Review of Community and Social Services.

Comptroller and Auditor General Review of Community and Social Services

10 December 2015

Review of Community and Social Services

Introduction

1. The Health and Social Services Department (HSSD) is responsible for ensuring delivery of community-based health and social care services for Jersey. HSSD's Community and Social Services Directorate (C&SSD) provides a number of these services.
2. HSSD faces significant challenges across its range of services provided to vulnerable client groups and, in the case of services for older adults, to an increasing number of potential clients. It predicts that by 2040 Jersey will have almost double the number of older people than in 2010, with the greatest increase in the over 85 population. It has identified a need for change, driven by:

• opportunities to secure more sustainable health and social care services; and
• issues with service quality, in particular as identified within C&SSD's children's services.

Background

3. A diverse range of community and social services are provided using:

• C&SSD staff;
• independent providers; and
• voluntary and not for profit organisations.

4. Since 2013 HSSD's System Redesign and Delivery Directorate has commissioned those services not provided by C&SSD staff.
5. C&SSD operates in four service areas, three defined by the age of the client – children, adults and older adults – and one bringing together different therapy services (see Exhibit 1).

1

Children's Services

6. Children's Services were the subject of three independent reviews in 2008, all identifying the need for improvements in service quality.
7. The response to the reviews included structural change, bringing a number of services together, an element of independent inspection and independent user groups. But the response was partial and key recommendations, such as those relating to limits on caseload size and complexity, were not implemented.
8. In 2011 the Care Inspectorate (the independent scrutiny and improvement body for care, social work and child protection services in Scotland) carried out the first independent inspection focussing on looked after children. The review published in 2012, identified a failure to implement some recommendations and significant need for improvement. The Care Inspectorate's follow-up review published in 2013 recognised improvements in key areas, such as lines of accountability and staff training, but identified important high risk areas requiring further action, including linking service plans and priorities to the strategic framework and using information for performance management.
9. In 2014 HSSD acknowledged significant problems in leadership, risk management and communication within Children's Services, identified in Scrutiny reports and Serious Case Reviews. As a result significant staff changes were made within C&SSD and Children's Services in particular, including senior interim management appointments.
10. The interim Director of Children's Services assessed immediate priorities and put in place Rapid Improvement Plans (RIPs) for Child and Adolescent Mental Health, 16 plus Leaving Care, Residential Care and Child Protection. By July 2015 the RIPs had been implemented.
11. Reviews against Ofsted standards were also completed in 2015 in four service areas - the Multi-Agency Safeguarding Hub, initial assessments, child protection plans and care planning for looked after children. Only the last of these was assessed as meeting minimum care standards. In response, management established a two-year Sustained Improvement Plan (SIP), designed to maintain progress and improve service quality.

Adult Services and Older Adult Services

12. In 2014 Jersey introduced a Long Term Care Scheme to provide funding for Jersey residents who are likely to need care for the rest of their life, either in their own home or in a care home. C&SSD has a key role in undertaking assessments and, based on those assessments, establishing packages of care that are in turn funded by the Long Term Care Fund maintained by the Social Security Department.

C&SSD-wide developments

13. In 2012, following a substantial review of the current service provision and anticipated future needs, HSSD published the White Paper Caring for each other, Caring for ourselves'. This concluded that HSSD needed to transform its services in order to support high quality, sustainable health services in the medium and longer term. This resulted in publication of the P82/2012 A New Way Forward for Health and Social Care', the initial focus of which was the changes needed in community and out-of-hospital services. From this developed a series of outline business cases and a transition plan, managed by the System Redesign and Delivery Directorate and rooted in a commissioning approach', overseen by a Transition Steering Group.
14. In 2015, the interim Managing Director looked across all C&SSD services and diagnosed underlying issues with corporate business basics':

• policies and processes;
• risk management;
• quality assurance and performance management; and
• budget management.

15. A programme of work has been established, chiefly taken forward by a new Quality Assurance and Governance Services (QA&GS) team, reporting to the interim Director of Governance and Nursing Practice.

Objectives and scope of the review

16. This review was designed to assess the extent to which HSSD:

• specifies what is required from C&SSD services in line with its overall strategic objectives and monitors the achievement of those objectives;  
• analyses existing provision and identifies options for change;
• chooses between in-house and external provision;  
• manages and monitors delivery;
• starting with children's services, has appropriately diagnosed the problems and identified what needs to change with services;
• identified the barriers to change and evaluated their significance;
• where barriers have been recognised, identified appropriate levers for change' and made appropriate plans for implementation; and
• where plans for overcoming barriers have been identified, implemented or are on course to implement those plans.

17. Below I consider the findings of the review grouped under five main themes (see Exhibit 2).

Exhibit 2: C&SSD Review – Themes

Overall management arrangements

Risk Monitoring  assessment

activities  processes

Implementation  Information and communication

Overall management arrangements

0. Overall management arrangements relate to organisation-wide standards, processes and structures. But importantly they also embrace how management leads and reinforces behaviours. Good overall management arrangements support attainment of organisational objectives, including securing value for money. My findings relate to:

• the governance framework;
• leadership; and
• clarity of message.

The governance framework

1. An effective governance framework documents the overall processes for effective oversight of an organisation, covering all services and business as usual' as well as change initiatives.
2. Elements of an effective governance framework have been in place. A Transition Steering Group (that confirmed priorities, developed preferred service models and progressed detailed planning to implement service models) has overseen the implementation of the P82/2012 Transition Plan with Ministerial sign-off for key decisions.
3. But this robust approach to governing strategic change contrasts with the lack of appropriate governance for managing business as usual' services. In Children's Services there were no robust arrangements in place to identify and then address declining service standards.
4. Recent work has started on developing a comprehensive C&SSD-wide governance framework, led by the QA&GS. The framework uses seven pillars of governance based on good practice in healthcare governance, mainly drawn from the UK National Health Service but with additional elements relevant to social care. A piloting process is currently underway but more work is required to develop the content of the framework (see Exhibit 3).

Exhibit 3: Governance Framework

Clinical and Social Care Audit

Co-production and service user/patient involvement

Risk management

Resource effectiveness (including staffing and staff management)

Education, training and continuing professional development

Information and communication

Evidence-based care

5. A Children's Social Work Improvement Board has also been established as a key component of the framework for ensuring the effective implementation of the SIP. It has broad senior representation: it is chaired by the Chief Minister and the other members comprise:

• the Minister for HSSD;
• senior officers within HSSD;
• an independent person with substantial experience of leading, managing and improving Children's Social Work; and
• the Independent Chair of Jersey's Safeguarding Partnership Board.

Recommendation

R1  Establish clear milestones for the completion and implementation of the

C&SSD-wide governance framework, covering all C&SSD services, business as usual' and change initiatives, and monitor delivery against those milestones.

Leadership

6. Consistent delivery of quality services requires not just appropriate standards and structures but also consistent leadership. The C&SSD Managing Director is now a permanent appointment but, whilst interim management has a valuable role, C&SSD is currently without permanent staff in place in key posts: since 2014 there have been two interim Directors of Children's Services and the Director of Governance and Nursing Practice post is currently filled on an interim basis.

7. C&SSD has been seeking to appoint substantively to the post of Director of Children's Services and, following a third recruitment campaign, expects a new appointee to start in March 2016.
8. More generally, C&SSD has a high vacancy rate, ranging up to 24% in Children's Services. Key operational posts are currently filled on an interim basis, including three of the four Heads of Service, some team managers and some key frontline staff. Vacancies or high reliance on interim cover for management positions dilute the capacity to lead in a time of change.

Recommendation

R2 In developing the workforce strategy for C&SSD, identify specific measures to

reduce reliance on interim staff.

Clarity of message

9. Effective management arrangements rely not just on structures and leadership but also on a consistent and clear message to staff throughout an organisation. For staff delivering services a clear understanding of what they are expected to do and how is pivotal to consistent delivery of quality services.
10. In the past C&SSD has not had a clearly defined set of policies and processes designed to meet its quality expectations and provide guidance for practitioners. Staff have not had an agreed operational manual' to support service delivery, which made it very difficult for everyone to be sure their practice is compliant with the requirements of quality standards.
11. This weakness was identified in 2008 but it was not until 2015 that C&SSD implemented a previously procured system, Tri.x which:

• facilitates the development of policies, procedures and good practice examples;
• makes them available on a web-enabled system;
• facilitates checking for consistency; and
• makes keeping documents up-to-date easier.

12. The first edition of C&SSD's Policy, Procedure and Guidance Manual is now available to staff in Adult Services and Older Adult Services but staff in Children's Services have not yet been included. C&SSD has plans in place to make sure all staff have access by March 2016. All service areas are currently involved in reviewing the policies and procedures that will go on Tri.x.
13. Encouragingly C&SSD plans to supplement its policies and procedures with a Practice Workbook that is currently in draft. The Workbook guides staff through the process of reflecting on their daily working practices to understand how it influences the outcomes attained by people who use services, and carers. It sets out guidance outlining key principles,

management arrangements and structures required to address the issues of care governance. It also includes a requirement to assess services against eleven Core Standards from the UK's Social Care Institute for Excellence. C&SSD plans to pilot the Workbook in two service areas and appoint champions to support rollout.

14. But clarity of message goes wider. A comprehensive communication plan was initially rolled out to support the P82/2012 Transition Plan. However, a number of officers have reported that some staff working within C&SSD services still feel a lack of engagement with the future plans for sustainable health and social care services. They reported that front line staff in services not so far directly involved in the P82/2012 Transition Plan do not always engage with the vision' or see the link between the strategic plan and their day-to-day work. Actions outlined as part of the SIP and within the QA&GS workstream are designed to address this disconnect. In addition, the recently appointed C&SSD Managing Director is prioritising work to engage better with staff across C&SSD.

Recommendations

R3 Put in place steps to evaluate the effectiveness of work designed to improve engagement with C&SSD staff and make changes where necessary.

Risk assessment processes

0. Key to attainment of objectives is effective risk management to:

• identify and evaluate risks to the attainment of objectives; and
• develop appropriate responses.

1. In the absence of effective risk management there is an increased risk of failure to provide high quality services on a consistent basis.

Risk identification and evaluation

2. The first stage in effective risk management is capturing and evaluating risks to the attainment of objectives. The System Redesign and Delivery Directorate has demonstrated some evidence of effective risk identification and evaluation:

• the development of the White Paper Caring for each other, Caring for ourselves' was based on a substantial review of current service provision and anticipated future needs and the risks of doing nothing; and
• a well established risks and issues log that is updated for quarterly discussions at the Transition Plan Steering Group. The log is supported by processes for scaling, scoring and escalating risks that informs the implementation of the P82/2012 Transition Plan.

3. However, the same evidence of rigour has not been seen in all areas. The initial assessment of the potential impact of the Long Term Care Scheme (LTCS) was weak, leading to unanticipated volumes of referrals and consequent strains on the system. This later led to further additional Social Worker resources being allocated, paid for by the Social Security Department (SSD). Monitoring and evaluation now continues through regular liaison meeting between C&SSD and SSD.
4. More fundamentally, for C&SSD activities as a whole, there has been no consistent, effective approach to risk identification and evaluation in place:

• whilst a risk register has been maintained, it has not been a reliable indicator of current risks. Important entries are out of date meaning that they are not being systematically evaluated. For example, in the July 2015 version there were individual entries with next review dates of September 2013, February 2015 and March 2015; and
• whilst risk logs and registers were maintained at service, division, departmental and corporate levels, and HSSD has set out in its Risk Management Framework the thresholds for escalating risks, risk identification and escalation is not yet operating effectively for C&SSD service areas.

5. The newly-appointed Managing Director for C&SSD has recognised weaknesses in this area and is at the early stages of making improvements, recognising that these involve not only improvements in processes but also instilling a change in culture. Early developments include:

• receipt of short reports on health and safety incidents to the newly- implemented Health and Safety meetings, providing details of incidents and their implications for future risks;
• charging the Performance and Finance Group with regular review and updating of the Directorate risk register;
• the Directorate Leadership Team reviews the register at each fortnightly meeting; and
• the HSSD Head of Risk Management challenges officers on the rigour with which they are managing risks.

Responding to risks

6. Effective risk management involves not only the identification and evaluation of risks but also the development and implementation of effective responses.
7. Historically, there have been significant weaknesses in this area. Key recommendations on Children's Services made in 2008 were not implemented on budgetary grounds. There was no effective escalation or consideration of the risks of not implementing key recommendations in the light of other risks and priorities.
8. The current risk management framework is not sufficiently developed to give confidence that identified risks are being appropriately managed. Not only are risk registers not up to date but there is also poor linkage from identified risks to specific actions designed to mitigate the risks.
9. The P82/2012 Transition Plan demonstrated a stronger approach to responding to identified risks but there was scope for greater clarity on timetables for the implementation of corrective action.
10. Despite the weaknesses in the arrangements in place, there are examples of development of effective responses to mitigate risk:

• using the HSSD-wide prioritisation framework to evaluate initiatives against three headings – Quality and Safety, Value and Customer – to inform budgetary discussions with the Council of Ministers and Directors;
• using Lean' tools to support the Safely Removing Costs (SRC) initiative; and
• undertaking a Lean' review to understand better why the introduction of the LTCS had put resources under pressure and, in light of that understanding, change working arrangements.

Recommendation

R4 Establish and monitor implementation of effective arrangements for reporting,

evaluating, escalating and responding to risks.

Information and communication

0. Effective management is dependent on good quality, relevant information, appropriately used and effectively communicated. In the context of health and social care such information allows the needs of vulnerable clients to be identified, assessed and responded to. The complexity of client needs and range of service delivery creates complex information needs and means that a focus on information and communication is even more important.
1. This review has considered a number of dimensions of information and communication (see Exhibit 4).

Exhibit 4: Information and communication

Overall approach

Information systems

Data quality

Performance against standards

Summary information Communication with staff

Overall approach

2. C&SSD management has recognised the importance of improved information and communication and taken some initial steps:

• a newly formed Performance and Finance meeting is starting to set out its data and information requirements. Significantly, C&SSD has identified that work is needed to ensure that managers and front line staff understand their responsibility for providing high quality data;
• committing to developing a more detailed, C&SSD-specific form of Integrated Reporting, based on the HSSD-wide approach and bringing together financial and performance information to highlight pressures and opportunities in the system; and
• the appointment of a C&SSD information analyst who undertook an information audit to map out, for clinical and non-clinical information:

• what is currently recorded and how;

• how this drives Key Performance Indicators (KPIs) and outcome measures;
• where, when, and how the information is reported and used; and
• what are the known gaps in information.

This important post was vacant for a period in 2015 delaying progressing the findings of the information audit.

Information systems

3. The operation of appropriate information systems is key to providing information to allow staff to undertake their work effectively and managers to manage.
4. HSSD has recognised the importance of investment in information systems. It has invested in its informatics function in 2015 and its Informatics Strategy is being taken forward through a recently updated Informatics Action Plan that sets out a two-year workplan. The Action Plan:

• includes a commitment to using information to drive better patient and client care and to improve outcomes; and
• recognises the importance of clinicians and practitioners, as well as service managers, having ready access to information and the ability to interpret the information easily and appropriately.

5. C&SSD has recognised significant weaknesses in current information systems and is investing in improvements.
6. FACE (Functional Assessment in Community Environments), which Jersey's mental health services have been using for some time, has been rolled out across all Adult Services, Older Adult Services and Special Needs Services, in a new web-based version. FACE:

• captures information on a person's needs;
• facilitates production of a care plan;
• aligns resources; and
• assigns costs to the services needed by the user, which is important to link to funding for the LTCS benefit.

7. In Children's Services, C&SSD recognises that Softbox, the current IT system used by fieldwork social workers, is no longer fit for purpose. Whilst Softbox provides electronic case records, it does not support assessments or the production of reports and care plans.
8. Additional funding of £400,000 has been allocated in 2015 to provide a new IT system for Children's Services. This is currently being procured working with Education Services to aid better information sharing.

9. FACE is not the equivalent of the Integrated Care Record (ICR) system used by HSSD for managing patients attending the General Hospital. Work to implement a community based ICR is highlighted in HSSD's Informatics Strategy but is dependent on an upgrade to the General Hospital's ICR (Trakcare) scheduled for 2016. If this is achieved, HSSD plans that FACE and the newly procured Children's Services system will be linked as feeder' systems to Trakcare.
10. There remain challenges:

• joining up information from FACE and the newly procured system for Children's Services which is particularly important where there are whole family issues which need to be managed together; and
• delivering meaningful management information from the systems. FACE can provide valuable monitoring information allowing assessment of the quality of service provision, such as elapsed time between a referral and delivery of an assessment. However, such information is not yet routinely being drawn from FACE and reported. Whilst a FACE user group is currently reviewing reporting options as part of the development of C&SSD Integrated Reporting, there is as yet no timetable or clearly identified set of expectations for management information.

Recommendations

R5 Develop mechanisms for sharing information between FACE and the newly

procured system for Children's Services to facilitate management of whole family issues.

R6 Develop a set of expectations and a timetable for the provision of

management information from FACE and the new system for Children's Services and monitor delivery.

Data quality

11. Information systems alone are not sufficient: they rely on the input of good quality data that is complete, accurate and up to date.
12. A strong culture of data quality is not yet in place in C&SSD:

• the information audit identified inconsistencies in completeness of performance data and recommended that each service clearly sets out what data it needs to collect;
• the introduction of the LTCS highlighted a need routinely to cleanse data to provide a better picture of active caseloads; and
• C&SSD has found that the data on completion of staff appraisals submitted by C&SSD managers to the Human Resources Information System (HRIS) is unreliable, under-recording the incidence of completion of staff appraisals.

13. As part of its Informatics Strategy Action Plan, HSSD has identified that it needs to review the quality of data in community based systems in the same way that it has focused onmaking improvements to its hospital based information.

Performance against standards

14. Information is at its most powerful when it can be compared against a reference point, such as an agreed standard. For example, information on the time taken from referral to assessment is most powerful when there is a target time, allowing action to be focussed on cases where the target is not met.
15. The development of the commissioning approach as part of the P82/2012 Transition Plan has led to an increased focus on performance management. From a low base, outsourced service providers now routinely provide important metrics on performance against standards contained in Service Level Agreements. These standards cover efficiency but also effectiveness, capturing outcomes, including through service user and staff views.
16. Whilst there are currently no equivalents to Service Level Agreements for services provided directly by C&SSD, performance management is being developed as part of the business basics' programme referred to above and the work of the QA&GS.

Recommendation

R7 For all C&SSD services:

• develop clear performance standards;
• identify the data required to monitor these;
• establish data quality criteria for all data items; and
• ensure information systems routinely record performance against service standards.

Summary information

17. Some of the most powerful tools of management are relevant, concise and accessible summary information that allow management, politicians and other stakeholders to monitor performance and initiate corrective action where appropriate.
18. C&SSD does not have a strong track record in collating information about its service delivery. Work has started in this area but is at an early stage. In addition to the Integrated Reporting referred to above C&SSD has:

• adopted the NHS safety thermometer' methodology to monitor community ward safety, using KPIs such as incidence of pressure ulcers and falls. Work has started on developing a Mental Health Safety Thermometer;

• implemented service user satisfaction surveys for some services – although C&SSD has yet to make full use of these as KPIs with targets and tolerances; and
• developed dashboards showing service-level performance management information, including data such as ward occupancy levels, length of stay, waiting times data, service user views, and staff information such as absences and vacancies. These dashboards have however yet to be established for all services.

Recommendation

R8 Establish a clear programme with milestones for delivery and use of summary

information for all community and social services, including KPIs and dashboards, and monitor delivery.

Communication with staff

19. Tobe effective policies, procedures and guidance need to be well communicated to staff. Arrangements have been weak although, as reported in the Background above, progress is being made.
20. Tri.x allows staff to create an icon on their desktop, laptop or tablet to link directly to the website, facilitating access for all staff, including those working remotely. Early feedback suggests that web-based policies and procedures are making it easier for staff who have access to make sure they use agreed and up to date guidance to deliver high quality services. C&SSD has stated its intention that staff will have the opportunity to comment on what is available, how it is presented and what could be done to further improve its value.
21. However, there is currently no system in place to monitor who is accessing the system or what they are viewing, which would provide useful indicators of impact and take-up. C&SSD has indicated that this is planned for later in 2015 or early in 2016.

Recommendation

R9 Monitor access to policies, procedures and guidance and take corrective

action as necessary.

Implementation

0. Effective management of service delivery relies on robust arrangements for implementation. As part of my review I have considered elements of:

• service planning;
• decision making;
• workforce development;
• programme and project management; and
• assessment of user needs.

Service planning

1. Robust planning of services facilitates implementation of strategic priorities. Despite the absence of robust overall management arrangements there has been evidence of effective planning of individual services, for example:

• the development of Outline Business Cases to support the P82/2012 Transition Plan; and
• in delivering the P82/2012 Transition Plan, decisions about tendering services have been made against clear and transparent criteria. The outcome of the tendering process has been continually reviewed to understand market development needs and options. HSSD is working proactively with potential service providers to develop new opportunities.

Decision making

2. Clear, objective decision making facilitates delivery. One of the key steps taken to improve the overall governance framework within C&SSD has been the establishment of a series of meetings to manage Performance and Finance, Health and Safety and Cross-Directorate Issues.
3. Despite the weaknesses in C&SSD decision making structures, there were examples of good decision making for community based services. Phase 1 of the P82/2012 process, which runs alongside the three year Medium Term Financial Plan to the end of 2015, has been well documented. Importantly, it is clear how services moved from outline planning to Ministerial decision.

Workforce

4. People are the key resource of C&SSD. Effective delivery therefore requires appropriate development of the skills and capabilities of the workforce.
5. HSSD has identified the need for support in establishing a robust workforce strategy and operational plan to ensure the right people with the right skills, competencies, values and behaviours are able to meet patient and client needs in the most appropriate settings to create a workforce able to meet HSSD business needs in the future.' HSSD has appointed consultants to

assist in developing a first draft workforce plan and development plan by the end of 2015, to be finalised by the spring of 2016.

6. HSSD is committed to the development of two additional inter-related strategies:

• an education and training strategy – intended to add to opportunities for Islanders to access employment in a key and growing sector of the Island economy'; and
• an organisational development strategy: HSSD wishes to build on its current services in ways that enable safe sustainable and affordable services to be provided in the face of the challenges to health and social care facing our Island community.'

7. C&SSD has identified a need for both up skilling' of the current workforce and recruitment of new staff with the required skill sets. It recognises that this needs to be managed in the context of a whole system' i.e. not shifting skills to one part of the system to the detriment of another.
8. Key developments include:

• an increased focus on annual staff appraisals to assess performance and identify training and development needs. In Children's Services these were moved from the anniversary of the recruitment (which made tracking and reporting difficult) to a timeframe of between January and March for all staff. The validated incidence of completion of 2015 staff appraisals for Children's Services was 78% but, as noted above, reliable figures are not available across C&SSD;
• design and start of implementation of a programme of Continuing Professional Development through the QA&GS function. This is supported through the Practice Workbook that teams within all services will be asked to complete. However, the timeframe for this is not yet set out; and
• commissioning of a trainer to help meet the learning and training needs identified in reviews of Children's Services. However, a longer-term solution has yet to be identified.

9. Encouragingly, and building on the Pre-registration Nurse Training Programme which has been in place for 10 years, since 2012 a nursing degree course has been available on-island. In 2014 the programme was extended to include mental health nursing. In contrast, a conscious decision has been made not to develop an on-island social work degree as students would not get adequate exposure to a range of clients and situations to prepare them for a role in social work. Instead islanders typically train in the UK and gain experience before, in some cases, returning to work in Jersey.

Recommendations

R10 Identify steps to improve:

• the recording and monitoring of the completion of annual appraisals; and
• the incidence of annual appraisals and their effectiveness.

R11 Establish a timeframe for the rollout of the Practice Workbook and monitor

delivery.

R12 Identify a longer-term solution to delivery of identified training needs. Programme and project management

10. There has been a history of weaknesses in programme and project management within parts of C&SSD. Programme and project management approaches were not adopted for responding to the previous reviews of Children's Services and a number of agreed actions were not implemented.
11. More robust programme and project management arrangements have been put in place as part of:

• delivery of the P82/2012 Transition Plan;
• C&SSD's implementation of the Children's Services SIP, including the establishment of an Improvement Board to oversee progress; and
• HSSD's focus on Safely Removing Costs (SRCs). HSSD has established a Programme Management Office to oversee the SRC programme and requires all projects forming part of the programme to have:

• a corporate director and clinical lead;
• a clear timetable;
• an established meeting structure; and
• a Lean link.

Assessment of user needs

12. A key driver of the delivery of services is the robustness and consistency of the assessment of user needs. Improved information systems and dissemination of policies, procedures and guidance should facilitate improvements in this area.
13. In the initial stages of the LTCS, two different grading systems were used for assessment, a weakness subsequently identified by the Lean review. A single grading system has now been agreed, based on a six stage grading of care needs. FACE can facilitate its implementation to secure consistency of assessments.
14. For Children's Services there is currently insufficient information on whether assessments are in line with policies and procedures.

Recommendation

R13 In implementing the new information system for Children's Services, ensure

that it supports consistent assessment in line with agreed policies and standards.

Monitoring activities

0. A key element of effective arrangements is monitoring through:

• review and accreditation of services;
• effective learning from complaints; and
• monitoring the implementation of agreed recommendations.

Review and accreditation of services

1. Review and accreditation of services are key means of providing assurance about standards and driving improvement. Accreditation is a means of comparing services not against historic performance but against other organisations and best practice.
2. Historically, such review and accreditation has not been an established part of the arrangements for all service areas within C&SSD:

• a key recommendation of the 2008 reviews of Children's Services was the establishment of a regular programme of external inspection. Management accepted this recommendation with a commitment to a first review in 2009, the second in 2010 and a bi-annual programme thereafter. However, the first review by the UK Care Inspectorate was not undertaken until 2011 (with publication in 2012) and the only subsequent review was a follow-up review in 2013;
• within Adult Services and Older Adult Services some but not all services have been subject to accreditation, for example by the National Autistic Society and the Royal College of Psychiatrists. However, there is no systematic and risk based approach to identifying accreditation priorities and, in any event, the approach to accreditation used has its limitations:

• it is a snapshot of services at a specific time;
• certification typically lasts for three years, even though services might change within that timeframe;
• some of the accreditation processes rely heavily on self-reporting; and
• although it assesses against standards, it does not always benchmark performance against current best practice.

3. Recently external review has been used to good effect by the interim Director of Children's Services. In a phased approach independent assessors from the UK evaluated children's social work services against Ofsted standards. C&SSD plans to undertake a process of external scrutiny in 2016.
4. To date the same rigorous approach has not been applied to Adult Services or Older Adult Services, although some of the issues identified maybe common.
5. However, C&SSD management has recognised the importance of a systematic approach to external review and accreditation. The QA&GS is:

• reviewing a sample of external accreditation frameworks and methodologies to assess strengths and weaknesses. These include schemes for services not yet accredited, for example from the British Institute for Learning Disabilities and for Drug and Alcohol services; and
• working to establish a comprehensive clinical and social care annual audit programme across C&SSD. It has developed a framework for service audit and inspection plans, to be completed annually and kept up to date by each division. However, arrangements to ensure all services are covered and that the standards bar' is not set too low (i.e. is based on an external benchmark rather than on current island-practice) are not yet clear.

Recommendation

R14 Adopt a C&SSD-wide risk based framework for review and/or accreditation

and/or audit of all services and monitor its implementation.

Learning from complaints

6. Complaints are a rich source of information about service delivery and can be used to drive improvement.
7. In mid-2015 C&SSD management identified a need to improve complaints management with a shift towards:

• earlier resolution through the establishment of a Service User and Complaints Lead within C&SSD; and
• enhanced learning from informal complaints.

8. A Lean review has started in this area to support development of a C&SSD- wide structured approach to learning from complaints.

Monitoring implementation

9. It is not sufficient that action is agreed in response to review, accreditation, complaints or other identified need for service change. Management should have confidence that the action has been implemented and has met the desired outcome.
10. There are examples of strong monitoring of the implementation of actions in the P82/2012 Transition Plan. In particular, the pilot for the planned new Community Intermediate Care Service (CICS) was closely evaluated against identified success criteria. As a result the System Redesign and Delivery team recommended that the CICS team's skills and capacity should be focused instead into a Rapid Response Service, to better meet patients' needs. The Transition Steering Group agreed this recommendation. The System Redesign and Delivery team continues to monitor implementation of the new Rapid Response Service against planned outcomes.
11. Historically, arrangements within C&SSD for monitoring the implementation of agreed recommendations have been weak:

• the Care Inspectorate report on Children's Services published in 2012 highlighted that a number of recommendations for improvement dating back 9 years had not been implemented. However, the 2013 follow-up review recognised progress in bringing together action plans to enable oversight of implementation of recommendations from previous reports; and
• within Adult Services and Older Adult Services there are no established arrangements for monitoring the implementation of agreed recommendations from accreditation.

Recommendation

R15 Adopt a C&SSD-wide structured approach to monitoring:

• the implementation of agreed actions arising from reviews, accreditation and complaints; and
• for assessing the effectiveness of the action taken.

Conclusion

0. C&SSD faces significant challenges across the range of services it provides. Management has taken significant steps to start to tackle these, especially in Children's Services. But the absence of effective arrangements across C&SSD means that officers cannot be confident that similar issues do not affect Adult Services and Older Adult Services. There is a risk that issues are masked because of weak arrangements, poor information and a lack of consistency in management.
1. The challenge now is to put in place robust and resilient arrangements across the whole of C&SSD, learning from the positive steps taken in the implementation of the P82/2012 Transition Plan, to ensure that:

• the right culture permeates throughout C&SSD;
• risks are systematically assessed and responded to;
• relevant, reliable and timely information is available to staff and managers;
• efficient and effective operational arrangements are in place; and
• effective scrutiny and review of activities takes place and is used to drive improvement.

2. Establishing those arrangements should:

• allow effective management of business as usual activities alongside change programmes;
• drive learning and improvement across C&SSD rather than within individual services; and
• facilitate better working with the rest of HSSD, other departments, the voluntary and community sectors and service users.

Appendix 1: Summary of recommendations

Overall management arrangements

R1 Establish clear milestones for the completion and implementation of the

C&SSD-wide governance framework, covering all C&SSD services, business as usual' and change initiatives, and monitor delivery against those milestones.

R2 In developing the workforce strategy for C&SSD, identify specific measures to

reduce reliance on interim staff.

R3 Put in place steps to evaluate the effectiveness of work designed to improve engagement with C&SSD staff and make changes where necessary.

Risk assessment processes

R4 Establish and monitor implementation of effective arrangements for reporting,

evaluating, escalating and responding to risks.

Information and communication

R5 Develop mechanisms for sharing information between FACE and the newly

procured system for Children's Services to facilitate management of whole family issues.

R6 Develop a set of expectations and a timetable for the provision of

management information from FACE and the new system for Children's Services and monitor delivery.

R7 For all C&SSD services:

• develop clear performance standards;
• identify the data required to monitor these;
• establish data quality criteria for all data items; and
• ensure information systems routinely record performance against service standards.

R8 Establish a clear programme with milestones for delivery and use of summary

information for all community and social services, including KPIs and dashboards, and monitor delivery.

R9 Monitor access to policies, procedures and guidance and take corrective

action as necessary.

Implementation

R10 Identify steps to improve:

• the recording and monitoring of the completion of annual appraisals; and
• the incidence of annual appraisals and their effectiveness.

R11 Establish a timeframe for the rollout of the Practice Workbook and monitor

delivery.

R12 Identify a longer-term solution to delivery of identified training needs.

R13 In implementing the new information system for Children's Services, ensure

that it supports consistent assessment in line with agreed policies and standards.

Monitoring activities

R14 Adopt a C&SSD-wide risk based framework for review and/or accreditation

and/or audit of all services and monitor its implementation.

R15 Adopt a C&SSD-wide structured approach to monitoring:

• the implementation of agreed actions arising from reviews, accreditation and complaints; and
• for assessing the effectiveness of the action taken.

KAREN McCONNELL COMPTROLLER and AUDITOR GENERAL

JERSEY AUDIT OFFICE, LINCOLN CHAMBERS (1ST FLOOR), 31 BROAD STREET, ST HELIER, JE2 3RR T: 00 44 1534 716800 E: enquiries@jerseyauditoffice.je W: www.jerseyauditoffice.je