43 areas for improvement but this was not reported to the CQC at the time.

The review also said the CQC should have been more proactive in identifying problems at Mendip House through inspections.

“The regulator acted once the harm was alleged to have occurred – without reference to the history of inspecting Somerset Court dwellings. The CQC’s decision to act after the whistleblowing is not good enough.”

The CQC eventually acted in May 2016 after two staff members raised concerns about unacceptable staff behaviour. It carried out an urgent focused inspection at Mendip House and was “satisfied that the staffing arrangements were adequate to keep people safe and ensure continuity of the service”.

It then decided to carry out comprehensive inspections of all Somerset Court locations in June and rated Mendip House ‘inadequate’ in all of its inspection criteria.

The CQC proposed to cancel the home’s registration, but the NAS decided to close the service of its own accord.

Residents reimbursed

Reported incidents of mistreatment included an employee making one resident crawl around on all fours, while staff threw cake at the head of another.

Almost £10,000 was reimbursed to Mendip House’s six residents after an audit of case files found residents had been funding meals of staff accompanying them during outings since 2014.

The review was particularly critical of practice in staff supervision sessions, stating it “beggars belief that staff were asked to sign a declaration each time they had a formal supervision session to confirm they had not witnessed any abuse”.

“There was recorded evidence that often a whistle-blower would themselves resign, while the alleged perpetrators were given warnings following disciplinaries and retained or recycled within the service,” it added.

Councillor David Huxtable, Somerset council’s cabinet member for adult services, said: “The report makes important recommendations for change that would bring more clarity on the responsibility for placing authorities to monitor the care being provided to the people they place.”

‘Very sorry’

NAS chief executive Mark Lever said: “We want to run the best possible residential services for autistic people, where they are safe and can thrive. We are very sorry that in May 2016 it became clear that we had failed to achieve this for the people living at our Mendip House care service, who were not shown proper care and respect and were mistreated by a group of our staff.

“We welcome the SAR report’s recommendations addressed to national agencies aimed at improving and monitoring the safety and quality of care placements. All of us who provide and commission care services need to make sure we have the right staff and robust systems in place as well as being prepared to take swift action if there are any signs that standards are dropping.”

Andrea Sutcliffe, the CQC’s chief inspector of adult social care, said: “We share the [safeguarding adults] board’s concerns over the outdated design of services like Mendip House: these days we would be unlikely to register a new service like this, and we are monitoring those services that already exist ever more closely.

“I am sorry that we did not do more when concerns were first raised with us instead of accepting assurances from the council and the NAS that those concerns had been dealt with.”

The Department of Health and Social Care (DHSC) is not doing enough to support a “sustainable” adult social care workforce and should produce a “robust national workforce strategy”, a review has found.

The report by the National Audit Office (NAO), which scrutinises public spending, criticised the government’s failure to have an up-to-date workforce strategy which took account of major developments in the sector, including the Care Act 2014, and for its lack of oversight of workforce planning in local areas.

It found there was no major workforce modelling or mapping of skills to support the government’s objective for greater integration between health and social care.

Councils were wary of challenging providers about workforce development issues due to the pressures they faced, the report said, and few were directly addressing providers’ recruitment and retention problems.

Although many people working in care say it is rewarding, the report found “widespread agreement that workers feel undervalued and there are limited opportunities for career progression, particularly compared with similar roles in health”.

Amyas Morse, head of the National Audit Office, said: “Social care cannot continue as a Cinderella service – without a valued and rewarded workforce, adult social care cannot fulfil its crucial role of supporting elderly and vulnerable people in society.

“Pressures and demands on the health and social care systems are increasing, so the Department needs to respond quickly to this challenge by giving the sector the attention it deserves and needs, instead of falling short and not delivering value for money.”

A spokesperson for the Department of Health and Social Care (DHSC) said it “recognises there are challenges in the social care workforce – that’s why we’ll soon launch a consultation on the adult social care workforce and are committed to publishing a health and care workforce strategy in the summer”.

Health Education England (HEE) launched a consultation on the health and care sector workforce late last year which the NAO said was “short and lacking detail” in its coverage of the care sector.

The DHSC and Skills for Care have now taken over the adult social care element of the consultation from HEE and have developed a set of consultation questions specific to the adult social care workforce that will go live soon.

Lack of strategy

The NAO identified problems with the DHSC’s actions including:

• No evidence that the department is overseeing workforce planning by local authorities and health and care partnerships. Without a national strategy “few local areas have detailed plans for sustaining the care workforce”.
• No up-to-date care workforce strategy and roles and responsibilities of the bodies involved in delivering care are not clear. Its last workforce strategy was published in 2009 but is only available on the National Archives website. It gives responsibility to some organisations that no longer exist and has not been refreshed despite major changes such as the Care Act 2014.
• No published forecasts on the social care workforce since the disbanding of the Centre for Workforce Intelligence in 2016.

The NAO recommended that the DHSC produces a “robust national workforce strategy” with the support of the Ministry of Housing, Communities and Local Government, and that it “encourages local and regional bodies to align their own plans to it”.

It said the department “also needs to invest more to enable commissioners to set appropriate fees for providers, so they can pay staff adequately and afford to offer career development and training opportunities”.

Local failings

As well as national failings, the NAO said local and regional bodies and partnerships were “not taking the lead on workforce planning in the absence of a national strategy”.

Under the Care Act 2014, councils must ensure services continuously improve and encourage a workforce that supports the local care market through standards, skills, qualifications and apprenticeships.

In case studies, the NAO found that councils do this through contract arrangements with providers. But councils told the NAO that they were “cautious about challenging providers over their investment in workforce development”, due to pressures facing providers and the negative consequences if a provider left the local authority funded market.

Few of a sample of 22 local authority market position statements, in which councils describe their activities to support local care markets, included “defined actions to address the issues that providers are experiencing with recruiting and retaining staff, or workforce development”.

Turnover and vacancy rates

The turnover rate in adult social care, with most workers providing direct care to service users, reached 27.8% in 2016-17 compared with 23.1% four years earlier. The vacancy rate was 6.6%, more than double the national average despite a reduction from the peak of 7% the previous year.

In addition, around half of care workers were paid £7.50 per hour or below (compared to the National Living Wage of £7.20 in 2016-17), equivalent to less than £15,000 per year.

“This, along with tough working conditions and a poor image, prevents workers from joining and remaining in the sector,” the report said.

The DHSC estimates the workforce will need to grow by 2.6% every year until 2035 due to increasing demand for care and complexity of needs. However, the NAO highlighted that annual growth in the number of jobs since 2013 had been 2% or lower.

The NAO also said the DHSC was unable to “demonstrate that the sector is sustainably funded, which impacts workforce planning”.

With local authorities spending 5.3% less on adult care in 2016-17 than in 2010-11, and further reductions expected, it said the social care market was “operating in challenging circumstances”, and care providers “are struggling to recruit and retain workers and are incurring additional costs as a result”.

‘Precarious’

Meg Hillier MP, chair of Parliament’s Public Accounts Committee, said the report showed the social care workforce was in “a precarious state”.

To date, the DHSC had “done little to help councils and providers prevent a looming workforce crisis”, she added.

Councillor Izzi Seccombe, chairman of the Local Government Association’s community wellbeing board, said the “worrying” report reflected the “historic underfunding of social care which is putting severe pressure on the care workforce, the provider market and the availability of care”.

“Councils only employ a minority of these staff using their own pay rates,” she said. “However, the increasing staff turnover rate and a vacancy rate more than double the national average amongst the wider provider group, shows the sector is struggling to recruit and retain staff who feel undervalued.”

Margaret Willcox, president of the Association of Directors of Adult Social Services (ADASS), said: “It is helpful that the report identifies that many people working in the sector find it rewarding, but if those same staff do not believe they are valued for the work they do, and believe there are limited opportunities for career progression, particularly compared with similar roles in health, there is a constant challenge of resulting high staff turnover, and difficulties with recruitment and retention.

“ADASS hopes the upcoming Adult Social Care green paper will provide a long-term, sustainable funding solution, and is committed to working with the Government to support them to achieve this. ADASS recognises, however, that the workforce challenges cannot be resolved with funding only and welcomes the report’s recommendation that the Department should produce a robust national workforce strategy to address the major challenges currently facing the care workforce.”

Widespread failings in multi-agency working and information sharing in Tameside mean risks to children often aren’t fully understood, inspectors have found.

Examples of good practice in the council’s children’s services were “exceptions” despite some progress, according to a report on an Ofsted monitoring visit in January 2018, the fourth since Tameside was judged ‘inadequate’ in December 2016.

Those examples were “the result of work done by individual practitioners rather than any systemic improvement”, it added.

Inspectors were particularly critical of multi-agency working, finding that the quality of information gathered to inform decisions about referrals was “often poor”.

“While most cases seen had information from schools, there was often an absence of information from other key agencies, such as health services and the police,” the report said.

“This means that children’s and parents’ needs are not fully understood.”

While immediate action is taken to keep children at risk of harm safe, strategy discussions usually only involved social care and the police, and “few of them involve other agencies”, Ofsted added.

Risk evaluation ‘ineffective’

Agencies “do not routinely contribute by sharing information, which leads to ineffective evaluation of risk”, inspectors found.

“The majority of cases seen during this visit demonstrated a lack of information from health services and the police,” the report said. “This means that decisions about the levels of risk to children are being made without the benefit of full and accurate information.”

Similar failings were identified in child protection investigations, where in some cases social workers or the police undertook single-agency action before strategy discussions had taken place.

In the “vast majority of cases seen”, information about the health needs of families was not obtained during the investigation period, “leading to incomplete evaluation of the presenting risks”.

The report added: “The lack of effective information gathering at all stages of a child’s journey means that the local authority cannot be sure that thresholds for decision-making are applied consistently or appropriately. As a result, children may not be getting the right support at the right time.”

‘Early signs of success’

Overall, inspectors found that there was “still considerable work to do to improve the quality” of child protection practice.

While Tameside had taken action to “address the previously slow pace of improvement” and there had been “some early signs of success”, the changes had “not yet had a sufficient impact on the service that children receive”.

Ofsted noted the recent impact of a new dedicated director of children’s services (DCS) post, after the council separated the DCS and director of adult services roles in September 2017.

Following the appointment in October of an experienced interim DCS, James Thomas (formerly of Newham and Westminster councils), Tameside had developed an “accurate self-assessment… [which] demonstrates a good understanding of the scale of change required in systems, culture and practice”. In addition, its revised improvement plan “shows more focus on improving outcomes for children”.

‘Social workers positive’

The report said social workers welcomed the “visibility of new senior leaders”, and felt the improvement plan “offers clearer direction and an increased focus on children”.

Workloads had become “more manageable for many social workers” following a reduction in caseloads across all teams, though they “remain high” in some.

A consultant social worker was ensuring newly qualified social workers received “good levels of support and supervision”.

But while there had been an increase in the number of social work posts and the permanent workforce was “stabilising”, there was “a reliance on high numbers of agency staff in some teams”, and the turnover of agency staff “continues to present a risk to practice improvement”.

In a statement, Tameside council said it was “pleased that Ofsted recognised we have taken appropriate action to accelerate the pace of improvement, and that we have an accurate understanding of ourselves, and that they recognise that it will take time for the new leadership and new improvement plan to have impact as at this point the quality of our social work with children and families is still not good enough”.

It added: “We are also pleased that inspectors found many examples of good practice and importantly did not find any children who had been left at risk. They also found improvement in management oversight of the service and reduced caseloads for social workers, and commended the commitment of our social workers.

“However, we know there remains significant work to do to ensure that every child and family receives the right support at the right time in Tameside and we remain unwavering in our commitment to deliver the improvement needed to make this happen.”

Other findings

– while assessments are completed in a timely way for all children, the vast majority of those seen by inspectors “only focused on the single presenting issue, and had significant gaps in their evaluation of history”.
– written plans were not child focused enough, and do not have clear outcomes, actions and timescales.
– case recording “does not reflect the work that is undertaken in order to help children”. Social workers had compiled good chronologies in a “small number” of cases, but these were mostly lacking.
– there is regular case discussion recorded on most children’s files, but records “do not yet evidence reflective discussion or analysis”, and there is “still not enough challenge from managers regarding the quality of practice”.
– there had been “some improvement” in the frequency and quality of supervision, but more work was needed to ensure this was consistent for all staff.

Children looked after by Wirral council have “unanimously expressed unhappiness” about the number of changes of social workers and independent reviewing officers (IROs) they have experienced.

A report on an Ofsted monitoring visit said looked-after children were becoming ”increasingly unwilling to form trusting relationships” with members of staff ”when they cannot be sure how long they will be their social worker for”.

Negative impacts of staff turnover highlighted by young people included not being given advance notice of a new worker or who it would be, and that new social workers did not always understand their past or what life was like for them.

Education and health professionals also reported that social worker turnover was leading to problems in sharing information, such as in advising other agencies of placement changes or breakdowns.

Inspectors highlighted concerns with “deficits” in assessment and care planning, saying these had “exacerbated the already traumatic experiences” of children who had been in care for a long time.

Temporary staff

The monitoring visit in December 2017 was the fourth since Wirral’s children’s services were judged to be ‘inadequate’ in September 2016. At the time, Ofsted also said children were experiencing ”too many changes of worker”.

The number of looked-after children in Wirral increased by almost a fifth to 837 between the ‘inadequate’ inspection and December 2017.

A Wirral Council spokesperson said the authority was creating 80 new children’s services jobs, including 46 full-time equivalent social worker posts, as part of a £20 million investment.

“This will reduce caseloads so that social workers can spend more time with children and improve the quality of their practice,” the spokesperson added.

“However, this investment and scale of recruitment has inevitably led to changes in social workers for some children. Any unnecessary change in social worker or IRO is unacceptable and every effort is made to avoid this.

“In a small number of cases this change has had to happen quickly and some children have understandably been unhappy about the disruption this has caused. In the medium and longer terms we are confident that increasing capacity will pay off and be better for all our children.”

Wirral said its turnover rate of social workers in children’s services fell to 6.7% in 2017 from 7.9% in 2016. In addition, 37% of social worker posts are currently vacant and 35% are filled by temporary workers, though the major recruitment campaign is ongoing.

‘Signs of making progress’

Overall, Ofsted inspectors said that, “following a slow start”, Wirral was “beginning to show signs of making some progress” in improving services for looked-after children, “though there is still a great deal of work to be done”.

Ofsted said an increase in the number of social work staff and managers was “a welcome response to managing the increasing demands on the service, even though this has necessitated an increase in temporary staff”.

Although Wirral was making “considerable effort” to stabilise the workforce, “with some early signs of success”, in most cases tracked by inspectors, children had had two or three social workers and IROs in 2017, as well as a number of changes in social worker in previous years.

Assessment problems

Inspectors also said that the absence of up-to-date assessments for looked-after children was a “key shortfall”, and that this “blunts the focus, and undermines the effectiveness, of plans and interventions”.

These plans, in addition, do not always take account of all of their [children’s] needs and do not progress swiftly enough”, and it “is not always clear what outcomes are expected for children looked after from their care experience”.

Inspectors also said permanency was “not well understood” by most of the staff they spoke to, while drift in care planning had led to some children ending up in long-term placements “by default rather than by good planning”.

Although case recording was “generally up to date”, Wirral’s electronic case recording system was “not being used to its maximum”, and case files showed “variable managerial case oversight and staff supervision”.

Social workers also “vary in the extent to which they undertake and record direct, purposeful work with children”.

IRO strength

However, inspectors said increasing numbers of escalations by IROs “show more strength from this service in addressing drift, and this is positive”.

They also saw better compliance with some essential minimum requirements, including completing plans, convening essential meetings and recording casework.

Social workers “understand the need for children to have plans”, including personal education plans (PEPs), though only half of looked-after children had an up-to-date PEP in November 2017 and the quality of PEPs “remains variable”.