Measuring the quality of care

The NSPCC works with children, young people and families who need help across the UK. Its services aim to protect children today, prevent abuse tomorrow and support wider efforts to make child cruelty a thing of the past. To improve understanding of best safeguarding practice, the NSPCC publishes evaluations of its services and interventions, and undertakes research and literature reviews. These are published on the NSPCC website to contribute to the evidence on what works to protect children and families.

When professionals are involved with a family and are worried about a child, it is not always easy for them to demonstrate neglect has occurred. It is important that those who have regular contact with children and families, such as children's centre workers, health visitors, family support workers and teachers, feel confident in their ability to recognise where the needs of a child are not being met and share this effectively with other professionals and the family.

Graded Care Profile 2 (GCP2) is a tool that can support professionals to assess the quality of care being given to a child and to identify when sub-optimal parenting is putting a child at risk of harm. It helps bring focus to the areas of parenting that require support and enables professionals to intervene in an informed way.

Upgrading GCP tool

The original Graded Care Profile (GCP) tool was developed in 1995 by community paediatrician Dr O.P. Srivastava. The GCP scale draws on the concept of a continuum of care rather than categorising it as neglectful or non-neglectful. There are five grades, which are based on three different factors: the level of care, commitment to care and the quality of care. The grades are applied to Maslow's hierarchy of needs: physical, safety, love and belongingness, and esteem.

In a 2012 Department of Education report, Systematic Reviews of Models of Analysing Significant Harm, Jane Barlow identified the original GCP as a tool that "could potentially improve both the assessment and analysis of data about children in need", but noted that there was limited evidence available. The report recommended that the tool should be "piloted and assessed for validity, reliability and impact".

Recognising the huge potential of the original tool and the value of robust evidence-based assessments, the NSPCC undertook the first national evaluation of GCP in 2015. Following this, they worked with Dr Srivastava to update and enhance the tool, which resulted in the creation of the only authorised update, GCP2. This update was assessed for validity and reliability and was found to have sound psychometric properties in aiding practitioners' assessments of neglect. It is now in use in over 58 localities across the UK, many of which have switched from using GCP to the new version of the tool.

Using the original GCP

The evaluation of the original GCP in 2015 explored the use of the tool by NSPCC staff and external agencies. The research team asked practitioners to complete questionnaires and invited GCP co-ordinators and trainers, parents, key stakeholders from within local authorities and local safeguarding children boards to take part in interviews.

Of those who were asked, 87 per cent of practitioners reported that GCP helped case planning. Practitioners found that using GCP contributed to a more constructive working relationship with the family, as it helped them to identify strengths as well as weaknesses, involved parents in the process and helped parents to understand the professionals' concerns. Practitioners also felt more confident about their ability to identify neglect and felt neglect became more visible and therefore easier to identify.

However, practitioners did also identify barriers to using GCP. A key concern for practitioners was the length of the original tool and the outdated language used. Practitioners were found to be making changes to the language in the tool, either verbally or on paper, and opting not to use certain sections. In doing so, the tool had moved away from its evidence base and the strong theoretical underpinning was lost.

Making the tool accessible to practitioners

The NSPCC took the insights it gathered from the evaluation and worked with the author of the original tool to make some key updates and improvements. First, it incorporated more up-to-date and relevant language in the new version. For example, "love" was changed to "emotional care", "esteem" to "developmental", and terms like "pomp and zeal" were changed to "celebration". The framework was also redesigned to be more engaging, by incorporating a traffic light colour coding system, so practitioners and families could easily understand the scoring given.

Gaps in the original GCP, in areas such as specific dietary needs and online safety, were filled in the new version. To support practitioners using the tool, more than 60 resources were produced to aid delivery, use and implementation. They include a parent leaflet, which is translated into the seven most commonly spoken languages, as well as an easy read version and a leaflet for young people. The template used for reporting was also reworked and is now more substantial and has a greater focus on the life of the child.

When the NSPCC started to redevelop GCP into GCP2, there were around 45 versions of the tool in circulation, owing to professionals' tendencies to make amendments. The new GCP2 is now the only licenced version of the tool, which means it has been tested for validity and reliability and proven to have both. Organisations are given a licence to use GCP2, but only after they have undergone training led by the NSPCC and once their teams have passed a test that demonstrates their competency in using the tool. With this approach, the NSPCC can ensure teams retain fidelity to the model and that there is common practice among those using the tool.

Using GCP2

The NSPCC has provided support to 58 local areas to help them successfully implement the tool and this number continues to increase. In an evaluation in 2018, they sought to understand the experiences of these professionals in using the updated GCP2 tool and receiving support from the NSPCC. Of those trained in the new tool, ninety-five per cent felt it assessed neglect "well" or "very well". Practitioners felt that referrals were clearer and more likely to lead to actions that would support the child.

Participants who had received post-training support from the NSPCC felt it was helpful, and ninety-two per cent of practitioners surveyed after 10 months said they still planned to use the tool within the next six months. One council team said: "The training provided by the NSPCC made the difference when it came to the effectiveness of the tool". Positive indicators of engagement at a strategic level and a commitment to using GCP2 were also evident. These included examples of GCP2 being referenced in policies, contracts for staff dedicated to supporting the rollout of GCP2 being extended and wide-reaching promotion of the tool within the organisation.

Importantly, families have also reported finding it useful to have clear ideas of parenting expectations set out through the GCP2 assessment. One council shared feedback with the NSPCC about its use with one mother, saying it felt the assessment "really helped" her to "understand how her daughter was feeling and the impact of her home environment on her daughter's development". Some families were also reported to have made positive health and lifestyle changes as a result of GCP2 being used with them.

How GCP2 helped care professionals identify the support needs of a family in crisis

Tommy was 15 years old when he was first introduced to Ste Heslop, targeted case worker for Stockton-on-Tees Borough Council, after his case was escalated by police following a minor criminal damage offence. Tommy had been expelled from school for allegedly dealing drugs and ended up in a gang.

Heslop saw that a lot of Tommy's frustration was due to him feeling like he wasn't being listened to by his mum or the school. His relationship with his dad was almost non-existent and his mum felt she just couldn't cope with him anymore. Tommy was left to do whatever he wanted. There were no boundaries in or out of the house and therefore had no reason to change his behaviour.

A clear path

Heslop used GCP2 to help identify exactly what was going wrong, assess what his mum was doing right and to help set a clear path for improving the situation between them. "I wanted to give mum the confidence that she was supplying him with everything, but [show her] he needed to be given more emotional care," he explained. "He was being provided for - there was physical care - but the neglect was there because his mum had given up. She didn't think she was good enough a parent."

The GCP2 assessment helped Heslop to identify where improvements needed to be made. "It was easier for Tommy to listen to us and identify where things were or weren't right for him, and for his mum," he says. Heslop identified two areas where focus was needed and also felt it showed mum what she was doing right. "The GCP2 tool showed her she was doing the best she could but also highlighted the things she wasn't doing as a parent. Once that started to be addressed, Tommy was able to talk."

During a six-week period after the assessment, the relationship between Tommy and his mum improved significantly. Tommy and his mum began to put boundaries in place and stick to them. As a result of the GCP2 assessment, there was also a focus on making sure Tommy was safe online and improve the emotional attachment between mum and son.

Tommy is now in college, is no longer part of a gang and started to build a relationship with his dad. Things are much better between him and his mum too, and his sister. Tommy's situation has dropped from "high" risk to "no" risk and his case is now closed.

FURTHER READING

Implementation Evaluation of The Scale-up of Graded Care Profile 2, Smith et al, 2018

Hurting Inside: NSPCC Report on the Learning from the NSPCC Helpline and Childline on Neglect

Realising the Potential: Tackling Child Neglect in Universal Services, Haynes, 2015