Setting

Mrs Carole Burgoyne Strategic Director for People Plymouth City Council Civic Centre Royal Parade Plymouth PL1 2AA

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Rebecca Harriott, Clinical Commissioning Group Chief Officer Jo Siney, local area nominated officer

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Joint local area SEND inspection in Plymouth

From 10 to 14 October 2016, Ofsted and the Care Quality Commission (CQC) conducted a joint inspection of the local area of Plymouth to judge the effectiveness of the local area in implementing the disability and special educational needs reforms as set out in the Children and Families Act 2014.

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Joint local area SEND inspection in Plymouth

The inspection was led by one of Her Majesty’s Inspectors from Ofsted. The team comprised an Ofsted Inspector and a children’s services inspector from the CQC.

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Joint local area SEND inspection in Plymouth

Inspectors spoke with children and young people who have special educational needs and/or disabilities, with parents and carers, representatives of the local authority and National Health Service (NHS) officers. They visited a range of providers and spoke to leaders, staff and governors about how they were implementing the special educational needs reforms. Inspectors looked at a range of information about the performance of the local area, including the local area’s self- evaluation. Inspectors also met with leaders from the local area for health, social care and education. Inspectors reviewed performance data and evidence about the local offer and joint commissioning.

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Joint local area SEND inspection in Plymouth

This letter outlines the findings from the inspection, including some areas of strength and areas for further improvement.

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Main Findings

 There has been a clear commitment from senior leaders to implement the reforms and ensure that children and young people who have special educational needs and/or disabilities are safe. At strategic level, the board’s co- commissioning, co-location, and pooled budget arrangements are contributing to a close working integrated multi-agency approach, particularly around the needs Ofsted Agora 6 Cumberland Place Nottingham NG1 6HJ T 0300 123 1231 Textphone 0161 618 8524 enquiries@ofsted.gov.uk www.gov.uk/ofsted Lasend.support@ofsted.gov.uk of young children and their families and for foster or residential placements for children and young people.  Leaders complete a reliable analysis of information so that they have a generally accurate view of their performance in relation to national figures. The areas of strength in assessment, provision and outcomes, and those that need development, are understood and well known. However, the clinical

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Main Findings

commissioning group (CCG) has not completed a self-evaluation of its performance. On this basis, it is not clear how the group is identifying areas for development and improvement without knowing gaps, for example in the low completion rates of ante-natal visits, a lack of resources to support the health needs of children looked after and significant delays in accessing speech and language therapy (SALT).  The health team for children looked after by the local authority is significantly under-resourced. Children and young people coming into care are not receiving timely initial health assessments and they do not align well enough with education, health and care (EHC) plans. This is a longstanding problem in Plymouth.  Families have limited knowledge of the local area parent/carer forum. The parent/carer forum has only very recently been reformed. It does not yet provide effective support to influence and inform strategic design of services. Currently,

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Main Findings

the forum is not fully representative of the range of cultures and ethnicities, and the variety of need in the local area.  The local area has successfully instigated a changing culture and practice to increase the amount of involvement of young people. An active young people’s forum is working with commissioners of services to inform planning and adapt the development of services.  The local offer is not sufficiently known or understood by parents, carers and some professionals. Much more work is needed to dispel misconceptions to enable families to have more reliable information and an accurate understanding of what they can expect from the local offer.  Post-16 and post-19 provision and the transition arrangements to adult services remain a concern for many families. Children, young people, parents and carers who communicated with inspectors gave mixed reports of the support that they receive from education settings, health services and social care provision.

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Main Findings

Greatest satisfaction rates were with services for the youngest children.  The Plymouth Information Advice and Support for SEND (PIAS) service deals with high volumes of enquiries. It is a valuable source of information both for those requiring universal services and for those seeking additional help and guidance. Parents and carers who know of, and have used, PIAS report very high levels of satisfaction with the support they receive.  The local area team are successfully building their capacity and have increased the effectiveness of school special educational needs coordinators (SENCos). Through training and information they have raised awareness of autism spectrum condition (ASC) and developed classroom-based adaptations for pupils. The clearly defined local area referral process has encouraged school staff to take responsibility and ownership of children’s assessments and provision.  The local area has converted double the proportion of EHC plans compared with

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Main Findings

national figures. Evidence of EHC plans seen by inspectors shows that there are high levels of family involvement and appropriate input from health, social care and education. Following annual reviews and conversion to plans there is clear evidence of adaptations to the curriculum, and exam modules, with greater account taken of pupil and parental opinions. Nevertheless, young people, particularly those on the autistic spectrum, do not always get the level of involvement that they would like in their reviews.

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Strengths

 Families and new-born infants benefit from timely ante- and post-natal screening checks. Performance is broadly in line with national indicators, with some evidence of exceeding targets. Hearing checks for new-born infants are carried out effectively by health visitors, with 99.5% of all new-borns receiving their check. Rigorous quality assurance ensures consistency in approach, and the number of inappropriate recalls is very low. Families report high satisfaction with the service as the test is carried out by practitioners who are already engaged with the family and are able to offer immediate advice, support and guidance.  A significant positive aspect of the local area’s work is the strong multi-agency approach which provides a team to support young children and their families (Team around the Family) and accurately identifies individual needs early in a child’s life. The Team Around Me (TAM) approach involves the relevant agencies

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Strengths

and the family in assessing the needs of the child and producing a plan in a common format. The plan is implemented and reviewed, based on set timescales in the planner provided by the local area, further increasing consistency. The early years transition framework identified 53 children as requiring statutory support and all transitioned into school with EHC plans. Around 40% of new EHC plans are issued for those under the age of five.  There is a very clear pathway for visual and hearing referrals in the early years to enable prompt identification, leading to well-timed support.  The overwhelming majority of Plymouth primary schools use a standardised ‘behaviour, attendance and emotional’ (BAE) assessment framework to audit all the pupils. These audits are then carefully analysed in order to provide carefully targeted services in three tiers that are increasingly successful in meeting individual pupils’ needs.

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Strengths

 Physiotherapy have introduced a service to assess the need for early intervention for new-born infants delivered up to 30 weeks and antenatal and neonates in the immediate post-partum period who would benefit from assessment to promote physical well-being. This is helping families to get an early referral to support services such as occupational therapy and Portage (an early intervention home learning service for pre-school-aged children with additional needs and/or disabilities and their families). However, this service has not been formally evaluated or commissioned, so the sustainability of this valuable input is not secure.  The Plymouth young people’s forum is working actively with commissioners of services to influence planning and development of services. A range of initiatives is successfully engaging young people to share and explore the opportunities provided by the 2014 reforms.  There is a high level of take-up of the two-year-old, and three- and four-year-old

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Strengths

funded provision. The local area has good oversight of these children, enabling education and care providers to better identify those not reaching age-related milestones.  There is an increasingly effective youth intervention team that supports young people who become known to the criminal justice system. Through joint working across services they are identifying and supporting young people to avoid criminal activity so that offending rates are in decline in the local area.  Pupils in all types of schools have a greater proportion of specialist assessments for their primary need than seen nationally. These good-quality assessments ensure that appropriate provision is identified in a timely manner.  Three quarters of the parents and carers who responded during the inspection to the poll questions from the webinar and the online Ofsted survey felt that their child’s needs had been effectively identified.

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Areas for development

 Over time, children and young people coming into care have not received timely initial health assessments. The current capacity at senior leadership level of the health team for children looked after is under-resourced, and this has had a negative impact on developing the services. Commissioners provided assurance that additional resources had been identified and have agreed to increase the capacity within the nursing children looked after service around December 2016.  The Designated Medical Officer (DMO) and Designated Clinical Officer (DCO) have not placed sufficient emphasis on gaining a clear understanding of the children and young people of Plymouth. They have focused their activities on effectively supporting the operational impact of the 2014 reforms, including the quality assurance of health contributions by the DCO. The CCG recognise that a stronger strategic role is needed and are currently evaluating the role and

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Areas for development

scoping future need.  New families do not always have ante-natal visits from health visitors. Only 48% of expectant mothers receive a visit prior to the birth of their baby. This is often a culmination of lack of availability in capacity and gaps in administrative processes between professionals. This reduces the impact that health visitors can have on supporting families with their young children. In addition, along with school nurses, their understanding of the local offer is weak and therefore they cannot promote it to their families.  General practitioners (GPs) are involved with the 2014 reforms at a strategic level and briefings have been undertaken through various forums with practice GPs. Anecdotally, it was reported that GPs are increasingly referring young people with a potential diagnosis of SEND into their service and that there was evidence of GPs carrying out earlier health checks for young people. The two

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Areas for development

nurses allocated to primary care are working effectively with GP communities to highlight and promote the health needs of these vulnerable people and to provide advice on specific cases. Figures on the rate of involvement are not collected or monitored to ensure consistency across the area.  At the initial stages of the implementation of the reforms, parents and carers were involved with helping to shape the local offer and provision in the area. The original parent and carers forum was dissolved last year. This new forum, and the new ways of working, are currently being re-established through online media. There is no longer an operating telephone helpline. The local area is aware that the forum is currently not effective. It is aware that it needs to continue to support and facilitate the development of the forum to ensure that opportunities for parental engagement are more effective, and so that parent

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Areas for development

carers are able to successfully support and contribute to strategic and service developments.  Parents/carers and young people are unclear about the range of options available post-16. There is even greater uncertainty throughout the local area about the post-19 offer. Many young people expressed their concerns about not being able to use their bus passes to get to college or work before 9.30 am. The ASC partnership board is aware that some young people find the signage around some bus stops confusing.  Leaders are using pilots and building on systems that have proven to work in primary schools into secondary schools. For example, the child and adolescent mental health services (CAMHS) community service team is now on-site in secondary schools for half a day per week as part of an emotional support package for pupils. As this only started in September 2016, there is no measurable impact of this work yet.

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Strengths

 A specialist infant mental health service effectively supports families with children under five years of age, with priority given to ante-natal referrals and children under one year old.  Children and young people with complex needs who are admitted to the local hospital are well supported by the learning disability nurse and children’s community nurses. Staff ensure a coordinated approach to their care and subsequent discharge. Specialist dental and phlebotomy services are used to support children when accessing care. This is important, as specialist skills and understanding of special educational needs are required to help these children when undergoing unfamiliar and frightening treatments.  Children under five who have been referred to the Child Development Centre (CDC) for a potential ASC are now benefiting from a more individualised assessment process. Clinicians work together to identify the most appropriate

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Strengths

setting in which to carry out the assessments to ensure that the child is seen functioning at their best in an environment in which they are familiar. The co- location and integration of multiple professionals mean that appointments are arranged to minimise disruption to families.  Children’s transition into school is improving noticeably with better preparation, appropriate additional support and records that give a detailed picture of the family context, family issues and children’s needs.  Children and young people in mental health crises are treated effectively by the crisis CAMHS team, who work to avoid admission into inpatient care. Most young people in Plymouth who need inpatient care are admitted into an age- appropriate facility in the local area. Some, however, will need to travel outside the local area because of the more specialist nature of their condition. There are no admissions of children into an adult ward.

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Strengths

 The ‘My PEPs’ programme is an evolving record of what needs to happen for children looked after to enable them to make expected progress and reach their potential. In Plymouth pupils attend meetings to present and discuss their needs and provide their ‘voice’. This is enabling them to have greater confidence and ownership of the support they receive. The EHC plan panel allows for healthy challenge between agencies to promote the child’s best interests, and is ensuring that the child’s voice is central in the decision-making process.  To date there have not been any cases of statements that have not converted to EHC plans.  Risk assessments for foster or residential placements for children and young people are well targeted, having a multi-agency approach to enable effective support, particularly for those of medium to high risk of placement breakdown. The improved alliance with education and health is helping to better meet the

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Strengths

care needs of these children and young people.  The monitoring of the progress that home-educated pupils make is regular, and includes home visits. The meetings to review support include all agencies working with the child, with the exception of school nurses. The cohort is very small. All those who had statements have had these converted to EHC plans.  A weekly panel reviews the needs of those young people not attending school due to their medical needs. These reviews are used to identify what support might be needed to enable them to re-integrate into their schools as soon as possible. This ensures that these youngsters are closely monitored and that supportive interventions are effectively put in place.  In response to a local serious case review, school leaders have assured the local area that special educational needs coordinators (SENCos) have the time and capacity to fulfil their roles and that they are not compromised by also being the

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Strengths

main school safeguarding leader. In addition, the ‘My PEP’ has also been extended to include a question about pupils’ experiences of bullying and feelings of safety.  SENCos are now enthusiastically sharing best practice, developing innovative new ways of working, and are getting high-quality central support and direction. They are beginning to unify their approach to supporting pupils, for example developing uniform proformas, supporting parental applications to the CDC and CAMHS.  There is a comprehensive short break offer and there are robust resource allocation processes which result in ‘total care plans’, providing positive and meaningful leisure activities for children and young people.  Just over half of the parents and carers who responded during the inspection to the poll questions from the webinar and the online Ofsted survey felt that their child’s needs had been effectively met.

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Areas for development

 The local offer does not adequately publicise or explain to parents and carers about additional and specific health services that are available. It is a generic directory of services which does not explain, in a meaningful way, how families can access specific services or what the thresholds are.  Children face delays in accessing specialist support from therapists and paediatricians through a protracted referral system.  Children and young people face significant delays in accessing SALT services, with some children waiting up to 27 weeks for treatment. To mitigate these long waits the local area has provided parents and carers with access to information and resources to provide early help while waiting for therapy support. SALT services are not commissioned to provide early intervention and training to universal services. Since the withdrawal of this service in 2012, there has been a direct link with the increase of referrals to their core service.

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Areas for development

 Children and young people are not benefiting from a cohesive package of support from the school nursing service. The universal offer is not well established. School nurse ‘drop-in visits’ are offered to schools, although the take-up is low. The offer to children and families is compromised by the current practice of rostering school nurses for six weeks on the child protection rota. This practice can impair the continuity of practitioners working with the family progressing into child protection processes. This is not in the interest of children, young people and their families. This practice ceased during the course of the inspection.  Children and young people of school age who are referred for a diagnosis of ASC via the CDC are waiting too long. Some children have been on the waiting list for over 18 months. The services recognise this and have a recovery plan in place; they have worked with partners to increase capacity and are meeting the

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Areas for development

trajectory for improvement.  Children and young people can face lengthy waits to receive specific care interventions from CAMHS, with some waiting up to 30 weeks. This is recognised by the local area, who are in the early stages of their CAMHS transformation. Investment in early identification and support of emotional health and well-being is a priority of the local area and plans are well advanced.  Young people who use specialist equipment to help them stand and walk are often unable to take their physiotherapy equipment into adulthood once they have left specialist educational provision. Those working with young people over 16 years of age also report that access to specialised therapeutic support is limited and hard to get hold of, increasingly so for those over 19 years old.

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Strengths

 Children attending the ‘ICAN unit’ make very good progress and historically the majority of children were able to access mainstream education. There are examples of some children improving their language scores significantly.  Children and young people who receive intervention from the SALT progress well. Families are involved in setting outcomes using the care aims approach, with evidence of measurable progress.  School nurses support children and young people by offering effective short-term interventions with clearly defined expected outcomes. During 2014/2015, 852 children were referred to school nursing for help, with only 16.5% of these referrals needing further specialist intervention or assessment.  Children looked after by the local authority have more stable home lives, in both foster care and residential provision. This has enabled almost all of these children to stay in the same area, attend the same school or transfer to senior

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Strengths

schools with their classmates. As a result they are establishing friendships, attending frequently, and are doing well at school.  Investment in good-quality, regular, up-to-date staff training, at all levels, is paying dividends. In one school highly trained healthcare assistants and close working relationships with the NHS ensure that pupils’ medical needs are met immediately. This has freed up parental and community nurse time as well as reducing hospital admissions. In addition, the training has increased parental confidence. Because of their enhanced skills pupils need to spend less time in hospital or at home recuperating. As a result, the expected recovery time before returning to school has halved over the last year, enabling them to learn more.  The participation rates of post-16 and post-19-year-olds in education and training for those young people who have statements or have an EHC plan in

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Strengths

2016 has increased steadily since 2014. This is higher than the rate for their peers locally. The overall education, employment and training (EET) rates for those post-16 is improving but remain below those of their peers and nationally.  Between key stages 1 and 2, pupils with EHC plans make significantly better than expected progress in mathematics and reading, with above expected progress in their writing. Those without a plan but with extra support make, or slightly exceed, the expected progress.  Between key stages 2 and 4, pupils with an EHC plan make just above expected progress in English.  Although cohort sizes are small, three quarters of the seven annual cohorts of supported internships at Derriford Hospital have resulted in successful employment.  Autism training has extended professionals’ and families’ understanding of autism. Case studies show that this higher level of understanding increases

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Strengths

expertise in ASC and improves the quality of support provided and, as a result, outcomes improve.  The Gateway re-organisation has reduced by three quarters the number of escalated calls to social care, due to families getting earlier intervention and support.  Around three quarters of the parents and carers who responded to the Ofsted surveys felt that outcomes for their child were improving.

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Areas for development

 The information about the impact of services and provision for those requiring additional support below an EHC plan or statement is often held at provider and service level when young people have left school. It is not widely explored by leaders to ensure that support is strong and effective. Without this information it is not possible to determine how well the offer for those young people and adults who need extra support is impacting on their preparation for adult life and sustained employability.  Occupational therapy and physiotherapy services are unable to measure or demonstrate the impact of their work and there is an over-reliance on anecdotal feedback. Within CAMHS, although outcomes are used to inform care planning at an individual therapeutic level, these are not routinely collected and used to inform service evaluation and strategic planning.  Between key stages 2 and 4, pupils with special educational needs do not make

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Areas for development

the expected progress they should in mathematics. In addition, those without an EHC plan do not make the expected progress in English. The local area leaders have identified these areas for improvement. ASC training has helped school staff have a better understanding about the challenges faced by children so they can better foresee barriers to learning, such as how five black dots on a page can represent the number five.  The proportion of care leavers with an EHC plan who are not in education, training or employment is higher than for other care leavers nationally. The employment rates of those young people who have statements or have an ECH plan in 2016, post-19 years of age, are lower than their peers and decreasing. This also applies to the overall EET rate.  Senior leaders of the local area do not have an overview of parental feelings across the whole local area. This is because most information is held at provider

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Areas for development

or service level. In particular, direct satisfaction rates and the parent forum voice fail to reach a broad audience to gather views and share communication.  The number of single homeless adults with complex and additional needs with an EHC plan in employment over the last three years is reducing. An Employability Pilot programme is beginning to overcome the lack of aspiration for the employability of those with learning difficulties. Although this work is in the early stages, the sense of partnership enthusiasm is beginning to be established. Those students involved in the project are developing their confidence and better understanding of their own learning needs.  Area leaders are also aware that the range of apprenticeships and supported internships needs to be extended, particularly for older young people, to enable them to gain sustained employability and/or make a positive contribution to their

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Areas for development

community. Several smaller employers are already successfully involved, as is the larger local hospital. Other larger institutions, such as the local authority and university, have yet to follow suit.

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Ofsted Care Quality Commission

Bradley Simmons HMI Regional Director, South West Ursula Gallagher Deputy Chief Inspector, Primary Medical Services (North), Children, Health and Justice.

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Ofsted Care Quality Commission

Steffi Penny HMI Lead Inspector Elizabeth Fox CQC Inspector

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Ofsted Care Quality Commission

CC: Clinical commissioning group(s) Director Public Health for the local area Department for Education Department of Health NHS England

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