The names of the service users have been changed

CASE NOTES
Practitioner: Helen Burrows, social worker, child care operations team; and Annette Forbes, home care manager, mental health. Both are now staff development officers.
Field: Child care services.
Location: Leicestershire.
Clients: Natalia Shaw, 13, lives with her mother, Mary-Ann, 50, who has schizophrenia and limited cognitive skills, and her grandmother, Lucille, 83, who has learning difficulties and is frail. 
Case History: The family was referred to the child care operations team by the county's access team, following threats of prosecution against Mary-Ann because of Natalia's non-attendance at school. The duty social worker had visited only to find the living conditions in the house "intolerable". The home care service deployed five people on a so-called "dig-out" to remove the rubbish and clean the property. It took four dig-outs to clear the house. The family had limited contacts outside of the house. When Natalia did attend school she was ostracised because she had never been taught self-care skills, and was the subject of verbal taunting and graffiti about how she "stank". Lucille sat, slept and ate on the sofa. Mary-Ann slept there too. Natalia also slept downstairs because the bedrooms had become unusable.
Dilemma: Although treated as a child in need case, it was bordering on child protection.
Risk factor: Socially isolated, Natalia was being neglected and her health was being put at risk.
Outcome: The family all remain at home with support - and Natalia has started a college course.  

The old battle over the benefits of specialist as opposed to generic social work rumbles on. On the whole, social work is dominated by children and families and, in any generic system, work with older or disabled people, for example, will almost always receive a lower priority.

However, there is genuine concern that specialist working can mean that while the focus may be strong in the centre, the bigger picture blurs badly out to the edges.

In the case of the Shaws, it was the work that child care services did with the adult family members that brought about a positive impact. Referred to social services for non-attendance at school, Natalia Shaw, 13, was found to be living in unhygienic conditions with her delusional mother, Mary-Ann, and frail grandmother, Lucille.

"When I got involved Natalia didn't go out," says Helen Burrows, who at the time was a social worker, child care operations team. "She only had a doll's pram to play with. She spent all her time watching TV with her mum and grandma, just eating chocolate and crisps because that was the main food in the house."

Mary-Ann, who had mental health problems and moderate learning difficulties, struggled with basic home skills. "She had no idea what to do with food once she had bought it - she would put frozen food in the fridge. Natalia often had stomach-aches and diarrhoea - which partly explained her non-attendance at school," says Burrows.

The child care team within home care services carried out some rehabilitation work teaching Mary-Ann to cook, clean and use the washing machine. Staff worked with Natalia to establish routines and make sure she was up, dressed, fed and escorted to school each morning. The welfare rights team sorted out the family's benefits.

However, one home care assistant rose to the challenge. "She took this family on," says the then home care manager, Annette Forbes. "She built up a great relationship with them and really sorted them out: clearing up, bills, redecorating the place - even stencilling tiles in the kitchen. They called her Carol Smillie - from Changing Rooms. She was an absolute star."

Although a child-in-need intervention, it was, according to Burrows, beginning to circle around child protection: "I would have had no difficulty in arguing thresholds for significant harm had we gone into care proceedings, which was likely if we couldn't get resources."

Personal hygiene awareness was also tackled. "All three had body lice - which were in the sofa and blankets. Grandma was also incontinent but still she and Mary-Ann slept on the sofa," says Forbes. "After encouraging Mary-Ann to take showers, the home care assistant began doing little things like washing Lucille's feet, and washing her hair at the sink. She got her up to having a body wash three or four times a week."

Burrows also worked directly with Natalia on independence skills. "She had to be taught how to shower, wash her hair and to deal with her periods," she says. "We taught her how to shop and buy clothes - all hers were too small."

The family had not allowed Natalia to do anything in the kitchen - not even make a cup of tea. "By the time I closed the case," says Burrows, "she could cook basic meals. She took on more responsibility and grew up very quickly."

Natalia's school attendance improved. She also began to make friends, and found somebody to travel with on the bus to school. She went on to pass her GCSEs. "The family took a copy of the certificate with some chocolates and a bunch of flowers into the home care office to say thank you," says Burrows. Natalia is now at college taking a GNVQ in hairdressing.

"It was important," adds Forbes, "that it was social services' in-house home care, because we had the flexibility, with a supportive social worker, to play with the care plan and build relationships. We went in to work with Natalia but built bridges with all family members."

This flexibility also needed management backing. "I was supported by a manager who liked to be creative in problem-solving - so I was able to take on responsibilities for the whole family," says Burrows. "I worked with mental health and learning difficulties services, education and home care to co-ordinate the whole thing. I was also permitted to do some direct work and you don't always get the time or luxury to do that."

And from that luxury a family is now able to live a simple, basic life - together.

Independent Comment

Modern child safeguarding practice calls on us to recognise that child protection and child welfare work are not two distinct and separate spheres, writes Patrick Ayre. 

From this perspective, children at risk are best seen as a subgroup of children in need, not as another category all together. However, that does not mean that we can safely ignore the distinction between the two.

If we are to keep children safe, we must recognise that if a child is suffering significant harm and if it seems that an interagency plan may be necessary to promote her well-being, the matter is essentially one which falls within the remit of the child protection system and we must act accordingly. 

In this case, Natalia was evidently suffering substantial neglect. Creative and intensive support ensured that the most pressing immediate effects of this neglect were addressed and allowed her to begin to lead a more normal life. 

However, the impact of living during her formative years in the sort of environment described would probably be neither superficial nor transitory. The practical support offered to this family was clearly exemplary, but with neglect, as with all forms of abuse, it is usually the emotional impact which must concern us most. In some ways, cleaning the house and teaching Natalia to look after herself, though important, represented a beginning not an end. They established an acceptable baseline from which interagency work on repairing the emotional damage and improving the emotional environment could commence.

Patrick Ayre is senior lecturer at the University of Luton and an independent child welfare consultant

Arguments for risk

• Working with the whole family meant that the bigger picture remained in focus. "The house is redecorated, they're getting personal care and they're eating regularly. Everything was becoming more ordered and their lives were back on track," says Forbes.
• Burrows identified that Lucille was pivotal in the family. "Although she was physically incapable of doing anything, she really held it together," she says. "It simply would not have been possible to leave Natalia with mum. And it wouldn't have been safe to leave mum on her own - so we could have ended up with all three in care."
• Lucille's mental health assessment found she did have a level of dementia. She began using day care services - which gave her a break. As did Mary - although at Natalia's suggestion. "She thought her mum should get out more and meet people and not just wander around shops buying big bottles of fizzy pop," says Burrows.  

Arguments against risk

• The abundant risks in this situation are worrying. With the mental and physical health problems of Lucille and Mary-Ann in tandem with a moderate level of learning difficulties it is astonishing that it took so long for them to appear on the radar of care services. 
• Burrows is clearly right that there would have been no difficulty in arguing the thresholds for harm. There were practical concerns over both adults' parenting abilities, a complete lack of awareness of Natalia's developmental needs and a potentially health-threatening disregard for the home environment. Mary-Ann's hallucinations and paranoia are also components of the risks tackled head-on by child care services.
• Lucille, according to Forbes, had been "the mainstay and kept things reasonably ticking over, but had become frail and less capable." It seemed that the family's decline mirrored Lucille's. At this point all three could have been placed in the care of specialist services.