BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST TRUST BOARD TO BE HELD ON WEDNESDAY 30 JULY 2014

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1 Item 8.2 BIRMINGHAM AND SOLIHULL MENTAL HEALTH NHS FOUNDATION TRUST TRUST BOARD TO BE HELD ON WEDNESDAY 30 JULY 2014 SAFEGUARDING ANNUAL REPORT Children Act Working Together to Safeguard Children No Secrets 2000 ACTION: The Board is asked to note the contents of the Annual Report and receive assurance on the issues identified Executive Summary The purpose of this paper is to present the Annual Safeguarding Report to inform members of the Board of the activity that has been undertaken to ensure that BSMHFT meets its statutory duties and responsibilities to protect children and vulnerable adults who are at risk of abuse and neglect. Key Issues Section 11 Audit completed for Birmingham BSCB in April 2013 demonstrated two red markers and six amber markers. A repeat audit for 2014 demonstrates improvement with no red markers and three ambers markers Section 11 Audit completed for Solihull LSCB in April 2013 demonstrated three amber markers but it should be noted that two of these markers have wider implications than BSMHFT across the whole LSCB economy Recommendations and Actions from Serious Case Reviews and Domestic Homicide Reviews continue to progress. The outstanding action relating to a SCR has now been completed and it is expected that the outstanding actions from a DHR will be completed by the end of Q2 Training - Safeguarding Children and Young People Level 1 (e-learning) uptake has been consistent at 95% Level 2 uptake has steadily improved through Q1 to Q3 to nearly 80% but there has been a dip in performance in Q4 - Safeguarding Adults at Risk Level 1 (e-learning) uptake has been consistent at just below 90% Level 2 training commenced in September Due to errors in recording accurate data is not available Key Risks Delivery against the 2013/14 work programme has been partly compromised due to capacity but the forthcoming review will provide clarity Action to Mitigate Risks Prior to the outcome of the Safeguarding Review the following has been put in place: An interim safeguarding lead, initially recruited to cover planned sick leave, has been extended until the end of October A fixed term trainer is to be recruited BOARD DIRECTOR SPONSOR: REPORT AUTHOR: APPENDIX: Appendix 1. Annual Report Sue Hartley, Executive Director of Nursing Kate Larard, Head of Safeguarding

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3 Birmingham & Solihull Mental Health NHS Foundation Trust Safeguarding Annual Report April 2013 March 2014 DRAFT REPORT Kate Larard Head of Safeguarding 01 May INTRODUCTION

4 The purpose of this report is to inform and update the Trust Board with regard to safeguarding vulnerable adults and children within Birmingham and Solihull Mental Health Foundation Trust (BSMHFT). The report will provide information regarding the activity that has taken place over the past year to meet national and local requirements. It will demonstrate the degree to which we work in partnership with other statutory and nonstatutory agencies in relation to the safeguarding agenda, the internal and external governance arrangements that we are subject to, and the responsibility we have in regard to our regulatory duties. The report will identify progress against the work plan of 2013/14 and the key objectives for 2014/15 in relation to the safeguarding agenda. 2.0 LEGISLATION 2.1 Safeguarding Vulnerable Adults In 2000 the Department of Health and the Home Office published guidance to underpin the adult safeguarding agenda. No Secrets places a duty on local authorities to put in place a framework to ensure that there are processes in place to protect vulnerable adults from abuse and neglect. A consultation and a review of the guidance was completed in 2009 but we continue to work with the original 2000 guidance as the recommendations of the review and the consultation have yet to be implemented. This includes the potential for legislation that would underpin adult safeguarding in the same way as the Children s Act underpins child safeguarding. In March 2011 the Department of Health published Safeguarding Adults: The role of health services which clarifies the duties health services have to safeguard vulnerable adults. The document provides the following good practice principles for preventing and responding to neglect and abuse, focusing on patients in the most vulnerable situations: Accountability; Prevention; Protection; Proportionality; Partnership and Empowerment BSMHFT has interpreted the No Secrets definition of a vulnerable adult in a way that means that we would consider all of our service users to be vulnerable meaning that we would expect the procedures to be implemented for any service user who was subject to abuse and neglect 2.2 Safeguarding Children The Children Acts1989and 2004 provide comprehensive legislation to protect and safeguard children and Section 11 of the Act places a duty on all agencies to: make arrangements to ensure that in discharging their functions, they have regard to the need to safeguard and promote the welfare of children In addition, Working Together to Safeguard Children 1999 and its revisions of 2006; 2010 and 2013 (DOH) include the need for: - senior management commitment and clear lines of accountability - a clear statement of the agency s responsibilities - appropriate service development and supported training programmes - safe recruitment - effective inter-agency working and information sharing. In July 2009, the Social Care Institute for Excellence (SCIE) published a guide entitled Think child, think parent, think family: a guide to parental mental health and child welfare to help services improve their response to parents with mental health problems and their families. In June 2010 the Munro Review was published advocating a move from a system that is over bureaucratised and focused on compliance to one that values and develops

5 professional expertise and is focused on the system and welfare of Children and Young People. The following recommendations were approved: that the government will oversee a radical reduction in the amount of regulation through the revision of the statutory framework that there will be greater emphasis to work directly with Children, Young People and families that there will be a new inspection framework with Children, Young People and families at the centre that there should be greater transparency and co-ordination of local arrangements to deliver early help. for a co-produced work programme between Department of Education, Department of Health, NHS bodies, local authorities and professional bodies to ensure improvement of safeguarding arrangements in healthcare reform 3.0 TRUST RESPONSIBILITES As a health organisation in relation to Safeguarding the Trust needs to demonstrate compliance with the following: 3.1 Safeguarding Vulnerable Adults - Standard 7 of the Care Quality Commission Essential Standards - No Secrets (DOH 2000) - Safeguarding Adults; the role of health services 3.2 Safeguarding Children and Young People - Section 11 Guidance of the Children Act (2004) - Working Together to Safeguarding Children (2013) - The National Service Framework for Children, Young People and Maternity Services (2004) - Safeguarding Children. A review of arrangements in the NHS for safeguarding children (Care Quality Commission July 2009) - The NICE guidance on When to Suspect Child Maltreatment - The Munro Review - Intercollegiate document: Safeguarding Children and Young people: roles and competencies for health care staff 2010 These recommendations include: - appropriate representation on Local Safeguarding Boards - co-operation and sharing of responsibility for the effective discharge of the Safeguarding Boards functions - ensuring effective arrangements and funding is in place to support the function of Named professionals - comprehensive single and multi-agency policies and procedures to safeguard and promote the welfare of vulnerable adults and children - appropriate infrastructures that provides advice and expertise to all healthcare professionals working in the health organisation and support staff to act on their concerns and fulfil their responsibilities in line with the procedures - the delivery of effective and accessible training (single or multi-agency) to staff targeted to assessed training needs so that staff are competent and able to identify early indicators of potential abuse or neglect and know how to act on their concerns in line with procedures - ensuring Safe Recruitment Practice at the outset of employment and at periodic updates

6 3.3 Safeguarding Team During this reporting period the Executive Director for Quality, Improvement and Patient Experience and the Interim Director of Nursing held the Trust Board level responsibility for safeguarding as part of their portfolio. The Safeguarding Team are responsible for the promotion of good professional practice and the provision of expert advice, supervision and training to fellow professionals to ensure that the workforce and the organisation protect vulnerable adults and children from abuse and neglect. The Safeguarding team comprises of: Role WTE Head of Safeguarding 1.00 Named Nurse for Safeguarding Children and Young People 1.00 Named Nurse for Safeguarding Adults at Risk of Abuse 1.00 Named Doctor for Safeguarding Children and Young People Internal Governance Arrangements The Joint Safeguarding Group was dissolved in September 2013 and replaced by the Safeguarding Committee, a sub-committee of the Integrated Quality Committee, in line with the Trust reconfiguration. The role of the Safeguarding Committee is to ensure that: BSMHFT is able to meet national guidance and local requirements in relation to adult safeguarding procedures and the principles of inter-agency working as set out in No Secrets (March 2000) BSMHFT is able to meet its statutory responsibilities under the Children Acts 1989 and 2004 and associated statutory guidance i.e. Working Together to Safeguard Children (2013) All BSMHFT staff are exposed to safeguarding training to raise their awareness and understanding of safeguarding and inter-agency working, including the impact of domestic violence on our service users and their families The needs and welfare of the children and families of our service users are at the centre of all adult specialist mental health care provided by BSMHFT i.e. within the principles and guidance set out in Think Family (SCIE 2010) The key safeguarding risks that may have an impact on the reputation of the Trust Board and the Partner arrangements with local Safeguarding Boards are identified and mitigated, via an action plan, reporting by exception to the Trust Clinical Governance Committee; Local Safeguarding Boards are assisted in meeting their work priorities; During this reporting period the Terms of Reference and membership of the committee were reviewed to ensure all service areas were appropriately represented. It is the responsibility of each member to disseminate key safeguarding messages to all Local Clinical Governance Committees and seeks to embed a positive culture around safeguarding for all our service users.

7 3.5 Progress against Work Plan 2013/14 Objective Actions to meet objective Progress at end of Q4 Strengthen Governance of Safeguarding within the Trust Ensure safeguarding is embedded across the organisation and safeguarding responsibilities are met at operational level Ensure good working practice with partner agencies in relation to safeguarding agenda Ensure actions from SCR/DHRs and other reviews are identified Monitor performance against Integrated Action Plan Assist BSCB to meet statutory functions in relation to Ofsted Improvement Plan Ensure Training Programme is in line with Intercollegiate Document Competencies and University of Bournemouth - establish Safeguarding Committee (SC) in line with governance re-organisation within the Trust - introduce standing items to agenda - develop terms of reference to ensure robust reporting and appropriate dissemination of safeguarding issues - review Membership of present JSG to ensure good representation from across all divisions/zone at an appropriate level with named deputy - work with Directors to identify appropriate membership for newly established SC - work with Directors to instil responsibility for taking forward safeguarding agenda at operational level - obtain local Clinical Governance Committee minutes to ensure actions/issues from Safeguarding Committee is disseminated appropriately - involve members of SC in task and finish groups to progress work and ensure sense of ownership - ensure BSMHFT is well represented on Boards; sub-committees and other relevant organisational bodies - develop an Integrated Safeguarding Action Plan to capture progress against action plans - Develop rolling programme of audit to reflect action plan from SCR/DHRs and other internal reviews - roll out Right Service; Right Time initiative - promote use of fcaf - promote Think Family and Strengthening Families agenda - review Induction Programme - review face to face Adult Safeguarding - review face to face Child Safeguarding Level 2 - develop Master Class (Level 3) sessions to reflect actions from SCRs etc - identify personnel to participate in Level 3 multiagency training - review Training Needs Analysis to accommodate developed and updated programmes Ongoing Outstanding Outstanding Outstanding

8 Objective Actions to meet objective Progress at end of Q4 National Standards Ensure MCA/DoLS training across organisation Ensure data collection meets requirements for CQC Outcome 7; Section 11; Safeguarding Boards and Commissioners Ensure all staff have access to expert knowledge, support and supervision as required on a day to day basis Enable Named Professionals to develop roles in accordance with JD Ensure Named Professionals have access to regular supervision Update Child Safeguarding Policy in line with Working Together 2013 Update internal and external safeguarding website Assist Trust to meet PREVENT agenda - work with Medical Director to develop face to face interactive sessions - work with mental Health Act lead to develop e- learning - - review Eclipse and RIO systems to maximise potential for capturing data - refine data collection to better illustrate trends and use of resources - develop further tools to enhance data collection - maintain roll out of child safeguarding supervision in key high risk areas across the organisation - identify key areas of risk in adult safeguarding - explore mechanisms for evidencing supervision - - relieve Named Nurses of responsibilities that should routinely sit with operations - draw up JD for Named Doctor - identify appropriate supervisors, set up regular supervision sessions Outstanding Outstanding Partially - review current policy - ensure website is user friendly, refreshed and maintained - disseminate PREVENT awareness leaflet with pay slips - liaise with L&D re Health WRAP on induction programme - liaise with L&D re rolling out Health WRAP training to Top 300 in autumn - work with Directors to identify champions to train as Outstanding

9 Objective Actions to meet objective Progress at end of Q4 trainers - work with colleagues to develop internal/external referral pathway - identify appropriate representation on Channel Panel 4.0 LOCAL SAFEGUARDING BOARDS BSMHFT is a signatory to partnership working agreements between the Birmingham and Solihull Local Authorities and Local Safeguarding Adults Boards (LSAB) and Local Safeguarding Children Boards (LSCB). BSMHFT is required to provide representation at each local multi-agency safeguarding board meeting and where invited, at sub-committees. Attendance is monitored by the Boards and there has been good attendance throughout this reporting period. Named professionals with deputising arrangements are in place. 4.1 Adult Boards and Sub-Committees During this reporting period the Trust has been represented on the Birmingham and Solihull Adult Safeguarding Boards by the Head of Safeguarding. BSMHFT has also been represented at the following LSABs sub committees: Birmingham Operational subcommittee; Birmingham Serious Case Review sub-committee; Solihull Operational subcommittee; Solihull Performance, Quality & Audit sub-committee; Solihull MCA subcommittee 4.2 Children Boards and Sub-Committees During this reporting period the Executive Director for Quality, Improvement and Patient Experience attended Birmingham LSCB until her departure. During the interim period, prior to appointment of the Director of Nursing, the Head of Safeguarding represented BSMHFT on the Birmingham LSCB and the Solihull LSCB. BSMHFT has also been represented at the following LSCB sub committees: Birmingham Operational Effectiveness sub-committee; Birmingham Serious Case Review sub-committee; Birmingham Training sub-committee; Birmingham Performance, Quality and Assurance sub-committee; Birmingham Health Advisory Group; Solihull Training sub-committee. In addition, BSMHFT clinicians based in Solihull have attended Solihull LSCB forum meetings which facilitate better networking and understanding of other agency roles and safeguarding processes for children. 4.3 Birmingham Ofsted and Le Grande Review The City Council has been subject to Government Improvement since 2009 with notices issued in 2010, 2011, 2012 and In February 2014 a review was under taken on behalf of the Government and an External Commissioner and expert panel were appointed to work alongside the City Council. An Improvement Plan 2014/15 has been published identifying that improvement will only be sustained through collective responsibility and a cultural shift. It is acknowledged that there is significant work and challenge ahead and BSMHFT, as a partner agency, are fully committed to working in partnership to affect change and improvement. A further Ofsted Inspection has taken place in March 2014 and the final report will be published in May Solihull CQC

10 A review of health services for Children Looked After and Safeguarding was undertaken in February 2014 and included perinatal mental health, adult mental health and addictions. A key risk in relation to Rio not having a flagging/alert system in place for Children Subject to a Child Protection Plan, was identified during the inspection. Immediate action was taken to rectify the situation and the inspectors were satisfied with the expedient response. The draft report is broadly positive with the following key areas identified for improvement - further strengthening and embedding of Think Family principles, greater consideration given to the voice of the child and the child s journey. The final report will be published in May There are twelve recommendations for BSMHFT and the first draft of the Action Plan has been drawn up. 4.5 Section 11 Audit Birmingham LSCB undertook their first Section 11 Audit in April An action plan was developed at the time and BSMHFT had two red markers and a total of six amber markers. Work undertaken over the past year has reduced this to no red markers and three amber markers in March Solihull LSCB undertook a full Section 11 audit in 2011 which has been reviewed annually. An action plan was developed at the time and BSMHFT had no red markers and total of 11 amber markers. Work undertaken over the past three years has reduced this to 3 amber markers in March It should be noted that 2 of these markers have wider LSCB implications. 4.4 Safer Recruitment and Allegations Against Staff All offers of employment made to prospective employees are subject to an enhanced Criminal Records check as are all substantive employees every three years. The Head of Safeguarding sits on the Disclosure and Barring Panel to consider any adverse disclosures. During this reporting period new guidance has been developed in relation to Allegations against Staff to promote a consistent and robust process. The safeguarding team supports human resources in relation to allegations against staff and are involved in complaints when there is a safeguarding element. A total of ten cases have been referred to the Local Authority in relation to allegations against staff, three adult allegations - Person in Position of Trust (PiPoT) and seven child allegations - Local Designated Officer (LADO) 4.6 Serious Case Reviews Serious Case Reviews (SCRs) are commissioned by the Local Safeguarding Boards when either an adult or child has suffered serious abuse or death. The purpose is to learn lessons around partnership working and multi-agency communication and examines events leading up to the incident. All organisations working with either a victim or perpetrator are required to complete an Individual Management Review (IMR). The Safeguarding Team have been involved in two SCRs and a number of multi-agency table top reviews during this reporting period. Review Commissioner BSMHFT Involved Serious Case Child S BSMHFT Safeguarding Team Involvement Safeguarding Children Solihull LSCB yes IMR - Named Nurse for Safeguarding Children Panel - Named Doctor

11 Serious Case Birmingham BSCB yes IMR - Named Nurse for Safeguarding Children Multiagency Case CL Birmingham BSCB yes Report - Named Nurse for Safeguarding Children and Young People Multiagency Case CW Birmingham BSCB yes Report - Named Nurse for Safeguarding Children and Young People Recommendations from the above reviews have been completed or are being progressed as per action plan. In Case there is an outstanding audit which is expected to be completed by end of Quarter Domestic Homicide Reviews Under Section 9 of the Domestic Violence, Crime and Victims Act (2004) the Home Office in April 2011 published guidance on establishing arrangements for undertaking Domestic Homicide Reviews (DHRs). Following a domestic homicide Birmingham Community Safety Partnership commissions a DHR. The purpose is similar to that of a SCR to learn lessons around partnership working and communication and similarly all organisations working with either the victim or perpetrator are required to undertake an Individual Management Review (IMR). Domestic Homicides are an organisational concern involving a number of disciplines and departments. A Trust wide action plan is agreed with leads identified. The Safeguarding Team have been involved with the following DHRs during this reporting period. DHR Commissioner BSMHFT involved BSMHFT Safeguarding Team Activity DHR 9 BCSP Yes IMR Named Nurse for Safeguarding Children DHR Panel - Named Nurse for Safeguarding Children BSMHFT Panel Named Nurse for Safeguarding Children DHR 11 BCSP Yes IMR - Named Nurse for Safeguarding Adults DHR Panel - Head of Safeguarding Recommendations from DHR 9 which are outstanding are being followed through with appropriate leads. It is anticipated that all outstanding actions will have been completed by the end of Quarter 2. Recommendations from DHR 11 are progressing as per action plan. 5.0 PARTNERSHIP WORKING Working in partnership with all agencies is an intrinsic part of safeguarding. In addition to working with the Local Safeguarding Boards the safeguarding team demonstrates BSMHFTs commitment to partnership working through representation at the following committees and steering groups: 5.1 PREVENT Regional Group - is part of the United Kingdom s counter-terrorism initiative. Its aim is to identify and work with vulnerable people who may be at risk of radicalisation or recruitment by a terrorist organization. The Head of Safeguarding is the Trust s Prevent lead and attends a monthly regional meeting. As part of the 2014/15 NHS Contract it is now a requirement that all staff are trained in relation to Prevent. The Department of Health have produced a standardised training

12 package HeathWRAP to be rolled out across all organisations. During this reporting period twenty five BSMHFT staff have been trained as trainers to deliver HealthWRAP training. The uptake for training at the end of Quarter 4 stands at 18%. 5.2 Channel Panel similarly this is part of the UKs counter-terrorism initiative. Channel Panel is the multi-agency forum where actual cases are discussed and where plans are put in place to support individuals who maybe being radicalised. BSMHFT is represented by a Clinical Psychologist who is undertaking specialist research in relation to the working of Channel Panel. 5.3 Multi-Agency Safeguarding Hub (MASH) - the aim of this hub is to improve the quality and timeliness of decision making to reduce the potential risk to children and young people. The model has been rolled out across the UK and locates key agencies together in a single work place, to enhance information sharing. The Safeguarding Team have been contributing in the development of the MASH at both strategic and operational level. Phase one of the MASH is due to commence in July 2014 and phase two is due to go live in September BSMHFT is expected to participate from phase two and requirements are being discussed with commissioners 5.4 Multi-Agency Risk Assessment (MARAC) - The aim of MARAC is to develop safety plans for the highest risk victims of domestic abuse i.e. those at risk of being murdered or suffering serious harm. The purpose of MARAC is to share information and to develop a risk management plan to provide a professional, co-ordinated approach to all reported incidents of domestic abuse. The safeguarding team attend the Birmingham and Solihull MARACs to contribute and share information and provide clinical expertise about significant mental ill health and how it impacts on the wellbeing of the whole family. This is a huge commitment of 7 MARAC sessions per month (6 in Birmingham and 1 in Solihull). 5.5 Domestic Homicide Steering Group - reports to the Birmingham Community Safety Partnership. The Head of Safeguarding attends monthly meetings 5.6 Birmingham Violence Against Women Board - The Named Nurse for Adults at Risk represent BSMHFT at this Board 5.7 Solihull Domestic Abuse Priority Group The Named Nurse for Adults at Risk represents BSMHFT on this monthly group 5.8 Birmingham Commissioners Safeguarding Adults Health Group- The Named Nurse for Adults at Risk represents BSMHFT on this bi-monthly group 5.9 Health Advisory Group - The Named Doctor for Safeguarding Children and Young People represents BSMHFT on this group. 6.0 CORE ACTIVITY The Head of Safeguarding takes the strategic lead in supporting the organisation to meet its statutory functions with regard to safeguarding vulnerable adults, children and young people. The Named Professionals, supported by the Head of Safeguarding, have a key role in promoting good professional practice, providing advice, expertise, training and supervision to all practitioners. A key part of the Named Nurse role is to provide daily support and advice for all staff. In September 2013 a basic tool was developed to capture this activity to help identify trends

13 and themes and inform future working. During Quarter 3 just over 200 telephone enquiries were made to the safeguarding team whereas, in Quarter 4 just over 500 telephone and enquiries were made. Early data indicates that enquiries made in relation to Safeguarding Adults have been predominantly associated with domestic abuse, financial abuse and sexual abuse. Whilst, for Safeguarding Children and Young People enquiries have been predominantly associated with issues of domestic abuse, sexual abuse and neglect. 6.1 Dashboard Reporting Number of Referrals Q1 Q2 Q3 Q4 Adult Safeguarding Alerts 54 (joint) Child Safeguarding Referrals 54 (joint) Deprivation of Liberty applications Mental Capacity Act referrals Court of Protection referrals Referrals in relation to Prevent Position of Trust referrals PiPot/LADO Supervision The Trust Clinical Supervision Policy includes reference to child safeguarding supervision to ensure that the requirements of Working Together to Safeguard Children (2013) are met and best practice processes are in place. The Named Nurse for Safeguarding Children and Young People provides child protection group supervision to senior staff in addictions, specialities and youth services. Supervision is cascaded through the teams in the form of Action Learning Sets facilitated by the senior staff. Currently there is no statutory requirement to provide supervision in relation to safeguarding adults. However all staff are able to seek advice and support and ad hoc supervision in relation to cases via the Named Nurse for Safeguarding Adults at Risk or through management via clinical supervision sessions. The Named Nurses receive clinical supervision via the Clinical Commissioning Group Designated Nurse for Children and Young People and the Lead Nurse for Safeguarding Adults. 6.3 Training As part of the Fundamental Training Programme statutory and mandatory training requirements for all staff have been identified. At the outset of this reporting period all core training packages were reviewed and updated in line with the Intercollegiate Document Roles and Competencies for Safeguarding Children and Young People 2010 and the National Competence Framework for Safeguarding Adults The Safeguarding Team have developed and delivered the following core training: - Induction - Safeguarding Children, Young People and Adults at Risk - Level 1 e-learning - Safeguarding Children and Young People (from Mar 2013) - Level 1 e-learning - Safeguarding Adults at Risk (from Mar 2013) - Level 2 face-to-face - Safeguarding Children and Young People (from Mar 2013) - Level 2 face-to-face - Safeguarding Adults at Risk (from Sept 2013) Uptake of Training

14 Q1 Q2 Q3 Q4 Safeguarding Children and Young People Level 1 95% 95% 96% 95% Safeguarding Children and Young People Level 2 79% 80% 83% 79% Safeguarding Adults at Risk recorded) Level 1&2 (jointly 89% 88% (91%) (90%) The table indicates that uptake for Level 1 Safeguarding Children and Young People training has been consistent at 95% or above. Uptake for Level 2 Safeguarding Children and Young People training has steadily improved through Quarter 1 to Quarter 3. However, data for Quarter 4 demonstrates a dip in performance, which may be attributed to insufficient training courses being available to meet demand. In relation to Safeguarding Adults at Risk Level 1 the uptake at Quarter 2 was at 88%. In September 2013 Level 2 training was introduced. The recording of the two levels of training was not separated out and has been recorded jointly. As a consequence accurate data on uptake for both levels is not available. A Training Needs Analysis has been completed to correct this discrepancy. As part of the Trust's partnership working with the Birmingham LSCB the Safeguarding Team have assisted in developing and delivering Right Service, Right Time training and Strengthening Families training on behalf of the LSCB With regard to partnership working with the Solihull LSCB the Safeguarding Team has codeveloped and presented on the LSCB Level 2 Multi-agency Training which runs twice a year. 7.0 OBJECTIVES AND WORK PROGRAMME FOR 2014/15 The following objectives and work programme for 2014/15 have been identified to support the requirements for safeguarding practice and ensure continuous improvement in practice. Objective Develop rolling programme of audit to deliver against Integrated Action Plan Develop Training Needs Analysis in line with Safeguarding CQUIN Develop training programmes to ensure actions from SCRs; DHRs; CQC and CQUIN requirements are met Ensure data collection Actions to meet objective - develop audit in relation to recommendations and actions following DHRs; SCRs; CQC inspections and S11 audit - draw up Training Needs Analysis for Level 3 Safeguarding Children - draw up Training Needs Analysis for Domestic Abuse - draw up Training Needs Analysis for HealthWrap PREVENT training - draw up Training Needs Analysis for Mental Capacity Act/DoLS - Incorporate Think Family and Domestic Abuse into Level 2 Safeguarding Training - Develop Level 2 Safeguarding Children update - Develop Level 2 Safeguarding Adults update - develop master class training in relation to Child Sexual Exploitation - develop master class training in relation to Routine Enquiry - develop data collection tool to capture advice calls to

15 Objective meets requirements for Safeguarding CQUIN, CQC Outcome 7; Section 11 and Safeguarding Boards Ensure all staff have access to expert knowledge, support and supervision as required on a day to day basis Ensure staff have adequate policy and guidance in relation to Domestic Abuse Update Adult Safeguarding Policy in line with Pan West Midlands Policy Update internal and external safeguarding website Actions to meet objective safeguarding team at clinical service area level - develop data collection tool to capture safeguarding activity at clinical service area level - refine data collection tool to better illustrate trends and use of resources - refine training data analysis to reflect service area/staff discipline training uptake - identify key areas of risk in adult safeguarding - commence roll out of adult safeguarding supervision in identified areas of risk - continue roll out of child safeguarding action learning sets in Youth and CAMHs - develop domestic abuse policy - review current Policy - ensure website is user friendly, refreshed and maintained 8.0 RECOMMENDATION The Clinical Governance Committee and Integrated Quality Committee are asked to note the content of this report and agree the Work Programme for 2014/15.