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1.2.3 Case Co-ordinator Guidance (Early Family Support)


  1. Rationale
  2. Involving Children and Families in the CAF Assessment Process
  3. When Practitioners Should Complete a CAF Assessment
  4. When is a CAF Assessment not Needed?
  5. What is the Case Co-ordinator?
  6. Assessing Need
  7. Confidentiality, Consent and the Family CAF
  8. Information Sharing
  9. Liaising with Specialist Services and Risk Assessments
  10. Appointing a Case Co-ordinator
  11. Team around the Child / Family
  12. Action Planning
  13. What to do if Unhappy with Decision
  14. Complex Cases
  15. Closing a CAF Family Assessment
  16. CAF Assessments and Specialist Assessments
  17. Escalation Process
  18. De-Escalation Process

    Appendix 1: Home Visiting Risk Assessment Form

    Appendix 2: Pre-CAF Checklist

    Appendix 3: Practitioner Self Assessment Checklist

    Appendix 4: Supervision Checklist

1. Rationale

This document is for professionals working with children and families who complete a CAF but then may also take on the role of Case Co-ordinator or co-ordinate Team around the child or family meetings.

Support for children, young people and families needs be offered at the earliest point to deal with the impact of difficulties and to prevent these from becoming more serious. Individual services need to work with children, young people and/or families to provide additional provision from within their own agency or another universal service before requesting additional services.

It is expected that in Trafford that all agencies offering universal and targeted support, including schools and educational settings, will use the CAF Assessment process to assess children and their families when they identify a child in need of additional services The CAF Family assessment will help practitioners to identify the family's strengths and needs, and produce an action plan that is reviewed regularly to make sure that the agreed expected progress is being made.

Where a range of services is being accessed for a child or family, one practitioner will take on the role of Case Coordinator, ensuring that the family has a clear contact and that action plans are coordinated through Team around the Child / Family (TAC / TAF) meetings.

Integrated Working Delivery Model:

Integrated Working Delivery Model

2. Involving Children and Families in the CAF Assessment Process

In the process of finding out what is happening to a child, it is important to listen to the child and develop an understanding of their wishes, feelings and It is also important to develop a co-operative working relationship with parents and carers so that they feel respected and informed, they believe practitioners are being open and honest with them and, in turn, they are confident about providing vital information about their child, themselves and their circumstances.

Where domestic abuse has been disclosed careful consideration should be given to the way in which the alleged abusive parent is involved in the process. Practitioners should discuss this with their Line Manager as no actions or interventions should be undertaken which could have the unintended consequence of increasing rather than decreasing the risks to the child or non abusing parent. Please refer to TSCP Safeguarding Procedure for further guidance or contact MARAT 0161 912 5125 for information and advice.

3. When Practitioners Should Complete a CAF Assessment

When a practitioner identifies that more than one additional service is needed to support a child/young person the team around the child / family assessment process should commence. This will ensure that information is shared, action plans are clear and coordinated, and that a Case Coordinator is agreed.

CAF Assessment flowchart

4. When is a CAF Assessment not Needed?

  • For a child / young person who is progressing well;
  • For children / young people who have a clear additional need where that need can be met by the existing service without the need for a comprehensive assessment;
  • For situations where an immediate statutory or specialist assessment is needed.

5. What is the Case Co-ordinator?

All children and young people who require integrated support from more than one practitioner should experience a seamless and effective service. This is delivered most effectively when one practitioner – a Case Coordinator – takes a primary role to ensure frontline services are coordinated, coherent and achieving intended outcomes. When putting together a package of support for a particular child and their family, representatives from the various agencies involved will agree with the child and family who is most appropriate to act as Case Coordinator, taking into account a wide range of factors. This will typically be as a result of an assessment using the Common Assessment Framework.

It is important the circumstances of each case are considered carefully by the parties concerned so that the best-placed person is agreed as Case Coordinator. The Case Coordinator may be based in any sector of the children, young people or family workforce, depending on the issues involved and the individual relationship with the child / family.

The Case Coordinator is not a new role, but a set of core functions to help deliver effective, integrated support, namely:

  • Act as a single point of contact for the child or family;
  • Coordinate the delivery of the actions agreed by the practitioners involved;
  • Reduce overlap and inconsistency in the services offered to families.

6. Assessing Need

Threshold Criteria - Level One, Two or Three

If support is needed from only one targeted agency, the following actions need to be taken:

  • The practitioner, young person and/or parent(s) carries out the single action to meet the identified unmet need;
  • The delivery plan is updated as appropriate;
  • All information to be recorded and updated on local eCAF system.

If however, multiple needs have been identified, an integrated response is required and the following actions need to be followed:

  • A Team Around the Child/Family (TAC) meeting is arranged;
  • The author of the assessment invites all identified services to the TAC meeting and grants them access to the CAF on the local eCAF system. If the practitioners are non users of the eCAF system the CAF author sends a copy of assessment to them so that any preparatory work can be undertaken prior to the TAC meeting.

7. Confidentiality, Consent and the Family CAF

When completing a CAF with a family, you will need to consider the confidentiality of individual family members. This may involve recording assessments on family members separately. This will be essential in engaging with individual family members who may not be comfortable with other family members knowing their private information or concerns, particularly where sensitive information is concerned e.g. sexual health, mental health or substance misuse for example (although individuals will have their own feelings on what they wish to keep private and this list is not exhaustive).

Consent will be required from or on behalf of all family members considered in the CAF. This is to make sure that we respect an individuals right to privacy, and meet the legal requirements in the Human Rights Act 1998 and the Data Protection Act 2018.

8. Information Sharing

A lot of information is collected by organisations working to support individuals. Some of this information may be collected by more than one organisation. Other information might be needed by another organisation to provide a service, or to work with a family.

So that we can provide better services for families, it is essential that we share information more effectively. Part of the role of a Case Coordinator is to make sure this happens.

If you are working with a family at an early intervention level, most information sharing will need the agreement (consent) of the person it is about. You should aim to get the consent of the person the information belongs to, or if they aren't capable, from the person who is authorised to do so. In the case of children and young people, you can use the Fraser Guidelines to judge whether a child is capable of giving their own consent. Any young person aged over 16 will give their own consent. Where a child under the age of 16 is not capable of giving their consent, then a person with parental responsibility must give consent on their behalf.

People aged over 16 must give their own consent. If they are not capable of giving their own informed consent then a person appointed on their behalf may do so. If you think this applies to a young person or adult you are working with, you should contact MARAT for further guidance. Examples of when this might be a concern include where the person has a learning difficulty, or if they are under the influence of drugs or alcohol.

In some circumstances you might need to share information without consent. This might be in circumstances where asking for consent might put a child at risk of Significant Harm, or an adult at risk of harm, or where asking for consent might prejudice the prevention or detection of crime. In these cases, it is acceptable to share information without consent.

In any situation where you are asked to share information with another person or organisation, you should always record your decision, and the reasons for it, whether you decide to share the information or not. This will help you to show why you did or didn't do something if questions are asked at a later date.

If you need advice about information sharing you can request a consultation via MARAT by ringing 0161 912 5125 and will not be obliged to share the details of the family unless you consider this to be appropriate.

And finally, when you are sharing personal information you should always make sure you do so securely and in the most appropriate manner i.e. whether you use secure email, the post, a telephone, face to face contact or use a shared database/computer system? Your organisation will have guidance on how to do this.

9. Liaising with Specialist Services and Risk Assessments

If on completion of the CAF assessment, areas of need are identified that require specialist services or there were three or more Red rated domains within the stage three Family assessment it is imperative to liaise with the specialist agency with regard to the initiation of specialist assessments. It is also expected that an initial Team around the Child or Family meeting will be convened with the family and professionals needed for support to that family. There are a range of additional risk assessment tools being trailed in Trafford and it is at a practitioner’s discretion if they choose to use additional risk assessments to gain further information and clearer insight to what support agencies may be relevant. One example of the additional tools is the Appendix 1: Home Visiting Risk Assessment Form which is used by some but not all CYPS services. A template of this form is available within the eCAF system so that the information can be safely stored and shared between professionals. Remember when a child is assessed to be a possible risk, MARAT must be consulted.

10. Appointing a Case Co-ordinator

In the majority of cases the Case Co-ordinator will be identified at the initial TAC/TAF meeting.

The criteria for identifying who takes on this role could include:

  • The predominant needs of the child or family and level of complexity of the case;
  • The level of trust built up with the child or family;
  • The wishes of the child or family;
  • The person with primary responsibility for addressing the child or family's needs;
  • A clear statutory responsibility to lead on work with the child or family;
  • A previous or potential ongoing relationship with the child;
  • The skills, ability and capacity to provide a leadership and co-ordinating role in relation to other practitioners involved with the child or family;
  • An ability to draw in and influence universal and specialist services identified;
  • An understanding of the surrounding support systems which are available to manage and sustain this;
  • Access to eCAF to ensure that all case file recording is updated on eCAF system.

11. Team around the Child / Family

Team around the Child/family meetings are the most effective way to support a family at a targeted support level and should be convened by the professional identifying the need via eCAF or by another agreed professional.

Who should be invited to the meetings?

Parents, carers and young people must always be invited to attend a TAC meeting. The meeting must be organised in a way that encourages this. The venue must be accessible and the meetings timed to take account of other family commitments. Practitioners may need to consider an advocate to support the young person and/or family e.g. a close friend.

Invitations should be issued to those practitioners already involved with the child/young person, and also to those practitioners/agencies who you consider may be able to provide the necessary support and services. You should provide a copy of the assessment prior to the TAC meeting so that all practitioners are clear on the identified unmet needs and what support and services may be required. It is good practice to invite those practitioners who are offering universal services to the child/young person; this includes school, nursery, health visitor, children's centre etc. Practitioners unable to attend must take responsibility for informing the assessor and provide information, which can be presented to the meeting in their absence. Where a parent is receiving support from domestic abuse services it is important that the alleged abusive parent is not informed of this and the support service will not attend meetings where the alleged perpetrator is present. Careful consideration should be given to ensuring that an abused parent is able to speak freely about what help they need.

What are the anticipated outcomes?

TAC meetings will always agree the following:

  • Action plan identifying who will be doing what and how this will be measured. Including the roles and actions for the family members as well as the professionals;
  • Named or continuing Case Co-ordinator, as required;
  • Date of review meeting;
  • Further assessments;
  • Request for services from agencies not present;
  • Agree risk assessment with family

12. Action Planning

Good action planning requires a methodical process that clearly identifies the components and steps needed for improved outcomes. This process should be:

  • Comprehensive – considering all significant options and impacts;
  • Efficient – not wasting time or resources;
  • Inclusive – the child or young person, their parent/carer and other people affected by the plan must be involved and encouraged to take on actions themselves where appropriate;
  • Informative – decisions are understood by the people involved;
  • Focused – short-term decisions support long-term goals;
  • Logical – each step leads to the next within a broad strategic framework of objectives and solution-focused outcomes;
  • Transparent – everybody involved understands how the process works;
  • Within scope – you cannot promise the delivery of services from other Practitioners, only that you will discuss involvement with them;
  • Structured – ensure that goals are prioritised, it's important not to overwhelm with an exhaustive list of actions, but set manageable objectives in a logical achievable order.

Remember that an action plan cannot solve every problem the child or young person has. The assessment must look at what you can put in place to help the situation. For example an assessment cannot solve a long-term medical condition but it may be possible to provide help and support for the family to help them deal with it. If further action is to be taken, you must then set a review date.

Do not use the action plan to promise what you cannot deliver. Even if you and the parent/carer agree that a child needs a specific service, you cannot promise that the service will agree to be involved. An action might be to talk to the service by a specific date and discuss whether they will accept the referral.

The completion of the delivery plan is to establish clear goals and realistic objectives, to be reviewed at each TAC meeting. "Who's going to do what by when?"

It is not the responsibility of the Case Co-ordinator to ensure that all practitioners actually fulfil their objectives. It may be appropriate for the Case Co-ordinator to make initial low key enquiries about the area of concern. However, resolving disagreements is not part of the role and needs to be embraced by Managers, in accordance with the resolution pathway.

13. What to do if Unhappy with Decision

Sometimes, especially where there are a number of people involved, there may be disagreement about who should be the Case Co-ordinator. Disagreements may also occur where practitioners are not able or willing to deliver their 'part' of the package of support for the child or family, or where there are differences in approaches to working with the child or family which cannot be resolved through regular meetings.

Where there is disagreement or issues surrounding the allocation of a Case Co-ordinator, initially this should be discussed with the practitioner's line manager. If this does not resolve the issue the case should be taken to the monthly Multi Agency Family Support Referral Panel meetings for discussion and resolution, in the relevant Area Family Support Team.

14. Complex Cases

Depending on the complexities of the case, or if a decision cannot be made to determine who will take on the role of CAF episode coordinator, the case can initially be discussed with one of the Operational Managers in the relevant Family Support Team.

In cases where there are a number of complex needs / issues in accordance to each agency's governance it may be that the role of the Case Co-ordinator should be one of the more senior members of the Team Around the Child / Family.

If there are issues surrounding complex cases these need to be taken to the AFST referral panel or alternatively the Complex and Additional Need Panel. The AFST Operational Managers will support and signpost throughout this process.

The National Guidance states that: "A clear line of accountability for the Lead Professional (Case Co-ordinator) would run from the practitioner, through line management in their home agency, through coordinated arrangements in the Children's Trust, and ultimately to the Director of Children's Services on behalf of the local authority." (The Lead Professional: Managers Guide 2006 Section5:10 Page 41) W.

Where there is a disagreement around the Case Co-ordinator or non-engagement then these should ideally be solved by having open channels of communication between the managers of the agencies concerned.

Resolution Pathway

Resolution Pathway flowchart

Caption: timescales
Action Timescale

When a concern arises Case Co-ordinator engages in low key activities to resolve them: Reports the situation to the Line Manager and an Operational Manager from AFST. If this does not resolve the situation the Manager takes responsibility for intervening to settle the disagreement.

5 working days
If the issue is unresolved Operational Manager contacts Case Co-ordinator and their Line Manager. Manager makes contact with the Manager in the partner agency. The Operational Manager acts to resolve issue. 5 working days
The professional completing the CAF and/or Case Co-ordinator to take case to appropriate Resource Allocation Panel meeting, chaired by Operational Managers. Operational Managers to follow up with appropriate staff and try to reach resolution. If unable to resolve the situation discussions to be taken to Heads of Service. 5 working days
If this situation remains unresolved this is now a significant risk and needs to be reported to the Joint Director Children and Young People Services Social Care or Health. 5 working days

15. Closing a CAF Family Assessment

Once work has been completed and outcomes have been achieved with a child/family the assessment process should be recorded as closed. This should be agreed with the child/young person and parent/carer(s) and other practitioners involved at the team around the family meeting if these meetings are taking place. Ensure that Case Closure Summary completed on eCAF system.

A CAF assessment may be closed for a number of other reasons, for example the child moves away from the area, or consent to participate in the CAF process is withdrawn by the family, and others.

The process outlined below should be used for finalising and completing an assessment. When the Case Co-ordinator reviews the assessment or action plan with the family or young person, they may find that all the issues raised have been dealt with. It is important that this is agreed by everyone involved with the child or young person.

Reasons for closing a CAF assessment include:

  • The child or young person's needs have been met;
  • The outcomes identified in the assessment are achieved;
  • The family no longer wish to engage with the process;
  • The family have moved out of the area;
  • The issues have been raised to a statutory level and specialist assessments are replacing the team around the child/family assessment process.

A final summary must be included in the closure of a CAF assessment. This must include information about the reasons for closing the assessment process and any ongoing actions for the family or practitioners in mainstream services. A final copy of the assessment and/or action plan must be given to the family and a copy must be kept with the assessment author/Case Co-ordinator. It is the responsibility of the Case Co-ordinator to close the case using the eCAF system.

Some families may choose to withdraw their consent during the CAF process because they may not agree with the practitioner undertaking the assessment or about the level of need of their child or they may feel that that they can meet the need themselves within their own resources. At this point the practitioner needs to decide whether this will place the child /young person at risk of experiencing Significant Harm. If so, then TSCP Safeguarding procedures must be adhered to contact with MARAT must be made to decide whether a referral is needed.

If the family/young person is planning a move out of the area, then every possible effort should be made to agree a new assessment owner from an appropriate agency in the new area and a copy of the CAF assessment should be sent securely to that person. (If regional see NW Regional Cross Border Protocol) If the move is sudden or unplanned, the closure process must still be followed.

16. CAF Assessments and Specialist Assessments

National guidance clearly identifies the need for a CAF / Family assessment process. These assessments should be used when a child or young person is at risk of not achieving their full potential and the reasons for this are not clear (level 1); or the reasons seem clear but the support of more than one agency is required (level 2 and 3). If a CAF Assessment and action plan is in place but improvements are not being made and the risk to the child/children increases then specialist holistic assessments should be utilised,(high level 3 and 4) these include Social Care assessments, Children and Young People’s Mental Health Services (CYPMHS) or Youth Offending Team (YOT) assessments. In cases of domestic abuse an associated assessment of the abused parent DASH (Domestic Abuse Stalking and Harassment) should be undertaken where possible, whatever the level of need for the child. The TAC meetings should act as a way of keeping specialist services such as children's social care informed (where relevant) so that if a family are to be escalated up the continuum of need this happens in a planned and informed manner.

17. Escalation Process

Immediate and high risk concerns should always be referred to the relevant specialist service (Social Care, CYPMHS or YOS) regardless of whether a CAF is in place.

However, in most situations specialist services will expect that a CAF assessment has been completed before a request is made to them to provide support. Based on the principles outlined above, services should have engaged with the child, young person and their family to assess worries and strengths and have an action plan in place using the CAF assessment process before accessing those specialist services.

Any work undertaken at high level 3 and 4 must take into account any previous CAF assessments. The practitioners involved with a child or young person before they enter high level 3 or 4 services should share information with specialist services. Sharing the early assessment documentation is a good way of doing this. At the point of escalation, the existing CAF assessment and action plan should be updated and shared with the appropriate specialist services. The CAF assessment should be kept open until it has been agreed that a specialist service will have ongoing involvement with the child, young person and family and only then is it appropriate to close the CAF assessment. If a child is referred to and accepted by children's social care then the role of the Case Co-ordinator should be reviewed. If social care's involvement goes beyond an assessment then the social worker will become the Case Co-ordinator. This process can be completed electronically transferring the CAF to MARAT via eCAF. The Social Worker can then choose to copy forward any information in the CAF / Action Plan to populate the Assessment with ICS (Integrated Children's System). Any case file recordings and standalone assessments / forms can also be transferred. The referral pathway must still be adhered to.

The child, young person and family must be informed and asked to give their consent for information to be shared with the relevant specialist service. Should the child, young person and family not give consent for the information to be shared, then practitioners should consider whether they have sufficient reason to over-ride the need for consent and record their reasons for sharing or not sharing information with other services.

18. De-Escalation Process

When a specialist service is to cease their involvement with a child, young person and family because their high level needs have been met or are no longer causing concern, but that there are ongoing needs being met by universal services/ targeted services then the family must be informed.

If the involvement of Children's Social Care with a child and their family is coming to an end after a period of support then the early help process can be used to assess what the ongoing needs of the child will be and which agencies should be involved in meeting them. The Social Care Allocated Worker must consider and liaise with the practitioners that they believe will be best placed to meet the family and child's continuing needs at a lower level of intervention. They will then invite these practitioners to a final Child In Need (CIN) meeting to agree jointly with the family what the new arrangements and plan will be once Social Care are no longer involved. This must be done with the child and family's consent. It is expected that at the meeting, the role of the Case Co-ordinator will be transferred from the allocated Social Worker to the most appropriate practitioner.

The new Case Co-ordinator will then log that a team around the family assessment has begun and they will manage the work going forward and children's social care will close the case. To avoid the need for the child and family to tell their story again, the existing Assessment and/ or Child in Need Plan will be shared and used as the basis for the ongoing support. The new Lead Professional will therefore only complete the family's personal details to log the CAF. However they will still need to complete the consent agreement and the action plan with the family. The action plan must make reference to the Child In Need Plan / Assessment.


Appendix 1: Home Visiting Risk Assessment Form

Appendix 2: Pre-CAF Checklist

Appendix 3: Practitioner Self Assessment Checklist

Appendix 4: Supervision Checklist