Core Documentation Pack

Updated December 2007 [Amended 27.10.09]

RanaSallam SNIP

14 Rillbank Terrace Edinburgh EH9 1LL

Tel: 0131 536 0360 Fax: 0131 536 0583

Email: rana.sallam@luht.scot.nhs.uk

Care Co-ordination and Keyworking Information ..................................... 3

Why Change: history and policy? .................................................................................................... 3

What is Care Co-ordination/Keyworking? ...................................................................................... 4

What we did ..................................................................................................................................... 4

THE KEYWORKER ROLE ............................................................................................................ 5

Care Co-ordination and ASL ....................................................................... 8

CARE CO-ORDINATION REFERRAL FLOWCHART ................................. 10

CARE CO-ORDINATION ADMINISTRATIVE FLOWCHART ....................... 11

REPORTS INFORMATION ACTION NOTE (No4) ...................................... 13

Referral Form ............................................................................................. 14

Initial Planning Meeting Letter ...................................................................... 16

REPORT FOR CARE CO-ORDINATION MEETINGS ................................. 17

PLANNING/REVIEW MEETING AGENDA .................................................. 18

Format for planning and review meetings .................................................... 19

MULTI AGENCY CARE CO-ORDINATION PLAN ...................................... 20

Planning / Review Meeting Minutes ............................................................. 21

Keyworker Meeting confirmation Letter................................................... 22

Planning Meeting Reminder Letter............................................................... 23

QUESTIONNAIRE FOR PARENTS AND PROFESSIONALS ..................... 24

INFORMATION LEAFLET .......................................................................... 25

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Care Co-ordination and Keyworking Information

Why Change: history and policy? There are a number of factors that came together to make this the perfect time to adopt a more co-ordinated approach to the care of children with complex needs. Families of children with complex needs have been saying for many years they wished professionals would work in a more ‘joined-up’ way. Families express concerns regarding the amount of meetings they are expected to attend eg school reviews, respite reviews, LAAC reviews which will have an individual focus but which involve the same information sharing around the needs of the child and family. There is a strong desire from families and professionals to reduced the number of meetings and therefore an attempt to pull them together under the umbrella of care co-ordination would be beneficial to all concerned. Families also expressed a wish to have a ‘keyworker’ assigned to them who could offer emotional support and liaise with all professionals involved in their child’s care. It is vital that families are well-supported and empowered and work in partnership with all involved professionals. A major study undertaken in South West Edinburgh in 2004, commissioned by the City of Edinburgh Council, Lothian Health and the voluntary sector through the Changing Children's Services Fund, found considerable support for more widespread adoption within children's services for a care co-ordination/keyworker approach and recommended that consideration be given to how best to take this forward.

4 Following the Community & Therapies Redesign

project, which was carried out by Elaine Dhouieb (RHSC), monies were allocated from the Changing Children’s Services Fund to appoint a full-time Care Co-ordination Facilitator (CCF) and Administrative Assistant, funded until March 2006. The remit if the CCF is to roll out the model of Care Co-ordination across the City of Edinburgh. The city of Edinburgh is divided into five local health care cooperative divisions and a roll out day was held in each locality. In the pilot phase, each area was tasked with forming a local multi agency steering group with a role to identify a minimum of ten children with contrasting social and medical backgrounds and then ‘test drive’ these children and families through existing systems to identify areas requiring improvement or change. This core resource pack was designed from this work and cascaded out to all statutory organisations in 2007 for local implementation. Successful models of care co-ordination have been developed throughout the UK and supported by the Care Co-ordination Network UK (CCNUK)

1. Quote by Sally Rees, Chair of

CCNUK is typical: “I don’t know what life would have been like for our family without our keyworker – before in the early days it was like being in a goldfish bowl, people looking in on our lives, appointments here and appointments there, knocks on the front door with another professional asking the same questions about our son. Enlightenment came in the form of our son’s speech therapist, who took on the role of keyworker. She was our liberator, she knew our family well, she helped organise and plan and was someone to whom we as a family (or should I say me!) could express our feelings at times of difficulty. It did and still does make a huge difference.” The Additional Support for Learning (Scotland) Act 2004

2 introduced a new framework for

identifying and supporting children and young people who require additional support to learn. It complements existing education and equality legislation by promoting collaborative working. The factors, which may give rise to additional support needs, are wide and varied. Additional support needs may result from children’s disability, social, health and emotional well-being, care and protection, family circumstances, or from their learning environment. A small number of children who’s additional support needs arise from long term complex or multiply factors that have a significant adverse effect on their school education may require a Co-ordinated Support Plan (CSP).

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CSPs are statutory working and planning documents that aim to co-ordinate multi-agency services over a long-term period for a child that focuses on learning outcomes.

The legislation

has significant implications for professionals working in education, health, social work and a range of other agencies. In order to ensure children are provided with the necessary support to aid their learning and help them achieve their full potential, a model of collaborative working among all those working to support children and young people will be necessary. The model of Care Co-ordination supports this legislation and provides a holistic person centred model, which can be used, for all children from birth until transition into adult services. Medical advances mean that there are a growing number of children with complex needs surviving, requiring an ever-increasing number of professionals involved in their care over a much longer time-span and into adulthood. The inclusion agenda, which offers parental choice of where children with complex needs can be educated, has led to many children having split placements between mainstream and special schools adding difficulty to co-ordinate these children’s care. ‘An Action Plan for Scotland’s Children’ (The Scottish Executive 2001),

3 sets out clearly a

requirement for better integration of services within local authorities, health services and the voluntary sector. The Changing Children's Services Fund was established to support this plan. Increased involvement of the voluntary sector in policy and planning has lead to greater demands from these services and a requirement for statutory agencies to communicate better with each other and provide more flexible, family centred services. What is Care Co-ordination/Keyworking? Care co-ordination with keyworking is a model of practice, which involves working with children/young people and their families. It can be applied to any group of children who require input from two or more services not including core services (eg general practitioner, health visitor, teacher, school nurse). It encompasses individual tailoring and joint planning of services based on assessment of need, inter-agency collaboration at strategic and practice levels, and the opportunity of a named keyworker for the child and family. What we did A criteria for inclusion in Care Co-ordination was developed:

“Child/young person must have complex needs with or without multiple disabilities which are significant and ongoing for at least six months, significantly affecting the child's functioning and

requiring resources from more than two service providers or agencies excluding universal services (e.g GP, health visitor, teacher, school nurse).”

In order to support transitions and uniformity within agencies a documentation pack was developed for use with all children/young people. A referral form is included which must record parental/carer/young person’s consent to evidence that this new way of working will be done in partnership. Any child/young person who meets the criteria can be referred in to Care Co-ordination by any carer, member of staff or family member. Self-referral would also be accepted. This documentation is available in hard copy, by disk or via email. As part of the development work towards a single parent held record the Chain notebook was introduced to all families taking part in the first stage of the pilot. A comment sheet was included in the back to encourage parents to feedback. The difficulty of developing one record, which fits all, is recognised and further work is being carried out across children’s services.

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The keyworker model has been adopted and the decision as to who should take on this role must be done in partnership with the parents. To support this way of working SNIP received funding from the Changing Children’s Service fund, until 2006, to provide Keyworker training which is available, free of charge, to all staff in children’s services. The training is also available to parents and carers. They also provide disability awareness and managers days where managers are given the opportunity to discuss the implications of this development in practice. THE KEYWORKER ROLE Purpose of the Role The Keyworker role is an integral part of the Care Co-ordination model. The Keyworker must work in partnership with the family and provide a link between all professionals/agencies involved in the child/young person’s care. Following the first part of the evaluation it was recognised that one of the essential skills required for Keyworkers is their ability to clarify their role, its limits and boundaries (e.g that it is not an emergency service). Therefore, in the initial stages of working with a family some of the following points may provide some guidance for discussion. What is the Keyworker role? To work in partnership with the family to provide an advocacy role, which ensures family

concerns, are identified and addressed. To provide a single point of contact and link between all professionals/agencies involved,

including making sure their agenda is well represented. To agree contact details/times in advance, including the period of notice required by both

parties for cancellation of meetings (eg 24 hour minimum). To hold responsibility for the production and maintenance of the inter-agency care plan,

which states clearly which action, will be done, by whom and by when. To have the responsibility for the initiation and overseeing of any inter-agency assessment

framework. To develop a pro-active, emotionally supportive relationship with families, which seek to

empower, rather than create dependency, whilst recognising that the family’s capacity to care will vary over time.

To hold responsibility for organising a chair and minute takers for the Care Co-ordination planning/review meetings.

How will the Keyworker role work alongside traditional roles? In the Lothian’s it was agreed that the Keyworkers are professionals who have agreed to take on the role and the tasks related to it, in addition to their usual practitioner role. Many of the tasks are already being carried out on an informal basis and Keyworking looks to formalise the role and thereby improve equity of service and delivery to families. The Keyworker ideally supports a minimum of two families and a maximum of three. The role can often be quite labour intensive at first and at times of transition, therefore it is essential that colleagues and fellow professionals have a clear understanding of what Keyworking involves. The Keyworker does not take on the delivery of services and interventions to a family; these continue to be provided by the various specialists. The role is one of co-ordination and ensuring that the family understands the purpose and potential outcomes of any interventions and that the families’ priorities are given centre stage in discussions. Improved inter-agency working will lead to better assessment of need which may not lead directly to increased services but may lead to services being provided in a more holistic way.

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Discussions may be needed regarding time limitation of role from either Keyworker or child/young person/family. The Keyworker role will be achieved by: Pro-active, agreed, regular contact between Keyworker and family/child/young person A supportive, open relationship based on respect for the views of parents, children and

young people. A family-centred not only a child-centred approach. Working across agencies - including agencies such as housing, leisure and the benefits

agency. Keyworkers need to know, or are prepared to find out, what different agencies offer and how to go about accessing different agencies.

Working with the families’ strengths, acting as an advocate or enabling parents, children and young people to access advocacy support as required. It is important that managers see this as an integral part of the keyworker's role.

Provision of induction training and on going training and development for keyworkers. Regular supervision of keyworkers, including both professional/clinical and management

supervision, from a manager who understands and is committed to the role of keyworker. Peer support systems should also be available.

Disabled children, young people and their families should be given a clear explanation of the role of the keyworker/care coordination service and the responsibilities of this role. Families, who do not wish a Keyworker, should continue to be offered this service as appropriate.

An inter-agency care plan giving keyworkers the agreed power to refer for resources and credibility with the agencies involved in provision for the family.

Appropriate professionals complete ensuring a single assessment. It is not the Keyworkers responsibility to carry out the assessment but it is their responsibility to make sure it has been/is in the process of being completed.

Organisational standards

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A successful keyworker service is dependent on: 1. Multi-agency commitment at a strategic and practice level. 2. Multi-agency management group including families and, at the minimum, representatives

from education, health, social services, and the voluntary sector if a stakeholder in the area. This group needs to include senior managers with the power to commit resources. The group should establish formal links with other agencies, including housing, leisure and benefits, to enable the keyworker service to access services from these agencies to meet families' needs.

3. An agreed referral system and specific guidelines for eligibility for the keyworker service. 4. A joint policy for information sharing between agencies. 5. A multi-agency protocol for joint assessment, drawing up an inter-agency care plans and

review of the needs of the disabled child and their family. 6. A communication strategy. All professionals working at all levels of the organisations

involved - managers and practitioners – as well as parents and children and young people need to be kept fully informed and, where appropriate, involved in the planning and development of the keyworker service.

7. A Care Co-ordination Facilitator to manage the service on a day-to-day basis and to report to the multi agency management group.

8. Ongoing resources to run the service including the provision of administrative support, induction and ongoing training and supervision for keyworkers.

9. An agreed system for cover for keyworkers in the event of long-term absence. 10. Setting up and maintaining links with other agencies that impact on the lives of disabled

children and young people, e.g. housing, benefits, leisure, voluntary sector. 11. Identifying the cultural needs of the local population, including minority ethnic groups, and

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ensuring that the service provides for these needs. 12.

Ongoing monitoring, reviewing and evaluation of the service4

Practice standards

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The role of the Keyworker should include: Providing information to families and other involved professionals. Identifying and addressing the needs of all family members. Providing emotional and practical support as required. Assisting families in their dealings with agencies and acting as an advocate if required. Referring the family for services following completion of the action plan, as appropriate.

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Benefits of Care Co-ordination/Keyworking to families/children/young people Referral into Care Co-ordination provides a single entry point for access to services. Use of a Single Shared Assessment (Section 23/integrated assessment framework) would

reduce the number of times families ‘tell the story’. Opportunity to have a Keyworker for children/young people and their families. Co-ordinated planning and review mechanisms/documentation across all agencies. Inter-agency care plan compiled, shared, recorded and agreed in partnership with families

and the people involved in the child/young persons care. Planned support and continuity of services during times of transition. Single parent held record (currently being developed across all agencies). Benefits of Care Co-ordination/Keyworking to professionals/agencies Increased job satisfaction with improved caseload management Enhanced relationships with families and other professionals Reduction in duplication of assessment Improved understanding of other’s roles Better identification of gaps in service provision More effective and targeted use of resources Benefits of assessment, planning and review Interagency assessment leading to an inter-agency care plan, building on and linking with

any other assessments undertaken, e.g. special educational needs, child development team, family service plan, social service assessment, disability register.

Agreed system and timing for inter-agency care plan and reviews. Supporting parents’ and young people preferences regarding assessment and review

meetings. Ensuring appropriate support for children and young people to participate in their

assessment and review, including children and young people who do not use speech to communicate.

Appropriate support for parents to participate in their assessment and review process. Consideration of support needs related to ethnicity and culture, including provision of

translation and interpreters, so that all families can participate in assessment and review. Accurate record keeping and recording. Parent and/or young person held records. Recognised Care Co-ordination principles Parental empowerment

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Professional empowerment Needs led, person centred approach appropriate for children and families Clear pathways of communication Negotiated, agreed and recorded inter-agency action plans Respect, openness and trust between families and professionals Shared professional understanding of roles, responsibilities, systems and funding

mechanisms Fully trained, supervised and managed keyworkers Clear lines of authority, respect, accountability – contractual Transparent ways for families to express opinion on service provision Holistic approach addressing families emotional, physical social and practical needs Identification of gaps in service provision Social model of disability Effective monitoring and evaluation processes

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Audit & Evaluation An essential part of Care Co-ordination is the evaluation. The first stage involved staff and families in the North East, North West, East Lothian and Midlothian. All staff that completed the keyworker training were sent a questionnaire, the response rate from which was low. A small sample of families were interviewed by SNIP. The aims of the questionnaire to professionals were to explore the training they had received and the role requirements of the Keyworker. Despite the low numbers of respondents the trends and positive comment about different aspects of the work is worthy of note in the future planning of Service. This roll-out has been a dynamic process and in a shifting landscape of services for disabled children and their families many changes have been enacted on a pragmatic basis. Any future evaluations developed would be enhanced by taking into account more specific aspects of Care Co-ordination and not just the Keyworker role. It would be unfair from this small sample to make special reference to some individual comment, however, in the daily work of Care Co-ordination specific concerns have arisen re: 1. The Care Co-ordination model requires to be embedded in Children’s Services. 2. Roll-out of Keyworker role is essential to support families of vulnerable children. Emphasis

will be required to ensure professionals explain clearly the role during initial contact with families.

3. The Care Co-ordination model is a whole family approach. Parents had mixed experiences of this in action therefore the area will require further development.

4. Interagency assessment framework/Section 23. The confusion around this assessment perhaps suggests a need for further examination of a cross-agency tool to be part of current developments within children’s services.

5. Questionnaire responses to support and supervision show a very disappointing lack of professional supervision. Reasons for this range from constraints on time to supervision being unavailable. This area also requires further examination to ensure supervision is available across all agencies.

6. Shared understanding of individual roles requires on going development. Identification of administrative support to arrange reviews in some areas has been highlighted

and will require further examination.

Care Co-ordination and ASL

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Care Co-ordination is an approach whereby the professionals involved with the family of a child/young person with complex needs work together to ensure that the needs of the whole family are met, particularly at times of transition. One of the involved practitioners takes the role of Key Worker, providing a single point of contact, emotional support and liaison with other practitioners. In all cases the child/young person in Care Co-ordination will be receiving education services. Care Co-ordination has been operating throughout Edinburgh for the past three years. The criteria for referral into Care Co-ordination are that ‘the a child/young person has complex needs, which significantly affect their functioning and are expected to be ongoing for six months or more, requiring resources from two or more agencies other than universal services’. Care Co-ordination is specifically referred to in the CEC’s Guidance ‘In on the Act’ in sections 4.7, 5.2 and appendix 9, as it is explicitly identified as the process for addressing the additional support needs of disabled children under 3. A Key Worker may also be the appropriate person to take on the role of co-ordinator for the Co-ordinated Support Plan (Supporting Children’s Learning – ASL code of practice, page 67). If a child or young person is in Care Co-ordination then good practice dictates that the number of meetings held to discuss their needs be reduced where possible. This can be done by ‘piggy backing’ a Care Co-ordination meeting onto a school review. Where a statutory review must take place e.g. Looked After Children (LAC) then these issues take priority on the agenda but will be reviewed in the context of the wider issues of the child’s care. The documentation provides templates including the agenda and minute for a Care Co-ordination meeting (pages 12 & 15) and as you can see the emphasis is on identifying actions needed to resolve issues for the child and family and identifying who will take forward the action and when. This approach reflects both the ASL Act and the guidance in the emphasis on effective communication, the child and family being at the centre of the discussions and the wider context in which the child’s learning is to be supported. If you have any queries about this process contact: 1CCNUK

2Scottish Executive 2004 - Additional Support for Learning (Scotland) Act 2004 – Planning for Change

3Scottish Executive 2001 – An Action Plan for Scotland Children

4The Improving Children's Services report, Putting Children First. There is also an associated Executive

Summary. Copies of both documents are available from Shajna Majid, 0131 469 3030. Email:

shajna.majid@educ.edin.gov.uk.

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CARE CO-ORDINATION REFERRAL FLOWCHART

Referrer discusses with young person/parent/carer

Care Co-ordination/Keyworker Role/Integrated Assessment Framework/Family Held Record

Parental/Young Person/Carer Consent Agreed

Referrer Completes - Care Co-ordination Referral Form* send to Care co-ordination Facilitator DATE, TIME, & VENUE for first Planning meeting must be recorded on front of referral form

Care Co-ordination Planning Meeting Organised by locally agreed admin

Care Co-ordination Planning Meeting Held

Future Care Co-ordination Reviews

Referrer discusses with young person/parent/carer Care Co-ordination/Keyworker Role/Intgrated Assessment Framework/Family Held Record Discussed

Parental/Young Person/Carer Consent Agreed

Pre-Planned Meetings Should Adopt Care Co-ordination Paperwork*/Framework

(No additional meetings required)

Care Co-ordination Review Meeting

NEW CHILD

New to Area New Concerns/Diagnosis Simpson’s Centre for

Reproductive Health

RHSC

(incl. SNS register)

KNOWN CHILD

Nursery Child & Family Centres School

*Documentation templates are available in hard copy, electronically and on disk

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CARE CO-ORDINATION ADMINISTRATIVE FLOWCHART

Referral Form Received into Central Admin Point

Acknowledgement of referral receipt action note (No1)

Meeting Already Arranged No Meeting Arranged

Referrer to arrange VENUE, DATE, TIME of meeting in consultation

with family

Issue Invitation* to attend meeting and Report Form* (approximately 6-8weeks prior to agreed date).

Reports should be submitted whether or not professionals are able to attend prior to the deadline date (2 weeks before planned meeting)

and returned to the address shown on the Report Form

Agenda Request Action Note*(No2) sent to Referrer/Keyworker (with return date included)

At report deadline date circluate Agenda* and reports to all those planning to attend (including Reports information note* (No4) naming reports not yet received)

Professionals Involved Sheet* and blank Multi-Agency Care Plan* sent to Referrer/Keyworker for updating/completing at meeting. Future meeting action note* (No3)

also sent to the Referrer Keyworker to complete at the end of the meeting

After Care Co-ordination Meeting

Referrer/Keyworker returns paperwork to agreed admin point along with future meetings action note

Circulate Multi Agency Care Plan*, updated contact details from back page of Referral Form* and Minutes* from meeting along with meeting information note* (No5)

Contact Keyworker 8-10weeks prior to scheduled review meeting to confirm arrangements*

Issue reminder Invitation* & Report* (approximately 6-8weeks prior to agreed date)

*Documentation templates are available in hard copy, electronically and on disk

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ACKNOWLEDGMENT OF REFERRAL RECEIPT ACTION NOTE (No1)

AGENDA REQUEST ACTION NOTE (No2)

FUTURE MEETINGS ACTION NOTE (No3)

To the Referrer I would like to acknowledge receipt of the referral form/s for: Name/s:…………………………………………………………… D.o.B:…………………

With Compliments

To the Keyworker/Referrer

In preparation for the meeting arranged for..…………….……………………………….

on.……………………………please forward any agenda items you or the child/

young person/family would like included. One week prior to the meeting the agenda

and submitted reports will be circulated to all those planning to attend.

With Compliments

With Compliments

To the Referrer/Keyworker

The date of the next review meeting for……………………………………… will be

held on …………………………………………………………………….. at………………………

The venue for the meeting will be……………………………… ……………………………….……

The Keyworker is……………………………………………………………………………………….

The administration for this meeting will be done by ………………………………………………..

(Insert your own contact details here)

(Insert your own contact details here)

(Insert your own contact details here)

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REPORTS INFORMATION ACTION NOTE (No4)

POST MEETING INFORMATION CIRCULATION ACTION NOTE (No5)

With Compliments

Please find enclosed reports submitted for: for meeting on

………………………………………………………….. at ……………………………….

Reports have been received from:

Attending: Apologies:

Reports or apologies not yet received from:

If you have still to submit your report, please can you send copies of the completed report to: ………………………………………………………………………………………………………………………………….

Also enclosed is a template agenda for the meeting.

Following the Care Co-ordination meeting for:

held on at

please find enclosed:

Multi-agency plan

Updated professional list

The next Care Co-ordination meeting for: will take place on

…………………………………………………………at …………………………………………………

(Your contact details inserted here)

(Your contact details inserted here)

With Compliments

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Referral Form Name: Parent/Carers Name:

Contact Details: (if different from child’s)

D.O.B. CHI No:

Address: Postcode:

Nursery/Child & Family Centre/School:

(include full address & telephone)

Telephone (home): Telephone (mobile):

Locality (please tick): NW NE SE SC SW Planning/Review Meeting Arranged: Yes No Date/Time & Venue

Name & contact details of referrer :

(include full address, telephone and email)

Planning/Review Meeting Required: Yes No Suggested Date/Time & Venue

Meeting to be arranged by:

Local admin Central admin Child has CSP*/Record of Need: Yes No Don’t know

Child is LAAC*: Yes No Don’t know

Child on SNS: Yes No Refer

Child on CPR: Yes No Don’t know

Reason for Referral (please tick box and give further details below): DIAGNOSIS (if known)………………………………………………………………………………….……………..

EDUCATIONAL Learning Difficulties …………………………………………………..…………………………..

School Related Problems ……………………………………..……………………..………….

MEDICAL Congenital Abnormality ……………………………………………………….………..………..

Delayed Development: - Motor …..…………………………………………………………

- Speech & Language ………..………………….……….….……

- Social/Personal Skills ………………………….…………………

Visual Impairment ……………………………………………………..………….……….……..

Hearing Impairment ………………………….…………………………………………………..

Illness ……………………………………………….……………………………………………..

Behavioural……..…………………………………….…………………………………………….

SOCIAL/FAMILY Socio-domestic Problems ……...……..…………….…………………………………………...

Child Carer ……..…………………………………………………………………………………

Significant Illness/Disability in family member ……………………………..…..…………….

OTHER ……..………………………………………………………….…………………………………….

FURTHER INFORMATION:

What are the family’s concerns?

Signature of Parent/ Young Person/Carer: ……………………………………………….…………Date:……………………

The parents/persons with parental responsibilities have agreed to this referral and to information about their child being obtained from and shared with professionals from other agencies eg. Health, Education, Social

Services, Support Needs System in order to co-ordinate future provision. Signature of Referrer: ……………………………………………….………………………………Date:……………………

*CSP=Co-ordinated Support Plan, SNS=Support Needs System, CPR= Child Protection Register, LAAC=Looked After & Accommodated

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PROFESSIONALS INVOLVED PLEASE CHECK WITH THE FAMILY THAT ALL INVOLVED PROFESSIONALS HAVE BEEN IDENTIFIED. (This should include any professionals who the child/young person has been referred to but is still awaiting an appointment.) If a planning/review meeting is required all named professionals will be invited and also will be required to submit a report.

Name Address Tel / email Child & Family Centre

Clinical Psychologist

Community Learning Disability Team

Community Nurses

Consultant Paediatrician

Community Care Worker

Dietician

Educational Psychologist

General Practitioner

Keyworker

Midwife/Public Health Practitioner/School Nurse

Named Person Record of Need/Co-ordinated Support Plan

Nursery/Class/Learning Support/Guidance Teacher

Occupational Therapist: 1) Health 2) Social Work

Physiotherapist

Psychiatrist

Respite services

Social Worker

Specialist Doctor

Speech & Language Therapist

Visiting Teaching Support Service

Voluntary Organisations

Other eg Housing, Leisure

Once completed, please return referral form to: Rana Sallam, SNIP, 14 Rillbank Terrace Edinburgh EH9 1LL

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Initial Planning Meeting Letter DATE Dear RE: (INSERT CHILD’S NAME & DATE OF BIRTH) A multi-agency care co-ordination model for children with complex needs has been established. Following a referral from (INSERT YOUR / REFERRER’S DETAIL’S), an initial planning meeting has been arranged for (INSERT CHILD’S NAME) family and professionals on:

(INSERT DATE, TIME & VENUE)

As you have been identified as providing a service for (INSERT CHILD’S NAME) you are invited to this meeting which will discuss:

Identification and role of the Keyworker

Issues arising from young person/parents/carers

Issues arising from professionals

Completion/update of multi-agency care co-ordination plan Enclosed is a report which you should complete, whether or not you are planning to attend, and return to the address below by (insert date). All submitted reports will be circulated prior to the meeting. Pre-meeting circulation of reports facilitates:

Awareness of the holistic service provision to the family

Consideration of your contribution to the multi-agency care co-ordination plan if unable to attend

Allows the family and Keyworker to consider any matters arising from submitted reports which they would like included in the agenda

The meeting should last no longer than one hour. I look forward to hearing from you. Yours sincerely Enc LETTERS SENT TO:

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REPORT FOR CARE CO-ORDINATION MEETINGS

Prior to the Care Co-ordination meeting, this report will be circulated to all individuals attending

Child’s Name ____________________________________________ DOB: ____________________________________________ Date of Meeting: ____________________________________________ Venue: ____________________________________________

Please outline your proposed /current plan of input to include existing/planned goals:

Please state current assessment, any areas of concern and frequency of contact with family:

I am able to attend the meeting I am unable to attend the meeting

Name: Job Title:

Telephone: Signature:

Email: Date: THANK YOU FOR YOUR CO-OPERATION

This report will be circulated prior to the meeting, therefore please return report by to: (Your contact details inserted here)

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PLANNING/REVIEW MEETING AGENDA

Planning Meeting held on (INSERT DATE) for (INSERT CHILD’S NAME)

at (INSERT VENUE) 1. WELCOME & APOLOGIES

a. Updating of key personnel contact details 2. ISSUES ARISING FROM YOUNG PERSON/PARENTS/CARERS

a. b. c. d.

3. KEYWORKER ROLE 4. ISSUES ARISING FROM PROFESSIONALS

a. b. c. d.

5. MULTI-AGENCY CARE CO-ORDINATION PLAN COMPLETION/UPDATE 6. ANY OTHER BUSINESS

a. Evaluation questionnaire to be offered to parents and professionals 7. DATE OF NEXT MEETING

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Format for planning and review meetings

Chair and minute taker can be any two people attending the meeting, out with the Keyworker

Action Person

1. Welcome to parents/young person/carer and professionals

Chair

2. Introduction of each person present & update contact details on page 2 of referral form (ensuring key personnel have been invited)

All

3. Outline the purpose of meeting:

Issues arising from young person/parents/carers

Keyworker role

Issues arising from professionals

Multi-agency Care Co-ordination plan completion/update

Chair

4. Reports from non-attendees to be heard Chair

5. Input from young person/parents/carers (if required) Young person/ Parents/carers

6. Input from Keyworker (if already nominated)

Keyworker

7. Input from professionals (as required) All

8. Complete and/or review Multi-Agency Care Co-ordination Plan, including recording of any unmet needs/service gaps identified

All

9. Any other business & date of next review meeting. Is child moving toward transition? Who needs to be invited/involved at next meeting?

All

10. Checklist : Completion of all timescales/actions in the Multi-agency co-ordination plan Referral to Support Needs System Benefits, e.g. DLA (Disability Living Allowance), Family Fund, etc.? Any further referrals and/or assessments required before review meeting eg Integrated Assessment Framework, Section 23? Statutory notification to Education? Nursery/school placement? Family support? Teaching of clinical tasks required? Equipment? Medication issues?

All

11. Thank participants for time and contributions. Circulation of questionnaires for parents and professionals

Chair

12. Following the meeting the Multi Agency Care Plan, updated contact details from back page of referral form and minutes should be circulated to all involved professionals with action note (No5)

Identify admin point

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MULTI AGENCY CARE CO-ORDINATION PLAN This plan will be circulated to all individuals invited to attend the Care Co-ordination meeting.

CHILD’S NAME: ……………………………………Date of Plan: ………………… KEYWORKER DETAILS: ……………………………………Version: ……………………… …………………………..………. …………………………..………. Date Action

Agreed ACTION BY WHOM BY WHEN

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Any ‘unmet need’ / service gaps identified:

Date of Next Meeting:

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Planning / Review Meeting Minutes

Child’s Name: ________________________ Keyworker: ______________________

Meeting held on: ____________________ Venue: __________________________

PRESENT:

APOLOGIES:

MINUTES:

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Keyworker Meeting confirmation Letter

Dear Keyworker RE: (Insert Child’s Name & DoB) Following the planning/review meeting for (insert child’s name), it was minuted that the next family care co-ordination review meeting will take place on:

(INSERT DATE & TIME INSERT VENUE)

Can you let me know if this meeting is still going ahead so reminder letters and reports can be issued to the professionals involved with (insert child’s name). I look forward to hearing from you. Yours sincerely

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KEYWORKER: (INSERT KEYWORKER DETAILS)

Planning Meeting Reminder Letter Dear ????? RE: (Insert Child’s Name & DoB) As you know, (insert child’s name) and his/her family are taking part in care co-ordination. The arrangements for the next family care co-ordination review meeting are as follows:

(INSERT DATE & TIME INSERT VENUE)

The purpose of the meeting is for parents and professionals to discuss the outcomes of the previous plan, attend to any new issues, formulate a fresh plan and decide whether (insert keyworker name) should continue to be the keyworker for the family. The meeting should last no more than one hour. Enclosed is a report that should be completed, whether or not you are planning to attend, and return to the address below by XX. All submitted reports will be circulated prior to the meeting. Pre-meeting circulation of reports facilitates:

Awareness of the holistic service provision to the family

Consideration of your contribution to the multi-agency care co-ordination plan if unable to attend

Allows the family and Keyworker to consider any matters arising from submitted reports which they would like included in the agenda

The meeting should last no longer than one hour. I look forward to hearing from you. Yours sincerely Enc LETTERS SENT TO:

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PLANNING/REVIEW MEETINGS

QUESTIONNAIRE FOR PARENTS AND PROFESSIONALS

As part of the ongoing evaluation of Care Co-ordination we would appreciate you taking a few minutes to complete this to allow us to monitor the quality of our planning meetings.

Ratings

1 (Very Good)

Yes 2

3 No

concerns 4

5 (Poor)

No

Was the purpose of the meeting well described?

Did you say what you wanted to? Did you feel your contribution was represented in the action plan?

Are you sure what plans have been made and the timescale for completion?

Did you feel there were unspoken issues ?

Did you think everyone stuck to their brief to state the current situation and their goals?

Now that there is a keyworker for the family do you feel confident about contacting them?

Please make any comments or suggestions:

THANK YOU FOR YOUR TIME

Please return to: Rana Sallam SNIP 14 Rillbank Terrace Edinburgh, EH9 1LL

Fax: 0131 536 0583

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INFORMATION LEAFLET

What is Care Co-ordination / Keyworking?

Care Co-ordination, including Keyworking, is a model of practice that involves inter-agency working with children/young people and their families.

It can be applied to any group of children who require input from two or more services not including core services (eg general practitioner, health visitor, school teacher, school nurse).

It encompasses individual tailoring of services based on shared assessment of need, inter-agency collaboration at strategic and practice levels, and a named keyworker for the child/young person and family.

Why is it needed?

Families of children with complex needs have been saying for many years they wished professionals would work in a more ‘joined-up’ way.

They have also expressed a wish to have a ‘keyworker’ assigned to them who could offer emotional support and liaise with all professionals involved in their child’s care.

The Additional Support for Learning Act 2004 introduced a new framework for identifying and supporting children/young people who require additional support to learn.

It is vital that families are well-supported and empowered and work in partnership with all involved professionals.

’An Action Plan for Scotland’s Children’ (The Scottish Executive 2001) sets out clearly a requirement for better integration of services within local authorities, health services and the voluntary sector.

A Care Co-ordination Facilitator and Administrative Assistant were appointed to rollout the model of Care Co-ordination, including Keyworking, across the city of Edinburgh.

Criteria for inclusion in Care Co-ordination

Any child/young person must have complex needs with or without multiple disabilities which are significant and ongoing for at least six months and significantly affect the child's functioning Require resource from more than two service providers or agencies excluding universal services.

ON CARE CO-ORDINATION FOR CHILDREN & YOUNG

PEOPLE AND THEIR FAMILIES

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What are the aims of Care Co-ordination?

To develop better co-ordination for families and professionals working together and planning in partnership.

To provide the Keyworker role to all families of children/young people with complex needs/multiple disabilities.

Reduce the number of times parents/young people have to ‘tell their stories’ by having a single shared assessment and one parent held record.

Working in partnership would increase the level of information which is shared with families.

Multi-agency care co-ordination planning will aid identification and recording of unmet need/gaps in service provision. If you would like to discuss or find out more about Care Co-ordination, please Rana Sallam SNIP 14 Rillbank Terrace Edinburgh EH9 1LL Tel: 0131 536 0360 Fax: 0131 536 0583

Email: rana.sallam@luht.scot.nhs.uk

What do Keyworkers do?

The Keyworker role is an integral part of the Care Co-ordination model. All staff working in children’s services have access to Keyworker training.

The Keyworker has an advocacy role and works in partnership with the family and provides a link between all professionals/agencies involved in the child/young persons care.

The Keyworker should hold responsibility for the production and maintenance of the interagency care plan which states clearly which action will be done, by whom and by when.

Have the responsibility for the initiation and overseeing of any single shared assessment.

Provide a single point of contact for the family/professionals around any issues relating to the child/young person’s chronic/complex disability or additional support needs.

Develop a pro-active, emotionally supportive relationship with families, which seek to empower, rather than create dependency, whilst recognising that the family’s capacity to care will vary over time.

How does Care Co-ordination benefit families?

Referral into Care Co-ordination provides a single entry point for access to services.

Use of a single shared assessment (Section 23/integrated assessment framework) would reduce the number of times families ‘tell their story’.

Opportunity to introduce a Keyworker for children/young people and families.

Co-ordinated planning and review mechanisms/documentation across all agencies.

Inter-agency care plan compiled, shared and agreed in partnership with families and the people involved in the child/young persons care.

Planned support and continuity of services during times of transition.

Single parent held record (currently being developed across education, health, social work and the voluntary sector in consultation with parents).