Trafford School Nursing Service Review

Transcription

1 Trafford School Nursing Service Review Authors: Andy Howard and Rebecca Fletcher, Integrated Commissioning Unit (ICU) Version control: 1.0 final Date: 25 th March 2013 Trafford Children and Young People s Service brings together council and health services to improve outcomes for children, young people, their families and schools.

2 Contents 1. Scope and Background Methodology Overview Project Advisory Board Data Gathering Information Gathering from experts Current Population and Service School Population (Reception to year 11) Out of Borough Pupils attending Trafford Schools Schools in Trafford School Nursing Workforce Core Programme Latest Guidance Findings Eligibility and population Capacity and resource Records and systems Community and Universal Universal Plus Universal Partnership Plus Recommendations Appendices: Findings from Qualitative Information Gathering with Professionals Findings from Work with Children and Young People Findings from Qualitative Work with Parents Quantitative Service and Population Data

3 1. Scope and Background The review of the Trafford School Nursing Service was carried out internally with Trafford CYPS, led by the Integrated Commissioning Unit (ICU) and supported by health colleagues. The aims of the review were: To undertake a timely review (July 2012 to March 2013) of the School Nursing Service in order to ensure that it can effectively deliver services that meet the changing health and wellbeing needs of Trafford s school age population and to maximise its contribution to improved outcomes; To inform the development / amendments to the commissioning service specification for 2013/14; To support the service with transitional arrangements so that it can deliver against the specification and the requirements within Getting it right for children, young people 1 ; To ensure that the Healthy Child Programme is effectively delivered locally; and To ensure that children, young people and their families are involved in the review and redesign of the service. The key deliverables of the review were: To produce a clear set of outcomes, aims and objectives for the service; and To produce an updated service specification that includes locally relevant key performance indicators. The outcomes for the review were: A service that is fit for purpose; More efficient and effective use of resources, expertise and highly developed skills; Improved outcomes for children, young people and their families; Engagement of a wide range of stakeholders; and Effective delivery of the Healthy Child Programme The School Nursing Service and the Special School Nursing Service were both included in the review. 1 Department of Health (2012) Getting it right for children, young people and families: Maximising the contribution of the school nursing team: Vision and Call to Action (p. 16 and 17) 2 Department of Health (2009) Healthy Child Programme from 5-19 years 3

4 2. Methodology The review aimed to ensure engagement and involvement from all interested stakeholders. This was achieved via involving professionals, children, young people and families in a variety of different ways Overview It was run on a project management structure and a Project Executive Board took day to day responsibility for the completion of tasks. This was made up of: Andy Howard (Commissioning Manager) Jan Trainor (Head of Service) Mark Bailey (Participation and Engagement) Rebecca Fletcher (Commissioning Officer) Project Manager 2.2. Project Advisory Board In order to ensure wider engagement and ownership of the review, a Project Advisory Board was established with a wide variety of stakeholders engaged. Two meetings were held to guide the review and to gather information from these stakeholders. Membership included: Children s Community Nursing Team (CCNT) Advocacy and Participation Young Person representative Safeguarding Public Health Commissioning Children in Care School Nursing Service (Various Bands) Child and Adolescent Mental Health Service (CAMHS) Education Welfare Connexions Schools Educational Psychology Health Visiting Social Care 2.3. Data Gathering Information was gathered from national and local sources to fully evaluate what the population to be served by the School Nursing Service was, what the needs were and what the current service activity was. This included information from: Census School population School Nursing Service database Time and motion data from school nursing staff (two weeks of information) Statements of Special Educational Needs (SEN) 2.4. Information Gathering from experts Information was also gathered from a range of stakeholders via the following methods. On-line questionnaires Thirteen school nurses completed an on-line questionnaire 4

5 Twelve professionals that work with school nurses completed an on-line questionnaire Eight schools completed an on-line questionnaire On-line questionnaire for parents Face to face work School councils attended by Mark Bailey Youth cabinet work Meetings of school heads attended to engage schools Project Advisory Board meetings Task and finish group work regarding the Special School Nursing Service 5

6 3. Current Population and Service This section details the population that are eligible for a service from the School Nursing Service School Population (Reception to year 11) The School Nursing Service currently provides to all pupils in Trafford schools from reception to year 11. The core service covers all the reception to year 11 pupils in Manor High, Egerton, Longford Park and the Pupil Referral Units, as well as all mainstream Trafford schools. This is a total of 32,665 pupils. This does not include independent schools in Trafford. Please see section 5 for more detail on independent school pupils. The special school element of the service covers the pupils at Pictor, Brentwood and Delamere schools. This is a total of 193 pupils School Year Schools Number of pupils Primary Infants 1317 Junior 1668 Mainstream Primary Total Secondary 8722 Grammar 5580 Mainstream Secondary Total Pupil Referral Unit 70 Pictor, Brentwood, and Delamere 193 Egerton, Manor, and Longford 219 Special School Total 482 Total Pupils in Trafford Schools The school population has grown since 2008 and is forecast to continue to do so. In 2012/13 there were more than two thousand more pupils than there were in 2007/08, and by 2016/17 it is forecasted that there will be four thousand more pupils than there were in 2007/08. The table below does not include pupils attending Trafford special schools Forecast Forecast Forecast Forecast Primary Secondary th Form Total Increase from /08 6

7 Mainstream School Population: actual (2007/ /13) and forecast (2013/ /17) Primary Secondary 6th Form Out of Borough Pupils attending Trafford Schools Between reception and year 11 at Trafford schools there were 3818 pupils who were from outside of Trafford. This makes up 11% of the population that the School Nursing Service covers. Out of Borough Pupils Reception 137 Year Year Year Year Year Year Primary Total 1068 Year Year Year Year Year Secondary Total 2750 Primary and 3818 Secondary Total Year Year Sixth Form Total 514 Total

8 3.3. Schools in Trafford The tables below describe the schools in Trafford. The Trafford School Nursing Service is provided in all these schools and covers all of their pupils (up to year 11). Primary Age Schools Type of Primary Church of Non- Catholic School England Religious Grand Total Infants Junior Primary Special Grand Total Secondary Age Schools Type of Secondary Grand Boys Girls Mixed School Total Grammar Total Catholic Non-Religious PRU Total Secondary Total Catholic Non-Religious Special Total Grand Total School Nursing Workforce The current core School Nursing Service is made up of: Two (1.66 WTE) team leaders, senior practitioner level Eleven (7.1 WTE) senior nurses Seven (3.95 WTE) staff nurses Seven (5.25 WTE) support workers 1.2 WTE clerical support The average school nurse in Trafford has two or three secondary schools and seven primary schools to support. The Royal College of Nursing best practice advice suggests one secondary and three primary schools to be managed by a team including a school nurse 3. The core School Nursing Service is based within the three CYPS Area Family Support Teams that contain a multiagency workforce. They are professionally managed via the Health Operational Managers and Jan Trainor, Head of Service North (Professional Lead for Health). 3 Royal College of Nursing (2005) School Nurses: Results from a census survey of RCN school nurses in

9 The Special School Nursing Service has three members of staff and is managed via the Children s Community Nursing Team, within the CYPS Complex and Additional Needs (CAN) Service Core Programme Throughout School A health questionnaire to parents / carers of all children moving into the Trafford school system for the first time during any academic year. Primary Reception Handover from the Health Visiting Service for children commencing school A health questionnaire to parents / carers of all children starting reception A hand washing lesson to all reception aged children Height and weight (National Child Measurement Programme) and hearing screening of all reception children (with parental consent) Year 6 National Child Measurement Programme for year 6 pupils (without parental opt out) Secondary All years A drop in service is provided in all secondary schools Year 7 A health questionnaire to parents / carers of all children starting secondary school Assembly / classroom lesson to all year 7 pupils to introduce school nursing team Year 8 HPV (Cervical Cancer) immunisations for year 8 girls Year 10 School leaver booster immunisations (plus MMR - Measles Mumps and Rubella if needed) for year 10 pupils 9

10 4. Latest Guidance The Department of Health (DH) publication in March 2012 of Getting it right for children, young people and families: Maximising the contribution of the school nursing team sets out a new vision and model for the profession. It is a framework to assist the delivery of the Healthy Child Programme 5 19 and to help local areas to shape their services. The framework is based in; The Healthy Child Programme 5-19; Public Health Outcomes Framework, and the recommendations of the Children s and Young People s Health Outcomes Strategy; and Quality improvements through the standards as set out in You re Welcome and from service users views on what good would look like. The new school nursing model is based on the following four tier framework with safeguarding as a key element running across all four tiers. Your Community describes a range of health services (including General Practitioner and community services) for children and young people and their families. School nurses will be involved in developing and providing these and making sure you know about them. Universal Services from your school nurse team provides the Healthy Child Programme to ensure a healthy start for every child. This includes promoting good health, for example through education and health checks, protecting health e.g. by immunisations and identifying problems early. Universal Plus provides a swift response from your school nurse service when you need specific expert help which might be identified through a health check or through providing accessible services where you can go with concerns. This could include managing long-term health issues and additional health needs, reassurance about a health worry, advice on sexual health, and support for emotional and mental health wellbeing. Universal Partnership Plus delivers on-going support by your school nursing team as part of a range of local services working together and with you/your family to deal with more complex problems over a longer period of time. 10

11 5. Findings This section provides a brief overview of the main findings. For more detailed information please go to the appendices. There are six key emerging themes from the review. They are: 5.1. Eligibility and population Within eligibility and population there were the following key issues affecting the School Nursing Service: The lack of service for 16 to 19 year olds, this will be an increasing issue with the change in the rules around staying in education or training until 18 The level of service for those pupils attending independent schools Electively home educated pupils The rising school population in Trafford 5.2. Capacity and resource The key issue for all respondents from the information gathering was the lack of capacity within the service. The review indicates that the service is able to fulfil its core offer to all schools but that the wider public health role, and the new government model would be a significant challenge with the current staffing levels. The School Nursing Service is small in terms of numbers and most staff are on term-time only contracts. There are also relatively few school nurses who have completed their specialist training. Information gathering indicates that there is good practice within the School Nursing Service across the board but that all respondents felt that the lack of capacity means that support at lower tiers is sometimes unable to be provided due to a lack of time and resource Records and systems Overwhelmingly, it was reported that the lack of electronic records is a barrier to effective and safe practice. Concerns regarding the reliance on paper records included: The amount of time spent transporting, and accessing records The storage of paper records and accessibility of this storage In addition to the concern regarding records, there is also a need for clear agreement for confidential spaces in schools for the school nurse to work. Children, young people and professionals all considered this to be an essential for effective school nursing practice. In terms of the systems, it was also clear that communication systems need to be clearer, with schools, children and families not always being clear about what service children and young people could expect Community and Universal At these levels the focus is on supporting and providing public health messages for the whole community and eligible population. The review found that in Trafford this level of service is highly appreciated and that there are some areas of good practice, in particular at the Universal level but this provision is compromised due to the limited resources of the service. Support for other services, and Universal level services are sometimes 11

12 unable to be provided due to higher level provision, in particular that at Universal Partnership Plus Universal Plus The information gathering showed that the School Nursing Service is providing targeted support to children and young people and that this is often felt to be of excellent practice and value. There is a demand for more targeted interventions for certain conditions in particular asthma and other long term conditions, as well as emotional health issues. This appears to be limited due to capacity or service structure. School nurses are an important resource for targeted interventions across the health priorities for children and young people. Targeted work is already being done on emotional health, obesity, and smoking amongst others but there appears to be a demand for greater work on these issues which are all key public health outcomes for children and young people Universal Partnership Plus The feedback and findings in this area were excellent and indicate that the School Nursing Service works well at this tier. There are increasing numbers and complexity of high tier safeguarding demands though and this is felt to take up a large proportion of the time of the School Nursing Service. Due to the risks at this level, this work is often prioritised leading to a reduction in provision at lower tiers. Case conferences, and review meetings for high tier safeguarding cases were of specific concern due to the length of time these take. It is worth noting that the input that the School Nursing Service carry out at this level was reported to be of excellent practice with few or no gaps. The concern here is related to managing the demand and workload at this tier. 12

13 6. Recommendations Stemming from the review and its key findings / themes, a number of recommendations are set out below. The school nursing service should 1. Support children and young people across all tiers of need according to the School Nursing Model. Regular monitoring of community and universal level provision is needed to ensure effective public health messages are delivered across the full population; 2. Develop a clear communication strategy to raise the profile of the service and to publicise public health messages to children, young people, schools and other services. The strategy should focus on existing communication routes and methods to ensure effectiveness and efficiency, including the Family Information Service and Schools, as well as developing greater use of and text; 3. Benchmark the service against the You re Welcome quality criteria and address any gaps identified including accessibility and confidentiality; 4. Meet the commitments outlined in the school nursing charter that has been developed with the Trafford youth cabinet; 5. Develop opportunities to work jointly with and signpost to and from other services, in particular children s centres, health visiting, holiday clubs, and the youth service; whilst preventing overlap or duplication; The commissioner and school nursing service should 1. Work together with Pennine Care NHS Foundation Trust (as the host provider organisation from 1/4/13) to ensure that the recommendations of the review are translated in a transitional action plan; 2. Work proactively with safeguarding colleagues to review and monitor the involvement of school nurses in the safeguarding process including conference attendance and report writing; 3. Engage with independent schools based within the borough of Trafford, to map their current nursing support and consider developing a school nursing offer for this population; 4. Work with schools, colleges and other services to ensure that the Healthy Child Programme (HCP) is delivered to young people that are in full time education in Trafford up to the age of 19; 5. Develop a clear business plan to address workforce issues, focusing on term time only working, specialist qualified staff, and the skill mix across the service; 6. Develop clear pathways for children with long term conditions and complex and additional needs in collaboration with the Children s Community Nursing Team (CCNT); 13

14 7. Develop a business case for moving the School Nursing Records onto an electronic records system, making clear the software and hardware needs of the service; 8. Consider a more flexible approach to the transition from Health Visiting to School Nursing to more effectively meet the needs of children and their families and deliver the Healthy Child Programme; 9. Engage with the implementation of the emotional health and wellbeing review to better meet the needs of children and young people; 10. Identify how the nursing skills in the special school nursing service could better support children and young people in other special or mainstream provision with nursing needs and long term conditions; 11. Work with schools to outline opportunities for them to commission additional provision to meet the needs of their pupil; and The commissioner should 1. Review the current level of investment against the model and core offer going forward to ensure that there is an equitable level of resource to deliver the revised specification. This review would be informed by a benchmarking of regional capacity and analysis of trends and trajectories in the school age population in Trafford schools. 14

15 7. Appendices: The detailed findings from each section of the review are provided below Findings from Qualitative Information Gathering with Professionals We gathered information from school nurses, schools and other professionals regarding what the good practice, gaps and priorities should be for the School Nursing Service. a. Responses Schools Eight responses: 4 primary schools 3 secondary age schools 1 further education college Other Professionals Twelve responses: General Practitioner Youth Service Children s Centres Safeguarding (two) Health Visitor Liaison School Nurses Thirteen responses: 9 band 6/7 2 band 5 2 band 2/3/4 Social Workers (2) CAN Service (Health) Education Support Children s Community Nursing Team (2) b. Aims and objectives of the service The quotes below lay out what the respondents felt should be the overall aims and objectives for the service. They serve as a way of defining what the service should be looking to achieve overall. The School Nursing Service should be delivering the core programme in line with the Healthy Child programme (5-19). They should also be assessing the needs of their school populations and using a needs led approach to determine what else they should be doing. (School Nurse) Should be offering a great service as identified in Healthy Child Programme - with close links to school and families - a service that people know about and can access that is welcoming to all, a service that meets the health needs of each school population (School Nurse) A more accessible year round service to the children and young people of Trafford (School Nurse) In summary: A service which does not virtually close down at holiday times A service which is available to 16 and 17 yr. olds A service which understands fully their responsibilities to safeguard and promote the welfare of children in the context of the service being more demand led rather than resource led A service which responds to the needs of children and young people - not schools!" (Other Professional) 15

16 c. Overall service Good practice The service that this school has had over the last 2 years is absolutely brilliant. I cannot heap enough praise on the professionalism of all concerned and the never ending support that we receive. (School) Our school nurses are fantastic and are an important source of support for our school supplying us with important health information and training. (School) I find school nurses to be approachable and always respond to any communications made Clearly school nurses ensure the health of each child/young person is of upmost importance, however education can make the role of a school nurse a difficult one to manage. Leadership skills shine through with the school nurses I have worked with in Trafford." (Other Professional) They should be offering a service that students can access. A service that provides support and advice for students. A service that works with the school to improve/provide pastoral care for all students. The barriers are obviously time/resources/money as the service that we have is 'superb' and vital and my only complaint is that we do not get enough time for our needs but I know we get the maximum that Trafford can provide given time and resources. (School) From my experience the school nursing service in Trafford (including support staff, nurses, team leaders and ops manager) are highly approachable, work extremely hard, and always strive to deliver an excellent service to children and families to meet children s health needs. I hope this review will address some of the barriers regarding school nurses, provide clarity to their service and support them in continuing to meet the health needs of Trafford s children (Other Professional) Our school nurse is fantastic and is always quick to get back to us with any information and advise we have requested on a variety of issues. She regularly attends important meetings to discuss provision for pupils with special needs. (School) As far as this school is concerned we do not have any gaps in service but would just like more time. (School) Our school nursing staff are excellent at this [safeguarding]! (School) Gaps and issues for the overall service Eligibility and gaps in coverage Children attending independent schools I have always thought that private schools should be included in our core programme as at the end of the day all children who should be offered the service. (School Nurse) 16 and 17 year olds I think that overall the SN service is offering a good service to Trafford children but the service needs extending to include young people at least up to 18 years. In particular now that compulsory education exceeds 16 years (Other Professional) 16

17 Some concerns regarding any extension of the service coverage I am aware that there is a gap in service for older students provision, which there is talk of adding to the school nurse workload. I feel it is vital that we are clear as to what is being delivered for students in the younger age bracket and ensure it is being done properly before stretching the service even further in catering for the older students. (School) Promotion of the service The service needs to be promoted to children, young people, parents, schools, and other professionals to ensure that the service is recognised and utilised by all. There is still felt to be a lack of knowledge about the service. The role of the school nurse is one that should be highly recognised as the service they provide is invaluable to the children/young people and their families within Trafford schools. Many young people still unaware of school nursing service and purpose The services which are offered should be promoted to other healthcare professionals to raise awareness of the services which are available to children and their families I often don t know how to signpost parents and children to the service Lack of resources The majority of responses from school nurses, and other professionals referenced the large caseloads, lack of resources and time We have no time as the core programme and school numbers and safeguarding have all increased yet our numbers have gone down. (School Nurse) Concern regarding the impact of the lack of resources on morale Technology Lack of electronic records School nurse records are not co located with the school nurses so there is a difficulty for school nurses in making assessments of a child s level of need when they receive information re a child i.e. a domestic abuse notification following DV protocol or receipt of an A&E or hospital attendance. (School Nurse) The school nurse records not being co-located are a real issue which needs addressing as from a safeguarding perspective serious case reviews always highlight the importance of reviewing histories, chronologies of significant events. An electronic solution would be ideal. (Other Professional) Not currently using or making best use of latest technology within the service such as text or to contact children, young people or parents Resources within schools Difficulties do arise with schools having no areas where a school nurse may work. This can sometimes delay when a child is seen. As school health no longer visit each school on a certain day / time (due to caseload and staffing levels) some schools find it difficult to accommodate the school nurse or provide an adequate room to work in. Workforce Qualified staff School nurses also need [to be] supported in becoming specialist practitioners at band 6 level in order to have the skills to provide a service at this level (Other Professional) Term time only staff 17

18 Due to lack of funding the majority of school nurses only have term time contracts. This therefore reduces the amount of time and availability of these skilled professionals. E.g. outside of school hours and weekends (School Nurse) Skill mix and diversity No male school nurses and a lack of multi ethnic backgrounds, especially in the North Area. (School Nurse) Skill mix and staffing levels should be closely looked at to ensure staff are not overstretched and are therefore able to fulfil their role successfully. (Other Professional) Multiagency cooperation Lead contact for other professionals I think the school nurse should probably be the key contact for a GP who has concerns about the welfare of a school age child. The school nurse might be the professional to organise the CAF process. The barrier is that GPs and school nurses do not know each other or how to make contact. (Other Professional) Increase capacity by working with other professionals in a smarter way There is an opportunity in my opinion to increase joint working and skill mix with the health visiting teams so the transition and family centred approach is extended in the primary years with school nurse expertise being used for vulnerable children and secondary school children (Other Professionals) 18

19 d. Community provision Good practice Community Clinics Change for Life Group Immunisation Nurse providing a clinic at a Children s Centre Sexual Health Clinic in Lostock Joint Working Parenting courses and drop-in sessions delivered in collaboration with senior family practitioner. Health promotion day during the summer holidays in a local park in collaboration with the youth service. Men s health sessions in collaboration with the youth service. In partnership with Sports Trafford and Trafford Council school nursing is delivering a family weight management programme Some developing work on parenting programmes (limited). Recently commenced a group with the Youth Service called 'Step up to the Plate'. This programme is aimed at improving young people s confidence and self-esteem, includes nutrition and fitness levels. I am currently involved in the young persons health clinic at Lostock, working with outreach workers/youth service and street based teams. This allows us to work in multiagency teams sharing good practice as well as utilising skills/knowledge. We are also able to access training courses that we previously would not have known about/not been able to access. For at least 5 years now, I have been involved in an annual healthy eating "stall" at Lostock Community Partnership fun Day. This involves giving children & any other family members the opportunity to try a small piece of a variety of fruit & vegetables, from the regular day to day types to the exotic. This allows them to try a small amount of the produce without the expense. I encourage them to challenge pre-conceived ideas about some foods. Gaps and issues for Community provision Specific additional services Many areas needing change for life groups, more sexual health clinics, lack of parenting support for families, stress management, advice/emotional health and wellbeing particularly for young people, quit smoking support, alcohol/drugs advice. No drop-in service or clinics outside of school settings Not enough support for overweight children under the age of 7, in particular family orientated groups, e.g. MEND Could provide drop ins in youth service settings More local young people s health clinics/ drop -in centres staffed by professionals equipped with communicating with young people instead of them having to access GP surgeries/adult clinics. These could be multiagency as at the Talk shop in Sale Lack of sexual health services in the west of the borough Need for wider health promotion in the community but not enough resources 19

20 Support for children to reduce referrals to CCNT including continence support Lack of resources, staffing and time Public health and community work given less priority that high tier safeguarding There is a lack of suitable accommodation where school nurses can be available to young people outside of the school setting. It is clear from the literature that young people do not want to attend local clinics. Maybe school nurses have a place within Leisure centres where young people access. Improve links with other services Even though work is being delivered with school nurses and the youth service, I feel there is still a gap within health and youth workers. For example school nurses and youth workers should be working more in schools together, I think youth service and health visitors could be working together more with teenage parents in all areas. Contact information of school nurse for local schools should be in Children s Centres and other services to help support families Better links with nursery nurses and holiday clubs 20

21 e. Universal provision Good practice All school nurses provide the same core package to all children and young people regardless of school Programme of work has been put in place to make sure School Nurses from all areas deliver the same 'package' to every school. i.e. hand washing, puberty education, health screening etc. Support the delivery of the Healthy Child Programme Guidance for electively home educated children to provide school health follow up to children who are home educated Promotion of the service Introduction to parents prior to reception Introduction to the school nurse delivered to all year 7 pupils as they start to become more independent in managing their own health needs Hand washing and introduction to the school nurse for all reception aged children Public Health Promotion Health promotion including puberty and hygiene lessons for upper primary age, alcohol road shows, and Year 10 on breast awareness/testicular awareness/ cervical smear tests awareness I think that more varied health promotion should be available to all Trafford children. This also gives a more visible presence enabling a more positive relationship between the young person and school health. Immunisations Provision of immunisations and following up on missed immunisations Universal Screening Health Questionnaire Screening for all reception, year 7 pupils and pupils moving into the Trafford school system Healthy lifestyle lesson for Year 6 pupils National Child Measurement Programme and follow up for very overweight children Audiology screening at reception and liaison with orthoptists re: vision screening. Joint Working Some school nurses have attended the Behaviour & Attendance Service Social & Emotional Aspects of Learning (SEAL) and TERN (Trafford Emotional Resilience) Networks which is a really good way of understanding what is already happening in schools and building on it rather than duplicating. Information and support provided to schools about infectious diseases was appreciated Gaps and issues in Universal provision Lack of prioritising this work and so health promotion is often rushed Staffing resource to provide all of the core programme in all schools Opportunity to check immunisation status on receipt of A&E forms etc. Translation services 21

22 f. Universal Plus provision Good practice Joint Working and Referrals Signposting and referrals onto other services Good relationships with schools, and other services Work closely with schools to identify and update on vulnerable children Working within the multiagency team Liaising with other professionals regarding referrals to speech and language, audiology, orthoptist, dietician, mental health services, occupational therapy, community paediatrician, chiropodists and more Drop Ins Drop ins at secondary schools and recently commenced termly drop-ins at primary Some drop ins for parents Targeted Services Chlamydia screening and sexual health advice Smoking cessation Support with children and young people who self-harm, misuse substances or have emotional health issues Support for children with illness I have twice phoned our school nurse regarding children who have had a lot of time off because they were sick - the support for these issues has been very good and resulted in one child in particular having much improved attendance. (School) Having a professional health worker at the end of the phone who will contact parents to give advice and support in situations like this is invaluable. (School) Assessments CAF Self-harm risk assessments and local pathway followed ADHA and motor coordination Training and Support Epi-Pen training to staff and parents Support the production of a plan of care for children with additional health needs Gaps and issues in Universal Plus provision Lack of resources and work at this level not always prioritised Sometimes there is a lack of private/confidential area to speak to child Drop ins cancelled due to higher priority work Do not feel offer much at this level as do not have the time to take on long term issues apart from signposting and referring on. Do not get involved in long term health issues unless a safeguarding concern Keeping up with training to cover all the issues Joint Working Providing joint sessions with other services Low levels of referrals to some other services 22

23 Improved working with CCNT on complex chronic conditions e.g. asthma, epilepsy Accessibility Service is not using the "You're Welcome" criteria Emotional Health and Wellbeing Support Anger management Bereavement counselling There was some concern from schools about duplication with primary mental health services Need for more targeted support for children with long term health conditions Home visit offered to undertake work with parents around issues such as obesity, healthy living, failure to take their children to health appointments, home conditions and the impact of poor home conditions on children's health and development etc. (Other Professional) More support within main stream schools for children with complex and additional health needs. Closer links with CCNT to support and work jointly with children and young people with long term health conditions. Support with children with less serious health conditions within school such as continence issues. Need for more targeted follow up Lack of targeted follow up for 16 and 17 year olds Lack of targeted follow up with lower tier needs There is an opportunity to address health needs when young people attend hospitals with substance misuse, sexual health, assaults, bullying, emotional health issues, if the child s needs require statutory intervention from social care they are followed up or if they require specific health care however if the children have a lower level of health care and follow up the school health service is not commissioned to provide support to these young people Lack of targeted work in the school holidays The school nursing service is not available in its entirety in the school holidays. School nurses should be available to school aged children (including 16/17 year olds) all year round. This would give school nurses the opportunity to see children at home 23

24 g. Universal Partnership Plus provision Good practice Joint Working and Referrals Working in the co-located multiagency teams School nurses already work closely with other agencies within and outside of our multiagency teams such as social workers, health visitors, youth workers, GP's and schools to provide the best possible outcomes for young people and families. Communication within these agencies has improved since being relocated into multi-agency teams (School Nurse) Good relationships with schools, and other services Our nurses regularly join all agency meetings to discuss the provision for children in school. They offer invaluable advice and support and signpost to the relevant outside agencies. They offer an important link between school and Paediatricians. (School) Work closely with schools to identify and update on vulnerable children Work closely with Education Welfare Officers and schools to address health issues affecting attendance. I work closely with EWO's and schools to address health issues enabling improvement in school attendance - thus increasing educational attainment/ peer support to promote well-being and emotional health. (School Nurse) Safeguarding Experience and Skills Experienced in managing Child Protection Cases Attending wide variety of safeguarding meetings Report writing, including for SEAM (Sex Exploitation and Missing) and MARAC (Multiagency Risk Assessment Conference) Holistic Health Assessments for all children on a protection plan Gaps and issues in Universal Partnership Plus provision Issues in the amount of resource that this section of the service takes up Meetings, reports and assessments take up a large amount of school nursing time. Limited capacity to deliver lower tier interventions including CAF support due to high tier demands Limited capacity to support training and care plans of children with medical needs in school Increasing numbers of children requiring Child Protection Plans increasing resource required in staff time Often we are just the health representative to make the meeting quorate and do not actually get involved in direct work with the family. This does not seem a good use of our time/skills. (School Nurse) Our school nurse does not have the time that she needs to spend with children in school as she attends so many child protection meetings. The information that the school nurse can bring to these meeting is vital, but it must be possible to access this information in a more efficient way. (School) Training Additional Safeguarding training such as domestic violence/abuse, mental health Systems Different record systems across the services making IT communication complicated 24

25 7.2. Findings from Work with Children and Young People The consultation involved speaking to Trafford school pupils at primary and secondary schools in Trafford, as well as working with the Trafford Youth Cabinet. 128 children in 11 Trafford primary schools were consulted directly. 27 young people of secondary school age were consulted directly. The consultation also took notice of Someone you know and can trust: a consultation with young people on the future of school nurses, conducted at Youthforia (North West Youth forum) on the 10th of July 2011 for Department of Health, School Nursing Programme of Development (Engagement Task and Finish Group) by Dan Moxon, Regional Participation Officer, NWRYWU. a. Primary school consultation: The pupils were asked the following questions and the responses have been collated into a series of infographics. The size of the word corresponds to how frequently children used it. Do you know your school nurse? What should a nurse be like? What should they do? 25

26 When should they come to school? How often? How should they advertise? What should be on the poster? 26

27 b. Secondary school age A consultation took place with one school council and with Trafford Youth Cabinet. The school council were asked the following questions (with answers): They were then asked whether they agreed with a draft promise from school nurse services to pupils: Do you know your school nurse? No What should a school nurse be like? Looks after you Sympathetic Comfortable Talk to you before and after the jab Trustworthy Female as males may be less sympathetic When should they come to school? Several times Break or lunch How should they advertise? Posters: times, what they do, how you can find them, picture Assemblies What should they do? Embarrassing bodies Family problems c. Charter for the service The Youth cabinet built on the previous work done at a regional level and came up with a list of ten things a new service should provide: 27

28 1. We want a confidential service 2. We want you to respect and maintain our right to privacy 3. We want a well promoted service 4. We want to be provided with a certain level of minimum provision (e.g. X hours per week) 5. We want a qualified workforce, and we want to know who is treating us 6. We want you to offer services to ALL children and young people 7. We want you to offer additional services to those who need it most 8. We want you to support us to access other health services 9. We want you to treat us with respect and provide a non-judgemental service 10. We want to be able to provide you with feedback on your service The primary aged pupils were all asked what they thought of the list of promises and they agreed that this was the right list Findings from Qualitative Work with Parents An on-line questionnaire was developed for parents to complete that focused on how they wanted the School Nursing service to communicate with them, and what information they would need from the service. Details of the questionnaire were distributed to parents via the following methods: ed to parent governors The Parents Forum for parents of children with disabilities Trafford CYPS School bulletin, where schools were requested to then distribute via their own networks 32 parents responded to the questionnaire representing a total of 39 children. Of these 24 were of primary school age, 13 secondary age and 2 sixth form age. Schools represented: Primary St Joseph's Catholic Primary School Navigation Primary School Tyntesfield Primary School Davyhulme Primary School Springfield Primary School, Sale Wellington Road, Timperley St Monica s R.C. Primary School Acre Hall Primary, Flixton St Hugh s Catholic Primary School, St Matthews Church of England Primary School, Stretford Woodheys Primary School Secondary Ashton on Mersey Sale Grammar School Altrincham Grammar School for Girls Altrincham College of arts Blessed Thomas Holford Catholic College, Altrincham Stretford Grammar School Special Schools Delamere Special School Pictor Special School Manor High School What information would you like to have about your school nursing service? Details of the services that are provided by the school nursing service Services available for children, secondary school age children, parents Who the school nurse is How parents can access the service if required 28

29 Contact details of the school nurse and the service Programme of events and times etc. What happens after a child leaves school What happens in relation to health checks and follow up support Child specific information Detail regarding how much information is given to parents about their children Feedback on services provided to their children, and information arising from health checks Information on any input to other professionals, in particular community paediatricians or specialists) Any specific concerns or issues that have arisen from a consultation Health information Public health information and information about wider health e.g. getting a dentist What kind of service is offered to kids on site in secondary schools? Is it somewhere kids can go to get confidential advice & information about STD s, contraception, drugs, alcohol etc. - all the things they may not want to talk to parents about but may be willing to talk to another adult about? Parents at school have recently received information via the school newsletter about the nursing service, how to make contact and when the school nurse is available in school. This is very useful information and regular mentions in the newsletter would be helpful to remind parents that the service is available. What interactions they have with my children and what they will do with the information ascertained and who they will share it with "I would like to know What the service does, if I don't come into contact with the service then that is fine, but I need to understand at what point I might need the service or what it could offer me and my child if I needed it. It's just a bit of a mystery at the moment! What is the best method of communication? By Letter 59% By 66% By Telephone 34% In Person 21% By letter Guaranteed to see it by post /telephone correspondence can be lost amongst the many messages received daily using both mediums, a physical letter also can be used as a reminder I am more likely to read a letter sent from school, also I do not have a mobile phone. By I believe this would be the fastest way for contact. Though I do think that it depends on the issue to be discussed; some cases may be best dealt with in person. Gives me a permanent record I can refer back to, and more environmentally friendly. - cheaper and faster than letter. I am always amazed that in times of cutbacks TMBC still do almost everything by letter. Why? Quicker, less unnecessary paper, easier to digest and respond to 29

30 There is a parent mail system in operation in the school, so most communication from school to parents is via now Flexible approach The best means of communication depends entirely on the issue to be discussed. I recently had a telephone conversation with the school nurse regarding one of my children and this was very useful and appropriate to the issue concerned. It would depend on the situation, general information by letter, more one to one communication regarding own child I would prefer by telephone or by person. Children with additional needs One of my children has complex physical/learning disabilities so communication is essential as necessary to support her appropriately Home To school book = class will also be aware of medical issues as needed. Telephone = messages can be left on answerphone if not at home. = fast way of communication. How might school nurses best advertise what they do and when they do it? Leaflets to parents (at set times and ad Targeted information for parents and hoc) carers School Noticeboards School prospectus Information meetings with parents School Bulletins Information on the school website Parents Evenings School newsletters Home Visits Posters at school Flyer in school starter pack for all new Letters home parents Informal meeting sessions for s to parents parents I think that a leaflet circulated at the beginning of the year is a good way to reach out to parents They shouldn't. Why do you need to advertise? Information can be provided by school in the usual school info forums. I would suggest the school newsletter, school website and a poster on the noticeboards where parents gather to collect children at the end of the school day. "Send out an overview of their details. List the things they do, the things only your GP can do, frequency of review appointments e.g. with specialist doctors" "Holding an informal session for parents to attend, maybe once a term to keep parents updated. Regular s to parents with updates." Advance warning to parents of routine checks they undertake (currently just get communications from School Nurses when they need permission to weigh etc. your child) What qualifications and skills do you think a school nurse should have? Good social and communication skills 30

31 Ability to communicate with parents Experience and skills of working with children and young people Non-judgemental Skilled at working with other professionals Being compassionate and understanding rather than patronising. Empathy with parents/carers patience, empathy, gentle manner Good interpersonal skills, and the ability to communicate well and work as part of a team with the teaching staff Medical qualifications and skills Nursing qualification and knowledge of child development A Child Development qualification, Qualified nurse who has specialised in caring for children Usual nursing qualification would seem adequate but if more specialised training available that could be useful too. Specific skills Emotional health and learning skills Learning disability and child mental health awareness etc. A fully qualified paediatric nurse with extra qualifications in children with special needs. Our children need and deserve this. CBT qualified, Knowledge Wider services Common childhood conditions including continence How medical conditions affect learning Child development School curriculum especially PSHE Nutrition Obviously a trained nurse but have pastoral skills so that the children feel then can confide in them if anything is worrying them "Obviously all relevant nursing qualifications but it is essential they have the following: Calm and caring manner and efficiency in ensuring reviews by specialists are carried out at regular intervals. I am not sure what the role of school nurse entails. However, I would imagine they need to be medically trained to the level the role requires. But overall, they need to have the social and communication skills to work well with children and their families and work well with other agencies within the community They should be able to provide accurate information advice and guidance and not be emotive, threatening, scaremongering or factually wrong. A really good all round knowledge so able to spot issues early and signpost or refer onto relevant services, both medical and community. Why do you feel that that this would be the best time for accessing the school nursing service? Before school 34% In break times at school, 50% 31

32 During lessons, 25% After school 31% Outside work 3% Anytime in school hours 6% Issues around: Disruption to the school day Ability for parents to be involved Enough time to deal with significant issues Confidentiality Flexibility Having availability to go and see a nurse at different times gives the children the option not to be put off by other students being around Some availability at break times would be helpful to enable children to call in without having to request permission or miss lesson time. The sessions which the school nurse has run for classes (e.g. on hygiene, hand washing etc.) have been very helpful and well-remembered by the children. No need for school nurse to cover out of school hours - that's my job to sort out and we have a GP to go to. As a parent I would expect the school nurse to work and be available for our children at any point during the school day. Should school nursing services be available outside school? and why Yes ten responses Convenience for parents Ability to talk away from school May also be easier for some children to approach for help in a venue away from school where less likely to attract other possibly unwanted attention & questions from other kids - greater privacy so may be more likely to use service offered Seems sensible to have universal spokesperson rather than dealing with GP and various other agencies individually No seven responses These were related to the availability of other health services outside of school hours. Possible five responses I'm not sure that this is required at primary level, it may be more appropriate for teenagers who may access the service independently and require 'joined up' support. "Yes, but perhaps only to existing cases - i.e. to those children and families who may need support during school holidays Parents may need to contact the relevant people outside of school hours. There could be set times/ days to do that I don't see this as required unless specifically requested by a parent to talk to a nurse after school about an important issue 32

33 Please detail any additional comments that you have or any further information that you think should be included in the review. Review the way you present medical fact or opinion. Make sure any presentations are balanced and correct. Do not frighten with scare stories. Have regard to different cultural sensitivities on many matters. Have regard to education in that you are acting as an educator often but do this task without training. I think in secondary schools it is probably more important to be informed of the role as parents do not attend the school as regularly as they would a primary school. Parents should be advised of details of every conversation that took part between the nurse and the child. Parents should be asked to give written consent prior to any vaccinations taking place. Both of my children have diseases of the immune system and immunisations can make them ill. Health issues often arise at school and a school nurse can provide the necessary care that teachers are not trained to provide. The wellbeing of young people is greatly enhanced by this service. Preventative care should be provided in school where possible information on teeth cleaning, healthy diets, and later sex education could be managed by school nurse. Similarly, they could provide a point for teachers to raise health concerns about pupils. "Procedures regarding frequency of appointments need to be clarified and checked to ensure nurses are following them. [particularly in relation to specialist appointments for children with additional needs]. I think there should be at least two full time school nurses for children to access at a school specifically at special needs schools. 33

34 7.4. Quantitative Service and Population Data The data in this section is divided into the following sub sections. a. Eligibility and population b. Capacity and resource c. School nursing activity database d. School nursing activity audit e. Activity at Community and Universal f. Activity at Universal Plus g. Activity at Universal Partnership Plus a. Eligibility and population In addition to the school population currently served referenced in the main body of the document, there are three key vulnerable populations. They are: 16 to 19 year olds, those pupils attending independent schools and electively home educated pupils. Year 12 and 13 School Nursing Service Special School Nursing Service School Year Y12+ TOTAL Mainstream & Manor, Egerton, Longford Park PRUs 0 70 Sub Total Pictor 0 89 Delamere 0 54 Brentwood Sub Total FINAL TOTAL An additional 2565 are attending year 12 and 13 within schools and this would constitute more than 7% of the current population that the School Nursing Service covers. In addition there are more than 3,000 students at Trafford College. One of the key issues is that this age cohort has some additional needs which would place additional pressure on the service. In particular, increasing sexual health, mental health and substance misuse issues. Independent schools School Primary Total 1386 Secondary Total 362 Secondary Special School Total 89 Total number of pupils attending independent schools in Trafford Number of Pupils ,837 pupils would be 5% of the current population that the School Nursing Service covers. There are nine independent schools in Trafford for a primary population and two for a secondary population. 34

35 The current provision for independent school pupils consists of: Routinely offered immunisations Support for any child that the service is made aware of at Child in Need or Child Protection level Training is provided for adrenaline auto-injectors (Epi-pen) in relation to children with known anaphylaxis Other services e.g. screening are only offered at parents / school request There is not any monitoring of migration into or out of these schools. Electively home educated pupils In addition to these, 37 pupils were being home educated in Trafford in the 2010/2011 school year which is an average of three pupils a year group. There is a new protocol that covers the School Nursing Service for this population. It states: In cases where a child has become Electively Home Educated the School Nurse will request the child health records. A letter should be sent to the child s parents offering them access to the School Nursing Service and providing relevant contact details. A copy of this letter should be sent to the child s General Practitioner (GP) and a copy filed in the child health record. Electronic Health Records should be updated and the child health record filed in the appropriate record store This is currently being embedded in Trafford. b. Capacity and resource The School Nursing Service is small in terms of numbers and most staff are on term-time only contracts. School nursing staffing by band: By cluster area: Band Headcount Whole Time Equivalent Band WTE Band WTE Band WTE Band WTE Band WTE Band WTE Total WTE Area Headcount Total Hours WTE Year Round Workers South Area WTE all year West Area WTE all year North Area WTE all year Totals WTE all year 35

36 Specialist Community Public Health Nurses What is a Specialist Community Public Health Nurse? School nurses or Specialist Community Public Health Nurses (SCPHN ) are qualified nurses or midwives with specialist graduate level education in community health and the health needs of school aged children and young people. The Specialist Community Public Health Nurse (SCPHN) qualification is recordable with the Nursing and Midwifery Council. School nurses lead and deliver the Healthy Child Programme (HCP) 5-19 and are equipped to work at community, family and individual levels. They are skilled in identifying issues early, determining potential risks, and providing early intervention to prevent issues escalating. 4 According to the figures in the new guidance (DoH, 2012) the number of nurses with a SCPHN qualification working in schools in September 2011 was 1165 with the annual census from 2010 indicating an additional 3000 registered nurses. This is a ratio of approximately 3: 1.2 nationally. Specialist Community Public Health Nurses (SCPHN) in Trafford by Cluster Area West Area: 2 Band 7 (1.66 wte) North Area: 1 Band 6 (1 wte) South Area: 1 Band 6 (0.7 wte) In Trafford there are a total of 20 registered nurses in the School Nursing Service. This results in a ratio of 4:1 of registered nurses to SCPHN qualified registered nurses. c. School nursing activity database As can be seen by the core programme, and the new government model, the School Nursing Service carries out a wide variety of activities including Universal provision including health promotion sessions, Universal Plus provision including drop ins for children and young people with emerging needs, and Universal Partnership Plus support such as working as part of a multiagency team to work with children with complex needs. The graph below shows the weekly activity for the School Nursing Service for four months (June, July, August, and September 2012). This shows the variety and volume of activity that the service carries out. It also demonstrates the lack of activity in August due to school holidays. The service as a whole can be carrying out more than two hundred face to face meetings with professionals within a week, and more than two hundred face to face meetings with children (on a week in September). The variation is important to note in relation to term time only working. During the long summer holidays, this work is mainly not being carried out. 4 Department of Health (2012) Getting it right for children, young people and families: Maximising the contribution of the school nursing team: Vision and Call to Action (p. 16 and 17) 36

37 2500 School Nurse Activity June - September 2012 Weekly Figures th Sept th Sept 10th Sept 3rd Sept August 30th July 23rd July 16th July 9th July 2nd July 25th June 18th June 11th June 4th June d. School nursing activity audit In order to fully explore the capacity, priorities and activities of the service, an activity audit was carried out with the staff over two weeks in November (the weeks commencing the 12 th and the 19 th of 2012). All staff completed detailed timetable of their activities over the two weeks. This has allowed a detailed view to be taken of what types of activity members of the team are under taking and how much time they are taking. Activities Please see the graph below for more detail. The largest amounts of time were spent on the following six specific activities: Record keeping National Child Measurement Programme (this includes follow up as well as the actual measurements) Travel Child focused meetings Screening of records Face-to-face or telephone conversations with professionals The central importance of an effective records system is illustrated by the amount of time spent on record keeping. Also we can see the wide variety of activities and priorities that the school nurse team carry out. In terms of the top six activities, we can see that most of these do not necessarily involve direct time spent in schools. 37

38 Activity by area When the activities are grouped by category (agreed in collaboration with the School Nursing Service), and analysed by cluster area, we can see that there is a similar picture across the piece with individual client work and records and follow up being the two largest categories. It is clear that there were some differences between the cluster areas in these two weeks. It is probably a result of the size of the south area cluster that travel makes up more than 10% of the school nursing team time and the additional time in the north area on service organisation and development was mainly due to case allocation meetings during those two weeks. We can see that in these two weeks, the south and north Area had more proportion of their time dedicated to individual client work (including assessments, measurements, and direct targeted input) and the west area had more proportion of their time spent on health education and promotion (including drop-ins and lessons) as well as more client focused meetings. This could be due to naturally shifting work priorities but it is important to see how when demand rises in one area, this takes time and resources from other areas. South North West Activity & Time Area Area Area Overall Individual Client Work 34.3% 30.6% 24.2% 30.1% Records and Follow Up 30.1% 22.3% 31.6% 29.0% Travel 10.4% 5.9% 7.6% 8.5% Client focused meetings 7.2% 5.7% 10.1% 7.9% Health Education and Promotion 5.3% 6.0% 10.9% 7.3% Resources and Office Work 5.8% 10.0% 4.8% 6.3% Professional Development 4.2% 7.9% 7.9% 6.2% Service Organisation and Development 2.7% 11.6% 2.9% 4.6% 38

39 8000 School Nursing Two Week Activity Audit: Standard Activities West Area North Area South Area

40 e. Activity at Community and Universal There is a need for public health interventions which is compromised due to the limited resources. The School Nursing Service carries out three key universal prevention sessions to pupils as part of their core offer. These are: A hand washing lesson delivered to all reception classes. The purpose of this is to introduce the school nursing team to the children and to promote hand hygiene which is aimed at reducing the spread of infection and promoting school attendance. All year 6 pupils received a lesson on healthy eating and body image prior to the NCMP measurements being carried out. The School Nursing Service delivers the part of the Crucial Crew programme that is aimed at raising awareness about the risks of alcohol consumption. Crucial Crew is a multi-agency safety event aimed at primary school children in year 6 (10 to 11 year olds). In 2011/2012 Crucial Crew was delivered to 2619 pupils. The service delivers other health education sessions on a variety of issues and these tend to be carried out at the request of schools. During the 2011/2012 academic year: Health Education Session Primary Age Health Education Secondary Children Session Age Children Puberty 1404 Alcohol 1024 Personal Hygiene 511 Sexual Health 1991 Dental Health 206 Men s Health 281 Medicine Safety 151 Immunisations 2801 Healthy Eating 145 Cancer Awareness 129 Transition to Secondary Transition School Sun Safety 120 Total 2555 Total 6281 f. Activity at Universal Plus The graph below shoes the numbers of pupils supported by the School Nursing Service by the need presented. Unsurprisingly, the needs of primary and secondary school age children are very different, though behaviour and emotions are key issues for both groups. Many of issues that school nurses work with children and young people about are priorities for Trafford CYPS. 40

41 There is a demand for targeted interventions for certain conditions (including asthma and other long term conditions, as well as emotional health issues). The table below shows the number of pupils with a statement for either medical or physical difficulties in November The numbers for medical and physical difficulties have been put together because of the small number of pupils. Statement Independent Primary Secondary Special Total Medical or Physical Difficulties Long term conditions School nurses support schools to ensure that children with additional medical needs have an appropriate care plans in place. The table below shows the numbers of pupils with a care plan with the School Nursing Service in 2011/12. Health Issue Primary Age Secondary Age Children Children Total Anaphylaxis Diabetes Epilepsy Asthma Other medical conditions Grand Total The low numbers of children with care plans for asthma has been identified as an issue by the School Nursing Service in particular when compared to the numbers of children who have asthma ( 1 in 11 in the UK - Asthma UK, 2012) 5. g. Activity at Universal Partnership Plus There are increasing numbers and complexity of high tier safeguarding demands. In spring 2012 an audit was carried out of the safeguarding supervision by school nurses. In total they discussed 290 cases. Of these, 115 were Child Protection cases and 143 were 5 Asthma UK (2012) Asthma and your child. Available from 41

42 Children in Need. The table below shows these numbers broken down by area team and level of safeguarding concern. 60 Number of children by safeguarding need seen by School Nursing Service: Spring 2012 Audit South North West 0 Child protection Child in need Professional Concern Child in Care The School Nursing Service has recently introduced a holistic health assessment that is undertaken with children who are subject to a child protection plan or vulnerable in other ways. During the academic year 285 health assessments were carried out. Following the identification of health issues, the school nurse is able to ensure that they are addressed. This has enabled school nurses to contribute in a meaningful way to child protection plans. Additional safeguarding work In 2011/12, school nurses completed health assessments for Children in Care whose placing authority was outside Trafford. This was approximately 59 per year. Health reports are completed on all school aged children who are discussed at new case strategy meetings and Multi Agency Risk Assessment Conferences (MARAC). This is approximately 35 per month. 42