Report re Future Provision at Shirle Hill Hospital School

Executive Summary

 

This report describes changes in clinical practice at Shirle Hill clinic for children with complex mental health difficulties and the opportunities that this provides in respect to the delivery of educational provision.  This clinic is part of the Children’s Hospital NHS Trust, and the new clinical model is attached as Annex 1. 

 

There is a statutory duty to provide education for all children who attend the clinical provision at Shirle Hill.   The changes to clinical practice have resulted in children accessing the clinical and educational provision on a part-time basis, with a stronger emphasis on more outreach support to identified children. It is therefore timely to review Shirle Hill Hospital School and make proposals for change that ensure the continued delivery of high quality, cost effective provision.

 

The impetus for reconfiguration of the clinical practice was triggered by three things; firstly a change in the nurse leadership, secondly, a wider interest in reconfiguring Tier 4 specialist services from the regional commissioners (NORCOM)[1] and thirdly, a realisation that the unit is not delivering the amount or kind of activity which best practice suggests is possible. An option appraisal was undertaken and completed, resulting in the new clinical model of delivery.  This new model was implemented in June 2006, following a period of consultation.

 

There are currently 10 children on the roll of the school, however only 4 are on the site at any given time.  In addition to the 10 children on roll currently a further 3 children receive outreach support. 

 

The Children and Young People’s Directorate (CYPD) has noted the clinical review and resulting changes. A review has been implemented in order to realign both therapy and education in a complementary new model that promotes best practice and good quality educational provision.  The resulting educational service will be a flexible service that is able to be responsive to demand led changes.  It will also support the DCSF principles of good practice for meeting the educational needs of children with complex mental health needs.

 

It is proposed that in place of the school the local authority will commission a service to operate from the existing Shirle Hill site.  This service could be managed either as part of the existing Hospital and Home Education Service or as a specialist service managed and delivered from Oakwood Hospital School on behalf of the Authority.

 

The current staffing model at Shirle Hill School is:  1 Associate Headteacher, 5 permanent Teaching & Support Staff and 1.5 Temporary Teaching & Support Staff.  The proposed model will continue to require a number of teaching and support staff and will be overseen by a Site Manager.  It is anticipated that the service will deliver an extended outreach model that could also benefit children with Tier 3 mental health needs.

 

It is proposed that the changes will take effect from January 2009.

 

In the long term this proposal produces revenue savings of approximately  £72k a year.

1.0       Background and context

 

1.1       The Children’s Hospital NHS Trust (CHNHST) developed a new service delivery model to support young children with mental health needs.  This reflects a shift away from existing clinical practices and interventions towards a more flexible, responsive day and outreach model of working that includes closer contact with the pupils’ own schools. More children are supported using a wider repertoire of intervention strategies.  It is described as an ‘intensive outreach and day unit’ service. This report sets out the CYPD’s review of the educational provision at Shirle Hill Hospital School in the light of this new clinical model.

 

1.2       The aim is to create an integrated service of excellence combining education and health care that continues to deliver high quality education that can meet the needs of these very vulnerable children and more effectively respond to changes in need and demand.

 

1.3       The plans described in this report demonstrate strategic city-wide planning with the health, well -being and educational attainment of children and young people at the heart of our work. It sits well alongside our broad strategic agenda under ‘Every Child Matters’.

 

1.4             The CHNHST established a steering group to manage the change process for the clinical model with a stated aim to be operational by June 2006. The project group included senior managers from CYPD so that all aspects of service delivery were considered in the round. The Trust’s new model is attached in annex 1.

 

1.5             A Steering Group was established in January 2007 to consider the options for future service delivery for Shirle Hill School.  Membership comprised of key stakeholders including Headteacher and Governor representatives from the hospital schools, mainstream schools, the primary and secondary pupil referral units, the Hospital and Home Education Service as well as officers from the Learning and Achievement Service, Organisational Development, Resources and Development, Children’s Specialist Services and Local Delivery Service.  Key representatives from the Children’s NHS Trust (CAMHS) were also involved.  The Steering Group met on 4 occasions between February and September 2007.

 

1.6             In addition to the Steering Group meetings a number of discussions have taken place with the Governing Bodies of both hospital schools and the staff at Shirle Hill School.

 

1.7             This report puts forward the final options considered by the Steering Group.

 

 

2.0       The role of Sheffield CHNHST in supporting children with mental health needs.

 

2.1       Child and Adolescent Mental Health Services (CAMHS) have responsibility for the delivery of services to school aged children and young people. Sheffield’s CHNHST is our key partner helping the CYPD to support young children with a range of needs. The National Service Framework (NSF) is a key policy document setting out the priorities and targets for Health services in partnership with all other key service areas in supporting children and young people with mental health needs.

 

3.0       The broader links with the regional commissioning of CAMHS services

 

3.1       The CHNHST delivers services on a regional basis for North Derbyshire, South Yorkshire and Bassetlaw Commissioning Consortium (NORCOM), who have been commissioned to provide a new framework for the specialised Child and Adolescent Mental Health Services (CAMHS) Tier 4 services.

 

4.0       DCSF principles of good practice

 

4.1       The DCSF commissioned the University of Manchester to establish a baseline for excellence in hospital schools. The principles agreed were:

 

 

5.0       The background to Shirle Hill Hospital School

 

5.1             Originally Shirle Hill Hospital School offered educational provision for children who attended the clinic for five days a week often, but not always, as in-patients for a period of up to 6 months.  This resulted in limited contact with their original school, and as such, Shirle Hill School became their main source of educational support.

 

5.2             Shirle Hill Hospital School is maintained and funded via the delegated funding formula, based on 14 full time places for pupils between the ages of 5 and 11.  Historically education has been provided for 46 weeks (230 days) which is 8 weeks (40 days) more than the academic year.

5.3             This model of operation was the rationale for running and maintaining the educational provision at Shirle Hill as a school.

 

5.4             The emphasis in clinical practice has now shifted.  Children remain linked to and supported by their own school to a greater extent, as best practice suggests, throughout the duration of the clinical and therapeutic intervention or assessment.

 

6.0       What educational provision would offer and best fit with the new clinical model?

 

6.1       The new clinical model moves away from the idea that children remain at Shirle Hill for 5 days. From June 2006, pupils have attended for a maximum of 2 days a week and for a period of time that is dependant on whether they are attending for assessment (in which case this could be for up to 6 weeks) or whether they attend for treatment.  The new model is based on an outreach programme and this means that teaching staffs play a greater role on school and home liaison.

 

6.2             A key role for all staff is to actively engage with schools and homes to facilitate a child’s individual reintegration plan, back to their main school.

 

6.3             Annex 2 provides a short report on the referrals made to the service during 2006/07.

 

7.0       The goals for each pupil

 

7.1       The re-integration of each pupil into mainstream education is always the main goal wherever it is a realistic and achievable aim.  Each pupil will be supported on an individual basis and no blanket policies are applied. Some pupils may ultimately require specialist educational provision, ie: educated in a special school.  The assessment and therapeutic intervention will often help to clarify this in conjunction with the advice from other professionals.

8.0       Current cost to the Local Authority

 

8.1             During the last 5 years a total of 100 pupils have been admitted to Shirle Hill.  This number is extremely low as most children stay for assessment purposes, which is for a period of about 6 weeks.  Only a small proportion stay for up to 6 months.

 

8.2             The per place cost, in the Section 52 Statement, is £20,927 based on the provision of 14 FTE places a year.  This is significantly higher than the placement cost at any other maintained special school in Sheffield.

 

8.3       90% of the pupils referred to above attended on a day basis and most came from Sheffield. Other pupils have been drawn from South Yorkshire and north Derbyshire and many of these occupied the beds as in-patients. The school operates on a 46 week a year basis. Occupancy by other Authorities as a proportion has varied over the years from approximately 10% up to 32%. The CYPD recoups education costs from neighbouring Authorities.  The actual level of recoupment varies year to year.  During the last 3 years this has ranged between £55k and £90k.

8.4       The current budget (for the school) alone is shown below:

 

Table 1 - Budget according to the current spending plan

 

9.0       Current staff in post

 

9.1       The number and grades of the current teaching staff is shown below.

 

1 Associate Headteacher (Leadership scale)
1 Acting Deputy Headteacher (Leadership scale) (substantive teacher with 2 SEN points)
3 Teachers (upper pay scale 2 with 2 SEN points) (2 permanent and 1 temporary)

2 Teaching Assistants (1.5 permanent and 0.5 temporary)

0.65 admin staff (special schools clerks allowance)

 

10.0    CYPD Proposals to make educational provision on site match the new clinical model

 

10.1        In response to the new clinical model to maintain high quality educational provision, the CYPD has put in place a review to consider a number of options.  For all options, it is considered essential to maintain a site manager, teaching and support staff on site at the Shirle Hill base.

 

10.2        In considering this, the options would need to look at a number of models of delivery other than a typical school model.  All models would need to consider any additional benefits such as the ability to respond flexibly to meet changing needs.

 

Delegated Special Schools Funding Formula

10.3    All special schools receive delegated budget shares generated by a funding formula.  This formula is based on an agreed number of full time equivalent places.

 

10.4    The agreed principle for determining funding in special schools was that all the different disabilities were equally complex and therefore each school would be funded at the same level per place.

 

10.5    As a result of these funding changes special schools have experienced a re-distribution of funding.  This re-distribution is being phased in over time.  The 2007/08 budgets for Shirle Hill and Oakwood have been safety netted for a period of time at a higher level than would be generated by the new formula. 

 

10.6        Option 1 – Shirle Hill remains as a school offering educational provision to support the clinical model and develops additional outreach services

No change to the existing school makes the education provision a very expensive option as this is a small sized school with only 4 pupils on site at any one time.  A school model requires a Headteacher and Deputy Headteacher structure, which in turn ties resources into a top- heavy management structure.

 

10.7        Such a model would provide a continuity of provision and resources with the option of developing a centre of excellence, providing additional outreach services for mainstream schools. 

10.8However, if the level of service required was to substantially increase or decrease in the future, changes to service provision could only be made subject to statutory approval.  This would limit the ability to offer a timely and responsive educational service.

 

10.9        Option 2 – Shirle Hill merges with Oakwood School and operates as a single school on a split site arrangement

This option would initiate statutory proposals to close Shirle Hill School and make a prescribed alteration to Oakwood School to incorporate additional provision for primary aged children.

 

10.10    Under this arrangement, the leadership and management would be provided by the Headteacher and Governing Body of Oakwood School.  This would ensure that the Hospital School ethos is preserved and would provide a slightly larger school, with greater flexibility and range of staff skills, to offer both the primary and secondary curriculum.  Oakwood School received an excellent OFSTED inspection and has been awarded a Charter Mark.  They have experience and proven track record of working in multi-disciplinary teams and this would also ensure a continuity of links with CAMHS.  This option would also support NORCOM’s aspiration to develop a single site for Hospital Schools.  The manager of the Shirle Hill base would report to the leadership team at Oakwood.  The detail of management time and support that comes with a split site arrangement would be developed in partnership with Oakwood School Headteacher and Governing Body.

 

10.11    Oakwood School would become re-designated as a primary and secondary school with 29 full time equivalent places operating on a split site arrangement.  This would result in the in-ability of Oakwood School to continue to deliver high quality educational service on both sites.  In addition to this, there would be limited ability to offer a timely and responsive service that meets changing demands.  Statutory approval would need to be gained prior to implementing any changes of this nature.

 

 

10.12    Option 3 –The local authority will commission a service to operate from the existing Shirle Hill site.  This service could be managed either as part of the existing Hospital and Home Education Service or as a specialist service managed and delivered from Oakwood Hospital School on behalf of the Authority.

 

10.13    The educational provision would operate on a similar basis to that in a typical education service, such as the Hospital & Home Education Service and, therefore, might be managed in future by an existing Senior Manager.  For example, this could be the Senior Manager, Access and Provision managed and delivered by the Hospital & Home Education Service.  An alternative model would be to commission a service to be managed and delivered by Oakwood Hospital School on behalf of the authority on the existing Shirle Hill site.  Oakwood School received an excellent OFSTED inspection and has been awarded a Charter Mark.  They have experience and proven track record of working in multi-disciplinary teams and this would also ensure a continuity of links with CAMHS.  This option would also support NORCOM’s aspiration to develop a single site for Hospital Schools.

 

10.14  A service model would ensure that the educational element is delivered to children and young people who are accessing provision at the Shirle Hill site.

 

10.15  The service model offers increased flexibility and ability to respond quickly to increased demand or changes to this provision.

 

10.16  The resulting commissioned service would be required to develop an outreach model of support in partnership with other services and providers to support children with identified mental health needs in mainstream settings.

 

10.17  For both considerations, funding at cost would be centrally retained and managed by the local authority in line with all other support services.

 

10.18  A service model means that a range of funding grants would be available to support services for vulnerable children.  No statutory processes would be required to make changes once established but as a matter of good practice the Authority would be required to consult prior to making any substantial changes.

 

 

10.19A notional staffing model for a new service (option 3) could be as follows:

 

 

10.20    Table 2 – The cost of providing a new service (option 3) and net savings

 

10.21It must be noted that this continues to be essential expenditure to meet the statutory educational needs of young children with very complex mental health needs who are in receipt of tier 4 services from the Sheffield Children’s NHS Trust.

 

10.22It is recognised that the cost of the service remains high when consideration is given to the small number of pupils that are being supported on the site whilst they attend the school/clinic for either assessment and/or treatment.  However, it should be noted that currently, there are 10 children on the school roll who are supported via a combination of on-site provision and the outreach model within their local community setting.  This consists of a personalised education package, which is arranged around the individual needs of every child.  A comprehensive transition package is put in place between Shirle Hill and the receiving schools to ensure that the child is appropriately supported.

 

10.23  In addition to this, a further 3 children are currently benefiting from outreach support in schools for 2 sessions a week.  It is anticipated that Shirle Hill will continue to develop the advice and guidance to mainstream schools on meeting the needs of children and young people with complex mental health needs.

 

10.24  Annex 3 provides an outline profile of a ‘typical’ young person who is referred to Shirle Hill.

 

11.0    Financial Implications

 

11.1    When the above notional models are compared to the existing staffing structure currently in place at Shirle Hill there would be no requirement for an Associate Headteacher and Acting Deputy Headteacher roles.

 

Impact

11.2    As a result of the proposed changes the Authority will work in partnership with the Governing Body of Shirle Hill School to minimise any potential redundancies.  Organisational Development will support any redeployment and redundancy processes as appropriate.

 

11.3    The new educational element of the proposed new structure will require a manager, teachers and support staff.  In line with the City Council’s procedures for managing employee reductions, posts established in the new service will be ringfenced to any potentially redundant staff, where there is a match in terms of salary, conditions of service, skills and experience.

 

Cost

11.4    The net saving on the preferred option is £71K  (see section 10.20) – this will benefit the overall Schools Budget and be redistributed to all schools as the saving is achieved. The potential cost of redundancy payments, if this proposal is implemented, will depend on whether any staffs are dismissed and what their individual entitlements are including any transitional arrangements in relation to safetynet or red-circling costs.  These would be the subject of negotiations as appropriate.

 

Timescale

11.5    Due to the Terms of Conditions of Employment in relation to the notice entitlements of current Shirle Hill School staff the earliest redundancy dismissal date, if appropriate, is likely to be the end of December 2008.  The CYPD may therefore decide that the new arrangements will take effect from 1st January 2009.

 

Support

11.6    All staff affected by the proposals will receive advice, guidance and support from both Organisational Development and the Trade Unions.  All processes followed will be in accordance with Employment and Education Law and City Council and School Policies.

 

11.7    Organisational Development will advise the Governing Body of Shirle Hill School in managing any potential redundancy situations and will support any potentially redundant employees.  Organisational Development will try to re-deploy any potentially redundant staff and where that is not possible ensure they receive their minimum entitlements for relevant redundancy pay and pension entitlement in accordance with the law.

 

11.8    Whilst this proposal is being managed Organisational Development along with appropriate CYPD Officers will ensure that there is full meaningful consultation with the staff and their trade unions.  Should this proposal be approved, OD will work with Governors to ensure staff’s appeal rights are managed in accordance with the law.

 

12.0Quality of provision for disabled pupils

 

12.1        The proposals will ensure that the needs of all children are fully recognised and will raise standards of education by:

 

§         Under current legislation the requirement of the Children’s Service Authority to ensure the improved quality of education

§         Improving the quality of the teaching and learning environment for staff and pupils by ensuring these pupils have access to educational provision which will continue to meet their needs

 

13.0    Equality Impact Assessment

 

13.1    The implementation of the LDD Strategy will ensure that children and young people with a disability and/or special educational needs have access to a range of appropriate, high quality and effective educational provision to support their learning, social aspirations and needs.

 

13.2.   These proposals are subject to a full consultation and statutory process and the Authority will work in partnership with the school to develop an agreed communication and consultation framework.

 

13.3    Implementing these proposals will ensure these pupils have access to educational provision which, will continue to meet their identified needs and secure adequate provision under the Education Act 1996.

 

13.4        A pre-requisite of the proposals is that good quality provision is in place.  All proposals will ensure that pupils are not exposed to unnecessary disruption.

 

14.0Broader consultation on the proposed models

 

14.1                        It is important that the proposed models, contained within this options appraisal, should be the subject of broader consultation with all key stakeholders.  This includes schools, governors, staff, parents and other agencies and will ensure that all interested parties views are considered and that they are fully informed and involved during the review process before a recommendation is made.

 

15.0Notional Timetable for consultation and statutory process

 

15.1             A notional timetable for the formal consultation and statutory process is set out in the table below:

 

 

 

17.0    Recommendations

 

17.1    It is recommended that:

 

§         the Interim Executive Director, Children & Young People’s Directorate proceeds with formal consultation with interested parties on the proposal to close Shirle Hill Hospital School and in its place commissions either the Hospital and Home Education Service or Oakwood School to provide a specialist service from the Shirle Hill site.

I:\SEN Strategy\Review of Shirle Hill\options appraisal paper 28 january 2007 final.doc

 

Annex 1

SHEFFIELD CHILDREN’S NHS TRUST

 

CHILD & ADOLESCENT MENTAL HEALTH DIRECTORATE

 

RECONFIGURATION OF SHIRLE HILL CHILDREN’S UNIT : PROPOSED MODEL FOR AN INTENSIVE DAY UNIT & OUTREACH SERVICE

 

 

1.         INTRODUCTION

 

For several years senior clinicians at Shirle Hill and in Tier 3 have emphasised the limitations of the present model of service delivery at Shirle Hill and the need for change.  Tier 4 services are an integral part of overall CAMHS and depend on good communication with multi-agency community services.  A close working relationship between Tier 3 and Tier 4 is key to the provision of an effective Tier 4 service.

 

In January 2004 the recommendations for a change in delivery of service at Shirle Hill were presented to NORCOM.  NORCOM endorsed the day treatment/outreach/one emergency bed model.

 

1.2       Responding to Policy and Strategy

 

In line with the recommendations of the Childrens NSF and the publication “What’s New” the service will contain the following elements:

 

 

This new service also recognises the need to provide an emergency bed for the relatively rare but very ill child.

 

Whilst CAMHS can be expected to address the needs of children with serious mental health problems the associated difficulties which include educational failure, family disruption and anti-social behaviour need a multi-agency approach to be able to achieve good outcomes.  The 2003 document “Every Child Matters” clearly states the need for a multi-agency approach with those children and families with the highest need to achieve high quality service provision.

 

The intensive treatment provided through this proposed service will be delivered therefore, using a day unit/outreach model. It will provide a secure and age appropriate environment with high staff ratios and the availability of a range of therapeutic activities. Similarly to Tier 3 services, this model delivers some interventions in the community. There is, however, a crucial difference: the outreach component will provide intensive assessment and intervention in the family home and at school, at times of day that are relevant for the family and at a frequency that is flexible and appropriate to the case.  This document will outline details of the provision of service and highlight a proposal for leading the changes.

 

2.         THE OUTREACH TEAM

 

The creation of an Outreach Team signifies a major development in Tier 4 services for younger children. A well-resourced team will be able to provide “hands-on” support, therapy and guidance in the home and at school. The aim of outreach will be to “close the gap” between clinic-based Tier 3 support and full day attendance at Shirle Hill. Home visits by the Outreach Team will provide support at crucial times of the day, such as meal times, bed times and preparing for school in the morning. The Outreach Team will also take an active role in helping parents to structure recreation time, and to develop positive relationships within the family. Teaching staff working in the Outreach Team will provide support and consultation to school staff, and will take an active role in helping children integrate into the classroom environment.

 

The team will consist of nurses, members of the multidisciplinary team – who will also work in the Day Unit – and teaching staff. Outreach will be available to the children attending the Day Unit, where appropriate, and to a maximum of 4 children who do not attend the Day Unit.

 

Each child referred to Shirle Hill will receive an assessment from the Outreach team, which will inform the care pathway for the child. This could involve Outreach-only treatment, Outreach treatment with Day Unit treatment, or Day Unit assessment. Alongside the Outreach assessment, a multi-professional meeting will be convened to ascertain the breadth of the network involved with the family and the interventions already offered.

 

2.1       Assessment

 

The Outreach Team will make assessments of children at home, building on information from referrers, but with the added advantage of being able to observe children and families in their home environments, and observe and guide interactions between parents and children. The team will also be able to observe children in school and help in evaluating strategies used by staff in schools.

 

2.2       Treatment

 

Treatment offered by the Outreach Team will consist of support and guidance in managing behaviour in the home; systemic family work with families in the home where practicable; individual interventions for children in the home; support for children in their schools of origin; and case-specific liaison and consultation to school staff.

 

 

3.         THE DAY UNIT

 

The Day Unit will provide assessment and treatment for a maximum total caseload of 16 children up to the age of 12. The total cohort of children will be divided into two age groups – five to eight years and nine to twelve years. Therapeutic activities and treatments developed for the younger age group will be offered on Mondays and Tuesdays, and interventions designed for the older age group will be available on Thursdays and Fridays. Wednesday of each week will be set aside for the weekly Multidisciplinary Clinical Team Meeting, clinical supervision, network meetings and structured parenting training groups.

 

3.1       Structure and Timetable

 

The Day Unit will be able to offer two particular services to children: a comprehensive, time-limited assessment that will generate recommendations for further treatment; and specific therapeutic packages. Children who attend for assessment and those who attend for therapy will follow separate programmes, although there will be times – particularly at the beginning of the day, during break times and at lunchtime – when they will form a single group. A typical day on the Unit will provide individual and group activities for children attending for assessment, plus individual and group treatments for those attending for treatment. This will be achieved by dividing the timetable between the Day Unit and the classroom, and rotating children through each.

 

3.2       Intensive Treatment Programme

 

Specific, “manualised” group interventions such as social skills training, anger management, communication skills training and occupational/creative group work will be provided for those children in the treatment programme, depending on need identified either by a Day Unit assessment or an assessment made by the Outreach Team. The groups will be staffed by a range of disciplines within the multidisciplinary team, but particularly by nursing and Occupational Therapy. One-to-one sessions will form an important part of the programme for most children: this may be in the form of individual time for a child with a nominated member of the team, or therapy with one of the therapists on the team. Family work would also form part of the programme, delivered by members of the MDT.

 

3.3       Assessment

 

Children attending for assessment will be offered a range of activities, both individually and in groups, during which they can be observed and the process of engagement undertaken. Assessment tasks specified in the assessment protocol, such as psychometric testing, occupational therapy assessment, family or social functioning, will be undertaken during a six-week assessment period.

 

3.4       The Role of Education

 

It is envisaged that teaching staff will play a major role in providing structure, containment and educational input for each child attending. Close liaison and co-operation between education and health staff is vitally important in achieving this. Each group of children will spend half of each day in educational pursuits, where their academic ability can be assessed, strategies for maximising learning developed and applied, and functioning within a classroom setting addressed.

 

3.5       Parent training

 

“Manualised” behavioural management training groups will run regularly on Wednesdays. Places in the groups will be offered to parents of children attending the Day Unit, parents of children receiving Outreach from the Tier 4 team, or parents referred to the group by Tier 3 CAMHS or the Pupil Inclusion Service. The groups could be run in the afternoon or evening, and would be staffed by suitably trained members of the Unit multidisciplinary team. There would be scope for including staff from other parts of CAMHS in running the groups. This could be extended to staff from external commissioning areas.

 

3.6       Transport

 

Children attending the Day Unit for assessment or treatment will have transport provided for each day that they attend. In the case of Sheffield children, the Education Authority will continue to provide transport as currently. For children from North Derbyshire, Rotherham and Barnsley, Shirle Hill would provide transport and suitable escorts. As the cost of this is highly variable, depending upon the numbers of children attending from each area and the number of taxis required to service the cohort at any one time, it is not easy to plan transport much in advance, or forecast accurate costs. However, costs from 2004-2005 indicate that around £19k was spent on transport on top of that provided by the LEA.

 

4.         SKILLS AND STAFFING

 

The skills required to operate the service are:

 

Groupwork

Mental health assessment

Behaviour management training for parents

Physical and emotional containment of children

Systemic family work

Non-directive individual work with children

Cognitive assessment

Education liaison

Structured individual work with children

Social skills training

Functional assessment of children

Teaching

Multiagency liaison

Prescribing

Case co-ordination/case management

 

The management of the entire nursing cohort will be overseen by a G grade or equivalent Unit Manager.

 

The Day Unit staff and the Outreach Team will each consist of a core team of 5 nurses:

 

1 x F grade or equivalent team leader

2 x E grade or equivalent senior staff nurses

1 x B grade or equivalent senior health care support worker

 

There will be some rotation between the two nursing teams over the course of time, in order to provide development opportunities. However, both teams will be regarded as discrete entities, and boundaries will be maintained between the Day Unit nursing team and the Outreach nursing team.

 

Other members of the multidisciplinary team will be members of both the Day Unit team and the Outreach team, providing hands-on clinical work, consultation and supervision:

 

 

Note:  Under Agenda for Change grades will become Bands, however, as this has not yet been completed for Shirle Hill the grading system has been used.  It is anticipated the Agenda for Change exercise will be completed shortly.

 

The multidisciplinary team would provide the skills listed above in the form of the following disciplines:

 

Psychiatry

Psychology

Creative Therapies

Occupational Therapy

Psychotherapy

Family Therapy

Social Work

Teaching

 

5.         REFERRAL & ACCESS

 

It is expected that the present criteria for referral in terms of age and functional level will remain unchanged.  Referrals will be accepted (as now) from experienced clinicians in the Community CAMHS Teams from Sheffield and neighbouring districts with the endorsement of the Team Leader.  In addition referrals will be accepted from the head of the Sheffield Primary Inclusion Service.  In the future it is hoped that the service will be able to respond rapidly to appropriate cases causing concern to social services, but it will be important to involve the Community Teams fully in any new arrangements so as not to distort the usual stepped care approach.

 

5.1       Assessment

 

Following referral an assessment of suitability will be made by members of the Outreach Team.  A judgement will be made having considered the following criteria:

 

 

 

 

 

 

Currently the average interval between referral and day patient admission (i.e. including assessment and time on waiting list) is 12 weeks.  It is anticipated that a substantial intervention will be offered significantly sooner in future because a broader range of approaches will be available and the bottleneck of peer mix in a unitary day programme will be improved.

 

Following assessment and negotiation with the family, referrer and other involved parties the family will be allocated to a programme of intensive outreach, day patient assessment or a specific day patient treatment programme.  As the situation evolves, this initial decision can be revised, so that for example if the child’s dependency increases, day patient assessment can be added to outreach, or following day patient assessment the family can move to a specific treatment programme.

 

 

6.         AUDIT & EVALUATION

 

As the new service is implemented Audit and Evaluation, in particular that envisaged by CORC, will be considered and incorporated into service delivery as appropriate.

 

7.         USER/CARER INVOLVEMENT

 

The new service specification should be discussed with users and carers.  Discussions will take place with the Trust to the development of a suitable process (focus group, use of groups already available, consultation by letter for example) for consultation with users and carers.

 

Consideration will be given to the feasibility of a carer being part of the implementation process.

 

8.         EDUCATION

 

A major component of the service will be an educational provision which will provide input and continuity for the children to ensure their educational needs are identified and met.  This service will be provided both in the day unit and on an outreach basis to enable close working with the child’s school the aim being to keep the child in their mainstream school where possible or to move them into appropriate educational provision as soon as possible.

 

9.         IMPLEMENTATION

 

The development of the new service will be led by a project steering group.  A project lead will be appointed.

 

Membership of this group will include:

 

 

The key tasks to take this initiative forward will be identified and timescales and lead person for completion of each task will be stated.

 

It is envisaged that the “old” Shirle Hill will close for a short period (possibly 4 weeks) and during that time training and development will be started for members of the team.

 

After this training period the “new” Shirle Hill will be officially opened.  This is a wonderful and exciting opportunity for those involved with children in Tier 4 services to provide high quality interventions for children with severe/complex psychiatric disorders and their families.

 

 

 

G:\EDU\A-I\Secretariate\SEN Strategy\supporting pupils with medical needs\options paper 2.doc

 

 

Annex 2

 

SHIRLE HILL REPORT

 

Following a period of consultation in late 2005 and early 2006, Shirle Hill Hospital and School closed briefly in May 2006 to complete an internal reorganisation.  The goals included: to increase the number and range of children that the service could help, to reduce waiting times, to broaden the skill mix of the team, to increase our focus on family and school based interventions and to increase the flexibility of the day patient programme.  The unit re-opened in late May with a dedicated outreach resource, a revised day patient programme, without beds and with funding identified for family therapy sessions, all within the team’s existing budget.

 

The first year of the new service has been challenging but positive.  Initial ambivalence about the project among some staff, recruitment difficulties, accommodating the CIP imposed on the Trust and working through the detailed implementation of new practices while maintaining a clinical service our all now nearly resolved.  Some staff have had to adapt and grow into new roles. 

 

Progress

 

The team has experienced a 50% increase in referrals during 06/07 compared with the previous several years (see graph 1).

 

It is difficult to equate waiting times for the new service directly with the previous model because of changes in both clinical practice and data collection but preliminary results indicate strongly that substantive clinical care is beginning earlier than formerly.

 

We have been able to offer a broader range of care packages than was possible previously and this has been valued by referrers, who are beginning to specify what elements they feel would be most helpful for individual cases.  For example, of 18 cases referred to the service during the first six months of the financial year 6 were allocated to an outreach only approach which would not have been possible before the reconfiguration.  The family would have been offered day patient attendance for the child with less family involvement, or nothing.

 

Some referrers had expressed anxiety about the closure of the beds.  While it is inevitable that there will be the very occasional child for whom a residential approach is the treatment of choice, a procedure established for the short term use of a paediatric bed in such circumstances has not been called upon.

 

 

 

 

 

Challenges

 

Teaching staff remain in a difficult and uncertain position.  They have participated enthusiastically in developing a new service and are now working in new ways but the question of how the teaching resource will be managed has not been finalised. 

 

While the increase in referrals is very welcome and a sign that the team is meeting referrer’s needs more fully than before, if the referral rate increases progressively, we shall need to become more active in managing demand (see graph 2 which shows referrals month by month for the year 06/07).

 

For out of Sheffield children, providing transport remains problematic and we need to continue monitoring this. 

 

For about half of the year the team has carried nursing and psychology staff vacancies due to recruitment difficulties in this niche clinical area.  The strain has been felt most in the outreach  part of the service, which has therefore developed somewhat more slowly than we would have liked. 

 

Although family therapy is now provided on a temporary part time basis the most appropriate long term arrangement has not yet been decided. 

 

Next Steps

 

In the short term it is hoped to introduce group approaches for parents (initially Webster Stratton Groups which have a good evidence base and are very applicable to a large proportion of families seen in this service).

 

The outreach workers hope to develop more standardised packages of care for certain commonly encountered situations. 

 

 

 

 

 

 

 

 

 

 

SRH/fjs

20th April 2007

 

 

 

 

 

Annex 3

 

Pupil A D.O.B 29/03/96

 

 

Referred CAMHS North team July 2006

Outreach/assessment and treatment only - 4 months

Admitted to Shirle Hill- treatment Package - further 11 months -2 days per week.

 

 

·  Obsessive compulsive type behaviours began to be problematic in October 2005.

·  These escalated dramatically and Child A was reported to be obsessed with tidiness and cleanliness, mother reported that these behaviours had become extensive and highly repetitive.

·  The families were under considerable strain as Child A tried to control the home environment refusing to let his younger sister play because of the mess and getting up in the middle of the night to tidy the house. His mother suffered depression during this period and was put on anti- depressants.

·  Child A had been subjected to an unprovoked physical attack in 2004 and this may have contributed to these difficulties.

·  At the time of the attack Child A was living in a very unstable home environment with his mother suffering from post natal depression and his father absent from the home most of the time.

·   Parents have continued to separate regularly but reconcile for short periods this has an impact on Child A’s emotional development.

·  The family were being seen by Tier 3 CAMHS and a referral was made to Shirle Hill for a Multi professional assessment and treatment package.

·  Shirle Hill outreach team were supporting Child A in school as part of the Outreach package two mornings per week and providing multi professional advice on strategies to manage a child with this condition.

·  During the outreach assessment period Child A struggled to manage his own anxieties around his OCD behaviours and was excluded for a week from Hinde House School Primary Phase for assaulting three teachers who tried to stop him completing his rituals

·  Child A was assessed by the outreach team at Shirle Hill and initially a treatment package was instigated as a series of home visits.

·  Child A was assessed as needing further treatment and was admitted to Shirle Hill in January 07.

·  School staff liaised with Hinde House School at  transition  and a reduced timetable in the LSU was supported by teachers at Shirle Hill working two mornings a week throughout Child A’s admission period at Shirle Hill.

· Family work was identified as essential to work through wider systemic issues within the family, and this was instigated through out the admission treatment period at Shirle Hill.

· Cognitive Behavioural Therapy was instigated at Shirle Hill to help Child A manage his OCD in the home environment and help him to use these strategies within the school setting.

· During admission at Shirle Hill Child A was observed experiencing facial tics and frequently using swear words. His behaviour became more difficult with the verbal attacks increasing.

· He was assessed for Tourettes but it was felt that the swearing and facial tics were a continuum of the OCD symptoms. He was still showing OCD symptoms at home, changing his clothes ten times during the day and night. This was reported to be better controlled whilst at school.

· Child A was put on medication to help control OCD symptoms.

· Child A presented in Shirle Hill School as over familiar, domineering and anxious to control the environment and activities. Vocally he shouted most of the time and his outbursts were almost explosive. He had a negative impact on the other children within the group encouraging poor behaviour. There was a notable improvement in these behaviours during his admission period.

· During the school summer holidays Child A was a victim of a sexual attack by a stranger in a local park. This had a very damaging effect on his progress.

· In the latter stages of his admission at Shirle Hill his educational placement at Hinde House was further reduced because of his increased anxiety about moving to Oakwood.

· A formal statement of Educational Needs was requested by Hinde House School July 2007.

· Child A was transferred to Oakwood YPC at the Northern General Hospital in November 07. This is to complete his ongoing CBT therapy and for the Educational Advice to be completed.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pupil B  dob 5.9.98.                                                      

 

 

Referred April; 2007 by CAMHS West team.

Outreach assessment/treatments   8 months ongoing

 

 

·       Adopted child – oldest of 2 boys ( 8 and 9 years) – been with adoptive parents since he was 3 ½  years.  Removed from both parents for neglect, physical abuse, emotional abuse and serious sexual abuse. 

·       Referred to CAMHS 2004.  Presenting as very anxious child, anxious in unfamiliar situations easly upset by minor incidents, experiencing night terrors. A vulnerable child with trauma-related attachment disorder.

·       Child B always experiences difficulties in school relating to anxiety , insecurity, possible learning difficulties or delay.

·       Prior to referral to Shirle Hill child B not wanting to attend school – parents find it increasingly difficult to support him to attend school.  PIC service became involved but as they did not have a relationship with the child and were unable to be of assistance.

·       The fact that he was now at home put increased pressure on the family relationships.

·       Initial 6/7 week outreach assessment including home visits, contact with school, meeting referrer.

·       The outreach treatment phase began with initial family with 2 CPN each week then became fortnightly with family therapist – (this is still ongoing)

·       Submission MPA – May 2007.

·       Problems containing child B in mainstream classroom continued.

·       Supported in mainstream school 2 mornings a week by teacher one morning, CPN another.   During this time staff received advice on managing the child’s behaviour, strategies that could be used in class and supplying information about working with traumatised children.

·       Statement issued Sept 2007 – offering 10 hrs support in mainstream.

·       School reassured that it was ok for the child to be in school feeling secure and comfortable but not necessarily making academic progress.

·       Psychotherapy assessment once per week began 21 Sept. – normally 3 sessions with child – child B unwilling to remain with therapist without other parent present therefore time scale extended.

·       needing increased  .

·       October – interim review of statement – child B began attending Shirle Hill

       ‘ inreach‘      1 morning per week and continued 1 morning support of child

      in school by teacher.

·       Mid Nov statement amended to provide 15 hrs support for child B in mainstream school

 

 

 

 

·               ‘Inreach’ at Shirle Hill – child B initially very cautious, unsure about Mum leaving but gradually became more relaxed and able to work with other adults than the teacher who worked with him in his mainstream school.  Seeing child B in the ‘inreach’ setting gives Shirle Hill teaching staff the opportunity to understand his strengths and weaknesses and therefore provide more guidance to mainstream school on developing his learning potential.

·               Case review in the New Year to plan how and when return case to Tier 3.

 

 

 

 

 

 

 

 

 

 

[1] NORCOM  - North Derbyshire, South Yorkshire, and Bassetlaw commissioning Consortium