London Borough of Merton Council Safeguarding Inspection Outcome

Transcription

1 Report on the Outcome of the Integrated Inspection of Safeguarding and Looked After Children s Services in London Borough of Merton Date of Inspection 9 th January th January 2012 Date of Joint Report 24 th February 2012 Commissioning PCT NHS Sutton & Merton CQC Inspector name Lea Pickerill Provider Services Included: CQC Region CQC Regional Director South West London & St George s Mental Health NHS Trust. Epsom & St Helier University Hospitals NHS Trust The Royal Marsden Hospital NHS Trust London Mr Matthew Trainer This report relates to the recent integrated inspection of safeguarding and services for looked after children which took place in the above Authority recently It provides more detailed evidence and feedback on the findings from the Care Quality Commission s (CQC) component of the inspection, and links these to the outcomes requirements as set out in the Essential Standards for Quality and Safety. Thank you for your contribution to the inspection and for accommodating the requests for interviews and focus groups with your staff and those of partner agencies at relatively short notice. The team provided feedback to your local Director of Children s Services at the end of fieldwork and the joint inspection report to the authority is now published on the Ofsted website and can be accessed via this link: The joint inspection report. London Borough of Merton Council Safeguarding Inspection Outcome Overall effectiveness of the safeguarding services Capacity for improvement The contribution of health agencies to keeping children and young people safe Looked After children Inspection Outcome Overall effectiveness of services for looked after children and young people Capacity for improvement of the council and its partners Being Healthy Aggregated inspection finding Good Good Good Aggregated inspection finding Good Good Good Page 1 of 16

2 This report includes findings from the overall inspection report, and provides greater detail about what we found, mapped where relevant to the Essential Standards, in order that your organisation can consider and act upon the specific issues raised. A copy of this report is being sent to your commissioning PCT, and CQC Regional Director. This report is also being copied to the Strategic Health Authority/Monitor as appropriate and CQC s Regional Director, who has overall responsibility for this inspection programme. The Inspection Process This inspection was conducted alongside the Ofsted-led programme of children s services inspections. These focus on safeguarding and the care of looked after children within a specific local authority. The inspection process comprises a range of methods for gathering information document reviews, interviews, focus groups (including where possible with children and young people) and visits in order to develop a corroborated set of evidence which contributes to the overall framework for the integrated inspection. CQC contributes to the inspection team and assesses the contribution of health services to safeguarding and the care of Looked after children relating to that authority. Our findings from the inspection contribute to the joint report published by Ofsted and also enrich the information we use to assess providers against the Essential Standards of Quality and Safety. This report sets out specifically the evidence we obtained in relation to these standards and extracts from the published report are included and identified. CQC used a range of documentary evidence in advance of and during this inspection, and interviewed individuals and focus groups of selected staff and, where possible, children and young people, their parents and carers in order to provide a robust basis for the findings and recommendations. This document sets out the findings in relation to the NHS organisations listed above, but includes some areas which may apply to one or more NHS bodies where pertinent. Page 2 of 16

3 Context: Merton is an outer London borough situated to the south west of central London and covers 14.7 square miles. Predominantly suburban in character, it is divided into 20 wards and has three main town centres; Wimbledon, Mitcham and Morden. The Children s Trust has been established since The Children s Trust Board has a very wide membership drawn from key agencies including children s social care services, NHS trusts, the Police, schools, Connexions, Jobcentre Plus and representatives from the local community and voluntary sector. The Merton Safeguarding Children Board has an independent chair and brings together the main organisations working with children, young people and families to deliver safeguarding services. The recently established shadow Health and Wellbeing Board includes appropriate representation from children s services, including the Director of Children s Services. Commissioning and planning of NHS services and primary care are carried out by NHS Sutton and Merton. In April 2011 NHS Sutton and Merton came together with the four primary care trusts in South West London (NHS Croydon, NHS Kingston, NHS Richmond and NHS Wandsworth) to form NHS South West London. NHS Sutton and Merton commissions the Royal Marsden NHS Foundation Trust to provide a comprehensive range of children s community health services. Community paediatricians and community children s nursing services are commissioned from Epsom and St. Helier University Hospitals NHS Trust. South West London and St. George s Mental Health NHS Trust is the main provider of specialist mental health services to children and young people throughout Merton. Acute hospital services are provided by hospitals in neighbouring boroughs. Services provided from St Helier Hospital were inspected as part of this inspection. Page 3 of 16

4 Outcome 1 Involving Users 1. Effective involvement of young people in working with local contraceptive and sexual health (CASH) services is good, with most outlets accredited under You re Welcome. Merton have made the decision to adopt a local standard for access to services for young people and this will now be included by commissioning in all contracts. 2. Good arrangements are in place to involve young people, looked after, in their health reviews. Young people are routinely asked where they would like to attend for their health review and this means that they are more likely to be engaged in their assessment and health plan. The Children in Care Council has recently made a recommendation that the health information provided to children and young people about the health assessment and health review should be more child focussed. The local authority and looked after child health team have responded to the suggestion and are working with young people to re-write the information leaflets. 3. Good engagement of young people in the tender process for Catch 22 and in the recruitment panel for staff made sure that the priorities and views of young people were heard and considered. Part of the service specification for Catch 22 is a requirement for a user forum panel and this work is in progress. Young people engaged with Catch 22 have said they want a building that they can identify with, rather than just working on an outreach basis and this is being looked at by the partnership to see how they can meet the needs of the young people. Outcome 4 Care and welfare of people who use services 4. The Paediatric A&E at St Helier Hospital is open 24 hours a day, 52 weeks a year and is appropriately staffed by paediatric trained nursing and medical staff. There is a shared A&E entrance with adult services. After booking in, families are directed to the relevant service. All children and young people up to 16 are seen in the paediatric A&E and up to their 17 th birthday if they are attending through self harming, substance misuse or have learning difficulties. There are 6 dedicated cubicles with a separate paediatric resuscitation bay. 5. Good arrangements are in place to ensure that children and young people attending the A&E at St. Helier Hospital are safeguarded well. All attendances of children and young people are checked to see how many times they have visited the department with clear guidance on how to respond to any third attendance within a twelve month period. Electronic flags indicate if a child has a child protection plan in place. Although there is no flag to highlight the attendance of a child or young person who is looked after, the aide memoire used in triage does prompt the question of who is the child/young person s carer. Any attendance of a child or young person, looked after, or who has a child protection plan in place is shared with the looked after children health team and social worker as appropriate, and this works well. Evidence of A&E attendances were seen in the records scrutinised as part of the inspection. All attendances are screened for potential child protection concerns against the National Institute of Clinical Excellence (NICE) guidance. Page 4 of 16

5 6. Good paediatric liaison ensures that any attendance of a child or young person is notified to GPs, health visitors and school nurses. The Paediatric Liaison Health Visitor (PLHV) also screens any attendance of adults following domestic violence where there are children in the family or where adult A&E staff made any referrals to children and families team. 7. Child and Adolescent Mental Health Services (CAMHS) offer good support to A&E and the young people who attend following an incident of self harm, substance, alcohol misuse or who are acutely unwell. However, Epsom & St Helier NHS Trust do not routinely admit young people who have self harmed to the paediatric ward for a period of cooling off and assessment, as suggested in NICE guidance. Any young person who attends the St Helier A&E following alcohol or substance misuse is asked if they would like a referral to the local service Catch A wide range of good emotional health and wellbeing services help support children and families. A flourishing third sector support statutory provision across the partnership, with access to most Tier 2 and some Tier 3 services through a multi agency family support panel. This helps to ensure that families are referred to the most appropriate support service for their circumstance. 9. Most referrals into core CAMH services are from GPs and an increasing number from schools. Referrals are triaged by a senior team on a daily basis. Those that are not appropriate are returned to the referrer and signposted to other services. The team are currently looking at how this process can be improved, with consents obtained at point of referral to avoid any delays if the referral is sent on to another service. The South West London & St George s Mental Health Trust offers specialist in patient mental health care in the Aquarius Unit and has a policy not to admit young people into an adult bed in an emergency. This is good practice. 10. Effective support is available to families with children who have complex health care needs. The communication disorders clinic is for those children aged five and over, where there is a view that the child may be on the autistic spectrum. The Pathway is compliant with NICE guidance, however, though there are between 8 9 months delay from point of referral to when assessment starts. This means that families are often under considerable stress whilst waiting for a diagnosis. 11. Catch 22 has been recently commissioned to provide advice and support to young people, carers and families on alcohol and substance misuse. Drop in sessions are available within community settings, schools and colleges that young people and their families can access. The team deliver drug education to young people who are identified as at risk of misusing substances and provide training on the Drug Use Screening Tool (DUST) as well as training professionals on how to make a good referral to the team. Work has recently taken place to modify the substance misuse training to include information on contraception and sexual health, recognising the close relationship in risk taking behaviours. Young people that remain engaged in the assessment process mostly complete their care plans, many with positive outcomes. A specialist CAMHS Drug Worker works with those young people where there is a dual diagnosis of mental health and substance misuse, this ensures that those young people receive an integrated service. Page 5 of 16

6 12. CASH services have recently restructured and now provide adequate access to contraception and sexual health services five days a week. The Point offers an integrated CASH and Genito Urinary Medicine (GUM) service at a dedicated young people s clinic once a week. This enables young people to receive all services within a single clinic appointment. Access to emergency contraception is good and is available from trained pharmacists, walk in centres and for young people aged under 16 at the local A&E at St Helier Hospital. Uptake of long acting reversible contraceptives continues to improve and the Borough has recently signed up to the London C Card Scheme. Good arrangements are in place to support young people under 16 and other vulnerable young women who undergo a termination of pregnancy. 13. A recently commissioned outreach service Check it Out works effectively with vulnerable young people, including groups of young males. They work with a Clinic in a Box" and provide CASH services in a variety of accessible settings. Feedback from the young people and other professionals is encouraging. The Check it Out team work in targeted schools and provide workshops on risk taking behaviour which are positively evaluated by young people. 14. Satisfactory arrangements are in place within midwifery service to safeguard unborn children. An initial comprehensive assessment of potential vulnerability takes place using a recently introduced parenting capacity tool and risk assessment. Space is available on the hand held notes to indicate the existence of additional midwifery notes held to support the woman and unborn child. However, there has been a recent change in the midwifery appointment system; the current process of arranging appointments for later in a woman s pregnancy is not monitored and midwives do not know if this has resulted in missed appointments and therefore missed opportunities for any newly emerging concerns to be identified. Where vulnerabilities are identified, Common Assessment Framework (CAF) is used to initiate referral to children and families service. All pregnant women with identified vulnerabilities are discussed at the regular multi agency midwifery safeguarding forum to ensure a co-ordinated approach to care and that appropriate arrangements are in place to support the family and newborn infant. 15. Good ante natal support is available to women who are pregnant and either misuse substances or alcohol or require additional support for their emotional health and wellbeing through the work of the specialist midwife. There is also a midwife with counselling skills that attends the safeguarding midwifery forum and is able to provide bereavement counselling to women as well as supporting staff. 16. A good system is in place to ensure that labour and post natal wards have up to date information on any pregnant woman that attends the hospital in labour, including whether there is a child protection plan in place for the baby once born. Discussion takes regularly at the safeguarding maternity forum on all families where there are vulnerabilities and this ensures co-ordination of care and support at birth. Page 6 of 16

7 17. Good, effective arrangements are in place to support vulnerable teenagers. Weekly ante natal clinics are held at a local children s centre alongside informal parent-craft classes. Families and young fathers are encouraged to attend. The teenage midwifery service also engage with the teenager on a one to one basis in the family home and build up good, trusting relationships that are welcomed and appreciated by the young person and their families. All teenagers that are seen by the teenage pregnancy service are offered contact with the local teenage parent support worker who works with the family to compile a personal care package, including access to benefits, education, housing and work. 18. Health visitors are delivering only some parts of the Healthy Child Programme as part of the core offer. All new parents are offered the new birth visit, the 8 week check and the 8 month check. Ante natal visits are arranged for vulnerable families. Development checks at 2 years and 3 ½ years do not routinely take place and this has led to unidentified and unmet health needs becoming apparent when a child enters formal education. The Children s Centre staff now contact all families with a 2 ½ year old child that are registered with them to offer a development check. The impact of this work has not been evaluated and does not include a health check. 19. Appropriate arrangements are in place to transfer children from health visiting into the school nursing service. Information is transferred electronically for those families where there are no concerns and face to face meetings are scheduled to discuss children that may require additional support. 20. The school nursing service works effectively across the London Borough of Merton. Nursery nurses carry out the new entry into schools health check and the school nurses prepare any health plans. Health plans are updated by school nurses on a regular basis. Nursery nurses and support workers for school measure the heights and weights of children as part of the national measurement programme and can provide advice on weight management or refer children and families to the Alive and Kicking Group. Any weights outside of a set of parameters are notified to the school nurse for consideration on next steps. This proactive approach helps to tackle childhood obesity. 21. School nurses offer drop in clinics in all secondary schools and work closely with the Check it Out team. Provision of sex and relationship education (SRE) is usually delivered by schools as part of their curriculum. However, an enhanced SRE package of support is provided by the partnership, including school nurses, to those schools that serve areas of high deprivation. School nurses provide training to education and support staff on how to maintain the health of a child with additional care needs so that they can access off site activities and trips. Page 7 of 16

8 22. CAMHS Learning Disability Team offer good support to children and families where the child has a learning disability. The CAMHS LD team have workers in both specialist schools to support children, families and education staff. There is a referral process to access support and examples were given on how CAMHS LD and Children and Families LD had carried out joint visits with families to help assess need. Multi Agency Pupil Welfare Meetings take place on a monthly basis at which children are discussed to ensure that their needs are being met. These regular meetings often help to identify potential problems early and prevent escalation. Good partnership working with health practitioners and the early years intervention team enables agencies to offer co-ordinated support as part of an integrated care pathway. The portage and key workers are particularly valued by parents and carers 23. Transition into adult health services is well planned for those children that are in special schools and transfer into special colleges. Community Paediatricians work with young people until they are Good and effective arrangements are in place to maintain the health of children and young people, looked after, in Merton. The percentage of looked after children with up to date immunisations and those who had their teeth checked by a dentist is significantly higher than statistical neighbours and national average. The percentage of children looked after with annual health assessment is also higher than national average. 25. The Initial Health Assessments of children coming into care are appropriately carried out by community paediatricians and quality assured by the designated doctor for looked after children. However, the service does not currently meet the statutory requirement to assess health needs of a child coming into care within 28 days. The service has recently lost the use of a nearby clinic and combined with delays in notifications means that some children are experiencing a delay. 26. Where it is likely that a child will be placed for adoption, then the doctor for fostering and adoption will carry out the initial health assessment as well as meeting with the potential adopters. This means that the doctor involved in the adoption process has a good knowledge of the child and can provide continuity to both child and prospective family. 27. Good processes ensure that timely health reviews are carried out by appropriately qualified health practitioners, with most health reviews for under 5 s undertaken by community paediatricians. School nurses, or the designated nurse for looked after children, carry out health reviews for school age children or those children and young people that are out of education. Appropriate arrangements are in place to ensure that children looked after, placed out of Merton, receive a regular health review. The designated nurse for looked after children often travels to neighbouring authorities to carry out the review herself and for those young people that she cannot visit, then arrangements are made with the receiving looked after children health team. Page 8 of 16

9 28. The designated nurse for looked after children reviews all initial health assessments, health reviews and health plans to check for appropriateness and these are copied to social workers, foster carers, GPs and the young person. There is no regular audit programme in place to check on the quality of health reviews or initial health assessments and this limits the ability to drive improvement. 29. Children and young people looked after have good access to effective emotional health and wellbeing services. All children new into care are assessed by the clinical CAMHS specialist worker and consultations are routinely available to support social work staff in working with their children. If a young person requires specialist CAMHS, then formal arrangements are in place to make a referral to the most appropriate team. There are currently no children or young people, looked after, waiting to access CAMHS. Specialist CAMHS support foster carers well and inspectors saw evidence of good joint work with foster carers and a young person to maintain placement stability and prevent breakdown. 30. Children and young people looked after have good access to universal services for alcohol and substance misuse through Catch 22. However, the local DUST is not used as part of the health review for young people looked after. This means that there is a missed opportunity for identifying and supporting young people who may be misusing alcohol or substances. A training programme is being arranged for all school nurses and social workers to be trained in the use of the local DUST. For those young people that require CASH services, additional support is available from Check it out. Looked after girls who wish to continue with a pregnancy are supported through the teenage pregnancy midwife and the designated nurse for looked after children, ensuring a flexible and individualised care plan is developed. 31. Health input into the preparation of young people leaving care is weak. Current arrangements include providing the young person with a copy of their last health review and ongoing support from the designated nurse for looked after children on how to access local health services. Merton Leaving Care Services, the designated nurse for looked after children and the specialist CAMHS looked after children practitioner have a meeting scheduled to look at how this important information can be included as part of an overall leaving care package. Outcome 6 Co-operating with others 32. Health visitors and school nurses work effectively to support families as part of the CAF and child protection plans, using skill mix to provide packages of care such as weaning, sleep training and behaviour management. Regular access to supervision in safeguarding children practice helps to monitor progress in delivering care as part of CAF and child protection plans. 33. Transition of young people into adult mental health services is adequate. For those young people that are expected to transfer into adult mental health services, joint meetings are arranged when the young person is around 17 ½ years old. CAMHS were able to describe cases of where transition had worked well. There is a trust wide CAMHS forum working on strengthening the transition policy Page 9 of 16

10 34. The designated nurse for looked after children is based within the Merton Social Service s looked after children team; this co-location promotes good opportunity to share information and promote the health of children, looked after. The designated nurse for looked after children is an active member of local multi agency groups, including Promote and Protect that work effectively to protect children and young people from exploitation and trafficking. 35. A partnership approach to foster carer training by CAMHS looked after children service and the designated nurse for looked after children helps to equip foster carers with the necessary skills and understanding of health issues that young people are faced with. The team also work with foster carers to give them the confidence to have conversations about risk taking behaviours. 36. Historical problems in information sharing between adult mental health services and Merton Children and Families Teams have been successfully resolved through joint agency multi agency workshops. These workshops have facilitated a greater understanding of managing professional risk across both agencies and more sessions are scheduled for later in the year. 37. Many opportunities exist across the London Borough of Merton to promote joint working in supporting vulnerable families and safeguarding children. A joint Health and Social care Liaison Meeting in Epsom & St Helier has recently been convened to look at cases where there is little or no progress in supporting vulnerable families. The multi agency maternity safeguarding forum is an excellent opportunity for practitioners across the partnership to work together to plan and monitor the care of pregnant women where there is vulnerability. The forum is well attended by representatives from children and families team, safeguarding children nurses, specialist midwives, teenage pregnancy midwife and health practitioners from the health visiting service. This excellent forum is also replicated in A&E and in the neonatal unit. Outcome 7 Safeguarding 38. Appropriate arrangements are in place for the line management and supervision of the designated safeguarding children professionals. The designated doctor is employed for 2 sessions a week for Merton and attends the LSCB. She is employed by the Epsom & St Helier University Hospitals NHS Trust and is commissioned to provide safeguarding designated doctor role for the PCT. Support is through the well established Sutton and Merton named professional group and the wider South West Named and Designated Group. In addition there is the London Group of named and designated safeguarding professionals. Page 10 of 16

11 39. The designated nurse is employed full time for both the London Boroughs of Merton and Sutton. The designated nurse has successfully developed a set of safeguarding children standards based on the NHS London Safeguarding Children Framework. The standards now form part of the contracting arrangements with providers. The designated nurse is working closely with NHS providers and the Merton LSCB to develop outcome focussed and multi agency key performance indicators that will support effective monitoring of services and support good safeguarding children practice. 40. Despite significant effort by NHS Sutton and Merton, there remains no named GP in post. The NHS South West are now exploring alternative arrangements through a cluster approach. This lack of named GP means that GPs are not fully engaged in the local safeguarding economy. The PCT does not have a robust mechanism of ensuring all GPs and their staff have attended Level 3 safeguarding children training and this extends to other independent contractors. Social workers reported during the inspection that there are sometimes delays in obtaining information for assessments from hospitals and GPs. Good partnership work is taking place through the Merton Safeguarding Children Board to identify GP practices that have high numbers of children with a child protection plan in place. This project is still in progress and has not yet been evaluated 41. Significant investment and board prioritisation on safeguarding children is evident within the Epsom & St Helier University Hospitals NHS Trust. The arrangements for the named safeguarding professionals meet fully the requirements of Working Together The trust has two named doctors, each has 2 PA per week and a lead anaesthetist for child protection was appointed during the course of the inspection. The named nurse is employed for 0.75 WTE and the named midwife is employed full time, with one session being allocated to clinic work to maintain her clinical skills. The named nurse has regular and formal one to ones with the Nursing and Governance Lead. 42. Arrangements for the named safeguarding children professionals within the Royal Marsden NHS Foundation Trust have recently been strengthened to meet the needs of the organisation following the transfer in of community services as part of the Transforming Community Services Agenda. The Paediatric Oncologist is the named doctor for child protection and at the time of the inspection did not have a formal job description for the role. 43. The named nurse for community services is employed for 0.75WTE and there is an additional 1WTE named nurse for community nurses in Sutton. The South West London cluster is looking at setting up a community named nurse forum to provide peer support and supervision for this group of staff. There is an additional 0.6WTE Domestic Violence Health Visitor. The named nurse samples supervision records on a regular basis and also audits 5 records a week in each borough as part of the performance framework for the Merton LSCB. The named nurse strives to spend a proportion of her time in the Duty and Assessment team each week to support social care staff and to promote information sharing. The safeguarding team monitor attendance at child protection meetings by community staff and attendance is good. Page 11 of 16

12 44. Communication between health visitors and primary care is good. Most health visitors attend regular meetings with GP practices to discuss families where there are vulnerabilities identified. This is a common feature in serious case reviews. 45. Improving arrangements are in place to identify children who are dependent on adult mental health service users. However, there is confusion amongst practitioners about the need to record full details of all children or where there can be discretion. This means that there is inconsistency in application of the South West London & St George s Hospital NHS trust policy. 46. Good arrangements are in place to safeguard children who visit their parents who are in patients on an adult mental health ward. There is a trust policy on visiting children and there are dedicated family rooms to facilitate the contact and visiting arrangements are a formal part of the care planning and CAF process. 47. Attendance at child protection conferences and sending of reports for conferences are prioritised by adult mental health practitioners. However, attendance is part of an individual practitioner s responsibility as part of their overall case management. There is no mechanism within the trust to monitor attendance or on the submission or quality of reports. The named nurse is implementing a new reporting system through children and families team to identify any non attendance or issues on reports for conference, though this is in the early stages of development and cannot yet demonstrate impact. 48. Adult mental health service practitioners were clear on how to refer safeguarding and child protection concerns. Most referrals were supported by a completed CAF, however, where this was not consented to by families then referrals were sent via the Local Authority s referral form. Health practitioners reported that they did not get feedback from the Merton Children & Families Team on what action had been taken in response to the referral. 49. The awareness on domestic violence and the impact on children in families across health practitioners in London Borough of Merton is good. Midwifery staff are receiving additional training in routine questioning on domestic violence and a new parenting capacity tool has been introduced to help identify if any additional support is likely. The vulnerable families form has been amended to include other family members. Health visitors and school nurses described how effective recent training had been and an identified health visitor was in post with specific responsibilities around domestic violence and MARAC. All police notifications of attendance at incidents of domestic violence are sent to the named nurse for community services who then screens them for relevance. Appropriate notifications are then sent on to the public health nurses. Independent Domestic Violence Advocates are now involved in training staff and will refer cases to MARAC. Page 12 of 16

13 50. An appropriately constituted and effective Child Death Overview Panel shared between Merton and Sutton reviews all unexpected deaths of children under 18. The panel is enriched by the attendance of a midwife who contributes well to the overall understanding and impact of ante natal care that mothers may have received. The Chair of the panel monitors actions against recommendations made by the panel through a rolling action plan. Findings from the panel have influenced changes to advice and care to mothers on co-sleeping of older, disabled children and revised guidance to urgent care on how to treat pregnant women with abdominal injury. There has been no formal evaluation of bereavement services available to families; however, as part of the process all families are contacted to ask if they require any additional support. No home visits take place as part of the rapid response to the child death. 51. Good arrangements are in place for children to be examined for a child protection medical. Children and young people who need an urgent referral for an examination following an alleged sexual abuse are seen at the local Haven where a paediatrician is in attendance. Good follow up arrangements are in place to provide ongoing treatment and support. Outcome 11 Safety, availability and suitability of equipment 52. Access to aids and adaptations was adequate, though somewhat confusing for families as there are different funding streams that have to be accessed, depending on what the aid is for. The key worker helps to co-ordinate this for families where the child is under 5 but for any new family with a child over five this is difficult. Outcome 13 Staffing numbers 53. Health Visitors have corporate caseloads that in the majority are aligned to GP Practices. Caseloads were descried as manageable and are weighted according to deprivation and needs of the families. 54. School nurses described an increasing need for their services that they were struggling to meet despite being staffed to establishment. This is recognised by their organisation and there is ongoing discussion with commissioners on future service provision. Outcome 14 Staffing support 55. School nurses are supported well by the designated nurse for looked after children when they are requested to carry out health reviews for looked after children. She also provides feedback on the content and quality of the reviews 56. New health visitors and school nurses are well supported by a period of preceptorship and assessments against competencies are used as part of the training for nursery nurses and support staff for schools. Page 13 of 16

14 57. Training within the Royal Marsden Hospital Foundation NHS Trust s community services is good, with 95% staff trained at Level 4, 75% at Level 3, 65% at Level 2 and 90% at Level 1. Training is also good in the Epsom and St Helier University Hospitals NHS Trust: Levels 1 and 2 training is 87% and high numbers of Level 3. Level 3 training is supported by a workbook which supports the training and ensures learning is embedded and continues. Completion of the book is part of performance development. This is good practice. Training is discussed at the statutory mandatory training committee and the performance management committee. 58. Epsom and St Helier University Hospitals NHS Trust are working to embed one to one supervision in maternity services and have recently commissioned some external training. Midwives spoken during the inspection confirmed that they did access supervision though this was often as a group. The specialist midwives, including the teenage pregnancy midwife accessed one to one supervision. However, the trust do not monitor uptake of supervision for those midwives who are working with women where there is either a child protection plan in place or where children and families are working with midwifery service to produce a child protection plan or child in need plan. Outcome 16 Audit and monitoring 59. Appropriate arrangements are in place to provide executive leadership on safeguarding children within NHS Sutton and Merton. The responsibilities of executive safeguarding lead are currently held by the Director of Policy who is deputising for the Chief Nurse. The board have recently had a board training day where they looked at how NHS Sutton and Merton was obtaining assurance around safeguarding from the providers. 60. Robust arrangements are in place to ensure sound PCT board assurance. Governance includes regular meetings with Quality Review Groups for each provider to examine performance and feed back information to the host commissioners. The performance indicators on safeguarding practice, designed by the designated nurse, have been trialled during 2011/12 and will be included formally as part of the contracts for 2012/ Further assurance will be obtained by providers completing the stand alone template for reporting safeguarding children activity. This was formally agreed in November 2011 and provider trusts are looking at how the template can be adopted by their organisation, with formal reporting due to start in April There are a number of fora at which the named and designated safeguarding children professionals meet to discuss safeguarding issues across Sutton and Merton and receive peer support and supervision. The PCT has recently issued Terms of Reference for the refresh of the Safeguarding Children Executive Group to provide a collective voice at strategic and senior level across all health partners that has formal accountability to the PCT board. However, this is not established and needs further discussion so that its remit is clear and avoids duplication with other groups either in existence or that are forming. Page 14 of 16

15 63. There are clear governance structures to provide good board assurance on safeguarding activity within the Epsom & St Helier Hospitals NHS Trust. These are being strengthened by the use of a comprehensive audit programme on safeguarding children activity. The board receive the annual report as well as a six monthly update and any exception reports. The key performance indicators include performance against CQC Outcome 7, uptake of training and supervision, attendance at conference. The trust board for Epsom & St Helier Hospitals NHS Trust have all received their board straining on safeguarding children. 64. The South West London & St George s Mental Health NHS Trust Board arrangements for providing assurance on safeguarding activity are adequate. The trust board receives the annual safeguarding children board report as well as quarterly reports for safeguarding. The Director of Nursing Services and Operations is the trust board lead and the board has recently appointed a non executive from ADASS with an interest in safeguarding to complement the team. The trust held a Think Family event in Autumn that board members supported and were highly visible at events across the trust to show their support for this approach. 65. The South West London & St George s Mental Health NHS Trust Board has recently agreed to implement a set of key performance indicators on safeguarding children activity. These include the identification of dependant children as well as children who are also carers. The trust also receives notification, through their incident reporting, of any young person under 18 admitted onto an adult mental health ward and there are appropriate safeguards built into the protocol. The trust is also looking at supporting adult staff on the Section 136 suite with additional training and input from the Consultant CAMHS to ensure that the team are better skilled to care for a young person. 66. The Royal Marsden Hospitals NHS Foundation Trust has managed well the integration of community health services. They have created new governance structures that combined with robust key performance indicators on safeguarding children activity will provide good assurance to the trust board. However, the impact of these new structures is not yet evident. Page 15 of 16

16 Recommendations Within 3 months (from report) Commissioners and the Royal Marsden Hospital NHS Foundation Trust put a plan in place to ensure the systematic reviewing of the progress of children aged between 2½ and 3½ years old, so that their health and developmental needs are identified before they start school. (Ofsted, 2012). Epsom and St Helier University Hospitals NHS Trust revise the process for arranging appointments later in pregnancy to ensure all cases are tracked and emerging needs are identified promptly by midwifery services. (Ofsted, 2012). South West London and St. George s Mental Health NHS Trust to identify any staff who have yet to receive safeguarding children training and ensure that appropriate training is delivered. (Ofsted, 2012). South West London and St. George s Mental Health NHS Trust and Epsom and St. Helier University Hospitals NHS Trust to ensure that staff working with families where there are child protection plans or child in need plans access supervision by appropriately trained staff on a regular basis, and that robust monitoring mechanisms are in place (Ofsted, 2012) The PCT, Epsom and St Helier University Hospitals NHS Trust and London Borough of Merton to review the arrangements for initial health assessments to ensure that they are carried out within 20 working days of a child or young person becoming looked after (Ofsted, 2012) The looked after children health team employed by the St Helier University Hospitals NHS Trust and the London Borough of Merton should ensure that looked after children and young people are provided with a comprehensive summary of their health history when they leave care (Ofsted, 2012) The looked after children health team, employed by St Helier University Hospitals NHS Trust and the London Borough of Merton should ensure that a robust audit and review programme is in place for all initial health assessments, review health assessments and health plans, so as to promote improvement in their quality. (Ofsted, 2012) Next steps An action plan is required from the commissioning PCT within 20 working days of receipt of this report. Please submit the action plan to your SHA copied to CQC through childrens-services-inspection@cqc.org.uk and it will be followed up through the regional team. Page 16 of 16