Survival skills first

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.