Joint area review

Audience Published Reference no. Joint area review of

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Staffordshire Children’s Services Authority Area

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Review of services for children and young people

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Adult Learning Inspectorate Audit Commission Commission for Social Care Inspection (CSCI) Healthcare Commission HM Crown Prosecution Service Inspectorate HM Inspectorate of Constabulary HM Inspectorate of Court Administration HM Inspectorate of Prisons HM Inspectorate of Probation Ofsted

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All [Date] [00000] Website: www.ofsted.gov.uk This document may be reproduced in whole or in part for non-commercial purposes, provided that the information quoted is reproduced without adaptation and the source and date of publication are stated.

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Further copies of this report are obtainable from the local authority or at www.ofsted.gov.uk Staffordshire joint area review of children’s services 3

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Summary report 6

Outcomes for children and young people 6

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assessment report 27

Staffordshire joint area review of children’s services 4

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Introduction

1. This joint area review was conducted using the arrangements required under Section 20 of the Children Act 2004. It was carried out by a multi- disciplinary team of eleven inspectors from the Office for Standards in Education (Ofsted), the Commission for Social Care Inspection (CSCI), the Healthcare Commission (CHAI), the Adult Learning Inspectorate (ALI), the Inspectorate of Probation (HMIP) and the Audit Commission. The review was undertaken according to the requirements of the Framework for the Inspection of Children’s Services.

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Introduction

2. The review was linked to the contemporaneous corporate assessment of the local council by the Audit Commission and its findings are represented in the relevant part of the corporate assessment report. In addition, inspections of the youth service, youth offending services and the two youth offending institutions (YOIs) at Brinsford and Werrington contributed to the findings of the review.

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Introduction

3. This review describes the outcomes achieved by children and young people growing up in the Staffordshire area and evaluates the way local services, taken together, contribute to their well-being. Joint area reviews focus on the extent to which children and young people are healthy, safe, enjoy and achieve, make a positive contribution and are well prepared to secure economic well being. This also includes the extent to which local services are provided to, and benefit, children and young people from outside Staffordshire who are held in the two YOIs.

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Introduction

4. The review evaluates the collective contribution made to each outcome for children and young people by relevant services in the area. It also judges the contributions made by the council’s services overall and, specifically, its education and children’s social care services. Particular attention is given to joint action by local services on behalf of those groups of children and young people who are vulnerable to poor outcomes. Two such groups are covered in detail: children and young people who are looked after by the council; and children and young people with learning difficulties and/or disabilities.

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Introduction

5. The review took place in two stages consisting in total of three weeks over a six-week period. The first stage reviewed all existing evidence including:

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Introduction

• self-assessment undertaken by local public service providers;

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Introduction

• a survey of children and young people;

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Introduction

• the findings of the contemporaneous inspection of the youth service;

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Introduction

• planning documents; Staffordshire joint area review of children’s services 5

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Introduction

• information from the inspection of local settings, such as schools, the two YOIs and day care provision;

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Introduction

• briefings from staff within inspectorates, commissions and other public bodies in contact with local providers; and

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Introduction

• evidence from a recent inspection of youth offending services.

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Introduction

6. The second stage included inspection fieldwork. This included studies of how far local services have improved outcomes for a small sample of children and young people, some of whom have the most complex needs, and a study of provision in two neighbourhoods, Chadsmoor and Burton-on-Trent. It also included gathering evidence on ten key judgements, selected because of their critical importance to improving outcomes for children and young people in the local area. This included discussions with elected members of the local council and their equivalents in other public agencies, officers from these agencies, service users and community representatives.

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Context

7. Staffordshire is a large, diverse county in the West Midlands of England. It has a population of 806,744, of whom nearly one quarter are children and young people aged 0–19 years. Minority ethnic groups, which represent almost 2% of the population, live mainly in the Burton area and around the county’s colleges and universities. The county’s main urban areas include six medium- sized towns. Three quarters of the total land area is rural and approximately one quarter of the population live in small rural communities. There has been a relative decline in the size of the population in north Staffordshire and an increase in the population in the south of the county.

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Context

8. Staffordshire contains some of the earliest industrialised areas in Britain, interspersed with areas of outstanding natural beauty. The traditional industries of coal mining, steel, ceramics and brewing have declined dramatically in recent years. Considerable investment has been made in regeneration and in establishing new industries in the county. The rate of long- term unemployment in Staffordshire is lower than the rates for England and the West Midlands but this masks wide variations in unemployment rates in the most deprived wards of the county. Although there are areas of considerable affluence in Staffordshire, there are significant pockets of deprivation at ward level particularly in the urban areas of Cannock, Tamworth, Burton-on-Trent, East Staffordshire and Newcastle-under-Lyme.

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Context

9. Staffordshire County Council’s services for children and young people are managed by the Children and Lifelong Learning department. The council has nominated a lead member, appointed a corporate director of children’s services and has embarked on an ambitious strategy, in partnership with the health service and voluntary and independent sector organisations, to integrate services across the county. Four children’s centres have been established in Staffordshire joint area review of children’s services 6

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Context

Staffordshire as part of a wider strategy of development of centres across the county. The council maintains 55 secondary schools, of which 47 have sixth forms; 14 middle schools; 306 primary schools; 19 infant schools; 15 junior schools; 50 first schools, 6 nursery schools, 23 special schools and 6 pupil referral units. There are eight locally based social care offices. A total of 674 children and young people are looked after by the council and placed in a range of settings both within and outside Staffordshire. Two YOIs hold approximately 350 children and young people, the majority of whom come from outside Staffordshire. Local health, education and social care services are provided to the YOIs. The eight district councils have nominated lead officers for children and young people and provide housing and leisure services.

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Context

10. Health services are delivered through one strategic health authority, six primary care trusts (PCTs), two acute trusts and an ambulance trust. There are plans to consolidate the six PCTs into a single trust for Staffordshire.

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Context

11. The Staffordshire strategic partnership for children was dissolved in April 2005 when the county established a Children’s Trust board. This board is chaired by the corporate director for children and lifelong learning for Staffordshire County Council and has representation from the strategic health authority, the six PCTs, the district councils, Staffordshire police, children’s voluntary and independent organisations and the Connexions service. The newly appointed children’s commissioner for Staffordshire will join the board shortly. An integrated strategy group for children brings together all the key agencies working with children in the county to translate board objectives into action. Wider partnership arrangements are in place locally across Staffordshire to plan and implement services for children and young people.

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Context

12. Staffordshire Learning and Skills Council partners Staffordshire County Council, colleges and schools in addressing the 14–19 strategy. Post 16 education and training is provided by colleges and sixth form colleges in the county alongside work-based training providers.

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Outcomes for children and young people

13. Outcomes for most children and young people in Staffordshire are adequate. Children and young people are generally healthy. High- quality childcare places are now available to all who require them. Educational standards are in line with those achieved nationally, and while standards in secondary schools have begun to improve, they are not yet uniform across all groups. Children who are particularly vulnerable and those who are the most able do not achieve well enough. Most children and young people behave responsibly and many make a good contribution to their schools and their community. Most children and young people feel safe in and out of school but social care services to the most vulnerable groups of children are inconsistent and systems to protect children from harm are under-developed. Road safety Staffordshire joint area review of children’s services 7

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Outcomes for children and young people

has improved, though hospital admissions for the under 18s are high and referrals by agencies regarding domestic violence have increased. Young people leaving care do not always find adequate and affordable housing and a small number of children and young people with mental health problems wait too long for help. Work with district councils to facilitate consistent access to suitable services is not consistently good enough. Outcomes for children with learning difficulties are adequate but those for children and young people with disabilities are often unsatisfactory because they experience delays in accessing appropriate services. Children in residential care homes do not receive good enough care and too many children looked after by the local authority are placed out of the county because of a lack of more local placement choice. Joint commissioning arrangements with health are under-developed. Good work is

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Outcomes for children and young people

being done to increase children’s and young people’s participation in planning, although more work is needed to help children and young people understand about complaints, reviews and bullying. Developments in corporate parenting are encouraging. There is good liaison and collaboration through regular partnership meetings between health providers and the two YOIs in the county.

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Being healthy

14. The combined work of all local services in securing the health of children and young people is adequate. Parents and carers are provided with focused support and advice to help them with parenting. They also receive satisfactory information about preventative services and the provision of treatment. Immunisation and vaccination rates are higher than in the rest of England. Children and young people have a good understanding of healthy lifestyles and there is wide participation in the ‘Healthy Schools’ initiative throughout the county. A range of projects and initiatives address important issues such as sexual health, teenage pregnancy, alcohol and substance misuse and smoking cessation. Child and Adolescent Mental Health Services (CAMHS) are being evaluated and demonstrate a positive impact. CAMHS provide a range of good services but provision across the county is inconsistent and not all agencies understand the vision for CAMHS in their area. Services for

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Being healthy

children with learning difficulties are satisfactory, with good practice in some areas. In general, children with disabilities, especially those with multiple complex needs, do not have full access to a co-ordinated range of appropriately responsive health services. There are some inconsistencies in the ‘sign-up’ of health partners to the vision and resourcing of integrated children’s services across the county.

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Staying safe

15. The overall contribution of services to keeping children and young people safe is inadequate. A number of good initiatives are in place to help keep children and young people safe. However, these preventative services are not available to all children and families across the county. Staffordshire joint area review of children’s services 8

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Staying safe

16. The management of the assessment, allocation and monitoring of child protection cases is unsatisfactory. Referrals are too frequently delayed due to the lack of understanding of roles and responsibilities, poor assessment of risk or management decision-making. In addition, the quality of social work is very variable, and there is often poor decision-making and prioritisation. Overall, case recording is of poor quality and systems to share information internally and with other agencies are not consistently developed. There are many staff vacancies within social care services and staff often feel unsupported. Performance management is adversely affected by poor and inaccurate data on referrals, action taken and caseloads, which makes it difficult for managers to monitor performance and outcomes for children. Significant numbers of children are placed out of county in placements that do not always meet their assessed

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Staying safe

needs and consequently do not provide good value for money. There are also too many children who are the subjects of care orders placed at home with friends or relatives and too many simultaneously placed on the child protection register who are also in care. Although action is being taken to review, monitor and reduce these cases, it is not having sufficient impact.

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Staying safe

17. Services across agencies for children with a disability, whilst ranging from good to limited, are not sufficiently well co-ordinated. The integration of children’s social care services with the lifelong learning directorate is at an early stage but there are signs that proposed developments will improve services and outcomes for children. Developments include the creation of a first response service for referrals, a new IT system and an increased commitment to training.

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Enjoying and achieving

18. The overall contribution of services to help children and young

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people enjoy their education and recreation and to achieve well is

adequate. Children in Staffordshire who were surveyed say that they enjoy school and are doing well. Young children are supported well and most make a good start in education. Older children attend school regularly and their attitudes to learning are usually good. Fewer children in both primary and secondary schools are excluded from schools in Staffordshire than across the country. Most children and young people achieve in line with national standards. The youngest pupils achieve above national standards by age 7. By age 11, standards are in line with those nationally and remain so during secondary education. Progress between ages 11 and 14 has shown improvement in the last two years, but standards for the most able are not yet high enough at age 16; this area has been identified by the council as a target for improvement. The council has set in place improved and more rigorous procedures to monitor, challenge and intervene in schools where performance

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people enjoy their education and recreation and to achieve well is

is unsatisfactory. Provision for children and young people with special educational needs has improved and is now adequate. However, the needs and progress of some more vulnerable groups such as looked after children and the minority of children who do not attend school are not yet fully identified, tracked or met. Provision for looked after children and some children with disabilities is currently unsatisfactory. Staffordshire joint area review of children’s services 9

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Making a positive contribution

19. The overall contribution of services in helping children and young people to contribute to society is good. This work has a high priority in Staffordshire. Plans have been drawn up to improve provision to meet the new expectations of the Children Act 2004. A wide range of services, most notably early years providers, Sure Start and children’s centres, schools, the youth service, the police, the youth offending team and the children’s advocacy and representation service, help children and young people contribute positively to their schools and communities.

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Making a positive contribution

20. Good structures are in place to seek the views of young people. However, these systems are predominantly led by the county youth service and do not involve a sufficiently high number of children and young people. A children’s commissioner has been appointed to build a more systematic approach. The majority of children and young people surveyed and who were met during the review feel that advice and support is available when they want it. Currently, much depends on the projects and initiatives of individual services and individual members of staff. There is no systematic strategic approach to ensure that resources are deployed more clearly in line with need or that the impact on outcomes for children and young people is carefully monitored. A good infrastructure for partnership working is established to tackle anti-social behaviour. Services which tackle youth offending are working effectively. The

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Making a positive contribution

relationship with youth offending services is realising improved outcomes for some young people. There are also some significant developments in helping looked after children and young people make a positive contribution, although there are still areas of longstanding weakness. Services targeted at developing the participation of children and young people with learning difficulties and disabilities are under-developed.

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Achieving economic well-being

21. The overall contribution of services to helping children and young people achieve economic well-being is adequate. The range and quality of childcare provision has improved; children’s centres are providing a good focus for parents in their areas and are promoting their continued education and training. Children and young people’s personal and social skills are well supported in education and leisure settings, particularly through the work of the youth service. Pupils have good access to careers education and guidance through their school and the Connexions service; a high percentage of young people undertake work experience. However, children and young people in the two YOIs were not as well served by the Connexions service. Effective structures exist to develop suitable strategies for 14–19 provision with strong links with the Learning and Skills Council. The implementation of the 14–19 strategy has been variable across the county and has not had a significant

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Achieving economic well-being

impact on the achievement of young people. The figures for those not in education, training and employment are low overall, although the level for those with learning difficulties and disabilities is too high. Strategies linked to Staffordshire joint area review of children’s services 10

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Achieving economic well-being

regeneration give high priority to improving housing for young people, including teenage parents, though availability varies between districts. Young people known to the youth offending service receive good support. Most looked after young people have leaving care plans but these are not reviewed systematically and many of the young people seen during the review did not find them useful.

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Service management

22. Overall, the management of services for children and young people is adequate. The capacity to improve further is adequate. Some education services are well managed, particularly early years schools, the youth service and the youth offending service; however, this is offset by significant weaknesses in services for social care and for some vulnerable children. There are clear ambitions and a strong commitment from all agencies to integrate and improve children’s services and these are being translated into clear priorities shared by partners and stakeholders. However, sign-up is variable and remains an area for further work. Progress to date has been hampered by previous lack of development in preventative services for children and a lack of delivery plans and co-ordinated arrangements for integration. Staffordshire has adequate capacity to deliver services, building on good existing examples of partnership working. Short-term plans are being developed

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Service management

to build capacity in areas of weakness. Resource, financial and budget management is generally effective and the council is re-prioritising services to ensure that resources are targeted more effectively. The majority of services for children and young people provide value for money. Performance management is inadequate; systems and processes are not fully integrated across services and have failed to identify major performance shortfalls in children’s social care. Managers in social care are failing to consistently apply basic management practice.

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Staffordshire joint area review of children’s services 11

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Action to improve social care services to children who are at risk of

23. Establish with partners the strategy for implementing the common assessment framework and associated processes including referral, review, risk analysis and performance management. Develop shared arrangements to manage ‘gate-keeping’ to ensure all children at risk of being looked after have been fully assessed and every effort has been made to provide family support services. Where care is deemed necessary, action is required to increase placement choice, preferably within the county. Develop commissioning and joint commissioning arrangements to support the provision of targeted services to the most vulnerable groups.

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For action over the next six months

24. Improve the quality of education provision for looked after children and children not educated in school to ensure statutory requirements are fully and consistently being met.

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For action over the next six months

25. Improve the quality of performance management by:

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For action over the next six months

• improving the systems for identifying, reporting on and taking the necessary management action regarding service performance (including the systematic use of complaints, user feedback and performance information to challenge service quality and performance);

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For action over the next six months

• ensuring that the management information systems for all partners are compatible and that a formalised system for passing and sharing operational information is developed. Staffordshire joint area review of children’s services 12

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For action over the next six months

26. Improve the quality of long-term planning by:

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For action over the next six months

• strengthening the planning, project and programme management and overall co-ordination of the key change projects. This includes workforce planning and staff deployment in social care, integrated IT provision with partners and the delivery of integrated children services.

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For action over the next six months

27. Improve access to mental health services for children and young people.

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Being healthy

28. The combined work of all local services in securing the health of children and young people is adequate. Health has an increasingly high priority across the county with satisfactory partnership working. Children and young people generally consider themselves to have a healthy lifestyle and parents and carers believe they have good access to a range of services to help maintain their children’s health. Joint commissioning arrangements are under- developed and the provision for some health services is inconsistent in some parts of the county.

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Being healthy

29. The ‘Healthy Schools’ initiative has been adopted in two thirds of schools in the county, which is on track to meet national targets. Most children and young people think the food in schools is satisfactory and the county council has invested £3,000,000 to improve eating environments in schools. The drugs and alcohol team has worked with staff from the education department to develop strategies and appropriate services for drugs and alcohol education in schools. The youth offending team (YOT) has developed an effective ‘addicted to sport’ programme as part of diversionary activity.

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Being healthy

30. Most children and young people, except in one or two disadvantaged areas, have increasing access to routine health checks through their GP practice. Cannock District Council has been awarded beacon status for its healthier communities initiative. This reflects the national picture. Child development centres in Staffordshire offer a good range of child and family assessment processes, using a single or multi-agency approach, which enables early identification of health needs.

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Being healthy

31. Mental health services for children and young people are adequate and are beginning to demonstrate a positive impact. The CAMHS draft strategy, developed by a multi-agency group, is close to being ratified by all the six PCTs. Children and young people, families and schools still feel that waiting times for CAMHS are too long. However, the pilot project for a school-based CAMHS worker, funded jointly by the local authority and the health service, has brought Staffordshire joint area review of children’s services 13

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Being healthy

the waiting list down significantly in Burton. In addition, CAMHS funds a range of projects and initiatives, thus making the best use of local providers such as 4–11s projects, MIND and NSPCC. Each project is designed to provide early support and preventive work. Transition planning for young people aged 15–19 moving from CAMHS to adult services is unsatisfactory. The youth action council (YAK) and the county council are developing more opportunities for self- referral to appropriate agencies by young people who self-harm.

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Being healthy

32. Local health services are developing targeted provision to better meet the specific needs of more vulnerable groups of children. Children looked after by the council are provided with an appropriate range of health-related advice and are increasingly in contact with a team of nurses with specialist knowledge; this is a strength. However, there is no agreed protocol between the social care service and the health service to ensure that health services can be provided in a timely way to children from out of county when they are placed in private residential care in Staffordshire. However, good health support is provided to the two YOIs in Staffordshire including health promotion, immunisations and access to a range of specialist health services.

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Being healthy

33. The health provision for children with learning difficulties is generally adequate. However, the recent move to a federated special school system in Tamworth and Burton-on-Trent did not include enhanced access to health services. Provision for disabled children with more complex needs could be improved. The equipment budget to support the particular need of these children is comparatively low. Some parents report that they received confusing instructions about direct payments, despite the four-fold increase in participation in the scheme over the last year. Parents of disabled children raised some concerns about the unhelpful attitudes and lack of sensitivity of some health care staff to the needs of disabled children and their families. In North Staffordshire, healthcare practitioners are working very effectively with families in a ‘special matters’ group where parents and staff have developed

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Being healthy

jointly an advisory care manual for use with children who are disabled with complex needs. This is good practice.

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Staying safe

34. The overall contribution of services to keeping children and young people safe is inadequate. Although most children and young people in Staffordshire feel and are kept safe, the review highlighted that more work is needed to sharpen the systems to protect the most vulnerable children from harm and neglect. Children and young people who were seen during the review said that they feel safe and happy at school and in their neighbourhood. Initiatives and projects to improve road safety across Staffordshire have been successful in reducing death and serious injuries to children. However, young people indicate that road safety training for adolescents is less accessible. They also say that knowing people in the area and having a mobile phone help them to feel safe, though a significant number of children state that they would Staffordshire joint area review of children’s services 14

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Staying safe

welcome more protection from gangs and bullies. Schools do good work in alerting children to danger in the community.

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Staying safe

35. There is a significant increase in the number of referrals relating to domestic violence. There is a policy on responding to domestic violence and the Area Child Protection Committee (ACPC) has arranged six multi-agency training events since March 2005. This is promoting greater awareness of the link between domestic violence and child abuse in addition to ensuring that learning from national research on this topic is disseminated. Young people and staff in some schools and children’s residential homes report bullying as a concern. Inappropriate placements for some children, insufficient training for some staff and insufficient support for individual children are contributory factors.

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Staying safe

36. Preventive services are available but work with families is not well co- ordinated and access is not consistent across all areas. Projects in areas where there is a significant black and minority ethnic population do not always reflect fully the needs of children and young people from minority ethnic communities. Initiatives to improve the understanding of referral processes by schools and area social care teams are not widely disseminated, thus reducing opportunities for shared learning. The four ‘early implementer’ projects, which are intended to develop a range of integrated co-located services and are funded and managed within four separate areas, have the potential to develop responsive arrangements for service provision.

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Staying safe

37. The county has implemented the findings of the Bichard enquiry and social services report relevant incidents to the police. All child protection cases are allocated to a qualified social worker. Management arrangements for assessing risk, allocating cases and monitoring outcomes are unsatisfactory. The roles and responsibilities of individual agencies and workers are not made sufficiently explicit; initial assessments are rarely undertaken by other agencies; they are not holistic or of good quality, reflecting unco-ordinated partnership working. Social care teams do not always take prompt or well-informed decisions based on a clear understanding of priorities. Child protection arrangements within the two young offenders’ institutions in Staffordshire are good.

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Staying safe

38. The quality of front-line social care services across the county varies from very good to poor and this is regardless of the particular pressures that teams are under. Some teams manage to produce good work whilst others under similar or less pressure do not. Social care case records are poorly maintained and have little focus on outcomes for children; referrals from other agencies are not consistently confirmed in writing and contain limited information; some cases, which contain details of potential harm to children, are not allocated to a social worker or assessed sufficiently for risk.

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Staying safe

39. Delays in the transfer of cases between the assessment teams and the care management, leaving care and specialist disability teams mean that children’s needs are often not met appropriately. The electronic management Staffordshire joint area review of children’s services 15

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Staying safe

recording system fails to provide reliable management information and is not being used effectively by managers to monitor casework and the service’s response to referrals. During this review it was noted that over two hundred cases remain recorded as awaiting action. In some of these cases it was not clear what action had already been taken.

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Staying safe

40. The county is confident that the planned introduction of a first response service across children’s services will accelerate the completion of initial assessments and improve the quality of joint working. Training is also taking place on the implementation of the common assessment framework, which will lead to improvements in the consistent use of this system.

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Staying safe

41. Agencies fail to monitor adequately the children who do not attend school and those whose whereabouts may be unknown. Communication between different councils, when families move, is unsatisfactory.

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Staying safe

42. Partner agencies are in the process of establishing a safeguarding board to replace the ACPC. The new arrangements will include the recently appointed children’s commissioner. Serious case reviews are well managed but the findings are not always communicated effectively to all staff within agencies. The implementation of recommendations emerging from reviews is not monitored rigorously enough to ensure that lessons are learnt and systems and services are improved. Staffordshire ACPC is the only one in the country to take the positive step to establish a subgroup specifically to consider the needs of children and young people in YOIs.

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Staying safe

43. Procedures for the recruitment of staff are well managed. Although appropriate systems are in place to check the suitability of staff, the local authority has been slow to initiate retrospective police checks on existing staff and volunteers. There remain significant vacancies within social care services, and sickness levels are high. Some staff feel unsupported, reflecting the poor working environment in many social care offices and a lack of contact by managers with those on long-term sick leave.

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Staying safe

44. There is a high commitment to and investment in training for staff. A trainee social worker scheme has been introduced to improve recruitment. The designated teachers for child protection and looked after children, appointed in all schools, receive appropriate training. The interagency policy and procedures developed by the ACPC are comprehensive. They were updated in accordance with Laming recommendations and amendments to interagency working arrangements are circulated on a quarterly basis. Information to the public is clearly written and considered to be helpful by young people. Public information leaflets routinely state that versions may be obtained in Braille, large print and other languages.

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Staying safe

45. Staffordshire council’s fostering services are rated highly by young people and the majority reported feeling safe. However, there are insufficient local foster and residential placements to meet needs, which results in increasing numbers of children being placed out of county, often in crisis situations. Many Staffordshire joint area review of children’s services 16

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Staying safe

of these placements quickly break down and do not provide a good service for the young person or value for money. A placement unit has now been established with the aim of increasing placement choice, stability and improving outcomes.

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Staying safe

46. The quality of council residential homes is variable. Fostering services recently received a positive inspection report from the Commission for Social Care Inspection. Foster carers are complimentary about the support they received, although views about contact with young people’s social workers varied from good to poor. The number of children placed at home on care orders is too high and includes children whose names are also on the child protection register. Reviews of children on care orders and on the child protection register lack rigour and do not ensure that the plan is in the best interests of the child and is being properly implemented. Changes in placement, whilst lower than the national average, are not well managed. The independent reviewing officers do not focus sufficiently on the needs and wishes of the young person or monitor adequately the quality of practice.

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Staying safe

47. The council has increased the range of respite provision available, and plans to extend its residential shared care to ensure better access. There are a range of holiday play schemes and some innovative recreation and holiday activities. The council has worked well with special schools and a local independent provider to develop residential services that have reduced dependence on out of county provision. Direct payments are used to enable more individualised and flexible arrangements. However, the assessments of carers are inconsistent and the council does not hold management information on the numbers of assessments undertaken of the parents and carers of children with disabilities. Valuable initial work has begun with young people using residential shared care to help them understand the complaints process and enable them to contribute their ideas for improvement. Specific training is available to social care staff in recognising and reducing the risk of harm to

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Enjoying and achieving

48. The overall contribution of services to help children and young

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people enjoy their education and recreation and to achieve well is

adequate. The council is working with schools to raise aspirations and to ensure that all children achieve their potential. However, the needs of some vulnerable groups and of some able pupils are not yet met.

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people enjoy their education and recreation and to achieve well is

49. A range of services supports parents and carers well in helping their children to enjoy and achieve. Family learning programmes provide a high quality and valuable focus for parents and their children through regular classes and residential activities. These include training for parents on how to support their child’s learning, support groups for Asian mothers, and father and son groups. Staffordshire joint area review of children’s services 17

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people enjoy their education and recreation and to achieve well is

50. Support for early years education is good. The quality of education is in line with national standards with around two thirds of children achieving early learning targets by the time they start school. Well-focused and sensible steps are being taken to increase provision, particularly for 3 year olds; the authority’s target for universal provision in 2005 was achieved. Four Sure Start areas offer a range of co-located health, care and education facilities and services and the four new children’s centres are developing as the hub for services and information on early years.

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people enjoy their education and recreation and to achieve well is

51. Pupils’ achievement is not yet high enough at Key Stage 4. Although many children and young people do well and standards have begun to rise, some, including more able children and young people, fail to make sufficient progress. The school improvement service has refocused its work to develop more rigorous procedures at district level to support schools’ own self- evaluation and to monitor, challenge and intervene in schools where performance is unsatisfactory. These interventions have led to improvement. Attendance in schools has improved as a result of improved monitoring by the education welfare service and targeted truancy sweeps. The number of permanent exclusions has fallen.

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people enjoy their education and recreation and to achieve well is

52. Provision for the education of children with special educational needs is now adequate; it was inadequate at the time of the previous local education authority inspection in 2002. Although the SEN and inclusion strategies were initially slow to demonstrate impact, children and young people in Staffordshire with learning difficulties and disabilities have increased opportunities and make better progress than previously. The early years service identifies the needs of young children well; there has been substantial improvement in the management of the statementing process, with all statements being completed on time. Although the number of statemented children will continue to be high in the short term, the increase in funding for special needs to all schools is enabling more children with physical disabilities to be educated in mainstream schools.

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people enjoy their education and recreation and to achieve well is

53. The provision for children who do not attend school varies between districts and is currently unsatisfactory. The record of the education provision for individual children educated other than at school is not complete. It is not recorded centrally and the local authority does not monitor systematically the quality of the education received. The re-integration rates into education are low. In the last few years the authority has introduced several strategies to improve provision. It has established six pupil referral units and there are some successful examples of effective district partnerships between the pupil referral unit, schools, the district inclusion panel and the Education Otherwise service. Where these work well, shared ownership at local level means that all services working with children and young people share information and take joint ownership of hard to place children in the district. The effective partnerships

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people enjoy their education and recreation and to achieve well is

succeed in re-engaging pupils in education, with the result that some pupils receiving alternative tuition achieve higher grades at GCSE, similar to those achieved nationally. However, this good practice is not yet consistent across Staffordshire joint area review of children’s services 18

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people enjoy their education and recreation and to achieve well is

the whole county. Arrangements to monitor the education of children educated at home are satisfactory.

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people enjoy their education and recreation and to achieve well is

54. The local authority in its self-assessment recognises that educational provision for looked after children is not good enough. Despite recent initiatives, the provision is currently unsatisfactory; some looked after children do not receive their entitlement to education. Staffordshire council has recently raised the profile of the education for looked after children through setting targets for their achievement and through establishing an education action group with the remit to improve achievement and remove barriers to learning for looked after children. As a result, access to transport arrangements has improved and the planned appointment of a data officer for looked after children is intended to improve procedures for tracking their progress. Each school now has a teacher with specific responsibility for looked after children, who has received guidance and training. A number of successful strategies to

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people enjoy their education and recreation and to achieve well is

recognise, celebrate and encourage achievement have been introduced. The proportion of these young people achieving higher levels at GCSE fluctuates from year to year. There is no cross-county register of looked after children and there is a lack of clarity on the roles of the children’s services directorate and schools in monitoring pupils’ personal education plans. The quality of alternative educational provision for looked after children is not monitored systematically, including that for those placed outside the county.

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people enjoy their education and recreation and to achieve well is

55. Children and young people have available to them a range of recreational activities, including sporting clubs and associations, four outdoor education centres and provision for the arts as well as out of school clubs and organisations. The quality of recreation facilities is not uniform in all parts of the county. The youth service, in partnership with the voluntary sector, provides a high-quality, diverse and wide-ranging service where participation is higher than in similar authorities and is rising rapidly, though some young people still choose not to use the service. Children’s centres are developing play strategies and make available to the public well-stocked and stimulating toy libraries. The contribution of district councils to the provision of services is adequate but variable across the county as a whole.

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Making a positive contribution

56. The overall contribution of services in helping children and young people to contribute to society is good. This outcome is afforded a high priority. Services overall, notably early years providers, Sure Start and children’s centres, schools, the youth service, the police, the youth offending team and the children’s advocacy and representation service, make a good input into ensuring children and young people make a positive contribution. Early years providers and schools make a good contribution to the social and emotional development of children and young people. Children, especially primary aged pupils, generally express a positive attitude to school. Transition between schools and phases of education is well managed. Staffordshire joint area review of children’s services 19

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Making a positive contribution

57. A large number of projects and initiatives support children and young people and their families in coping with traumatic events and major changes in their lives. Generally young people acknowledge that support is available when they need it. Some of this support is excellent. For example, in the neighbourhood visited during the review, preventive services for parents and children under 5 are co-ordinated effectively through the Sure Start and children’s centre. However, the quality and effectiveness of these projects and initiatives varies, often because of a lack of effective monitoring and co- ordination between services. Services for the over 5s, while available, are not well co-ordinated at the local level and do show significant variation. Outline plans are being formulated to improve this patchy approach through a countywide network of integrated children’s centres and extended schools.

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Making a positive contribution

This has the potential to deliver the objectives of the Children’s Trust and to provide more consistent services, which are responsive to local needs. Detailed project management is not yet in place to ensure that these plans are implemented in a timely way.

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Making a positive contribution

58. Adequate support to tackle bullying and harassment is available to schools from at least eight different services or projects. The county council has issued guidance to help schools develop their policy in which it makes clear the legal and local attitude to bullying. However, there is no county policy which details a consistent approach or lists the support available, including how it best fits circumstances and needs. Monitoring of the schools’ policies on bullying takes place through district adviser visits and through governors. Racial incidents in schools are reported to the county council. Services which have had opportunities to talk with young people make joint visits to schools at least annually to discuss the personal and social issues that schools face with their learners and the support required to tackle them. Nonetheless, the extent to which children and young people’s views are routinely taken into account and

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Making a positive contribution

schools make use of the support is generally dependent on the school’s own assessment of need. In more serious cases where a crime is reported to the police, their handling of hate crime is judged good by the HMI (Constabulary) baseline assessment for 2005.

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Making a positive contribution

59. Children and young people’s views are taken into account in developing plans and making decisions. The youth service has taken the lead in the county council for the development of very good structures to seek the views of children and young people, although currently the number of children and young people who have a direct involvement is comparatively small. County council elected members are willing to meet and to hear the views of young people. They have allocated a budget to the youth action council. Young people have also been asked to give their views on candidates who apply for appropriate posts in the county council, and those who have contributed to this process feel that their views have been listened to. Most district councils included children’s views when formulating their crime and reduction strategy. The vast majority of secondary schools have school councils. However, the extent to which school councils are involved in policy and decision-making

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Making a positive contribution

varies. A survey has been conducted and the findings will form the basis for Staffordshire joint area review of children’s services 20

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Making a positive contribution

development of greater consistency across schools. The Children’s Trust has acted appropriately by appointing a children’s commissioner, who will also sit on the trust board to ensure that children and young people’s views are systematically gathered and considered.

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Making a positive contribution

60. Behaviour in schools is generally good. Social inclusion panels operate in most but not all districts, and intervene at an early stage to prevent school exclusion. District crime and disorder reduction strategies are comprehensive and reflect an assessment of local needs, including the views of children and young people. The police have set up a good multi-disciplinary framework for reducing anti-social behaviour, which has the capacity to deliver a timely, flexible and multi-disciplinary approach. In the neighbourhood visited for this inspection, the police had deployed their staff in line with needs, the area was patrolled regularly and staff also helped to provide reassurance to residents. The area did show effective use of closed circuit television and traffic calming in a particularly unsafe area. However, in this area there is a shortage of activities for older adolescents, so that they aimlessly hang around on street

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Making a positive contribution

corners and need to be periodically moved on by police. Young people themselves identified this as a concern.

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Making a positive contribution

61. The youth offending service provides a good service overall. Children and young people are assessed and plans drawn up in line with the required timescales. Young people are appropriately involved in this process, although the assessment of the risk they pose in harming others is not sufficiently well developed. Work with children and young people who are at risk of a custodial sentence is very good and includes a range of innovative, behavioural and educational elements. Other strengths in provision include the service for children and young people engaging in sexually harmful behaviour and for drug and alcohol misuse. Co-ordination of services to prevent offending is at an early stage. Responsibility for developing the preventative strategy has been clearly allocated to the head of the youth offending service.

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Making a positive contribution

62. The support to enable looked after children and young people make a positive contribution presents a mixed but improving picture with some real strengths but also areas of longstanding weakness. The children and young people confirm that they are involved in reviews and most have relevant matters explained to them. They have also helped to devise the leaving care grant, which has been a significant success. The young peoples’ participation groups are well developed and meet monthly, and attendance is good. Appropriate action has been taken to ensure that serious concerns raised by children and young people are referred to and acted on by social care managers. The children’s advocacy and representation service provides very good support. The complaints procedure is clear, although a low percentage of children and young people recorded that they knew how to make a complaint. Recent inspections of some residential homes have identified serious concerns

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Making a positive contribution

about the behaviour and social and emotional development of young people placed there. These are being acted on by the council and will be the subject of monitoring by the Commission for Social Care Inspection. Staffordshire joint area review of children’s services 21

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Making a positive contribution

63. There are no specific projects or initiatives targeted at seeking the views of children and young people with learning difficulties and disabilities or helping them to make a positive contribution. Services vary in the extent to which they seek views, although the youth service and visually impaired service are taking some effective steps. Transition reviews at age 14 take place, are generally well attended and are effective. Arrangements for respite care are good.

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Achieving economic well-being

64. The overall contribution of services to helping children and young people achieve economic well-being is adequate. The early years unit and the work of the children’s centres make a good contribution to the outcomes for children and young people. The local authority has increased significantly the number of placements available for childcare and good use is made of the national framework of targets to expand provision and the quality of provision for 3 year olds. A good range of agencies ensure that information about benefits is available for families. Sure Start centres promote the continuing education and training of parents, including teenage mothers. However, parents who are drug users sometimes find it difficult to obtain childcare so that they can attend therapeutic programmes. There is little evidence of an overall strategy to address the difficulties parents and carers may experience in funding activities for their children.

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Achieving economic well-being

65. The development of young people’s personal and social skills is well supported in both education and leisure settings. The work of the youth service ensures there is good development of young people’s confidence and team working skills. Citizenship education in schools supports their development of financial awareness. Many young people study vocational options at Key Stage 4, although in some schools vocational options are provided only for disaffected young people or those of lower ability. Provision for developing the skills of gifted and talented young people is underdeveloped in too many schools.

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Achieving economic well-being

66. Pupils aged 14–16 have good opportunities to undertake work experience and the vast majority of pupils, including those in the pupil referral units, take up this offer. Approximately 30 schools provide enterprise education for students aged 16 and above. All pupils have access to careers education and guidance through schools and the Connexions service. The Connexions service provides comprehensive, impartial information about all types of further education. In a minority of schools the information provided, for example at careers evenings, is confined to the sixth form. There is good guidance and support for young people aged 16 to 19 in colleges. Their progress is monitored well and they have access to good quality additional learning support. Despite this, the high drop out rate in some parts of the county at the age of 17 suggests that advice and guidance may not be sufficiently well targeted.

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Achieving economic well-being

67. The implementation of the 14–19 strategy has been slow and has had a limited impact on the achievement of this group. Management of the strategy Staffordshire joint area review of children’s services 22

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Achieving economic well-being

is complex, the strategic area review has not yet been completed and there has been little analysis of the cost effectiveness of the provision. However, there is a productive relationship between the local authority and the Learning and Skills Council, (LSC) which provides a good basis for future working. Some district plans do not reflect sufficiently the overarching aims of the strategy. Provision is beginning to be planned collaboratively and there are regular meetings of 14–19 providers across Staffordshire. At a local level there have been some good initiatives to broaden the opportunities for young people and to improve the transition from school to post 16 education and training, for example in Lichfield and Tamworth. In some areas there are insufficient work- based learning opportunities and some learners’ choices are restricted because of lack of transport. All post 16 providers produce an annual self-assessment

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Achieving economic well-being

report, and collegiate arrangements ensure effective monitoring of education and training providers and a common approach to quality assurance. Almost all post 16 providers have equality of opportunity practices that are at least satisfactory.

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Achieving economic well-being

68. There is a clear regeneration strategy for the county, which has focused appropriately on the areas of greatest need. The plans for North Staffordshire offer the potential for increased employment opportunities for young people. Some individual initiatives, such as that of the youth service in South Staffordshire, are having a good impact on improving the environment for the community. In the neighbourhood visited during the review funding has largely been used to improve housing stock and employability but the level of unemployment is still high. There is little evidence of the impact of substantial investment on the physical environment of the neighbourhood and some recreation areas for young people are of poor quality.

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Achieving economic well-being

69. The five-year ‘Supporting People’ strategy 2005–10 gives top priority to addressing the housing and support needs of children and young people. There is relatively good access to supported housing for teenage parents but the overall availability of housing varies considerably between districts, particularly in terms of the provision for care leavers. In one area a community development officer is supporting the demolition and replacement of substandard accommodation. Young people known to the youth offending service receive good support and the county exceeds the Youth Justice Board target for having suitable accommodation for this group.

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Achieving economic well-being

70. The percentage of looked after children in education training or employment at the age of 19 is increasing from a low base and is projected to be above the national average by 2006. A number of agencies, including the Connexions service, work well together to support these young people. Although there are some good individual schemes and work for care leavers, the relationships between those leaving care and social workers are adversely affected by the lack of continuity in staffing. Most care leavers have Pathway plans but they are not reviewed systematically and many young people do not find them useful. Staffordshire joint area review of children’s services 23

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Achieving economic well-being

71. Transition reviews for young people who have learning difficulties and disabilities have a clear structure but are not always well managed. The level of direct payments for those with disabilities and their families is good. A high proportion of this group is not in education, employment or training, reflecting the inadequate provision in some districts and poor use of locally available data to plan education provision for vulnerable groups. Few young people with learning difficulties and disabilities go on to higher education. The strategy to ensure a smooth transfer to adult services is unclear, with the result that some young people are unable to build on the good skills they have acquired at school and college.

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Service management

72. The management of services for children and young people is adequate. The council has acted quickly to implement the requirements of the Children’s Act 2004 and has ambitious and challenging plans for working with partners to make children’s services more integrated. Although at an early stage of development, further detailed work is needed by all partners to develop integrated patterns of working, including the creation of pooled budgets and joint local teams. Many parts of the service are performing well, but there are some important weaknesses in some services for vulnerable children and young people.

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Service management

73. There is a strong commitment in Staffordshire from all agencies to improve children’s services. It is the top priority for the council and has strong political and corporate support. The move to establish an integrated service under the corporate director of children’s services is seen not only as a way of meeting statutory duties under the 2004 Children’s Act but also as a means of energising the organisation and harnessing the commitment of partners. The council has set clear ambitions for services for children and young people that are reflected in its corporate strategies. These ambitions will inform the Children and Young People’s Plan for Staffordshire 2006. The Children’s Trust board, established in April 2005, has representation from all the major statutory and independent partner organisations including voluntary and community groups. It is developing a unified vision, terms of reference and structures.

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Service management

74. The council and its partners prioritise well, but there are some weaknesses in translating these priorities into plans. Prioritisation processes are therefore adequate. The understanding of local needs is good, although there is no corporate steer for the development of provision for some minority groups. Health priorities are well focused on the needs of the area and the reconfiguration of services to meet these needs. The directorate improvement plan for education sets clear priorities and outcome targets. The council understands well how extended schools and children’s centres will deliver integrated services that will improve early intervention and enhance preventive responses. The trust is, however, very new and the plans for translating these ambitions and priorities into action are being developed. There has been a previous lack of development of children’s social care services across the

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Service management

Staffordshire joint area review of children’s services 24

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Service management

county, in particular in reshaping and refocusing provision. This is now being dealt with but clearly this makes the task more difficult.

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Service management

75. Staffordshire has adequate capacity to deliver services. There are some good examples of multi-disciplinary working, for example the district inclusion panels in Newcastle-under-Lyme and Tamworth, which are meeting locally determined needs. The work of the district councils to jointly develop provision for children is well established and is delivering positive outcomes. The development of children’s centres is impressive, as is the work of such organisations as Sure Start and Home Start. At a local level these multi- disciplinary services are having an impact and are able to assist children and families at early stages. Although locality-planning arrangements are emerging, a strategic overview and co-ordination of the work of different services is lacking. Established partnership arrangements and structures, and the pooling or aligning of budgets with other key agencies, are limited. However, the

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Service management

council is developing formalised partnership arrangements for the new CAMHS partnership, which includes integrated service delivery, joint-funding arrangements and shared targets, protocols and procedures. The lessons learned from this process will be used to inform all future partnerships.

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Service management

76. The capacity for the delivery of education services is good, however staffing resources across the council’s services are not yet matched securely to the needs of vulnerable children or the requirements of the trust. Strategic capacity within children’s social care is uncertain and key vacancies and skill shortfalls have adversely affected the performance of the service. The council has developed a recruitment and retention strategy for social care staff for 2005/06, targeting certain areas of the county. This strategy draws upon the council’s successful recruitment and retention policy for teachers. The council is also in the process of commissioning consultants to complement its social care capacity and recent appointments have been focused on strengthening the overall capacity of the Children’s Trust. Under the new corporate director of children’s services, the service has embarked on an integration plan to build

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Service management

and improve its strategic management capacity. This includes a corporate post to oversee development of integrated children’s services, four strategic posts to support the work for vulnerable children and some jointly funded appointments.

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Service management

77. The council has been innovative in its approach to procurement in order to enhance capacity, for example through the purchase of school buses to provide home to school transport. Commissioning and joint commissioning for children and young people are being developed but need to be tied more to essential activities, key priorities and effective gate keeping.

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Service management

78. Resources are adequately managed and work is being undertaken to ensure that they are targeted more effectively. The council continues to adopt a prudent approach to its finances. Budget management and monitoring is generally effective, for example the council took action in dealing with poor service and financial performance in special educational needs (SEN) following the Ofsted inspection in 2002. Improvements have been made in the Staffordshire joint area review of children’s services 25

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Service management

monitoring and management of capital schemes and children and family services have spent to budget in 2004/05, following significant under-spends in previous years. The management and control of its education budgets is effective, particularly in high-spending areas such as SEN and home to school transport. However, the council is having difficulty in controlling its demand-led budgets in social care. It is projected to overspend significantly by £5.8 million in children and family services in 2005/06. The council has still to formulate concrete proposals to reduce this overspend.

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Service management

79. The council’s medium-term financial strategy does not fully reflect longer- term needs or priorities. It has put in place a priorities methodology, as part of the 2005/06 budget round, to ensure closer links between the budget and the council’s priorities. Corporately, there is a commitment to vulnerable children’s services and it is anticipated that they will be allocated some of the reprioritised funding in 2006/07 in addition to £11 million targeted for SEN between 2002 and 2005 and improvement funding for the library service.

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Service management

80. Performance management is inadequate, illustrated by the failure to identify and a slow response in addressing major performance issues in children’s social care. The current arrangements across corporate, departmental and partnership structures for performance management and business management are too diffuse. This is impeding the council from focusing on its key priorities. The council’s corporate and directorate improvement plans are strong planning frameworks for managing change and driving improvement, but are not yet fully utilised by social care. Planning and performance management processes within children’s services have not yet been fully integrated. Different processes are being used and there are inconsistencies in the quality of the performance monitoring and control. Processes are more rigorous in the education and youth services. Further work is needed to establish performance management arrangements with partners.

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Service management

Targets and milestones are not in place to enable the trust board to monitor the implementation of agreed strategies and services.

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Service management

81. The council collects and analyses data on the services it provides and monitors its performance against clearly identified performance indicators. However, there are few examples of performance information being used to evaluate the efficiency and effectiveness of services. Complaints and user feedback are not used systematically to inform and improve service delivery. The culture of comparison is not sufficiently embedded.

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Service management

82. The council has not fully aligned business planning, resource planning and performance management processes. Therefore, the council does not systematically use cost, performance and quality information in an integrated and structured way to assess value for money. The council does provide good value for money in many of its education services, where it is performing adequately at relatively low costs. There are, however, some priority areas such as social care where high spend has not been reflected in improvements in service delivery and performance. The Social Services Improvement Board has Staffordshire joint area review of children’s services 26

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Service management

begun to discuss costs and benefits but these developments are at an early stage.

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Service management

83. The council has undertaken a number of service reviews that have generated some improvements in service provision and delivery, for example the school improvement service, the youth service, the library service and SEN. The systematic monitoring, evaluating and reviewing of the impact and outcomes of these service reviews is under-developed. Staffordshire joint area review of children’s services 27

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section of the corporate assessment report

1. The council is performing adequately in this area. It has acted quickly to implement the requirements of the Children Act 2004 and has ambitious and challenging plans for working with partners to make children’s services more integrated, but detailed work has yet to start to get partners fully signed up and establish pooled budgets and joint teams. Many parts of the service are performing well, but there are some important weaknesses in some services for vulnerable children and young people.

p.27

section of the corporate assessment report

2. The council has given children’s services high priority and new money. It has been early and imaginative in its planning for integrated services, with a Children’s Trust board established in May 2005, led by the newly appointed corporate director for children and lifelong learning. It has created a network of four children’s centres, with more planned. These are incorporating good joint working, which is already having an impact on areas of high deprivation. There are many excellent new initiatives, although these have yet to be evaluated, and their learning incorporated into building blocks for mainstream delivery.

p.27

section of the corporate assessment report

3. The majority of children in Staffordshire enjoy school and achieve well, although school performance is uneven. There is scope for identifying special needs, including potential high achievers, earlier. The council and its partners consult and involve children well and children mostly feel listened to and able to voice concerns. The portfolio-holder for children’s services is taking a strong lead in strengthening corporate parenting. The council has appointed a children’s commissioner who will sit on the trust board, which is a positive move.

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section of the corporate assessment report

4. Children’s social services are still doing a lot of high-intervention work, having been slow in the past to move to preventive family support. Too many children and young people are being placed outside the county at high cost, often with poor outcomes. New partnerships give capacity to shift the focus to prevention and the opportunity to establish joint gate keeping and commissioning. There is scope for more joint planning, budget pooling and commissioning with health.

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section of the corporate assessment report

5. Social care practice to protect very vulnerable children from harm is inadequate, ranging from very good to poor. Assessment, planning and monitoring by all agencies have weaknesses. Cases where a child is thought to be at risk are not being regularly scrutinised. Documentation is sometimes lacking. The council is not auditing records and practice regularly to ensure consistency. Other provision to ensure children and young people feel safe is generally satisfactory, with well-established road safety and safer schools approaches. Some children excluded from school, including looked after children, are not getting enough educational provision, which needs to be Staffordshire joint area review of children’s services 28

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section of the corporate assessment report

tackled urgently. But there are some recent improvements for looked after children, including specialist teachers and transport to keep them at the same school when they move home.

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section of the corporate assessment report

6. Performance management and human resource management are under- developed, particularly in social care. Planning objectives and outcomes are not closely monitored and accountability for improvement targets is not clear enough. Data are not being well used and progress reporting is not sharp enough. Staff shortages in key areas could impede integration and the council is only just starting to tackle these strategically.

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section of the corporate assessment report

7. The Learning and Skills Council works well in partnership with the council but needs to be more involved in strategic planning; access to services for young people aged 14–19 is inconsistent. The Connexions service provides good support to meet the needs of individual young people. Transition services and structures will need to be strengthened as children’s and adult care services separate.

p.28