Safeguarding in Portsmouth

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1 Safeguarding in Portsmouth Annual Report Author Tina Scarborough, Head of Safeguarding and Patient Safety June 2016 (Ratified at CCG Governing Board Meeting ) 1

2 Contents 1 Introduction 3 2 Purpose 3 3 Statutory Framework and National Policy Drivers 3 NHS Governance Arrangements for Safeguarding at NHS Portsmouth 4 Clinical Commissioning Group (CCG) 5 5 Partnership Working and Assurance 8 6 Care Quality Commission Inspections 10 7 Monitoring 10 8 Children's Safeguarding 11 9 Looked After Children (LAC) Adult Safeguarding Safeguarding Adult Reviews Domestic Homicide Review (DHR) Mental Health Review Prevent Mental Capacity Act and Deprivation of Liberty Safeguards Key Achievements 2015/ Areas for Development for 2016/

3 1. Introduction This is the second annual report to Governing Body of NHS Portsmouth Clinical Commissioning Group (CCG) and covers the period from 1 st April 2015 to 31 st March Purpose This report provides Portsmouth CCG s Governing Body with an overview of safeguarding across health services in Portsmouth during 2015/16. The report reviews the work across the year, giving assurance that the CCG has discharged its statutory responsibility to safeguard the welfare of children and adults across the health services it commissions. It includes the actions taken over the previous year to meet these responsibilities and identifies priorities for 2015/16. It is not intended that this report will simply replicate information that is being made available through other annual reporting documents, for example Provider Organisations and Safeguarding Boards Annual Reports. The report will be shared with the Portsmouth Safeguarding Children Board (PSCB), the Portsmouth Safeguarding Adults Board (PSAB) and the Wessex Area Team, NHS England 3. Statutory Framework and National Policy Drivers NHS Portsmouth CCG is committed to safeguarding and promoting the welfare of children and adults. The responsibilities for safeguarding are enshrined in legislation. Some duties apply only to children; some apply only to adults, and some to both. 3.1 Safeguarding Vulnerable People in the NHS: Accountability and Assurance Framework (July 2015). The purpose of the framework is to set out clearly the safeguarding roles, duties and responsibilities of all organisations commissioning NHS health and social care. The framework replaced the Safeguarding Vulnerable People in the NHS (March 2013) to recognise the new responsibilities set out in the Care Act Additional statutory guidance is in place to provide a framework to support NHS organisations in order to fulfil their child and adult safeguarding duties: 3.2 Working Together to Safeguard Children 2015 (WWT) (HM Government) The updated WT was published in March 2015 to include changes due to the Care Act 2014 and Counter terrorism and Security Act Additionally, there have been minor updates to include child sexual exploitation (CSE) and female genital mutilation (FGM). 3.3 Promoting the health and well-being of Looked After Children (DH March 2015) The document first published in 2009 has been updated to reflect reforms to the NHS following the Health and Social Care Act Royal College of Paediatrics and Child Health, Safeguarding children and young people: roles and competences for health care staff INTERCOLLEGIATE DOCUMENT (March 2014) Safeguarding competences are the set of abilities that enable staff to effectively safeguard, protect and promote the welfare of children and young people. They are a combination of skills, knowledge, 3

4 attitudes and values that are required for safe and effective practice. The document identifies the training requirements of all health care staff and also outlines the roles of key professionals in Safeguarding Children. 3.5 Royal College of Nursing and the Royal College of Paediatrics and Child Health, Looked after children: Knowledge, skills and competences of health care staff INTERCOLLEGIATE ROLE FRAMEWORK (March 2015) The competences encompassed in the framework are the set of abilities that enable staff to effectively safeguard, protect and promote the welfare; health and wellbeing of looked after children and young people, as well as care leavers. They are a combination of skills, knowledge, attitudes and values that are required for safe and effective practice. 3.6 The Care Act 2014 The Care Bill received Royal Assent on 14th May 2014 and was effective from 1st April The Act consolidates good practice into statute and also brings in new reforms. It embeds and extends personalisation as well as having an increased focus on wellbeing and prevention. The Act made significant changes to adult safeguarding as it imposes new duties on Local Authorities and introduces new terms. The Act provides the first statutory framework for adult safeguarding, and sets out key responsibilities of local authorities and partners: Safeguarding Adults Boards must be created in every local Authority area. Each local authority has a duty to carry out enquiries where it suspects that an adult is at risk of abuse or neglect. Each Safeguarding Adults Board (SAB) must include the local authority, CCGs and the police to co-ordinate activity to protect adults from abuse and neglect. A duty is placed on the organisations making up the SAB to co-operate with one another and if they are unable to do so they must explain why in writing to the Secretary of State. SABs must carry out safeguarding reviews into cases where someone dies and there is a concern about how authorities acted, to ensure that lessons are learnt. 3.7 Care and Support Statutory Guidance October 2014 The statutory guidance was intended to provide local authorities with the information they need about how they should meet the legal obligations placed on them by the Care Act and the regulations. Local authorities are required to act under the guidance, which means that they must follow it, unless they can demonstrate legally sound reasons for not doing so. This Guidance was updated in March Safeguarding Adults: Roles and competences for health care staff Intercollegiate Document (Feb 2016). NHS England published the intercollegiate document to give detail to the competences and roles within adult safeguarding. The guidance is to be used for the training of healthcare based staff in the safeguarding of adults who may be at risk of harm, abuse or neglect. 3.9 The Counter-Terrorism and Security Act 2015 The Act received Royal Assent on 12 February 2015 (see Prevent- Section 14) and includes a duty on specified bodies, including the police, prisons, local authorities, schools and universities, to have due regard to preventing people being drawn into terrorism. It also makes Channel (the voluntary programme for people at risk of radicalisation) a legal requirement for public bodies so that it is delivered consistently across the country. 4

5 3.10 Counter-Extremism Strategy 2015 The Strategy supports the implementation of the Counter-Terrorism and Security Act It builds on the PREVENT duty and focuses on four areas: countering extremist ideology, building a partnership with those opposed to extremism, disrupting extremists and building more cohesive communities Modern Slavery Act 2015 The Modern Slavery Act received Royal Assent on 26 th March 2015 and makes it easier to prosecute traffickers and slave masters. There is added protection for survivors 3.12 Serious Crime Act 2015 The Serious Crime Act gives effect to a number of legislative proposals in the Serious and Organised Crime Strategy. In doing so, it builds on current law to ensure that the National Crime Agency, the police and other law enforcement agencies have the powers they need to effectively and relentlessly pursue, disrupt and bring to justice serious and organised criminals. In addition, the Act includes provisions to strengthen the protection of vulnerable children and others (including to tackle female genital mutilation and domestic abuse). Healthcare professionals must report to the police any cases of female genital mutilation (FGM) in girls under 18 that they come across in their work. This duty came into force on 31 October NHS Governance arrangements for safeguarding at NHS Portsmouth Clinical Commissioning Group (CCG) 4.1 The CCG recognises that it has a duty to ensure all statutory requirements as outlined in the Safeguarding Vulnerable People in the NHS: Accountability and Assurance Framework (2015) and Working Together to Safeguard Children (2015) are in place. This includes all NHS commissioned services having Named Professionals in place with dedicated time to fulfil their roles and responsibilities as detailed in the Safeguarding children and young people: roles and responsibilities: Intercollegiate Document (2014). All statutory safeguarding roles are currently filled across the NHS Portsmouth CCG area with Child Deaths being covered by the Designated Doctor. 4.2 The GP Executive Leads for Safeguarding are responsible for ensuring that safeguarding is firmly embedded within the whole health economy. This is delivered through local commissioning arrangements. The Head of Safeguarding and Patient Safety reporting to the Director of Quality and Commissioning ensures that the monitoring of safeguarding takes place through the CCG Quality and Safeguarding Executive Group and the Portsmouth Safeguarding Children and Adult Boards. 4.3 Both Designated Nurses (Adults and Children) left their roles during 2015/16. These posts were shared with the IOW CCG. This provided the opportunity for both CCGs to review their arrangements for these roles. Portsmouth CCG designed a new role of Head of Safeguarding and Patient Safety incorporating the Designated Nurse (Adult and Children) functions and a new post holder was recruited and commenced in post on 08 February To support this new role, two Associate Designated Nurse posts, one for Adults and one for Children have been created and appointed to. 4.4 The Designated Looked After Children (LAC) Nurse Role was reviewed and the Service Level Agreement with Solent NHS Trust to provide this function ended on 31 March This function has been incorporated into the new role of Associate Designated Nurse for Safeguarding Children and LAC. 5

6 4.5 Commissioners of Health Care have a duty to ensure that appropriate recognition is made to protect children and adults at risk of abuse and that processes are in place to support practitioners to respond to concerns. Safeguarding is particularly relevant to the domains within the NHS Outcomes Framework 2015/2016 and is a fundamental requirement for registration and compliance with the Care Quality Commission. 6

7 Safeguarding Business Officer NHS Portsmouth CCG Safeguarding Governance Structure Local Authority NHS England Local Area Team Health and Wellbeing Board Portsmouth Safeguarding Children Board Portsmouth Safeguarding Adults Board CCG Governing Board Designated Paediatrician Child Death Reviews Designated Doctor Child Safeguarding Designated LAC Doctor NHS Portsmouth CCG Safeguarding Team Head of Safeguarding and Patient Safety Associate Designated Nurse Safeguarding Children and LAC Associate Designated Nurse Safeguarding Adults Quality & Safeguarding Executive Group CCG Accountable Officer Named GP 7

8 5. Partnership Working and Assurance 5.1 Safeguarding Strategy and Action Plan There are a number of documents and processes to support the CCG in meeting their obligations for safeguarding adults and children. These include: Safeguarding Policy (Adults and Children) Safeguarding Strategy Safeguarding Strategy Delivery Plan (2015/16) Safeguarding Training Strategy The Strategy identifies key adult and child safeguarding priorities upon which the Delivery Plan was developed. 5.2 Accountability NHS England has a statutory requirement to oversee assurance of CCGs in their commissioning role. This is done through the application of the CCG Assurance Framework. NHS Portsmouth CCG is accountable to NHS England Wessex. The following information demonstrates the CCG accountability and provides assurance that the CCG is meeting its statutory duties NHS Portsmouth CCG Quality and Safeguarding Executive Group (QSEG) Assurance about the quality of safeguarding provision of local providers is monitored through the QSEG. A monthly quality and performance report includes safeguarding assurance, progress against the strategic delivery plan and the CCGs response to national and local publications Portsmouth Safeguarding Children Board (PSCB) The CCG is required to demonstrate engagement and effective inter-agency working with local authorities, the police and third sector organisations which includes appropriate arrangements to cooperate with local authorities in the operation of Local Safeguarding Children Boards, Safeguarding Adult Boards and Health and Wellbeing Boards. Portsmouth CCG has remained fully engaged with the work of Portsmouth Safeguarding Children Board. Attendance at the Board and sub groups is monitored (table 1 below). Several sub groups are chaired by designated or named professionals. Table 1 Health Agency PSCB PSCB Executive Monitoring, Evaluation & Scrutiny Committee Child Death Overview Panel Case Review Committee Portsmouth 100% 80% 60% 100% 100% N/A CCG Portsmouth 80% 60% N/A 50% N/A N/A Hospitals Trust Solent NHS 100% 40% N/A N/A N/A 60% Trust SCAS 20% N/A N/A N/A 60% N/A Missing, Exploited & Trafficked Strategic Group Designated Doctor N/A 60% N/A 100% 100% N/A 8

9 The priorities for PSCB in 2015/16 were set out in the Business Plan. These were: Neglect, Views of children and young people, Improving Communication, Tackling Exploitation and Abuse. Work has been done to promote the PSCB Neglect Tool across the health economy. PSCB held an Away Day on 10 th March 2016 and agreed the following four priorities following feedback from Young People for 2016/17: Improve the effectiveness of agencies and the community in addressing neglect; Improve the awareness of Safeguarding, including the work of the Board, amongst practitioners and the community; Tackling exploitation and abuse across young people in Portsmouth, including Child Sexual Exploitation; Tackling bullying in schools and online Portsmouth Safeguarding Adults Board (PSAB) The CCG, along with the Police and the Local Authority are the stipulated statutory partners of the Board. There was a Board Development Day in June 2015 and a clear vision was developed: Portsmouth is a city where adults at risk of harm are safe and empowered to make their own decisions and where safeguarding is everyone s business Four key work streams were identified: Effective Governance (including strategy, and roles and responsibilities) Communication and Promotion of safeguarding Personalisation and Engagement Quality Assurance and Performance The PSAB had a new chair during this reporting period. There has been a long period with no board manager or administrative support and as a result the Board has struggled to meet its Business plan and develop the work streams. The Safeguarding Adult Review (SAR) subgroup chaired by a member of the CCG was the only Group that met consistently throughout the year. The CCG monitors engagement and participation of health providers at all SAB meetings and sub committees of the Board Portsmouth CCG Safeguarding Week The CCG held its second Safeguarding week on 22 nd -28 th June The event included awareness raising displays, learning opportunities, launching of new safeguarding forms including the SAF, and the launch of a resource folder for GP surgeries containing information regarding safeguarding children, produced by the CCG. The designated nurses took part in interaction with passer-by s and raising the profile of the CCG Portsmouth NHS Child Safeguarding Forum This group has continued to grow over the last year and has a flourishing membership. Its key aim is to coordinate child protection and safeguarding activity for NHS staff within Portsmouth as well as providing a platform for shared learning. Throughout 2015 there has been a wealth of guests and specialist speakers who have attended the group and shared current audits and improvements in their services as well as new services to be rolled out across the city. The group continues to meet 9

10 quarterly and memberships consists of safeguarding leads from all health providers across Portsmouth. It is chaired by the Designated Nurse and reports into the Portsmouth Safeguarding Children Executive Committee Provider Safeguarding Committees These are held quarterly and chaired by the Director of Nursing of each organisation. The CCG Head of Safeguarding and Patients Safety and previously the Designated Nurses attend when possible providing opportunity for external scrutiny and a conduit for information sharing Wessex Area Team Safeguarding Network Continues to host a Safeguarding Network Group which provides designated professionals and named GPs with an educational forum and ensures national developments are disseminated. 6. Care Quality Commission Inspections 6.1 The CQC is due to inspect Solent NHS Trust in June The CQC inspection report of Portsmouth Hospitals NHS Trust (PHT) which took place in February and March 2015 was published in June The report rated services for children and young people and services for maternity and gynaecology as good. Both have an outstanding rating for caring. The CQC found Safeguarding processes to protect vulnerable adults, children and young people were embedded across the hospital staff has attended appropriate training, and there was a culture of appropriate reporting. However in April 2016 CQC imposed four conditions on PHT related to the Emergency Department. The staffing and capacity issues in the Emergency Department and pressure to discharge patients are likely to impact on the quality of Safeguarding across the hospital. 6.3 CQC carried out an announced inspection of Hampshire Doctors on Call Service Out of Hours Service in November Overall the service was rated as good. However, there were two areas of practice where improvements were needed. These related practices around chaperoning and ensuring relevant staff receive all mandatory training including safeguarding children and basic life support. 7. Monitoring 7.1 NHS Portsmouth CCG gains assurance from the organisations from which they commission services using a variety of methods. Contracts are monitored against Section C Part 7.2: Safeguarding Policies and Procedures of the Standard NHS Contract. A reporting framework is provided within each contract schedule and quarterly reports are shared with the designated professionals. Annual safeguarding reports from provider organisations are also received. Where possible, providers are encouraged to submit evidence already provided to their own internal assurance processes rather than compile extra data for contract monitoring. 7.2 Concerns raised are addressed through Clinical Quality Review Meetings (CQRMs) which also provide scrutiny and assurance. The CCG will become involved in safeguarding interagency processes where it is felt that there is an increased need for oversight in relation to specific healthcare issues. 7.3 The designated nurses have been involved in the oversight and closure of any Serious Investigations Requiring Investigation (SIRIs) that have a safeguarding element. The appointment of 10

11 the Head of Safeguarding and Patient Safety will provide scrutiny on all SIRIs to ensure safeguarding concerns are not missed. 7.4 Child safeguarding supervision is provided by the designated professionals to safeguarding leads across the Portsmouth Health Services. 8. Children's Safeguarding 8.1 National context Over the past year, child abuse has rarely been out of the public eye. We have seen the continued fallout from decades of horrendous sexual abuse committed by Jimmy Savile, grooming and trafficking in Rotherham, greater awareness of the dangers of online abuse and a concerted attempt to tackle it alongside an increasing awareness of the impact of emotional as well as physical abuse (How Safe are Our Children, NSPCC 2015) 8.2 Local Context Children and young people under the age of 20 years make up 24.68% of the population of Portsmouth with approximately 51, year old children living in Portsmouth. Deprivation is higher than average with 9035 children under 20 living in poverty (21.4% compared to 18% national average). This masks huge differences between wards. 29% of school-age children are of non-white British ethnicity (45% of school children living in St Thomas ward and 38% in St Jude ward are of non-white British ethnicity). The health and wellbeing of children in Portsmouth is mixed compared with England average. The infant mortality rate is better and the child mortality rate is similar to the England average. The rate of family homelessness is worse than the England average. The proportions of children overweight or obese at Reception Year and Year 6 are slightly above the national average. Rates of smoking by pregnant women remain above the national average and are high in under 20 year olds. In 2013/14, hospital admissions for intentional self-harm by local young people aged years were significantly higher than England (533 admissions per 100,000 compared with 412 admissions per 100,000 young people aged years). Nationally, between 2004/05 and 2013/14, hospital admissions for self-harm for young people aged years increased by 67%, and for young people aged years by 60%, and it has been suggested that these large increases may be attributed to improved data collection. However, it is concerning that the local admission rate for self-harm is reportedly significantly higher than the national rate. Further local investigations are underway to examine the issues around self-harm in young people. Hospital admissions for local young people aged years for substance misuse (100 admissions per 100,000 young people aged years) were significantly higher than England (81 admissions per 100,000 such young people) whilst hospital admissions for alcohol for 0-17 year-olds (38 per 100,000 young people aged 0-17 years) were lower than England (40 admissions per 100,000 such young people). For young people new psychoactive substances are now the third most reported substance use after alcohol and cannabis. 53% of secondary school pupils report having drunk a whole alcoholic drink compared to 51% nationally (2014) 11

12 At the 31 st March 2016, there were approximately 275 children subject to a Child Protection Plan in Portsmouth. This is lower than the statistical neighbour but higher than the England average. There were approximately 648 children subject to Child in Need Plans and approximately 322 children who were being looked after by PCC including 32 Unaccompanied Asylum Seeking Children. The data presented to PSCB April 2016 indicated that these numbers had remained fairly constant through 2015/16. Neglect remains by far the highest number for Child Protection Plans and remains a priority for PSCB in 2016/17. The number of Early Help SAF assessments completed within this year has risen slightly from 500 in 2014/15 to 628 in 2015/16. The Board has recognised that there needs to be further work on Early Help. 8.3 Joint Action Team (JAT) to Multi-Agency Safeguarding Hub (MASH) The multi-agency Portsmouth Joint Action Team that had been operational since July 2012 was successfully developed to a full Multi-Agency Safeguarding Hub (MASH) and went live on 01 November The CCG has funded a specialist nurse to act as health navigator. The post holder has been seconded to PCC and line managed within the MASH structure and receives professional supervision from the Associate Designated Nurse. 8.4 PSCB Section 11 Audit Nine GP Practices, PHT Maternity Services, Partnership Health Limited and Solent NHS Trust Family Nurse Partnership, Speech & Language, Specialist Health Visiting Team, Children's Community Nursing and Community Paediatrics, were selected to participate in the audit in December 2015/January % completed audits were returned from health services. Action plans are being monitored through the PSCB Monitoring, Effectiveness and Scrutiny Committee (MESC). 8.5 Safeguarding Training Throughout 2015/16 a significant amount of training was delivered by the CCG safeguarding team. This included child safeguarding updates at TARGET, training delivered within GP Practices to clinical and non-clinical staff this has now been accessed by 11 of the 18 surgeries in Portsmouth directly with representatives from others attending the Level 2 and Level 3 study days, Level 4 updates for Provider Safeguarding Leads, CCG Senior Management and Executive Team Level 5 update and lunch and learn events during the CCG safeguarding week. 8.6 Support for Primary Care Since September 2014, this development programme has been in place, and it was extended in September 2015 by the role being shared between a Health Visitor and a School Nurse. Their role has included support GP practices with fulfilling their safeguarding responsibilities supported by the Named GP for Safeguarding Children. 8.7 Launch of the Safeguarding Children and Child Protection Resource Folder During safeguarding week in June 2015, a successful launch lunch occurred for GP safeguarding clinical leads to attend to hear about the file and to receive a copy for their surgery. The file contained comprehensive information regarding policies and processes for safeguarding and child protection as well as key information regarding information sharing and training. Within the folder was also a newly designed case conference report form to standardise and make easier the information needed for conference and the GP s ability to provide it. An induction pack was also 12

13 included for surgeries to give to new clinical and non-clinical staff at commencement of their work to ensure they are made aware of current safeguarding issues and encouraged to attend relevant training. The folder was also made available electronically to GP practice via Portsmouth PIP. 8.8 Audit of Safeguarding Children knowledge and practices within GP surgeries in Portsmouth Following on from the launch of the resource file, the specialist nurse distributed a Survey Monkey at the beginning of September to ascertain both the resources file usage and quality as well as addressing a number of other issues that had been raised within the safeguarding team in the CCG. The report from this was distributed September 2015 and had a number of interesting finding and the following four recommendations: To ensure continued improvements in partnership working are implement across all surgeries within Portsmouth. This may be in a more structured way to ensure consistency in this across the whole area. To ensure that an initial knowledge and understanding of safeguarding children is included in all job descriptions for positions within the GP surgery regardless of clinical or non-clinical based roles. To ensure that all surgeries across Portsmouth are recording who else is living in an address with a child and what school if any that the children are attending, to ensure that the wider picture is seen. To ensure that all staff working with a GP surgery feel confident in addressing CSE and Prevent, should the need arise, by providing quality, focused training in the coming year. This has guided a number of projects and audits that have occurred through to Audit of the Multi-Agency Business as Usual Audit tool for MESC In collaboration with Solent NHS Trust an audit of an audit tool produced by MESC was completed in August The aim was to assess the validity of the audit tool across different services to ensure that the results gained where both useful and comparable. The audit concluded that the tool was not fit for purpose for Health Agencies. The tool was overly long and cumbersome and did not answer the questions posed within health LSCB Child Death Overview Panel (CDOP) to PSCB CDOP For Portsmouth there were 11 deaths between to , 5 were expected and 6 unexpected. Three of these deaths have been reviewed by the new Portsmouth CDOP but no themes or learning have been identified to date. The full 4LSCB report is not yet available but will be published on the PSCB website when available. A review of the 4LSCB CDOP arrangements was initiated by the Isle of Wight Safeguarding Children Board in response to concerns raised by Ofsted in their most recent review, and also concerns raised in an SCR about the effectiveness of CDOP and Rapid Response arrangements on the Island. This led to a broader discussion about the governance and accountability of the arrangements across the 4LSCBs. As a result the 4LSCB CDOP arrange was disbanded on 31 October PSCB CDOP held its first meeting in January Two key points were agreed by the 4LSCB s Each LSCB is committed to having agreed Rapid Response procedures, as well as standard CDOP forms, across the four areas. There will be shared learning and data sharing on a minimum annual basis. There will also be a joint annual reporting (which Hampshire will coordinate). 13

14 8.11 Referrals to Local Authority Designated Officer (LADO) During the period 01 April 2015 to 31st March 2016 there were 3 referrals received by the Portsmouth City Council LADO relating to allegations regarding people working in health services. All three cases did not reach criteria for LADO oversight and intervention 8.12 Mandatory Reporting of Female Genital Mutilation (FGM) From 31 October 2015 regulated health and social care professionals and teachers are required now to report cases of FGM in girls under 18s which they identify in the course of their professional work to the police. To ensure that GP Practices and the wider Health economy comply with this a number of awareness raising activities have been carried out. This includes training events, updates at Target Training for GPs, information available in folders and on Portsmouth PIP, and cascade Serious Case Reviews and Other Multi-Agency Reviews PSCB Case Review Committee (CRC) is chaired by Portsmouth CCG s Designated Doctor for Safeguarding Children. The CRC meets monthly and receives referrals from other agencies regarding Serious Childcare Incidents and other cases for consideration for review and audit. The CRC makes recommendations to the PSCB Chair regarding whether a review should or should not be undertaken and terms of reference for reviews The CRC also scrutinises, monitors and collects evidence that supports the implementation of individual agency and PSCB Action Plans The PSCB commissioned an external review of a case in September The review aims to explore lessons learnt and the final report was published by the PSCB in September This case has received significant media attention. Health services were fully engaged in this review. The main learning for health is that whilst the hospital attempted to accommodate the parents wishes they did not respond speedily to their request for a second opinion. In addition an area for improvement was the multi-agency governance by senior managers of the management of the media. The safeguarding risks were appropriately managed via the 4LSCB child protection procedures, but these did not address the wider media concerns, and the need for senior management oversight because of the sensitivity of the case work decisions and the probable public interest. One Serious Case Review has been completed in this reporting period but has not yet been published due to criminal proceedings. The main learning related to the significance of a concealed pregnancy and the subsequent risks to the child. There were three referrals to the CRC between April 2015 and March The threshold for a Serious Case Review was not met in all three cases. One case was reviewed by CDOP and no further action taken. The other two cases were closed with no further action following completion of the scoping exercises. 9. Looked After Children (LAC) There has been an increase in the number of Looked After Children (LAC) this year with a significant increase the number of Unaccompanied Asylum Seeking Children (UASC) (see Table 2 below). This increase is expected to continue. The UASC are mostly male and 14 years or above. These children have a number of health needs as well as concerns regarding trafficking and exploitation including slavery. Year Number of LAC Number of UASC Table / / / /

15 There have been challenges obtaining NHS numbers in a timely manner, registering with a GP, Immunisations, TB screening and dental care which potentially could be a public health risk. The Designated Doctor for Looked After Children has taken an active role in the Corporate Parenting Board, the Health for LAC as well as co-ordinating and chairing the LAC Health Team Meetings. The Designated Doctor has also been engaged in supporting training, developing the use of a health passport App and meeting with the Children in Care Council, reporting to the CCG on the implications of policies and procedures (Intercollegiate guidance, Promoting the health of LAC). 10. Adult Safeguarding 10.1 National context The Care Act 2014 put adult safeguarding on a legal footing and from April 2015 each local authority must: make enquiries, or ensure others do so, if it believes an adult is subject to, or at risk of, abuse or neglect. set up a Safeguarding Adults Board (SAB) with core membership from the local authority, the Police and the NHS (specifically the local Clinical Commissioning Group/s) The Government s policy objective continues to be to prevent and reduce the risk of significant harm to adults from abuse or other types of exploitation, whilst supporting individuals in maintaining control over their lives and in making informed choices without coercion Local Context Portsmouth has an estimated population of 205,000 people residing within 15.5 square miles. This makes Portsmouth the most densely populated City in the UK outside of London. 62% of the population are aged and 13.9% are aged 65+. Largely as a result of the large student population in the city, Portsmouth has nearly twice as many young people in their early 20s as the England average (the age group account for 12.3% of the city s population compared to 6.8% of the England population). 218,000 people are registered with a Portsmouth GP and there has been a notable 12.5% growth in the 85+ age range within the last 10 years. In terms of gender split, there are slightly more men than women (50.4% and 49.6% respectively) In terms of ethnicity 84% of the population is White British, with the BME community accounting for an estimated 16% of the population. According to Council tax data there are 88,000 dwellings in Portsmouth, 81% of these are privately owned. Portsmouth is ranked within the top three performing authorities in a number of areas including: female life expectancy; employment of people with long term health conditions; lower rate of hospital admissions for violence; infant mortality and hip fractures for the over 80s. In terms of physical and mental health outcomes, males in Portsmouth's most deprived areas die 9.4 years earlier than males in Portsmouth's least deprived areas. The gap in life expectancy for females is 5.8 years. The health of people in Portsmouth is generally worse than the England average and that there are significant health and wellbeing inequalities. Portsmouth has a significantly higher level of overall deprivation than the England average. 15

16 Portsmouth is among the worst local authorities in England for alcohol-related hospital admissions, although the gap is closing. There are high alcohol mortality rates with life expectancy reduced in Portsmouth as a result. Alcohol related violence and sexual violence is significantly higher than the England average. Approximately 40,000, drink at levels which could harm their health. Of these, around 9,000 drink at a level which is a high risk to their health. The Home Office estimates that Portsmouth has 1,429 heroin (opiate) and crack cocaine users (OCU). Domestic violence accounts for at least 25% of assaults. Domestic violence has consistently been the largest driver of violence since 2006/ Monitoring The CCG Safeguarding Team has been involved in announced and unannounced visits as part of the wider quality and safeguarding agenda. These are to provide an insight into how staff at an operational level are embracing and embedding safeguarding, the Mental Capacity Act (MCA) and the Deprivation of Liberty Safeguards (DoLS) into their everyday practice. Working closely with the CCG Quality Team helps prevent, identify and secure action for potential safeguarding concerns. 11. Safeguarding Adult Reviews The previous Designated Nurse for Safeguarding Adults and subsequently from February 2016 the newly appointed Head of Safeguarding and Patient Safety chair the Portsmouth Safeguarding Adult Board (PSAB) Safeguarding Adult Review (SAR) Sub-Group Number of Referrals and outcomes Between 01 April 2015 and 31 Mar 2016 there were 3 referrals for consideration for a SAR. None of these reached the criteria for a SAR or other learning event Mr A A serious case review was undertaken in 2014 and published in December 2014 in relation to the care and treatment provided to Mr A by health and social care agencies. The Action Plan developed from the recommendations in this review has been monitored by the SAR Sub-Group and are now complete Mrs B and Mr C A serious case review was commissioned at the end of Mrs B was a lady living in a care home that was pushed over by a fellow resident and subsequently died. Questions were raised about the commissioning and subsequent monitoring of people who are transferred to residential care and risk assessments and monitoring for people who are in receipt of mental health services. This Review is now complete and has been ratified by the PSAB for publication shortly. An action plan has been developed from the recommendations in this review. The SAR sub-group has been regularly monitoring and reviewing the action plan and progress is being made with over half the actions now complete. 16

17 12. Domestic Homicide Review (DHR) 12.1 A domestic homicide is defined as a review of the circumstances in which the death of a person 16 years or over has, or appears to have, resulted from violence, abuse or neglect by a person to whom they were related, or a person with whom there was or had been an intimate personal relationship, or a member of the same household. There is Multi-agency Statutory Guidance for the Conduct of Domestic Homicides. This statutory guidance requires Community Safety Partnerships to consider the circumstances of every domestic homicide within the Local Authority area and determine whether to undertake a full review to identify if there are lessons to be learned. The serious case review model has been adopted to undertake DHRs There has been no DHR s in Portsmouth during the reporting period There was a Mental Health Homicide Review published in March The CCG met with the family prior to publication and this was appreciated by the family. NHS England are monitoring the action plan 13. Mental Health Homicide Review NHS England commissioned an independent review into a mental health homicide which happened in May The CCG hosted two pre-publication meetings at the end of March 2016 giving the victim and perpetrator s families the opportunity to hear the findings from the review, Solent NHS Trust s response and talk about the impact of the homicide on themselves and their families. The report was published in April 2016 and NHS England has commissioned a 6 month follow up review of the action plan. 14. Prevent 14.1 Prevent is the preventative strand of the Government counter terrorism strategy and recognises that some vulnerable groups may be susceptible to exploitation. Prevent aims to protect those who are vulnerable to exploitation from those who seek to get people to support or commit acts of violence The Counter-Terrorism and Security Act 2015 has created a general duty on a range of organisations to prevent people being drawn into terrorism. Prevent Duty Guidance was issued by the Government in March The duty requires certain bodies, including NHS Trusts, to have due regard to the need to prevent people from being drawn into terrorism when exercising their functions. It is fundamental to our duty to care and falls within statutory safeguarding responsibilities The health sector has no enforcement or surveillance role, but one of embedding Prevent in safeguarding activity to protect children and adults at risk of radicalisation. Where healthcare workers identify signs of radicalisation it is important they have the confidence to refer the individual for support before any crimes are committed Portsmouth has been classified as a priority area for Prevent and therefore there are robust arrangements in place. Portsmouth s Prevent Channel Panel is facilitated by the City Council and the Designated Nurse for Safeguarding Adults sits on the panel. Quarterly monitoring arrangements across the health economy are reported to NHS England via the CCG. 17

18 14.5 Following the quarter 4 data return to NHS England, the CCG have developed a comprehensive action plan. All PCCG staff will be expected to complete the PREVENT on-line training which is now mandatory for all staff. 15. Mental Capacity Act and Deprivation of Liberty Safeguards 15.1 Recent legal judgments on the Mental Capacity Act (MCA), Deprivation of Liberty Safeguards (DoLS) have begun to have an impact on health and social care services. These cases have placed additional responsibilities on health/ care providers to conduct mental capacity assessments and ensure that appropriate safeguards are in place Mental Capacity Act (MCA) Monitoring and assurance of MCA compliance is included in commissioning contracts with the larger health providers through the quality contracts and monitoring visits The Deprivation of Liberty Safeguards (DoLS) The Deprivation of Liberty Safeguards (DoLS) is an amendment to the Mental Capacity Act 2005 and were introduced in 2009 to provide a statutory framework for the deprivation of liberty of people in hospitals and care homes. The CCGs are continuing to monitor the activity of DoLS at the major providers and independent providers as part of the quality schedule and contracting. There have been no referrals to the Court of Protection within the reporting period in terms of CHC funded patients living in their own home or within supported living that the CCG have responsibility for Mental Capacity Act Funds NHS Portsmouth CCG successfully bid for a portion of national funds made available for embedding MCA. These funds have been used to help increase knowledge through educational events. This has included staff from care homes and domiciliary care. MCA retractable pens have been purchased and distributed to providers and professionals. The CCG has supported the training of two Best Interests Assessors for the DoLS Team at the Local Authority. There are some funds left and the CCG are working with Portsmouth City Council to decide the most effective use of those funds. Delivering training via an external training provider is being considered. 16. Key Achievements 2015/2016 The achievements for 2015/2016 include: The Head of Safeguarding and Patient Safety incorporating the Designated Nurse (Adult and Children) commenced in post on 08 February An Associate Designated Nurse Safeguarding Adults has been recruited from 22 February An Associate Designated Nurse for Safeguarding Children and LAC has been advertised and recruited to. Safeguarding Policy reviewed and updated. Portsmouth CCG Safeguarding Week took place in June % of all GP Practices across Portsmouth have a named clinical lead and a named nonclinical lead. Health Visitor Secondment Programme was successful and provided succession planning for the CCG. 18

19 PSCB Section 11 Audit 20115/16-100% participation from health services asked to participate. Strong attendance, facilitation and participation at both Boards and associated subgroups. A significant amount of child and adult safeguarding training was delivered through TARGET, within the CCG, to GP Practices and study days. The Designated Looked After Children (LAC) Nurse Role was reviewed and the previous secondment arrangement ended on 31 March This role has been incorporated in to a substantive role of Associate Designated Nurse for Safeguarding Children and LAC. Health Services were fully engaged in the development of the Portsmouth Multi-Agency Safeguarding Hub (MASH) Portsmouth Child Death Overview Panel (CDOP) was successfully developed and a Designated Dr for Child Deaths appointed. Safeguarding Children resource file for GP Practices successfully developed and launched. Positive feedback from GP s. A report format for GPs to complete when requested to provide information for child protection conferences developed. Successful engagement in PSCB / PSAB Safeguarding Week in June Police, Children s Social Care and Health liaison meetings to provide a forum for senior agency safeguarding leads to reflect on any local safeguarding cases / issues and to consider any learning, to support joint working developed. 17. Areas for Development for 2016/2017 To invite GP Clinical Leads to join the NHS Child Safeguarding Forum Explore options for either amalgamating the NHS Child Safeguarding Forum with a similar Adults Forum or develop an NHS Adult Forum. To ensure health services across Portsmouth remain fully involved in the work of the PSCB / PSAB to support achievement of the priorities as set out in their Business Plans. Empower NHS Providers to continue to develop the Police, Children s Social Care and Health liaison meetings started in Continue to support and empower NHS Provider organisations with the national rollout and implementation of the Child Protection Information Sharing System (CP-IS). To ensure safeguarding remains a priority in primary care and clear pathways are in place. To work with the PSCB and partner agencies to prepare for the Integrated Inspection Process. Continue to work on improving practices and embedding MCA/DOLS. Continue to strengthen contracting and commissioning arrangements to include adult safeguarding to ensure that individual rights are protected. Support the ongoing development of the Portsmouth Safeguarding Adult Board and subgroups To work with the PSCB and partner agencies to raise awareness of FGM across agencies and to ensure GP Practices and other Health providers are supported to fulfil their responsibilities. To support and empower Health Providers including Primary Care to recognise and respond to Missing, Exploited and Trafficked Children Provide and monitor training in Prevent across the health economy Prevent Referrals from health agencies have been identified as an area for improvement over the next year. A training and awareness raising strategy for health professionals is being developed by the safeguarding team to improve the quality and number of referrals from the health sector. 19

20 Following the quarter 4 data Prevent return to NHS England, the CCG to develop a comprehensive action plan to include mandatory training for all staff PCCG staff to complete the PREVENT on-line training Key professionals within Quality and Safeguarding team will complete a two hour face to face Prevent (WRAP) session Develop an action plan and deliver PREVENT Training to GPs Develop a robust training strategy to include Safeguarding Children, Adults, Prevent, MCA/DOLS and Domestic Abuse. Continue to develop the health input in the Multi-Agency Safeguarding Hub (MASH) Monitor the impact of the increasing numbers of Unaccompanied Asylum Seeking Children and work with Health agencies to ensure their needs are met. Continue to raise awareness of key developments and learning regarding the safeguarding agenda across the health economy Develop Safeguarding Adult Leads for each GP practice in line with safeguarding children Develop a Resource Package for GP s regarding Safeguarding Adults, MCA/DOLS and Prevent in line with safeguarding Children Further develop joint working with Adult Social Care Safeguarding Team Further develop and evaluate the Multi-Agency Safeguarding Hub. 20

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