Setting

Mr D Johnson Director of Social Care and Health Sefton Metropolitan Borough Council 9 th Floor Merton House Stanley Road Bootle L20 3JA

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Mr P Wong, Clinical Commissioning Group Chief Officer, South Sefton and Southport and Formby Mrs Sally Richardson, Local Area Nominated Officer

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Joint local area SEND inspection in Sefton

From 21 November 2016 to 25 November 2016, Ofsted and the Care Quality Commission (CQC) conducted a joint inspection of the local area of Sefton to judge the effectiveness of the 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 Sefton

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

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Joint local area SEND inspection in Sefton

Inspectors spoke with children and young people who have special educational needs and/or disabilities, 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 Sefton

As a result of the findings of this inspection and in accordance with the Children Act 2004 (Joint Area Reviews) Regulations 2015, Her Majesty’s Chief Inspector (HMCI) has determined that a Written Statement of Action is required because of significant areas of weakness in the local area’s practice. HMCI has also determined that the Ofsted Agora 6 Cumberland Place Nottingham NG1 6HJ T 0300 123 1231 Textphone 0161 618 8524 enquiries@ofsted.gov.uk www.ofsted.gov.uk Lasend.support@ofsted.gov.uk local authority and the area’s clinical commissioning groups (CCGs) are responsible for submitting the written statement to Ofsted.

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Joint local area SEND inspection in Sefton

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

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Main findings

 Pupils in key stages 2 and 4 who have a statement of special educational needs or an education, health and care plan (EHCP) do not make enough progress from their starting points.  Waiting times for health services, such as speech and language therapy, paediatrics, audiology and occupational therapy, are unacceptably high. Some children and young people wait much longer than others for health services because of where they live in the borough.  The designated clinical officer (DCO) is not providing effective operational leadership of SEND across health agencies. Many health practitioners are unaware of whether their work with children or young people is part of an EHCP.  Leaders have been too slow to set up joint commissioning between education, health and care. Only very recently has a model been agreed and put in place.  Co-production with parents, especially in health and care services, is weak. There

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Main findings

are some recent examples of effective co-production, but too often, plans are presented to parent representatives for feedback as opposed to parents being involved at the initial planning stage.  Many EHCPs are too generic, not focused on outcomes and have targets that lack clarity.  Health practitioners are not routinely contributing to EHCPs. As a result, they are often not aware of the references to health in plans, even when they are the named professional contributing to the plan.  The use of personal budgets within the education, health and care planning process is limited. To date, very few families have taken up a personal budget as part of an EHCP.  The number of young people who have special educational needs and/or disabilities moving on to paid employment remains stubbornly low. Plans, such as supported internships, are in place to help address this, but are only available in one area of Sefton and are yet to show any impact.

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Main findings

 Leaders have established clear procedures to help prevent the fixed-term or permanent exclusion of children and young people who have special educational needs and/or disabilities. As a result, the proportion of pupils excluded from schools is below the national average.  Most children and young people who have special educational needs and/or disabilities benefit from successful transitions when they move from one school to another.  New EHCPs, and those which have been transferred from statements of special educational needs, are completed in a timely manner. There are effective systems in place to ensure that plans are agreed within the expected timescales.

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Strengths

 Health visitors are delivering the full healthy child programme. Over 93% of children in Sefton are receiving their two-year development check to help identify any emerging development needs. This check includes an assessment of the child’s social and emotional needs. Where any developmental concerns are identified, an increasing number of integrated two to two-and-a-half year checks with early years settings are being used to accurately identify need and to provide a coordinated response.  Families with school-age children are supported well by school nurses. There is an effective core programme of Reception class screening for vision and hearing, national child measurement programmes at Reception and Year 6, and immunisations. These programmes, coupled with drop-ins for parents at high schools on a weekly basis and primary schools on a monthly basis, support the timely identification of needs.  There is a well-established process in place for detecting hearing impairment and

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Strengths

visual impairment in new-born babies and there are further opportunities for the identification of needs when children enter school through the school nursing service. The support offered by the hearing and visual impairment teams is well regarded by parents.  There is an effective system to ensure that existing statements of special educational needs are transferred to EHCPs in a timely manner. Very effective tracking of individual cases has meant that the local area has exceeded its targets for conversion within the given timescales.

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Areas for development

 Initial health assessments for children looked after are not completed within statutory timescales. This is the case for over half of this group and means that needs are not identified in a timely enough fashion. The local area has identified that a number of breaches in timeliness are due to non-attendance of children who are looked after but remain living at home with their parents. The local area recognises that there needs to be a more robust approach to ensure that those children who remain in the care of their parents, while still the responsibility of children’s social care, attend their initial health assessment at the earliest opportunity.  Children looked after who receive support through either SEN support or with an EHCP are not routinely notified to the children looked after health team. This means that important information which would inform reviews and the EHCP planning processes is not available.

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Areas for development

 Children looked after are not benefiting from the use of the strengths and difficulties questionnaires (SDQs) to measure and track their emotional health and well-being. This is a significant gap in identification and ongoing assessment of their needs.  The timely identification of needs across the local area is unclear and leaves parents and some school leaders confused. This is because there is a lack of transparency about the systems leading to statutory assessment. Parents and some school leaders think that decisions about statutory assessment can take years and that the systems are inflexible. However, a significant number of children and young people have moved directly to statutory assessment without having to go through the local area’s graduated response process.  Unacceptably high waiting times delay the identification of need, particularly for speech and language therapy, paediatricians and occupational therapy. As a result

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Areas for development

of these waiting times, needs are not identified and met quickly enough in a significant number of cases.

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Strengths

 In response to local demand, sensory workshops are provided by occupational therapists. An individual action plan is written and this informs parents of strategies to better support their children. Parents have an opportunity to share their experiences with other families and have the opportunity for one-to-one time with a qualified occupational therapist. As a result, parents have a greater understanding of their children’s sensory processing difficulties.  Children under three who have been identified as needing specialist assessment by more than one practitioner from speech and language, physiotherapy or occupational therapy are referred to the speech, physiotherapy and occupational therapy (SPOT) team. The first assessment is undertaken jointly by all three therapy teams. This offers a coordinated approach to care that supports the ‘tell it once’ approach for these young children.  Referrals are made to physiotherapy from special care units for babies born before

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Strengths

32 weeks. Children are assessed and offered monitoring for up to two years. Those families are then offered open access to any future appointments.  Health visitors meet regularly with most general practitioner (GP) practices and children’s centres across Sefton to discuss vulnerable families. This enables early intervention and multi-agency working to support children and families.  A specialist school nurse is employed as a link nurse for children who are not attending school. The service effectively supports children back into formal education and facilitates access to core health services.  There is a flexible approach across Sefton to promoting direct referrals by practitioners working with children where a more specialist assessment is needed. For example, health visitors and school nurses are able to refer to therapies and community paediatricians directly. This means that delay is minimised between

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Strengths

identification and referral for specialist assessment.  Children and young people living in north Sefton who have complex health needs benefit from a commissioned continuing healthcare (CHC) nursing team. They also act as key workers to provide continuity of support for families. This is recognised as best practice in the SEND code.  Once children have a diagnosis of autism or attention deficit hyperactivity disorder (ADHD) they are able to access the local autism/ADHD nursing service. Families are offered an assessment of their support needs and the team works flexibly with families to provide packages of care, for example around behaviour support, continence, managing emotions and anxiety.  Local services have responded positively to an increase in children being diagnosed with pathological demand avoidance (PDA). Some practitioners have very recently accessed specialist training, recognising that these children need

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Strengths

different support and care management.  Transition arrangements between schools enable greater involvement from parents. Most parents spoken to confirm that these transition arrangements are managed well and that their children have a successful start. Where a pupil has high needs funding in primary school, this funding transfers with the pupil to secondary school and helps to support effective transition.  Support given to young people with highly complex needs when transferring to adult social care is a strength. Social care work with young people from 14 to 19 and their families in readiness for transfer. They work with a large number of young people and monitor progress until they are allocated a social worker, who then provides support up to age 25. They meet specific needs, for example when finding a barber who understands autism and uses non-vibrating clippers.  There is an open referral system to support children with complex needs before

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Strengths

they start school. Joint visits are undertaken at schools as part of an access assessment. This includes the environmental assessment of a setting to determine any reasonable adjustments which may be needed. This joint work involves parents, school staff, physiotherapists and occupational therapists and is appreciated by leaders in settings. The process ensures that the needs of pupils are met in a timely way.  There are well-established processes in place to support the accommodation and care needs for those young people who are transitioning into adult social care where specialist provision is identified as a need.  Young people transitioning into adult social care who have an Alder Hey consultant paediatrician are held on a transitional exception register. Where there is no identified care pathway to transfer into adult services, young people can still be admitted to the hospital via the accident and emergency department, post-19.

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Strengths

This ensures that these young people continue to receive the specialist care they need.  The responsibility for safeguarding children and young people who have special educational needs and/or disabilities who become subject to a child protection plan is carefully managed. The most relevant department, which is considered best placed to meet individual needs, accepts overall safeguarding responsibility. The same safeguarding procedures and practices apply to children and young people who are looked after, whether they are educated within or out of the borough. Visits and review meetings are not limited by the distance social workers need to travel.

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Areas for development

 South Sefton clinical commissioning group and Southport and Formby clinical commissioning group have incorporated the function of the DCO into the role of chief nurse. The job description is in draft form and awaiting final sign off, despite this arrangement being in place since the reforms began. There is a lack of operational leadership of SEND within health services across Sefton. Many health professionals are unaware of the role and function of the DCO.  Sefton has only recently formalised an approach to joint commissioning for special educational needs and/or disabilities which has been endorsed by senior leaders across the local area. The CCGs acknowledge that progress has been hindered by the legacy of historical commissioning and, where possible, new contracts are being negotiated with a requirement for more robust data collection on need and outcomes. Although there are recent successes of joint commissioning, including

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Areas for development

the integrated 0 to 19 family nursing service and the local area’s emotional health and well-being strategy, leaders understand that they have been slow to act.  Although individual families have started conversations with the local authority and the CCGs, very few families have taken up the offer of a personal budget as part of an EHCP. The policy and guidance for personal health budgets is in place, but frontline health practitioners are directing requests for uncommissioned specialist therapy services through the NHS complaints procedures. This is confusing and frustrating for families.  There is a lack of strategic vision for speech and language services across Sefton, which is contributing to a reactive approach to meeting the communication needs of families. Referrals to speech and language therapy are exceeding the capacity of an already stretched service, and this is leading to increased and unacceptable

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Areas for development

waiting times. Waiting times are further exacerbated by a lack of cover for long- term sickness and maternity leave.  There is inequality between the north and south of the local area, meaning families in Sefton have access to a different level of service and support depending on where they live. This is particularly relevant to children who meet the criteria for complex health needs and for those children who are waiting to access occupational therapy. Children referred for occupational therapy who live in the south of the borough are currently waiting up to 24 weeks to access services. This is too long. If a child is referred for support and they live in the north of Sefton, they are usually seen within nine weeks. This disparity in provision is unacceptable.  Health practitioners are not routinely invited to contribute to EHCPs. Clinic letters are sometimes used to inform the EHCP without the knowledge or consent of the

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Areas for development

professional writing it. Health practitioners are then not given the opportunity to comment on the draft plan to endorse how their information was interpreted. In addition, finalised plans are not being routinely shared with all health practitioners. This weak practice does not support the effective meeting of needs.  Very effective support for pupils who have special educational needs and/or disabilities exists in health which is often conducted alongside other professionals. However, this is too often outside of the EHCP process. Inspection evidence highlighted case files where health practitioners were working very effectively to deliver clinical interventions but were unaware if a child was supported by an EHCP and had not been asked to contribute to multi-agency planning. In many cases, health practitioners are not aware if an EHCP is in existence.  While there have been awareness-raising sessions for health practitioners on the

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Areas for development

SEND reforms, practitioners have not received any training around writing outcomes for EHCPs. This is reflected in the poor quality of contributions seen in plans.  Increasing numbers of children who need specialist dietetic support are being referred to the Sefton dietician. This is an over-stretched service that has recently been given additional resource until March 2017 in recognition of the high risk surrounding the over-reliance on one clinician. However, there is not a robust contingency plan for this service; the interim arrangements are fragile.  There is no published autism pathway in Sefton. This lack of a clear pathway for diagnosis is adding to the confusion and general dissatisfaction of some parents with services across Sefton. Parents are already facing unacceptably long waiting times to access community paediatricians, speech and language therapy and in some cases occupational therapy. Leaders are aware of the negative experience of

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Areas for development

families, which has been ongoing for over two years. Plans to address these issues are not robust enough.  A significant number of parents report that there is a lack of consistency between schools in the support that they offer to children who have special educational needs and/or disabilities. There is exemplary practice in some schools in Sefton, but this has not been harnessed and shared with other settings to help ensure that needs are met more consistently in all schools. Action plans to drive improvement in weaker schools are not robust enough and do not set clear enough targets for rapid improvement.  Co-production with parents is weak, particularly in health and social care. There are some recent examples of effective co-production, such as with the emotional health and well-being strategy. However, parents are usually presented with plans and strategies for feedback as opposed to being involved at the planning stage in

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Areas for development

the spirit of true co-production.  There is a lack of transparency around access to provision, such as the resourced provision for children who have special educational needs and/or disabilities in nurseries. This is an early years service which parents are unaware of, and it is not displayed on the local offer.  The information, advice and support service (SENDIASS) is stretched and is working at capacity. The service is not able to provide all of the support it would like to due to the high number of calls coming in from parents. The service is also unavailable outside of term times. This means that parents do not always receive advice and support in a timely manner.  Communication with parents in the local area is poor. Many parents report that they are not informed when there are changes in provision, such as amendments to transport arrangements and support services for children and young people

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Areas for development

with autism. This causes anxiety and confusion.  Too many EHCPs are not focused on outcomes for children, are too generic and do not have clear targets. As a result, it is difficult to measure progress and to hold professionals to account.  There is a lack of support for parents further to the diagnosis of a special educational need. A significant number of parents report that they have to find out what support is available for themselves or they find out from other parents. Despite delivering a clear marketing campaign, many parents are not aware of the local offer as a starting point to find out about what services are available in Sefton.

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Strengths

 The ‘Aiming High’ group provides effective support for children and young people who have special educational needs and/or disabilities. This support helps to improve children and young people’s wider outcomes, such as keeping healthy and developing independence. Most parents using the service value the work completed. Although some parents were concerned that some activities or venues were not always suitable for children and young people with particular needs, there are many examples where tailored clubs or visits have been arranged. These include supporting pupils with autism in swimming sessions and in hosting youth clubs for young people with autism.  The proportion of SEN support students at key stage 5 who are qualified to level 2 or level 3 has been at least in line with the national average for the last four years.  Robust systems are in place to help prevent exclusions. There are clear guidelines

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Strengths

given to headteachers and governors around the exclusion of pupils who have special educational needs and/or disabilities. High needs funding is used well to support crisis situations. There is also an effective managed transfer system, which is used to move pupils to alternative schools when appropriate. In addition, pupil referral units are used to support pupils who are at risk of exclusion. As a result of these effective systems, the number of fixed-term and permanent exclusions for pupils is below the national average.  Supported internships have been successfully introduced in one college in Sefton, an initiative which has received funding from the local area. Young people are able to experience up to five different work experiences to help them decide on the type of employment they might want to consider in the future. This initiative helps to build confidence, teaches interpersonal skills and shows young people

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Strengths

how to deal with the public. These young people are aspirational and confident about leading successful adult lives.  Records demonstrate the positive impact of health visitors and school nurses in identifying and coordinating support to families of children who have special educational needs and/or disabilities. Appropriate referrals are made in a timely manner and interventions are successful in addressing need and supporting progress. Evidence shows how children’s speech, weight, physical movement and dental health have all improved.

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Areas for development

 The progress from starting points of key stage 2 and key stage 4 pupils with a statement of special educational needs or an EHCP was well below the national average in 2014 and 2015. This remained the case for key stage 4 pupils in 2016.  The proportion of key stage 2 pupils with a statement of special educational needs or an EHCP achieving the expected standards in reading, writing and mathematics has been declining since 2012-13. The difference between this proportion of pupils and the proportion nationally who achieved the expected standards has widened from 4% in 2012-13 to 9% in 2014-15.  The proportion of SEN support pupils achieving the expected five GCSEs at grades A* to C, including English and mathematics, at key stage 4 has been below the national average since 2012-13 and shows no sign of improvement.  At key stage 5, the proportion of students with a statement of special educational

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Areas for development

needs or an EHCP achieving level 2 qualifications has declined for the last two years and is now below the national average. The proportion of students achieving level 3 qualifications has declined for the last four years, moving from 2% above to 5.6% below the national average in 2014-15.  Records within children’s community health nursing, health visiting and school nursing are not always outcome-focused and instead there is an over-reliance on recording activity. This does not help practitioners or families in identifying or measuring success.  The number of adults with learning disabilities in paid employment is too low and remains well below the national average. Leaders are making improvements, for example with supported internships, but this development is not yet available in all areas of Sefton. Parents also report that there are limited opportunities for young people to engage positively in the community post-19.

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The inspection raises significant concerns about the effectiveness of the

The local area is required to produce and submit a Written Statement of Action to Ofsted that explains how the local area will tackle the following areas of significant weakness:

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The inspection raises significant concerns about the effectiveness of the

 the poor progress made from starting points by pupils with a statement of special educational needs or an EHCP at key stages 2 and 4  the poor operational oversight of the DCO across health services in supporting children and young people who have special educational needs and/or disabilities and their families  the lack of awareness and understanding of health professionals in terms of their responsibilities and contribution to EHCPs  the weakness of co-production with parents, and more generally in communications with parents  the weakness of joint commissioning in ensuring that there are adequate services to meet local demand.

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The inspection raises significant concerns about the effectiveness of the

The approach to responding to findings from inspections, including the production and review of the statement of action, is set out in Annex A of the ‘Local area SEND inspection handbook’.

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Ofsted Care Quality Commission

Andrew Cook Regional Director Alison Holbourn, Deputy Chief Inspector, Primary Medical Services (North), Children, Health and Justice.

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Ofsted Care Quality Commission

Ian Hardman HMI, Lead Inspector Emma Wilson 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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