18 Safeguarding cover paper oct 16.doc 18.1 Combined executive summary Oct 2016 Final.docx 18.2 Safeguarding Adults Annual Report Oct 2016 Final.

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1 18 Safeguarding cover paper oct 16.doc 18.1 Combined executive summary Oct 2016 Final.docx 18.2 Safeguarding Adults Annual Report Oct 2016 Final.docx 18.3 Safeguarding Annual Report _V10_14 final Sept 7th 16.docx 19 Shadow Joint Commissioning Board.docx 19a TOR BNSSG CCGs joint commissioning board v1.2.docx 20 Cover paper Q&G ToR Oct 2016.docx 20b QAGC ToR (Bristol version).docx 21 Corporate Risk Register - GB cover paper.doc 21a Corporate Risk Register - CRR Oct v2.xlsx 21b Corporate Risk Register - CRR Risk tracker Oct.xlsx

2 Meeting of Bristol Clinical Commissioning Group Governing Body To be held on 25 October 2016, commencing at 1.30pm at Barton Hill Settlement, 43 Ducie Road, BS5 0AX Title: safeguarding annual report Agenda Item: 18 1 Purpose To provide an annual assurance review of the safeguarding arrangements for Bristol CCG 2 Background This safeguarding item includes 3 reports, the safeguarding annual report for adults, the safeguarding annual report for children and a combined executive summary. It is a requirement with in children s safeguarding that under the section 111 audit that the CCG governing body receive an annual report on safeguarding. This report fulfils this requirement. Previous annual reports have been used as effective evidence in internal and external audit reviews of safeguarding arrangement within the CCG and how the CCG quality assurance the commissioned health services. 3 How have service users, carers and local people been involved? These reports have used contributions from health providers, it includes summaries of supervision and support offered by the safeguarding team and includes learning from Serious case reviews, Serious Adult reviews and Domestic Homicides. Families views and opinions are included in these reports. 4 Implications on equalities and health inequalities. As these reports reflect the vulnerabilities of children and young people the impact on health inequalities is reviewed throughout the reports. There is no need for a Quality Impact assessment Please indicate below the age group/s covered by the service/affected by the issue discussed Children/Young People Vulnerable young people unborn 18 years Adults Vulnerable adults Evidence Informed Commissioning If you need this document in a different format telephone the CCG on Page 1 of 2

3 Meeting of Bristol CCG date - subject The reports reflects any references to national legislation. It also includes local guidance and learning related to safeguarding 6 Financial Implications The financial implications are discussed in these papers and the board lead for safeguarding regularly reviews the financial position and needs around safeguarding. The CCG has agreed some increased resources for safeguarding going forward. 7 Legal implications There are no legal implication indicated 8 Recommendation(s) The recommendations have been included in the executive summary and the CCG safeguarding group will monitor progress on these recommendations and provide exception reports to the quality and Governance Committee Jacalyn Mathers Designated Safeguarding Nurse Paulette Nuttall Safeguarding Adults Lead Alison Moon Director of Transformation and Quality Page 2 of 2

4 Safeguarding Children and Adults Annual Report Combined Executive Summary Author: Paulette Nuttall Designated Safeguarding Adults and MCA Lead Nurse Date September 2016 Directors: Alison Moon Transformation and Quality Director Richard Lyle Programme Director, Community, Partnerships 1

5 Safeguarding Children and Adults Reports Executive Summary 1. Introduction The combined executive summary is taken from Bristol CCGs individual Safeguarding Children and Adult s 2015/16 Annual Reports. The executive summary provides Bristol CCG s safeguarding and Quality and Governance Committee an overview of the safeguarding work, giving assurance that the CCG working in partnership has discharged its statutory responsibility to safeguard the welfare of children and adults across the health services it commissions. This has been a very busy year for Children and Adults Safeguarding and aspects of this work is written in more detail in the individual Safeguarding Children s and Adults 2015/16 Annual Reports(See Appendix 1 and 2). 2. Responsibilities for safeguarding in the CCG Bristol CCGs are statutorily responsible for ensuring that the organisations from which they commission services provide a safe system that safeguards children and adults at risk of abuse or neglect. Bristol CCG are required to provide assurance that activity within all commissioned safeguarding services meets national safeguarding standards and demonstrates a model of continuous improvement. This is reflected in local policy and procedure in the CCG governance framework and safeguarding children and adults work programmes. As an organisation, Bristol CCG will also ensure that there is effective safeguarding arrangement in place. This is delivered through the Safeguarding Children and Adults leads who work with commissioners, quality and contract monitoring teams. This also includes the provision of leadership, training, supervision, specialist clinical advice on safeguarding to the CCG and the provider organisations. Bristol CCG has a robust set of safeguarding standards which the main providers provide quarterly reporting on key performance indicators. The children s standards have an annual self-assessment audit return which is based on elements from the section 11 audit. There are proportionate standards in place for small providers too. The safeguarding adult s standards are based on statutory legislation, guidance, current good practice and evidence research. The standards are in line with the 6 key principles that underpin safeguarding adults work and include sections on Mental Capacity Act (2015) and Prevent. The implementation of the care act (2014) in April 2015 has meant that discussions to merge the children and adults standard into one document for providers; was deferred until

6 However, early this year funding had been secured to develop a combined children and adult safeguarding standards. The activity for this is referenced in Appendix 1 of the safeguarding children s report. 2.1 Bristol CCG Safeguarding Group and Governance Structure External Internal Local Authority Bristol CCG NHS England Health and wellbeing Board Governing Body Designated Doctor and Nurse Forum BSAB BSCB Quality & Governance Committee BSAB Sub Groups BSCB Sub Groups Safeguarding Group Named professional Groups Children and Adults Links to relevant steering Groups Dementia, Care Homes, Mental Health and Children 3. Bristol CCG Internal Audit Report Safeguarding As part of the 2015/16 annual audit plan an internal audit undertook a review of the process in place within the CCG to monitor and manage safeguarding systems and processes within organisations for children and adults. The review is aimed to provide assurance to the Governing Body that the CCG has a robust and effective process in place to ensure that commissioned services are compliant with safeguarding duties. The CCGs overall assurance opinion on the design and operating controls is green. 3

7 4. Statutory requirements for Children and Adult 4.1. Children s Working together to safeguard children March 2015 highlights the statutory responsibility on Local authorities to safeguard and promote the welfare of children and protect them from suffering significant harm (children act 1989). The children act 2004 section 10 and 11 place a duty on statutory agencies including all CCGs and NHS England: Section 10 places a duty to co-operate with Local authorities, police, etc to improve the well-being of children in the area in relation to: Their physical and mental health and emotional well being Protection from harm and neglect Education, training and recreation The contribution they make to society Their social and economic well-being And section 11 requires the same agencies to ensure that their functions are discharged having regard to the need to safeguard and promote the welfare of children. WTSC /Working_Together_to_Safeguard_Children.pdf Pages of Working together to safeguard children provides the statutory guidance for Health and indicates health s role in safeguarding. This includes training of staff and ensuring they have the core knowledge, skills and competencies, to recognise and respond to safeguarding issues. These competencies are clearly identified in the intercollegiate document Adults Since the implementation of the Care Act (2014) in April 2015 safeguarding adults work within the CCG continues develop in discharging it statutory duties. Bristol CCG has worked effectively through strategic and multiagency arrangements, with partner agencies working with the remit of the Safeguarding Vulnerable People in the NHS The Safeguarding Adults: Roles and competences for health care staff Intercollegiate Document was developed in response to policy developments. This includes Transforming Care a National response to Winterbourne View Hospital (2012), the Care Act 2014, and Themes and lessons learnt from NHS investigations into matters relating to Jimmy Savile, (2015). All had identified the need for training across the UK and reinforced the need to improve the safeguarding skills and understanding of health staff, and to improve access to safeguarding training. 4

8 This document was released following publication in early 2016 and was subsequently removed. NHSE released a statement indicating that the document needed further work from the colleges to be done.. 5. Safeguarding Education and Training Safeguarding children adults training is monitored for compliance through commissioner s contract compliance, quality assurance meetings and quarterly reporting. 5.1 Children The main safeguarding reports highlight the compliance across all safeguarding training levels. The CCG have addressed any compliance issues with each provider individually and there has been progress especially with level 1 and 2 training. The lower compliance with level 3 training has been attributed to the number of new junior Doctors joining acute trusts, changes in IT systems and recording training and vacant named nurse posts. Most of these will be resolved in The new Designated Doctors will review the Doctor training in the next reporting period. The table below highlights the trends in safeguarding level 3 children s training across the 4 main providers and the CCG in the last 4 years. The standards indicate all providers should reach and maintain a 90% compliance with their safeguarding children s training. The lack of compliance with this training must be monitored and addressed more closely and in the next reporting period. 120% 100% Safeguarding Children Level 3 training % 60% 40% 20% March 31st 2013 March 31st 2014 March 31st 2015 March 31st % UHB NBT BCH AWP Bristol AWP Specialist BCCG Anyone who has not met this target has to provide exception reporting and this is monitored through the regular quality performance meeting with the commissioners or through their governing bodies. Although the training compliance has not reached the agreed standards in UHB there is an increased number of referrals and activity around safeguarding. Both UHB and NBT had 5

9 positive results from their CQC safeguarding inspections especially for staff knowledge and awareness of their safeguarding teams. There are very small numbers of staff in the CCG who require level 3 training. Some staff booked on training in a timely manner but the courses were cancelled. The CCG has reported their concern about cancelled courses to the BSCB. The level 3 training is now monitored monthly. 5.2 Adults Safeguarding means protecting an adult s right to live in safety, free from abuse and neglect. It is about people and organisations working together to prevent and stop both risks and experience of abuse or neglect, while at the same time ensuring the adult s wellbeing is promoted, including where appropriate, having regard to their views, wishes, feelings and beliefs in deciding on any action. Professionals should work with the adults to establish what being safe means to them and how that can be best achieved. Since the implementation of the Care Act 2015, single and miluagency training for commissioners and providers includes the key principles of safeguarding and the voice of the adult (making safeguarding personal) and other elements of the Act. A change to the Mental Capacity Act 2014 and the work of Prevent has also meant that training in these areas was also inextricably linked to the work safeguarding adults. Compliance training for Safeguarding Adults and Mental Capacity Act (MCA)is set at 90% for CCG and Commissioned provider/s. Workshop to Raise Awareness of Prevent (WRAP) training is set at 85% over 3 years as stated in NHSE prevent competency framework Bristol CCG Safeguarding Adults Level 1 training 1-3 year expiry is captured in a graph below. Method of delivery for this training is at induction and e-leaning Compliance Percentages Safaguarding Adults Level 1 MCA Q2 July -15 Q4 Jan-15 Q1 April -16 Q2July -16 6

10 6. Serious Case Reviews (SCR) Safeguarding Adult Reviews (SAR) and Domestic Homicide Review (DHR) There has been an increase in the number of Serious Case Reviews (SCRs), Safeguarding Adults reviews (SARs) and Domestic Homicide Reviews (DHRs).Local areas are expected to undertake multiagency reviews working with agencies involved in identifying the lessons that can be learned with a view to changing practice. The reviews take a while to be completed and published. So during the review process the safeguarding children and adults lead provide regular updates to the safeguarding group and Quality and Governance Committee. 6.1 Children (SCRs) In Bristol we have published two SCR in One was Child T which related to the death of a young baby. The father was jailed for 6 years for manslaughter. The other case was Operation Brooke, which was a major criminal investigation into child sexual exploitation in the Bristol region. There were 13 perpetrators convicted of 42 child sexual exploitation offenses and they received a combined prison sentence totalling 116 years. The learning from this case has been incorporated into the BSCB SCE sub Group. There is strong health leadership and engagement with this work. There are a further 3 SCR which have progressed through with a plan to publish these in autumn All 3 cases had involved either criminal or coroners courts. These processes have delayed the progression of these cases. There are also 4 Child Protection- Independent Reviews (CP-IR) these cases have raised concerns about multi-agency working but have not reached the threshold for a full SCR. There is a Health co-chair on 3 of these cases and health staff have been involved in the case groups. These cases should be reported in The high volumes of SCR have a huge impact on the capacity of the safeguarding teams and this will be monitored across health more closely in This work will also be informed by any changes implemented from the Wood Report which was under consultation during The final report with the government s response has now been published and will be part of the safeguarding work plan for Adults (SARs) The Safeguarding Adults requirements of the Care Act will be implemented on 1st April Safeguarding Adults Boards(SAB) must arrange a Safeguarding Adults Review (SAR) when an adult in its area dies, or is subject to serious abuse or neglect, and there is concern that partner agencies could have worked more effectively to protect the adult. The process for undertaking a SAR is to be presented to Bristol Safeguarding Adults Board (BSAB) in April SAR findings and subsequent action plans must be published in the SAB s annual report. From 1st April 2015 the term SAR will be used for lessons learned activities 7

11 commissioned by the BSAB. The term Serious Case Review will no longer be used. However, prior to the implementation of the Care Act in April 2015 Bristol had 4 cases which will be published under the title of Serious Case Reviews. RC Serious Care Review and the Bristol Safeguarding Adults Board Response 2016 : Domestic Homicide Reviews (DHRs) 7. Key Achievements Domestic Homicide Reviews (DHRs) were established on a statutory basis under Section 9 of the Domestic Violence, Crime and Adults Act (2004). They came into effect on 13 April The aim in publishing the reviews is to restore public confidence and improve transparency of the processes in place, across all agencies, to protect victims. Since June 2014 there has been 3 published Bristol Domestic Homicide Reviewshttps:// to Safeguarding Adults Reviews, we have also seen a rise in the request for Domestic Homicide Reviews. There is currently 1 active DHR in progress following the sentencing of the perpetrator. The Domestic Advisory Group has met to discuss a further 3 Domestic Homicides which had occurred in Bristol within the last 4 months. The Safeguarding Adults Lead has been keeping the CCG and NHSE updated. 7.1 Children The level of health engagement with Bristol Safeguarding Childrens Board, (BSCB) including Vice Chair, there is now a health representative and every appropriate sub group. Also during this reporting period the named professionals group chaired by the CCG has now been accepted as an official BSCB sub group. It has been renamed the BSCB Health Sub Group The work of the BSCB Child Sexual Exploitation (CSE) sub group has been very intensive this year with the publication of the Serious case review operation Brooke which related to CSE. The deputy designated nurse for safeguarding is now the co-chair of this group. The CCG have provided several training events for GPs to learn about CSE and how to recognise and respond to any identified risks The Designated Doctor has been the chair of the BSCB training sub group and this work included organising the BSCB annual conference and coordinating an audit of the learning culture for all the services and organisations working in Bristol. Bristol has continued to demonstrate national leadership in the CCGs work on FGM. The designated Nurse and the lead commissioner for the Bristol 8

12 Community Rose clinic led a workshop at the NHS England Conference for FGM international zero tolerance day in London Bristol has been very successful with appointing a new Designated Doctor. This succession n planning and future proofing of this role through new commissioning provides security for the CCGs continued support from a Designated Doctor for the next 5 years. The safeguarding team have recorded a 26% increase in the amount of supervision and support offered to a range of professionals. This level is an under reporting as it does not accurately include the contact received by the named and designated doctor. The Link GP meetings have continue to be developed this year and the meeting and newsletters have covered a large number of important topics as well as providing the link GPs with an opportunity to discuss cases. These meetings are valued by the Link GPs and this year 96% of the GP practices have attended a link GP meeting. The number of GPs attending Training this year increased from 107 to 135. The level 3 training is supported by a local social worker. Looked After Childrens work in Bristol has continued to be demanding, there were 455 children who were recorded as being in care for more than 1 year. There are over 700 children in care. The looked after service have piloted a care leavers passport during and this will be in place for all care leavers in Mental health and well-being is part of the statutory duty for health services to act and safeguard children. The children s commissioning team have secured funding to work on the local transformation plan. This is a 5 year program which will tackle many aspects of mental health and well-being. Community based eating disorder services are the first priority The safeguard teams both adult and children have secured 80,000 from NHS England funding. The funding is split between 2 projects and both projects are managed jointly with south Gloucestershire CCG. The projects are developing combined safeguarding adults and childrens standards, and piloting a Multiagency Safeguarding Hubs (MASH) in Bristol 7.2 Adults The work of Adult Safeguarding is now fully established in the CCG, the Strategy and operational framework,multi- agency processes and systems that were initiated within the last 2 years are now embedded and operational The Professional Adult Safeguarding Group has met three times this year and is chaired by the CCGs Transformation and Quality Director. Our purpose is to promote good working relationships between NHS providers 9

13 working within the parameters statutory requirements and Legislation for adult safeguarding. Terms of reference have been drafted and membership to this group is safeguarding adult s leads from CCG, AWPT, BCH, BRISDOC, Care Uk SWAST and NBT The CCGs role as a statutory core member of the Bristol Safeguarding Adults Board (BSAB) is now established Being a direct point of contact within health to support the queries raised by health colleagues when they are confronted with a safeguarding concern and they require signposting to the most appropriate person or professional. As part of the 2015/16 annual audit plan an internal audit undertook a review of the process in place within the CCG to monitor and manager safeguarding events with organisations. The review is aimed to provide assurance to the Audit Committee that the CCG has a robust and effective process in place to ensure that commissioned services are compliant with safeguarding duties. The CCGs overall assurance opinion on the design and operating controls is green. To support the increasing work capacity of safeguarding adults within the CCG, funding for a band 7 Safeguarding Adults Deputy has been secured All practices have nominated a practice lead in Adult Safeguarding and every lead has attended level 3 training which has included Self Neglect, Domestic Violence, Human Trafficking, Prevent, and Safeguarding in Learning Difficulties. supported by The CCG Safeguarding GP and the Safeguarding Adults Lead The Designated Safeguarding Adults and MCA Lead provide safeguarding level 2 (including MCA) training for the LMC/ GP Education when requested. Training has also been delivered to GP and Practice staff across the city. The development of a Safeguarding Adults workbook has proved successful and is being used to support ongoing practice in the work place We have secured funding through Better Care 206/17 to continue the work of the Care Home Support Team. The teams primary objective will be to improve quality of care provided in care home with nursing WRAP training for CCG is at 66% The Development of the Care Home Directory for Care home staff. The purpose of the directory is to inform Care Home Staff of all the specialist and community services they can access for residents. The directory provides a list of services available and with contact details about each of the services and criteria for referral. 10

14 8. Challenges We have identified that there is work to be undertaken regarding the development of the transition between safeguarding children and adults. Safeguarding Children s procedures cover children and young adults up to the age of 18 years and. Safeguarding Adults procedures cover all adults from the age of 18 years. Our work will need to include how we work with commissioners and local authority colleagues. Key areas to consider:- Principles Investigation Protection plan arrangements The management of case transfers 8.1 Children The main challenges for Children safeguarding over the next months are To ensure the CCG can evidence it has a robust process in place to monitor and influence all providers compliance with their safeguarding training especially around level 3 Ensuring the improvements in Bristol mental health are maintained and the safeguarding team is established and has enough time to be effective. To monitor NBT s compliance with FGM mandatory recording. Staff have been collecting the data but there has been some internal failure in the process for uploading and sharing this data with the HSCIC. This lack of data has been highlighted by NHS England and the DH. The issue has been raised with the safeguarding board lead in NBT and they have committed to addressing this issue. Bristol continues to have a high volume of SCR and CP-IR. The process currently used is time consuming and requires a high level of commitment from both front line staff and health staff on the review team. Currently this work is not recorded. The Wood report will be reviewing the SCR process and the outcome from that needs to be monitored. The CCG must work with each provider to ensure they have reviewed their practice and identified and implemented any single agency learning from each case. 8.2 Adults Similar to children s there has also been an increase in the number of requests for Safeguarding Adults and Domestic Homicide Reviews and the ongoing work activities this brings. As a result of the statutory requirements related to the BSAB and sub groups, this has increased the CCG multiagency working both internal and external 11

15 The Safeguarding Adults: Roles and competences for health care staff Intercollegiate Document is not yet available. this has caused a setback in the work of providers working together to standardise Level 3 training Raising a section 42 enquiry about individuals who are failing to care for they i.e. self-neglect; is deemed not appropriate. The amendment of the Act states that Section 42 is primarily aimed at those suffering abuse or neglect from a third party. This amendment has caused concerns amongst professionals who are working with complex individuals within the community. Facilitating WRAP training for GPs and practice staff all agencies are to be WRAP trained and 85% compliant over a period of 3 years. Prevent Returns are now being requested for information to seek assurance that NHS partner agencies are undertaking WRAP training in line with the NHSE Prevent Competency Framework. Due to conflicting priorities for providers there is a risk of not receiving prevent returns in a timely manner. 9. Future work 9.1 Children The safeguarding childrens team have a work plan for This is based on the BSCB business and work plan and the CQC inspection process. The Wood report May 2016 will have implications for LSCB, SCR and the Child Death Review Process. Some of these changes will need legislative changes especially around the change in accountability for the LSCB from the Local Authority to a triparty system with equal responsibility across health, police and the local authority. The implication is to work better together and not be restricted by organisational boundaries. The implications from this may mirror some of the work of the STPs. The outcome on this is yet unknown and will require senior leadership engagement. The CCG will need to consider how it responds to the statutory guidance for Looked after children service. This will include scoping how the CG accesses strategic nursing leadership and if the current process is sufficient. The progress and outcomes from the two NHS England Funded Projects will be a large focus on how Adult and Childrens Safeguarding can work together. The safeguarding group will receive regular briefings on these projects. The outcomes of the projects will be shared with NHS England South West Region at a regional conference in November Adults The work of Adult Safeguarding is now fully established in the CCG, the Strategy and operational framework,multi- agency processes and systems that were initiated within the last 2 years are now embedded and operational (subject to further legislative changes). The updated Work Programme provides an insight of the associated activities that underpins 12

16 and maintains the work of safeguarding and has links with the BSAB strategic plan. Paulette Nuttall Designated Safeguarding Adults and MCA Lead Nurse Jacalyn Mathers Designated Nurse for Safeguarding Children 13

17 Appendix 2 Safeguarding Adults Annual Report Author Paulette Nuttall Designated Safeguarding Adults and MCA Lead Date June 2016 Directors Richard Lyle Programme Director, Community, Partnerships Alison Moon Transformation and Quality Director 1

18 Contents 1. Introduction Purpose Safeguarding Adults National Context Care Act (2014) update How will the changes to the Care Act guidance impact on NHSE policies Health and Social Care? Actions for the CCG Safeguarding Adults: Roles and Competencies for health care staff Intercollegiate Document NHS and Prevent Safeguarding and Prevent NHSE England Prevent Updates Prevent work Local to Bristol Workshop to Raise Awareness Prevent (WRAP) Training for the CCG. 9 5 Mental Capacity Act (2005) and Deprivation of Liberty Safeguards Mental Capacity Act Deprivation of Liberty Safeguards Deprivation of Liberty in domestic settings Safeguarding Adults Local Context Safeguarding Adults within the CCG Bristol CCG Internal Audit Report 04/ Policy and Practice Safeguarding Adult standards 2016/ Training and Education for the CCG Standardising Safeguarding Adults Level 3 Training Safeguarding Adults, MCA and WRAP training Bristol CCG Safeguarding Adults Level 1 training 1-3 year expiry Interpreting the data Mental Capacity Act and Deprivation of Liberty Safeguards Other training and updates provided by the by the Safeguarding Adults Lead for the CCG Safeguarding Adults and MCA training figures from Commissioned NHS Providers Safeguarding and Leadership Bristol CCG Safeguarding GP lead, Dr Pippa Stables, appointed

19 April Future work Quality Assurance Care Quality Commission Monitoring Meetings Care Home with Nursing and Safeguarding Organisational abuse Care Home Support Team Challenges Moving forward Care Home Support Team and Virtual Team Care Home Support Team s Objective The nature of work and support provided by the Care Home Support Team will include: Care Home Directory Care Quality Commission ratings and safeguarding concerns CQC rating response (Appendix1) Safeguarding response (Appendix 3) Managing Care Homes Closures guidance Multiagency Risk Assessment Conference (MARAC) Bristol. Ali Mann MARAC Health Professional Overview of MARAC Bristol MARAC MARAC Statistics January to December Overview of the MARAC Health Professional Role CCG Health Professional MARAC Activity January 2016 to May Identification and Referral to Improve Safety (IRIS) Multiagency Partnership Working Bristol Safeguarding Adults Board (BSAB) Financial Contribution for the BSAB for the joint Business Unit NHS Contributions for 2016/ Safeguarding Adults Reviews Background for Safeguarding Adults Reviews RC Serious Care Review and the Bristol Safeguarding Adults Board Response BC Serious Case Review... Error! Bookmark not defined SR Serious Case Review... Error! Bookmark not defined MM Serious Case Review... Error! Bookmark not defined. 3

20 16.6 Update on the work of Safeguarding Adults Reviews Domestic Homicide Reviews Challenges for 2016/ Safeguarding Adults programme of work for Bristol CCG April 2016 to March Appendix a. Appendix 1: Care Quality Commission Report Protocol for Full-Funded CCG Placements b. Appendix 2: Safeguarding Alert Protocol for Fully-Funded CCG Placements

21 1. Introduction Safeguarding is everyone s business. Bristol Clinical Commissioning Group (CCG) is committed to working with partner agencies to ensure the safety and health and well-being of the local people in Bristol. Protecting the vulnerable is a key part of our approach to commissioning and, together with a focus on quality and patient experience, is integral to how we work. Our approach to safeguarding is underpinned by a performance management culture, contracting systems and processes that aim to reduce the risk of harm and respond quickly to any concerns. Over the last year the CCG has been developing its statutory duties role and responsibilities working in partnership with other NHS and statutory agencies. This is the second CCG Safeguarding Adults Annual Report and provides an overview of the key achievements and ongoing work with some of the key challenges following the implementation of the Care Act in April The CCG Safeguarding Adults programme of work is regularly reviewed and updated by the Safeguarding Adults and Mental Capacity Act Lead nurse and the Safeguarding Adult GP Lead. 2. Purpose The purpose of this report is to inform Bristol CCG s Governing Body, Quality and Governance Committee and the Safeguarding Group how the CCG is ensuring that statutory duties and requirements for safeguarding adults are being met. 3. Safeguarding Adults National Context The work of Safeguarding Adults within the NHS continues to evolve, in particular the role of the CCG as an organisation, discharging its statutory duties and ensuring that safeguarding arrangements are in place. Since the implementation of the Care Act (2014) in April 2015, there has been a number changes, in particular Chapter 14 of the Care Act. 4. Care Act (2014) update On March 10 th 2016, the Department of Health published the refreshed edition of the Care and Support statutory guidance. The statutory guidance supports implementation of Part 1 of the Care Act 2014 by local authorities, the NHS, the police and other partners. The new edition supersedes the version issued in October It takes account of regulatory changes, feedback from stakeholders and the care sector and developments following the postponement of social care funding reforms to

22 Chapter 14 Safeguarding has had the most significant amendment made for reason of accuracy or clarity. changes have been made through reflective learning, the first period of implementation and feedback from stakeholders and partners. 4.1 How will the changes to the Care Act guidance impact on NHSE policies Health and Social Care? Claire Crawley, Senior Policy Manager, Adult Safeguarding at the Department of Health for the Care Act, spoke at the South West ADASS Annual Safeguarding Conference on the 17 th March In summary, the Care Act guidance remains woolly in areas and more work is required. Initially, there was a drive to align the statutory guidance with children s. However, there was a general recognition that the expectation and the work related to this was not possible. The Designated Safeguarding Adults Manager (DSAM) title may have been removed from the guidance, but the message was clear in that the functionality and leadership role and responsibilities still exists. However, a greater emphasis is placed on the role of the Principle Social Worker within the Local Authority. Raising a Section 42 enquiry about individuals who are failing to care for themselves (i.e. self-neglect) is not deemed appropriate. The amendment of the Act states that Section 42 is primarily aimed at those suffering abuse or neglect from a third party. 4.2 Actions for the CCG The CCG is to seek clarity from NHSE on the interpretation of the DSAM role within the 2015 Accountability and Assurance Framework and to agree a response, i.e. communicating a business as usual approach to NHS providers. The Safeguarding Adults Lead GP will be working on interpreting what the changes to the Section 42 enquiry and self-neglect mean in practice for GPs. The Bristol CCG Safeguarding Adults Policy will be amended to reflect the changes in the Care Act guidance. 4.3 Safeguarding Adults: Roles and Competencies for health care staff Intercollegiate Document The intercollegiate document was developed in response to policy developments, including Transforming Care: A National Response to Winterbourne View Hospital (2012), the Care Act 2014, and Themes and lessons learnt from NHS investigations into matters relating to Jimmy Savile, (2015), which all identified the need for training across the UK and reinforced 6

23 the need to improve the safeguarding skills and understanding of health staff, and to improve access to safeguarding training. This document was released following publication in early 2016 and was subsequently removed. NHSE released statement indicating that the document is still under review and is being ratified by the royal colleges. Advice has been given to use the existing document for guidance only. 4.4 NHS and Prevent The CCG has a responsibility to oversee how the organisations from which it commissions services are complying with the requirements of the National NHS contract, in which Prevent is now included in Service Condition 32 in which every organisation is required to: Nominate a Prevent Lead Programme to raise awareness of Prevent include in relevant policies and procedures a programme to raise awareness of the Government Prevent Strategy among Staff and volunteers in line with the NHS England Prevent Training and Competencies Framework; and include in relevant policies and procedures a WRAP delivery plan that is sufficient resourced with WRAP facilitators. The CCG s has two roles in relation to Prevent the first is the responsibility for its own staff and the second, to ensure that commissioned services are safe, fit for purpose and compliant with safeguarding requirements. Radicalisation is now considered to be a specific safeguarding category under The Care Act 2014 for adults, as well as for children and young people. However, it is acknowledged that his cannot be undertaken without the involvement of the following stakeholders illustrated in

24 4.4.1 Safeguarding and Prevent Safeguarding Information & Communication Local Security Management Specialist Chaplaincy Prevent Lead Local Authority/Statutory partners Learning & Development HR/Workforce CTU Emergency Planning Safeguarding Prevent is a safeguarding responsibility, however, in some organisations where Prevent does not sit in safeguarding, it is recommended that in these cases working together to forge strong links must be made. Local Security Management Specialists and Emergency Planning already conduct work in relation to the other Counter Terrorism Strategy (CONTEST) work streams Ps, Protect, Prepare, and Pursue. The Prevent Lead is expected to maintain working relations with the parallel work streams. Local Authorities have the coordination lead for the Prevent activities which provides an opportunity to engage with and listen to community leaders. In Bristol the CCG, Prevent Lead attends the Local Authority Prevent meetings. Any actions and outcomes are shared with the NHSE Regional Prevent Co-ordinator. Counter Terrorism Unit (CTU) colleagues provide support and guidance for NHSE CCG and NHS Providers. Their knowledge and skills will help colleagues to understand risks and threats in the areas their services operate. Information they share is extremely useful to Workshop to Raise Awareness of Prevent (WRAP) Facilitators who can use it to highlight previous terrorist incidents or current activity a local audience can relate to, and makes the issues more relevant to them. HR will provide expert input on staff making referrals about colleagues, as they are familiar with whistle blowing procedures and existing support mechanisms available to staff. 8

25 It can be a challenge for prevent leads to incorporate WRAP training in to their organisations training delivery plan. It is recommended that the Prevent Lead should be supported by their executive Lead and Learning and Development department. This would be to establish ways in which existing training can be modified or existing programmes updated to ensure staff receive Prevent training relevant to their role as per the NHS England Prevent Training & Competencies Framework. (See 4.4.4) ICT will be the experts who know or can enhance IT and communications access applications and restrictions to ensure NHS resources are not abused for, or to support, terrorist related activity NHSE England Prevent Updates NHS England provides updates to CCG prevent leads in priority and non-priority areas. (Local authorities across the UK are categorised by the Home Office on the basis of risk as either Priority or non-priority Areas). The workshops serve to share best practice and to provide advice and guidance for Prevent Leads. This year s focus is on embedding Prevent in safeguarding activity and to ensure there is a wider understanding from professionals that radicalisation is a safeguarding issue for 2016/17 and the challenges this brings in implementing the Prevent Duty Guidance Prevent work Local to Bristol Building the Bridge is a Bristol-based forum that links Bristol s Muslim communities and groups with the City Council, police education and NHS in the city. The forum aims to encourage and support the Muslim community to play an active part within the communities of Bristol. The Board meets quarterly and have a programme of work. It receives regular Prevent Case Management and Quarterly Channel Updates for Bristol. Working groups which feed into the Board include the following working groups and Partnership Advisory Groups (PAGs): Training and Communications Extreme Right Wing PAG Women s PAG Muslim Forum PAG: Workshop to Raise Awareness Prevent (WRAP) Training for the CCG Since February 2016 the CCG has received WRAP training from the Safeguarding Adults Lead. 9

26 The workshop is about an hour long and aims to: - Understand the aim of Prevent - Think about who may be vulnerable to terrorism - See why some people are able to influence and manipulate others to commit crimes - Recognise when vulnerable individuals may be in need of help - Be clear about what help and support looks like in this area and who to turn if there are concerns The training is available to all CCG Staff and LEG members and so far the sessions have been well attended. The WRAP delegate feedback forms completed following the sessions by the attendees are sent on to NHSE Regional Prevent Coordinator. The feedback is collated nationally and the information is used to review and to evaluate the Government training resource. Training compliance for all organisations for WRAP training is 85% over 3 years (NHS England Prevent Training and Competencies Framework 2015). Our WRAP training figures is at 67% compliance. The Safeguarding Adults Lead is currently working with Learning and Development CSU to ensure that the training is recorded on the new management learning system. The progress of this is reported quarterly to the CCG Safeguarding Group and Quality and Governance groups. Further training resources has also been provided by the SW Counter Terrorism Intelligence Unit Avon and Somerset and Wiltshire Constabularies Prevent Lead. These are to be made available for staff to access for updates once they have undertaken the WRAP training. _Awareness - A minute awareness raising package - Let s Talk About It preventing people becoming terrorists. - a link to a YouTube video by Avon and Somerset police called Community Response. This is a series of community members talking about extremism, jihadism and other issues. - This short film focuses on three Syrian refugee mothers speaking directly to mothers in the UK about the realities of life in Syria and asking why any mother would want to take their family to live in a war zone. It is complemented by open letters (below) that the women have written urging mothers in this country to take steps to prevent their daughters from travelling to Syria. 10

27 5 Mental Capacity Act (2005) and Deprivation of Liberty Safeguards 5.1 Mental Capacity Act The Mental Capacity Act is integral to the CCG primarily as we need to be assured that the services we commission on behalf of the Bristol population are being delivered in a way that respects individuals who are less able to make decisions on their own behalf. Everyone has a duty to ensure that they are aware of their responsibility as they may be the best person to advocate on behalf of a service user in order to ensure the best outcomes achieved in each individual circumstance. Secondly, in circumstances where there is a failure to provide care within the MCA framework, this could be deemed unlawful. However, whilst the provider organisation is primarily responsible for acting with the law, the commissioner could also be found liable. The CCG is also responsible for ensuring that all services we commission for people aged over 16 demonstrate compliance with the MCA. 5.2 Deprivation of Liberty Safeguards The Deprivation of Liberty (DoLs) safeguards within the MCA provides a legal protective framework for those vulnerable/at risk people who are deprived of their liberty and not detained under the Mental Health Act Article 5 of the European Convention on Human Rights. The safeguards apply to people in hospitals and homes (whether privately or publicly funded) and their purpose is to prevent arbitrary decisions that deprive vulnerable people of their liberty. In the event of it being necessary to deprive a person of their liberty, the safeguards give them rights to representation, appeal and for any authorisation to be monitored and reviewed. People can be deprived of their liberty in settings other than hospitals and care homes such as supported living but in such cases the deprivation can only be approved by the Court of Protection and applications for authorisations in such circumstances should be made to the Court Deprivation of Liberty in domestic settings The Supreme Court held that a deprivation of liberty can occur in domestic settings where the State is responsible for imposing such arrangements. This includes a placement in a supported living arrangement in the community. Where there is, or is likely to be, a deprivation of liberty in such placements, it must be authorised by the Court of Protection. The changes in the Mental Health Act following the Cheshire West Ruling in March 2014 has had a significant impact on how commissioners discharge their duty of care in monitoring Service 11

28 Level agreement and Quality Assurance. In addition, the CCG provides care packages for a number of services users within the remit who are likely to be deprived of their liberty in the community. The Bristol CCG Continuing Health Care (CHC) team is aware of the impact that community DoLs will have on the CCG and continue to review their CHC patients. We currently have 5 active Court of Protection cases led by the CHC Programme Manager and members of the commissioning team. Mental Capacity Act update training for commissioners are in the process of being arranged to ensure that commissioners understand their roles and responsibilities in accordance with current legislation training. The CCG Mental Capacity and DoLs 2016/17 policy is currently being reviewed to ensure that the policy meets legislation requirements. 6 Safeguarding Adults Local Context Bristol CCG is responsible for commissioning hospital and community healthcare services. The CCG will need to assure itself that the organisations from which we commission have effective safeguarding arrangements in place throughout the year to ensure continuous improvements. These are monitored and communicated through a number of routes: Safeguarding Adults Standards, quality accounts and annual reports, quarterly training reports and quality and governance i.e. Serious incidents and Root Cause Analysis. 6.1 Safeguarding Adults within the CCG In terms of Adult Safeguarding, the CCG as a statutory body has ensured that safeguarding is integral both internal and external to the organisation. How we work is reflected through service development, quality improvement, and clinical governance and risk management arrangements. Our role as a core member to the BSAB executive board and partner agency membership to the BSAB subgroups has been influential in decision making. (See work programme at the end of this report). 6.2 Bristol CCG Internal Audit Report 04/16 As part of the 2015/16 annual audit plan, an internal audit undertook a review of the process in place within the CCG to monitor and manager safeguarding events with organisations. The review is aimed to provide assurance to the Audit Committee that the CCG has a robust and effective process in place to ensure that commissioned services are compliant with safeguarding duties. The CCG s overall assurance opinion on the design and operating controls is green. 12