CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST

Transcription

1 Agenda Item 9.1 CENTRAL MANCHESTER UNIVERSITY HOSPITALS NHS FOUNDATION TRUST Report of: Professor R. Pearson Medical Director Paper prepared by: Bridget Thomas - Head of Safeguarding Sue Ward Director of Nursing Date of paper: Subject: July 2017 Safeguarding Children, Adults and Looked After Children Annual Report 2016/17 Indicate which by Information to note Purpose of Report: Support Resolution Approval Consideration of Risk against Key Priorities Patient Experience & Patient Safety Recommendations Contact: The Board of Directors is asked to note the content of this report, the work undertaken during 2016/17 and the assurance provided that the Trust is meeting its statutory obligations. Name: Bridget Thomas Tel:

2 Central Manchester University Hospitals NHS Foundation Trust Safeguarding Children, Adults and Looked After Children Annual Report 2016/17 Authors: Bridget Thomas, Head of Safeguarding Sue Ward, Director of Nursing

3 Contents 1. Executive Summary Purpose of the Report Underpinning Values The Voice of Young People in CMFT Our Manchester Manchester Profile Key facts about the children of Manchester Safeguarding Children Manchester Profile Key facts about the adults of Manchester Safeguarding Adults CMFT Accountability Within an Integrated Safeguarding System Achievements and Activity Safeguarding Training Child Sexual Exploitation Forced Marriage & Honour Based Violence (HBV) Female Genital Mutilation (FGM) Domestic Abuse Deprivation of Liberty Safeguards (DoLS) and Mental Capacity Act (MCA) Prevent CMFT Contribution to Multi-Agency Safeguarding Priorities Adverse Events Assurance Conclusion...70 Page 3

4 1. Executive Summary 1.1 Central Manchester University Hospitals NHS Foundation Trust (CMFT) remains committed to ensuring safeguarding is a fundamental component of care and recognises that safeguarding children, adults and Looked After Children (LAC) who access services across the Trust is everyone s responsibility. This report provides an overview of the Trust s safeguarding activity over the last 12 months (April 2016-March 2017) incorporating the work of the Safeguarding Team and of the Divisions within the Trust. 1.2 The underpinning principle of safeguarding activity continues to be that every person regardless of age, ability, gender or ethnicity has the right to live a life free from abuse and neglect. The Safeguarding Team logo and strap line: We listen, We belive, We act place service users at the heart of the service to ensure we listen to their concerns, we believe what they are telling us and we act to keep them safe and protected. 1.3 Throughout 2016/17 CMFT has continued to work with partner agencies to ensure the safety and protection of the most vulnerable people in the city and an effective response is provided when needed. 1.4 There have been many new challenges in safeguarding and in the past year the need to acknowledge and respond effectively to the complex safeguarding agenda spanning adult and children s safeguarding has become a priority across all agencies. This requires a different response to meet the increasing complexities of local communities and patients. 1.5 CMFT continues to work closely with Mancester Children s Services on the city s improvement journey both strategically and operationally. Direct operational leadership input is porvided by a team of Named Nurses for Safeguarding into the Multi-Agency Safeguarding Hub (MASH) which is now the single point of contact for all safeguarding referrals. Links have been established with the Early Help Hubs and the multiagency Early Help Assessment and Signs of Safety approach have been embedded across frontline services and into policies, procedures and training. The Signs of Safety approach is a new way of engaging with children and families through an asset, relationship and a strengths-based approach and this aligns closely with wider Public Sector Reform /17 saw a greater focus on raising the profile of the voice of the vulnerable child and adult. Work will be ongoing in 2017/18, underpinned by engagement with service users, to ensure the voice of the child is a key priority across Page 4

5 children s acute and community services and that the Making Safeguarding Personal agenda is embedded across all adult services. 1.7 The Deprivation of Liberties Safeguards (DoLS) agenda continues to present challenges; the Trust continues to work within current legistation however new legistaion proposed over the coming years will mean significant changes to the DoLS process and a different focus for provider organisations as to how these requirements are implemented. 1.8 Safeguarding operational and strategic practice continues to ensure that the Trust s strategic objectives and those of Manchester Safeguarding Children and Adults Boards underpin practice. The Trust Safeguarding Team support all staff to ensure that every patient whether adult or child is safe in our care, have an opportunity to raise concerns and feel secure in the knowledge that they will be listened to and taken seriously /18 will provide more challenges and opportunities for the development of safeguarding services through the Single Hospital Service programme and development of the Local Care Organisation. The outcome of the recent Community Children s Services Review and development of new joint commissioning arrangements for children s services across the city will also impact the future safeguarding infrastructure CMFT will continue to support the development of the Adult MASH and continue to work closely with partners to further embed Early Help and Signs of Safety across services. The Trust Safeguarding Team will co-ordinate the implementation of the Child Protection Information Sharing (CP-IS) system into the Trust s urgent care services, prepare for challeges that new service delivery brings and ensure services are responsive to inspections such as Joint Targeted Area Inspections (JTAI), CQC and Ofsted ensuring that the safety and protection of the most vulnerable is paramount and central in all care provided. Page 5

6 2 Purpose of the Report 2.1 The 2016/17 Safeguarding Annual Report provides assurance to the Board of Directors that the Trust is fulfilling its safeguarding responsibilities to ensure that all adults, children and their families who use any service across CMFT acute and community services are safe in our care and protected from harm or neglect. 2.2 This assurance spans from pre-birth to end of life and applies to all services including volunteers and external contractors. 2.3 This Safeguarding Annual Report for Children, Adults and Looked After Children (LAC) provides the Board of Directors with information regarding internal and external safeguarding activity undertaken in 2016/17 and outlines key priority areas scheduled for implementation through the Safeguarding work plan in 2017/ Safeguarding activity is underpinned by the regulatory standards and statutory requirements outlined below. Regulatory standards and statutory requirements CQC registration standards, Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 13 The Children Act (1989, 2004) The Sexual Offences Act (2003) Safeguarding Vulnerable People in the NHS Accountability and Assurance Framework (2015) Safeguarding Adults: Roles and competences for health care staff Intercollegiate Document (2016) No Secrets (2000) CQC National Standards of Quality and Safety Outcomes 7-11; Essential standards of quality and safety The Care Act (2014) Working Together (2015) Safeguarding Children and Young People: Roles and Competences for Healthcare Staff Intercollegiate Document (2014), Promoting the health and well-being of Looked After Children (2015) Page 6

7 3 Underpinning Values 3.1 Safeguarding across CMFT continues to be a priority and is underpinned by the Trust values. Pride Respect Dignity Empathy Compassion Consideration These values are integrated into safeguarding activity as follows: Align to others' emotions and feelings Ensure safe, secure and caring support for all Give our best to keep others safe Be caring but curious Acknowledge others' needs and circumstances Value the diverse needs of others Understand others' rights and views Page 7

8 4 The Voice of Young People in CMFT 4.1 Listening to the voice of children and young people is a key priority for the Manchester Safeguarding Children Board. This year, young people from the Royal Manchester Children s Hospital (RMCH) Youth Forum were asked what their safeguarding priorities were and what safeguarding meant to them; responses included: Engagement and communication with children, young people and families Every child having someone to look out for them such as a school nurse Signposting support, rights, sexual health Focusing on general safety sexual health Ensuring young people have information including who to tell about Ensuring children and young people do not fall through the gap between areas Children and young people have support for stigmatised issues The Youth Forum outlined their top 5 priorities 1. Bullying - including peer pressure, recognising that boys and girls bully differently, online/social media bullying, sexting and blackmail 2. Child Sexual Exploitation - including helping young people to develop appropriate relationships, emotional abuse in relationships and consent within relationships 3. Neglect - including how to identify signs of neglect 4. Early Identification - help and support for children, young people and families to prevent unsafe situations 5. Vulnerability - including learning disability, disability, young carers Page 8

9 4.2 The Youth Forum members also discussed their views on a range of other issues that affect the safety of children and young people. These included: Mental health including eating disorders and exam stress Domestic violence and abuse young people felt there was a connection to neglect LGBTQ issues Issues relating to race/religion/culture including forced marriage, FGM and so called honour based violence 4.3 The following underpinning principles were considered by Youth Forum members to be important to keeping children safe: Every child having someone to look out for them such as a school nurse Children and young people have support for stigmatised issues Ensuring young people have information including who to tell about concerns, signposting to support, young people s rights and sexual health Maintaining a focus on general safety Engagement and communication with children, young people and families Ensuring children and young people do not fall through the gap between areas 4.4 This valuable feedback from young people contributed to a wider consultation led by Manchester Safeguarding Children Board to inform the Board s priorities and work programme. Page 9

10 5 Our Manchester 5.1 Manchester is the United Kingdom's second-most populated urban area, with a population of 530,300. Many visitors come to Manchester to experience both cultural and leisure activities and Manchester has a long established student population from all over the world. The number of people living in the city is growing rapidly and the city is becoming younger and more diverse. Manchester is proud of its diverse and welcoming population and many communities are long-established across the city, alongside significant numbers of new residents. 5.2 However, despite urban growth and development, Manchester is ranked 5 th in England in terms of its overall deprivation, making Manchester more deprived than any other Greater Manchester district. When compared with other areas across Greater Manchester, the level of deprivation is stark. The next most deprived neighbour is Salford (30 th ) while in contrast, Trafford, at 198 th, falls into the least deprived half of the country s ranking. 5.3 Deprivation has a significant impact on health outcomes within Manchester: Smoking Alcohol Healthy Weight Health Screening Long illness disability Cancer term or 25% of registered GP patients surveyed class themselves as occasional or regular smokers. Manchester has more hospital admissions for alcohol-related conditions than the England average. The Active People Survey (2012) found that in Manchester, 26% of respondents had a Body Mass Index (BMI) that suggested they were obese. This is higher than the 24.3% of respondents in the North West and 23% in England. In 2013/14, 60.5% of eligible women (aged 53-64) in Manchester attended breast screening, compared to 72.4% in the North West and 75.7% in England. The 2011 Census revealed that, 17.8% of residents have a limiting longterm condition or disability that affects their ability to do their usual day-today activities. For the period , the North West Cancer Intelligence Service (NWCIS) has published an age standardised incidence rate of per 100,000 populations in Manchester, compared to in the North West and in England. Page 10

11 6 Manchester Profile Key facts about the children of Manchester 6.1 The Public Health England Child Health Profile (March 2016) provides a snapshot of child health in Manchester. Children and young people under the age of 20 years make up 25.4% of the population of Manchester; some 59.3% of school children are from a minority ethnic group. Population The 2015 mid-year population estimate was 530,300. Children and young people represent around a third, with one fifth being under 16 years old. Deprivation Manchester is England s fifth most deprived local authority Ethnicity Black, Asian and minority ethnic (BAME) residents make up 33.4% of Manchester s population. 59.3% of school children are from a minority ethnic group. Life Expectancy A boy born in a low income Manchester family is expected to live to 75.5 years In the North West this is 78 years and in England 79.4 years A girl is expected to live to 80 years compared with almost 82 years in the North West and 83 years in England Health Outcomes Health and wellbeing of children is generally worse than the England average. Child mortality rate is worse than the England average. Level of child poverty is worse than the England average % of children aged under 16 years living in poverty The rate of family homelessness is worse than the England average. Drugs and Alcohol Estimated 27,000 alcohol or drug dependent adults in the city Nearly 50% of adults in contact with alcohol and drug treatment are parents Parental substance misuse has been found to feature in 25% of Serious Case Reviews Alcohol is a factor in up to 70% of care proceedings Page 11

12 7 Safeguarding Children Levels of Need for Children 7.1 In April 2016 the Manchester Safeguarding Children Board (MSCB) launched a refreshed Multi-Agency Need and Response Framework to assist practitioners working with children, young people and their families in Manchester. 7.2 The Framework assists practitioners in achieving Manchester s vision to build a safe, happy, healthy and successful future for children and young people. CMFT have contributed to the production of this framework and work is ongoing across the Trust to ensure this is incorporated in all safeguarding children work streams. 7.3 The Multi-Agency Decisions Framework, set out in Diagram 1 and Table 1, defines 5 levels of need across all services for children in Manchester and seeks to improve support to families where needs are responded to and met at the lowest possible level to avoid difficulties escalating. CMFT practitioners work within this framework at all levels. Diagram 1: Manchester Levels of Need Page 12

13 Table 1: Levels of Need Definitions Level 1 - Universal Services Levels 2-4 Early Help Services Level 5 Specialist Intervention Services available to all children for example: Early Years School Nursing, Health Visiting, GPs and Midwives. Most children s needs are being met by parents, carers. Early Help Services encompass three levels of service: Level 2 - Child, young person or family, can be sufficiently supported by a single agency Early Help Assessment (EHA) and response; or by signposting to an additional agency. Level 3 - Child, young person or family who would benefit from a coordinated programme of support from more than one agency using the EHA and a Team around the Child/Family meeting. Level 4 - Child, young person or family who requires intensive and coordinated support for complex issues via Targeted Services / Early Help Hubs and where support at Level 3 has not improved outcomes. Section 17 Child in Need, spans levels 3 and 4 depending on need. Child or young person at risk of, or suffering significant harm, due to compromised parenting, or whose needs require acute services or care away from their home. These children will receive a Statutory/Specialist Assessment. Child Protection 7.4 There are many factors such as; going missing from home, living in households where there is domestic violence and abuse, substance misuse and/or parents who are mentally ill that can place children at increased risk of harm from abuse and/or neglect. 7.5 Manchester has a significant number of children and young people who need statutory intervention to keep them safe. 7.6 Table 2, below, outlines the number of children and young people subject to child protection plans in Manchester on 31 st March 2016 and shows how this compares with statistical neighbours and the national position. Table 2: Child Protection Plan Comparisons with Statistical Neighbours Area Children subject to a Child Protection Plan on 31st March 2016 % on a CPP per 0-19 Population Statistical Neighbours England 50,310 North West 8,400 Manchester 840 Liverpool 430 Newcastle ,532 population % on CPP = 0.62% 105,100 population % on CPP = 0.41% 68,000 population % on CPP = 0.62% Page 13

14 Child Protection Plan (CPP) 7.7 Children who have a CPP are considered to be in need of protection from either neglect, physical, sexual or emotional abuse, or a combination of one or more of these. The CPP details the main areas of concern, what action will be taken to reduce these concerns and by whom, and how we will know when progress is being made. 7.8 It is evident that Manchester has a higher number of children with a CPP than its statistical neighbours and for this reason the multi-agency partnerships are focusing on delivery of early help with the aim of reducing the levels of need and complexity. Looked After Children (LAC) 7.9 A child is 'looked after' if they are in the care of the local authority for more than 24 hours. Legally, this could be when they are: With foster carers. At home with their parents under the supervision of social services. In residential children's homes. Other residential settings like schools or secure units. They might have been placed in care voluntarily by parents struggling to cope. Children's services may have intervened because a child was at significant risk of harm and an interim or full care order is in place Table 3 presents a comparison of the Manchester Looked After Children population against the national and regional position, as well as against Manchester s statistical neighbours. This shows that Manchester has a higher than expected number of Looked After Children. This issue a key area of improvement for the city. Table 3: Looked After Children Comparisons with Statistical Neighbours Statistical Neighbours Area England 70,440 North West 9,280 Manchester 1,236 Liverpool 750 Newcastle 340 Looked After Children on 31st March 2016 % LAC per 0-19 Population 135,532 population % on CPP = 0.9% 105,100 population % on CPP = 0.7% 68,000 population % on CPP = 0.5% 7.11 Diagram 2 highlights the vulnerabilities of being Looked After and emphasises why safe reduction of this number has been prioritised. Page 14

15 Diagram 2: Facts about Looked After Children in Manchester 56% male 44% female 77.9% in foster care or adoption; 16.1% Underfives 520 placed in Manchester 29.9% 5 to 10 years 1080 placed in Greater Manchester 19.6% 16 plus 159 placed out of area 34.3% 11-15yrs CMFT Safeguarding Service 7.12 The Trust s Safeguarding and LAC Teams support staff to recognise and respond to the needs of the most vulnerable. It is recognised that some groups of children are more vulnerable than their peers, these include: Children for whom there are concerns about their development and wellbeing. Children who are at risk of being subject to abuse. Children who have been subject to abuse including sexual exploitation. Children who go missing from their home or from a care placement. Unaccompanied asylum seeking children. Privately fostered children. Children at risk of Forced Marriage and Honour Based Violence Children at risk of Female Genital Mutilation Children at risk of radicalisation Children at risk of Modern Slavery and Trafficking Page 15

16 8 Manchester Profile Key facts about the adults of Manchester Learning Disability In 2014, there were approximately 8,843 adults aged with a learning disability and approximately 3,641 adults aged with autistic spectrum disorders (ASD) in Manchester. The number of adults in Manchester with a learning disability is projected to increase by 7.7% between 2014 and 2030 while the number of adults with ASD is projected to increase by 9.9% Long term illness or disability 17.8% of residents have a limiting longterm condition or disability that affects their ability to do their usual day-today activities Mortality Significantly higher than the rest of England. Manchester is ranked 150th out of 150 local authorities in England for deaths in people aged under 75 Life expectancy At the age of 65 in Manchester is below the national average. Manchester ranks worst in the country for male life expectancy and third worst for female life expectancy Older People 9.5% of the population of Manchester are aged 65 years or over. The number of residents aged 65 and over is projected to start to increase slowly until the end of the decade, and then grow rapidly to the end of the 2020s. Quality of Life Quality of life in Manchester is worse than the North West and England Loneliness and isolation In Manchester 40% of residents aged 65 or over are living alone compared with 31.5% in England Deprivation 37% of older people residing in Manchester suffered from income deprivation Falls Manchester has a higher rate of hospital admissions due to an unintentional fall in older people aged 65 and over compared to England. Page 16

17 9 Safeguarding Adults 9.1 Safeguarding Adults Boards became a statutory function in April 2015 under the Care Act Since then CMFT have worked in partnership with the Manchester Safeguarding Adults Board (MSAB) to ensure vulnerable adults are safeguarded across Manchester. 9.2 Safeguarding Adults is underpinned by six principles, which are set out in the Care Act and form the basis of the MSAB assurance framework, which partner agencies are required to submit annually. These are as follows: 1. Empowerment 2. Prevention 3. Proportionality 4. Protection 5. Partnership 6. Accountability Personalisation and the presumption of person led decisions and informed consent. CMFT works in a way that considers how to achieve the outcomes that people have identified and how to ensure that people make their own decisions about their own lives; this is the key to empowering people to keep themselves safer in the future. It is better to take action before harm occurs The Safeguarding Team is central to ensuring good standards of safeguarding practice across the Trust through support, advice, training and supervision. The Team work closely with Divisional Leads to ensure that clinical practice is safe and responsive to the needs of our most vulnerable patients. Proportionate and least intrusive response appropriate to the risk The Safeguarding Team supports practitioners to apply a balanced approach between providing support and intruding and taking over people s lives. This ensures that people can make important decisions about their own safety, but at the same time, making sure that the minimum level of involvement does not leave people at risk of harm. Support and representation for those in greatest need Within CMFT, safeguarding is everyone s business to ensure that we continue to work together as an organisation to safeguard and support the most vulnerable in our care. Local solutions through services working with their local communities CMFT work with partner agencies and with our patients to support and empower them to keep themselves safe. All of the partners work together, through the Board and as organisations to recognise report, respond and reflect on safeguarding concerns. Accountability and transparency in delivering safeguarding. Trust staff are accountable to the Board of Directors and the organisation is accountable to the MSAB to ensure robust Governance arrangements are in place to ensure safe systems are embedded for all staff across the Trust to enable vulnerable patients to be safeguarded. 9.3 Key areas where work has been undertaken by CMFT in partnership with the Safeguarding Adults Board are as follows: Safeguarding of victims of Domestic Violence and Abuse (DV&A) Complex safeguarding which requires a robust multi-agency response to the changing and challenging nature of safeguarding pressures and risks and 1 Care Act Page 17

18 includes: Prevent, Human trafficking, Counter terrorism, Gangs and gun crime and Sexual Exploitation Deprivation of Liberty Safeguards (DoLS) Mental health Learning disability 10 Accountability Within an Integrated Safeguarding System 10.1 CMFT continues to be a key partner in joint working with other agencies to keep our most vulnerable safe. This includes involvement at Greater Manchester, Manchester and locality levels, both from a strategic and operational perspective Within CMFT, work is on-going to support Divisions across the Trust to take ownership of their safeguarding responsibilities within a clear governance and accountability framework. In 2016/17 the Trust combined its Children s and Adults Safeguarding Groups into a combined Trust Safeguarding Group (TSG) with a revised membership and terms of reference. This allows a more joined up approach to safeguarding across adult and children s specialities. The approach is to ensure that safeguarding is considered holistically, through a family approach, and not deal with children and adult safeguarding in silos The links with the Manchester Safeguarding Adults and Children s Boards and associated subgroups continues as reported in the 2015/16 Safeguarding Annual report and the internal governance arrangements are set out in Diagram 3 below Accountability to the Board of Directors for Safeguarding provision in the Trust is via the Safeguarding Effectiveness Committee (SEC). Page 18

19 Diagram 3: Safeguarding Accountability in CMFT Board of Directors Clinical Effectiveness Committee Safeguarding Effectiveness Committee MSAB MSCB Trust Safeguarding Group CSE Sub-Group FGM Sub-Group DV & A Sub-Group Early Help Sub-group Sub-groups & Strategic Groups Divisional Safeguarding Operational Groups Divisional Governance Groups Frontline Practitioners 11 Achievements and Activity 11.1 This section of the report provides an overview of achievements and activity across the range of safeguarding services provided by the Trust in 2016/17 and summarises areas for development in 2017/18. Diagram 4 shows the specific teams that make up the Trust-wide Safeguarding Service. Page 19

20 Diagram 4: CMFT Safeguarding Teams Acute Children's Team Safeguarding Children Trafford Hospital Community Children's Team CMFT Safeguarding Service Safeguarding Adults Trafford Hospital Looked After Children's team Safeguarding Adults Team Central site Page 20

21 Children s Acute Safeguarding Team 11.2 The Acute Children s Safeguarding Team provide support to staff working in the acute services provided by the Trust. Achievements and on-going developments in this area of safeguarding practice are as follows: Service Key Achievements 2016/17 Children s Acute Safeguarding Team Following appointments to vacant positions, development of skills and experience of team members has been a priority. Review of Level 3 Safeguarding Training to provide a full day s training to ensure compliance with Intercollegiate Guidance and embed learning from local and national Serious Case Reviews (SCRs). Further development of safeguarding processes across the Burns Unit and Paediatric Intensive Care Unit (PICU) to improve communication and information sharing with Community Practitioners On-going work across Royal Manchester Children s Hospital (RMCH) ward areas and PICU to improve early identification and management of complex safeguarding issues. Continued development of RMCH Link Nurses and introduction of a programme to promote shared learning and development of safeguarding knowledge. Development of Child Protection Information Sharing system (CP- IS) across Local Authority and CMFT in progress with implementation anticipated in Q2 of 2017/18. On-going development Further development of the Safeguarding Team to meet increasing demands relating to complex safeguarding. Continued development and evaluation of the Level 3 Safeguarding Training and review of additional safeguarding training requirements within the Trust. Continue development of safeguarding processes in the Burns Unit and PICU and share learning across other relevant areas. Continued work to increase Specialist Safeguarding Nurses access and visibility on wards and within RMCH to continue to promote effective safeguarding practice across the Trust. On-going awareness raising regarding the needs of Looked After Children to promote appropriate information sharing and ensure their health needs are addressed. Further development of Safeguarding Supervision for Specialist Nurses working in RMCH in line with the updated Safeguarding Supervision Policy. Plans for 2017/18 Further development of links with partner agencies and continued improvement in safeguarding practice within the Trust in line with MSCB priorities. Involvement in CMFT Acute and Multi-Agency Audits to identify areas requiring further development and highlight areas of good practice to effectively safeguard children. Implementation of CP-IS across Local Authority and CMFT. Page 21

22 Acute Safeguarding Activity 2016/ Chart 1 below demonstrates that the highest numbers of acute referrals come from the Sexual Assault Referral Centre (SARC), Adult Emergency Department (ED) and wards. This accounts for why the highest categories of abuse seen in the acute service are Sexual Abuse and concerns regarding Parenting. Chart 1: Categories of Referral No of referrals Table 4: Comparison with previous years referral data 2014/ / / This data shows a 29% increase in referrals to the acute children s safeguarding service in 2016/17 compared to 2015/16. This increase demonstrates the on-going impact of the safeguarding training programme, which supports recognition and reporting of safeguarding concerns. Central Site Adult Acute and Community Safeguarding Team 11.5 The central site Adult and Community Safeguarding Team is made up of nurses with expertise in adult safeguarding who are able to provide support across the pathway focused around the patient rather than their location. Achievements and on-going developments in this area of safeguarding practice are as follows: Page 22

23 Service Key Achievements 2016/17 On-going development Plans for 2017/18 Central Site Adult Acute and Community Safeguarding Team Increased ward walks to raise the profile of adult safeguarding and support of frontline staff in real time. Introduction of a consistent and user friendly Mental Capacity Act (MCA) training package. Bespoke training of MCA/DoLS across all divisions. Collaboration with the Informatics Department in the development of the Deprivation of Liberty Safeguards (DoLS) portal to streamline the DoLS application process and allow accurate monitoring and recording. Close working with the MSAB, Police and Local Authority on the emerging agenda of sexual exploitation and grooming in adult patients who are vulnerable. Working in partnership with the Named Nurse Safeguarding Children (Community) to develop a domestic violence and abuse training plan and complete a DV&A training needs analysis with all divisions across the Trust. Delivered bespoke domestic abuse training to out of hours clinicians in both acute and community services. Embedding the requirements of the Safeguarding Adults: Roles and competences for health care Intercollegiate document, across the Trust. Developed Adult Safeguarding core competencies which reflect the Intercollegiate guidance and adult social care safeguarding process Developed a rolling programme of speakers for safeguarding champions meetings with support and co-operation from the divisions in nominating staff from each ward. Developed and delivering an adult safeguarding Level 3 package Collaborative working with the MSAB on the Serious Case Review sub group. Representing the Trust on the MSAB Communication, and the Learning and Development sub groups. Developed a close working relationship with CMFT Learning Disability team throughout Manchester. Developed an electronic safeguarding notification database, which enables safeguarding practitioners both at the Central site and Trafford to access and merge information received. Updated a number of adult safeguarding policies with the Named Nurse Adult Safeguarding at Trafford. To continue to recruit to and develop an adult safeguarding team that is knowledgeable, visible and effective across the Trust. A Band 6 post has been converted to a Band 7 post in recognition of the needs of frontline staff and the level of knowledge, skill and experience required to support the adult safeguarding agenda. To lead and develop meaningful audit across the Trust that will inform safeguarding practice. To forge further links with MCC DoLS teams to ensure good communication and a joined-up approach to the management of DoLS applications. To introduce a system to attend ward board rounds where the Safeguarding Team can support the multidisciplinary team in identifying safeguarding concerns in real time. To work with the Tissue Viability Nurses to increase the understanding of and enable identification of harm and neglect in compromised Page 23

24 patients. To develop an acute internal process for adult Multi Agency Risk Assessment Conference (MARAC) cases to be presented by CMFT. Develop a 1 day Level 3 training package to include MCA/DoLS, which will encompass the recent Law Commission reforms. To further identify ways to capture that staff are listening to the voice of the vulnerable adult/child and that this informs the plan of care. Central Site Adult Safeguarding Team Activity 2016/ Chart 2, below, shows the referral activity for the adult safeguarding service. The Team undertook significant work in 2016/17 to empower divisions to manage MCA assessments and DoLS applications. The success of this work can be seen in the comparison of the 2015/16 referrals to those received in 2016/17, where there has been a reduction in the amount of support frontline staff need to complete MCA Assessments and DoLS applications, as a result of increased knowledge and confidence. This has also been supported by a new MCA/DoLS training package and monthly training with Informatics on a rolling basis on the use of the DoLS portal. Chart 2: Referrals to the Adult Team 2015/ /17 comparison Adult Safeguarding Referrals DoLS support Domestic Emotional Financial Homeless Learning Abuse Abuse Abuse Disability MCA support Neglect Physical abuse Sexual abuse Substance Misuse 2015/ / /17 also saw the emergence and recognition of categories of complex safeguarding such as trafficking and gangs, which are described in table 5, below. It expected that, in line with the MSAB and MSCB newly formed Complex Safeguarding Sub-group, the recognition of these risks and vulnerabilities will increase in 2017/18. Page 24

25 Table 5: Other Adult Safeguarding Referral Categories Category 2015/ /17 Assault 0 1 Gang Violence 2 3 Self-Harm 0 5 Sexual Exploitation 14 1 Trafficking 9 2 Multi Agency Risk Assessment Conference (MARAC) 11.8 MARACs address the highest risk cases of domestic abuse. Regular MARAC meetings are attended by relevant agencies (both statutory and voluntary) in order to collate information about high risk cases of domestic abuse with a view to creating a co-ordinated safety plan for the victim and children, if any are involved. The Adult Safeguarding Team attend MARACs for adult-only cases Chart 3 shows that the actual number of adult referrals to MARAC has reduced when compared to 2015/16, which represents a 9% reduction in referrals. However, this level of activity is aligned to normal variation across the city. Within the work of Delivering Differently across Manchester, there is a greater focus on early recognition and intervention around Domestic Abuse. With the development of the adult Multi-Agency Safeguarding Hub (MASH), it is expected that Domestic Abuse incidents will be dealt with at an early stage, thereby preventing cases reaching a MARAC threshold. Chart 3: MARAC Activity Adult only MARAC MARAC Adult only cases 2015/ /17 Looked After Children Specialist Health Team The Trust provides a dedicated service, which works to support the health needs of Looked After Children. This team works closely with Designated Professionals and Local Authority partners to meet the requirements set out in Page 25

26 statutory guidance 2. Achievements and on-going developments in this area of safeguarding practice are as follows: Service Looked After Children (LAC) Specialist Health Team Key Achievements 2016/17 What is working well Scoping exercise completed to understand the challenges faced by acute services when they come into contact with looked after children and young people (LACYP) and to explore the journey of looked after children through acute settings. Established a targeted immunisation service to LACYP in their home (residential and foster care). LAC administration team are now based and fully aligned with the Specialist LAC nursing team and management structure, which has led to improved systems, processes and communication. Nurse pathways have been developed for LACYP who are reluctant to engage with their Initial Health Assessments (IHA) and for those LACYP who have been seen by a Paediatrician for a child protection medical. The Named Doctor for LAC previously provided a service for the majority of Unaccompanied Asylum Seeking Children (UASC) requiring IHA. In 2016/17 a wider group of Paediatricians have increased their experience and are providing holistic IHA for UASC with awareness of the disease profile in areas of the world from which these young people have migrated. A Senior Specialist LAC Nurse for UASC is now carrying out some triage assessments prior to paediatric appointments. Specialist LAC team have continued to deliver a responsive and flexible service whilst meeting key performance priorities, working to a high profile agenda that has on-going external scrutiny and oversight. As part of the promise to Care for you, the team is striving to ensure that more children and young people receive their health assessments on time. This includes children who are placed outside of the city, ensuring that children and young people can access the health care they need. CMFT performance for children placed in Manchester remains above 90% in the following key areas: - Review Health Assessments - Immunisations - Developmental Reviews Partnership working with the City Council regarding the Initial and Review Health Assessment processes and shared responsibility for the statutory process is on-going. Focused improvement work is on-going with City Council colleagues at a strategic and operational level. The Named Nurse for LAC and Senior Specialist Nurses for LAC have continued to contribute to Multi-Agency Panels; LAC 2 DoH/DfE (March 2015). Promoting the health and well-being of looked-after children Statutory guidance for local authorities, clinical commissioning groups and NHS England. Page 26

27 On-going development Plans for 2017/18 Permanency Monitoring Panel, Missing from Home and Care Panels and Fostering Panel. UASC LAC nurse regularly provides advice and support to nursing colleagues across Greater Manchester. Multi-agency audit shows that the quality of CMFT-completed health assessments is good with some outstanding. New LAC Policy to be developed to include guidance, procedures and practice standards for both the acute and community services. To continue to address the delay in Health Assessments for Manchester children placed out of area in partnership with the City Council and the Clinical Commissioning Group (CCG). To continue to work with City Council and the Designated professionals to improve the timeliness of initial health assessments. To work more closely with practitioners to ensure the drive for good and outstanding in the quality assurance of the written health assessments, does not shift focus from the time spent interacting with the child/young person and ultimately the health outcome for that child. Shift the focus from performance and health assessment documentation standards to the impact and outcomes for young people including, interaction and engagement and being able to demonstrate if this makes a difference, and improves outcomes for the LACYP. Develop a training passport for practitioners working with LAC that is linked to the Intercollegiate Framework for LAC (2015), to capture all the relevant training undertaken that evidences knowledge, skills and competences required for LAC. Further strengthen partnership with Safeguarding Improvement Unit and their Independent Reviewing Officers for LAC. Specialist LAC nursing team to begin to use the CMFT patient experience approach What Matters to me. Timely notifications and health assessments request along with timely health assessments will remain high priority Overview of LAC performance for 2016/17 against Key Performance Indicators Table 6, below shows that performance across key health indicator generally exceeds the over 95% target. For both Review Health Assessments and Immunisations, 2016/17 performance is the highest to date when compared to previous years. However, there is on-going work with regard to achieving over 95% up to date immunisations for Manchester Looked After Children placed out of area, for whom Manchester City Council remain responsible. Page 27

28 Table 6: LAC performance for 2016/17 against Key Performance Indicators KPI Review Health Assessment up to date Immunisations up to date Developmental Assessment up to date Dental check up to date Manchester LAC - Manchester Placed Manchester LAC Out of Area placed Manchester LAC Total *Total CMFT performance 95% 93% 94% 96% 95% 90% 92% 93% 96% 91% 93% 98% 96% 96% 96% * Total Performance includes Manchester LAC placed in Manchester, Manchester LAC placed in other LA areas, other local authority LAC, placed in Manchester or attending a Manchester school As the Corporate Parent for Manchester s Looked After Children, MCC has publicised the city s commitments to Looked After Children 3. In support of the promise to Care for you, intensive work is taking place to provide children and young people with timely health assessments, including children who are placed outside of the city. Table 7 demonstrates that performance for Initial Health Assessments (IHA) has been inconsistent. Initial Health Assessments are a medical assessment, and are completed by community paediatricians. It is expected that these assessments are completed within 20 working days of a child becoming Looked After. Table 7: Percentage of Initial Health Assessments completed within 20 working days of a child becoming looked after Month Manchester LAC placed in Manchester Manchester LAC placed Out of Area 2016 March 69% 40% 50% April 15% 5% 10% May 15% 11% 14% June 23% 20% 22% July 26% 15% 22% Aug 47% 20% 32% September 80% 22% 53% October 53% 17% 37% November 40% 25% 35% December 71% 50% 62% Total Manchester LAC 3 Page 28

29 2017 January 75% 30% 50% February 100% 27% 56% March 35% 17% 28% In order to complete an Initial Health Assessment, a paediatrician needs to be notified that a child has become Looked After and needs to receive paperwork and consent from the Local Authority in order to schedule and complete this assessment. Any delay in the information being provided, significantly affects the ability to schedule the child/children within the 20 day timeframe Extensive improvement work has been undertaken in partnership with MCC since 2015 to improve this process; however some challenges have remained with regard to achieving the performance target, which is also impacted by capacity pressures in community paediatrics. Performance is regularly discussed at the Manchester Children s Services Improvement Board, which was established following the city s inadequate Ofsted rating, following inspection in The Director of Nursing represents the organisation on this board Improvements seen in 2016/17 following considerable engagement and monitoring between CMFT and Local Authority teams include: An increase in timeliness of requests for IHA from MCC, which has improved in Q3 and 4. Systems and escalation processes are in place between health and social care to monitor and respond to late requests and further development of these is being undertaken. An action plan is in place to monitor challenges and risks and allow monitoring of progress. Review of options to increase capacity and flexibility of the service offer. Nurse pathways are in place for those young people who are reluctant to engage with the initial health assessment and for those children who have a child protection medical and have already been seen by a paediatrician. The quality of assessments completed by CMFT Paediatricians remains high, as evidenced through the quality assurance process. For example in Quarter 4 of 2016/17, 92% of all health assessments completed by CMFT staff were rated as being of a good to outstanding quality It is recognised that this is on-going work, which will require continuous monitoring and improvement and CMFT are committed to undertaking this improvement work to ensure the best health outcomes for Looked After Children, regardless of placement. Page 29

30 Trafford Hospital Safeguarding Adults Acute Service An on-site safeguarding service is provided by a Safeguarding Matron to support staff working at Trafford Hospital to safeguard adults. Achievements and on-going developments in this service are as follows: Service Key Achievements 2016/17 What is working well Trafford Division Safeguarding Adults Acute The Safeguarding Adults Matron has continued to provide support in the clinical areas with weekly ward walks and attendance at Board Rounds to assist staff to identify safeguarding concerns and to raise the profile of the MCA and DoLS agenda. Raised the profile of the MCA process within Trafford and Altrincham Hospitals out-patient departments with bespoke training for clinical staff both medical and nursing. Designed posters and MCA boxes to support staff following MCA training and these are available in every out- patient clinic room. 83 posters and boxes were distributed across Trafford and Altrincham Hospitals. Following training on the MCA for ENT, Dermatology, Gastroenterology and Orthopaedic medical staff there has been an increase in the number of requests for support and advice relating to the MCA in the out-patient setting. Identified appropriate staff within the Trafford Division who require Domestic Abuse training in line with the CMFT Domestic Abuse Training Strategy. Developed CMFT Safeguarding Adults Training Strategy in line with Safeguarding adults roles and competencies for health care staff intercollegiate document Contributed to the review and update the following polices: - Safeguarding Adults Policy - MCA and Best Interest Decision Making Policy - Restrictive Practice and deprivation of liberty Policy Safeguarding Champions identified in all inpatient and outpatient areas. Established representation from Trafford Division at the safeguarding champions meetings at the central site. Training on mental capacity, best interest and consent for the theatre scheduling and orthopaedic secretaries in order to ensure that appointments are long enough to assess capacity and best interest when needed. Developed a Safeguarding Adults data recording system which is accessible by Trafford and Central Safeguarding Teams Monthly safeguarding adults Level 3 training. Monthly MCA/ DoLS Master Class training. Bespoke safeguarding adults Level 3 and MCA/DoLS master class training for groups and individuals. Weekly Individual meetings with the Ward Managers to discuss and monitor the use of DoLS on their ward. Monthly MDT learning disability reasonable adjustment meetings for patients who need to access health care Page 30

31 On-going development provision at Trafford Hospital (attended by the community learning disability team, an anaesthetist, surgical ward staff, an operating department practitioner (ODP), safeguarding adults matron and community dental consultant and nurse) Collaborative working with Trafford Community Learning Disability Team to ensure good health outcomes and patient experience for patients with a learning disability. The DoLS process is now embedded within the division with regard to the monitoring, checking and tracking of authorisations. Ward Managers have now taken ownership of this and there is a shared responsibility with the Safeguarding Adults Matron. Representation on Trafford Safeguarding Adults Board (TSAB) Representation on TSAB Quality and Performance Sub Group Representation on TSAB Safeguarding Adults Review (SAR) Sub Group Divisional representation at Trafford MARAC each fortnight Increased report writing and attendance at Coroner s inquests by the Safeguarding Adults Matron in relation to patients who have died when they have been subject to an Urgent or Standard Deprivation of Liberty order. o 2 Inquests attended o 4 Coroner s reports provided Domestic abuse training - 3 sessions delivered in the Division Providing safeguarding adults updates and training on the divisional ACE days. Presentations given include: o Update on recent Domestic Homicide Reviews (DHR) and SCRs o Mental Capacity, Best Interest and Consent o Court of Protection cases Facilitating outside speakers from Hempson s Solicitors on MCA 2005 TSAB/TSCB are currently undergoing a transformation process, of which the outcome has not been finalised. The possibility of a joint children s and adults board has been proposed. At this time there is an interim Chair of both boards. Embedding of the safeguarding champions and attendance at the Divisional safeguarding champions meeting. DoLS process in relation to unlawful detention of patients due to untimely assessments by the Supervisory Body. Plans for 2017/18 Assist with the implementation of the Law Commission Reforms in relation to Mental Capacity and DoLS across the Trust To evidence that the voice of the adult is being captured when adults access services within the Trafford Division Embed the divisional champions meetings and ensure that they are well attended. Trafford Adult Safeguarding Activity 2016/ Tables 8 to 15 below demonstrate the safeguarding activity undertaken at Trafford Hospital in 2016/17. Improvements have been made to data Page 31

32 collection this year, enabling more detail to be provided than in previous reports The data shows that physical abuse accounted for the highest number of referrals. It is also noteworthy that Trafford Hospital makes relatively high numbers of DoLS applications, reflecting the needs of the specific patientgroup who receive care at Trafford Hospital. In response to this specific need, Master classes have been provided to staff to continue to develop their knowledge and skills in this area of safeguarding practice. Table 8: Trafford MARAC referrals Referrals from other CMFT divisions 6 Referrals from Trafford Division (Urgent Care Centre) 5 Total 11 Table 9: Safeguarding Adults Level 3 training Number of sessions held 13 Number of staff trained 77 Table 10: MCA/DoLS Master Class Number of sessions held 10 Number of staff trained 63 Table 11: Domestic Abuse training Number of sessions held 3 Number of staff trained 30 Safeguarding Adult Referrals made to the Local Authority The number of referrals shown in Table 12, below, represents those submitted to the Local Authority from Trafford Hospital to enable multi-agency assessment and investigation. Table 12: Category of Adult Referrals made to the Local Authority Category of Referral 1 st April st March 2017 Physical abuse 29 Emotional abuse 4 Sexual abuse 3 Neglect and acts of omission 14 Discriminatory abuse 1 Self-neglect 0 Financial 1 Capacity issues 9 Total 61 Page 32

33 Table 13: Referring Ward/Area within Trafford Division Area referrals generated Number of referrals made Out Patients Department 11 Urgent Care Centre 14 Minor Injuries Unit Altrincham 2 INRU 6 Stroke ward 2 3 AMU 7 Ward 4 14 Ward 6 3 Ward 12 1 Total 61 Table 14: Number of DoLS Applications made within Trafford Division Month of the year Urgent DoLS applications made April May June July August September October November December January February March Total 143 Table 15: Number of Safeguarding Adult Reviews (Trafford Safeguarding Adults Board) Number of SAR Scopings 3 Number of SAR commissioned 1 Safeguarding Children Trafford Division An on-site safeguarding service is provided by a part time Named Nurse/Safeguarding Matron for Children to support staff working at Trafford Hospital to safeguard children. Achievements and on-going developments in this service are as follows: Service Safeguarding Children Trafford Hospital Key Achievements 2016/17 The Named Nurse, Safeguarding Children works across Trafford Division, the Central site Acute Safeguarding service and with the LAC Named Nurse to raise the profile of LAC within the acute setting. The Named Nurse is a member of the CMFT Child Sexual Exploitation (CSE) Sub Group and the Domestic Violence and Page 33

34 What is working well On-going development Plans for 2017/18 Abuse (DV&A) and Female Genital Mutilation (FGM) Sub Group. The Named Nurse is a member of the Trafford Safeguarding Children Board (TSCB) subcommittees for FGM, Learning and Improvement Committee (LIC) and the Performance and Management Audit Committee The Named Nurse and Divisional Director represent CMFT at the TSCB Board meetings. Safeguarding Supervision has been delivered as per policy to the Children s Learning Disability Team, Trafford Early Development Service and Children s Palliative Care Nurse (part of Trafford s Children s Community Nursing Team) who sit within the Trafford Division. Utilising ACE Days within the Division to offer training to staff within settings that find it harder to release staff for training routinely. Working with the Modern Matron, Safeguarding Adults and the Urgent Care Sister to contribute on behalf of CMFT to the Trafford Division MARAC. Working in conjunction with the Divisional Director to ensure CMFT representation and contribution to the Trafford Safeguarding Children s Board. TSCB/TSAB are currently going through a transformation process, to which the division are contributing. Delivering Level 3 Safeguarding Children Training on site at Trafford General Hospital and beginning the roll out of the full day level 3 Safeguarding Children Training. The full day Level 3 Safeguarding Children Training to continue to be rolled out within the Division. To increase and raise awareness regarding the needs of LAC when they access an acute hospital service. To continue to promote and improve the contribution of CMFT to the TSCB to provide assurance regarding the organisation s safeguarding arrangements for the children of Trafford and children accessing the Trust s services within the Trafford Division. To continue to develop methods of capturing the child s/ young person s voice within safeguarding processes. Child Sexual Exploitation training sessions to be delivered to staff within the Urgent Care Centre setting. To promote the LAC agenda within the Trafford Division. To evidence that the voice of the child is being captured when children and young people access services within the Trafford Division. Trafford Safeguarding Children Activity 2016/ Chart 4, below, shows a reduction in the number of referrals relating to children from Trafford Hospital when compared to the previous year, which equates to a 25% reduction. Notably referral relating to Domestic Abuse, Page 34

35 mental health and neglect fell considerably in 16/17. No clear cause has been identified for the reduction in referrals and this will continue to be monitored. Chart 4: Trafford Children s Safeguarding Referral Categories Referral Categories Domestic Abuse 4 4 Substance misuse 0 0 Emotional Abuse 3 3 LAC Mental health Neglect Parenting Physical abuse 10 6 Sexual abuse 8 14 Other 2015/ / Chart 5 shows that the number of MARAC referrals from Trafford was low in comparison to other agencies. However this is reflective of the Trafford patient profile. Domestic Abuse training has been delivered to 11 staff working with at Trafford Hospital in 2016/17 with a greater focus on response and completing DASH risk assessments. It is expected that this will impact on the number of MARAC referrals in 2017/18. Chart 5: Trafford MARAC Referrals MARAC Referrals No referrals to MARAC No referrals with children Adult only referrals No of referrals from CMFT 2014/ / / The training delivered to staff responsible for the care of children on the Trafford site is set out in Table 16. In addition, 19 staff received Child Sexual Exploitation training. Page 35

36 Table 16: Trafford Level 3 Safeguarding Children Training Number of sessions held 4 Number of staff trained 77 Children s Community Safeguarding Team The Trust provides a city-wide community safeguarding service for children. This Team supports community-based staff by providing specialist advice, support and supervision. Team-members also work closely with partner agencies in the management of safeguarding cases and represent the organisation on a number of multi-agency groups, including sub groups of the MSCB. Achievements and on-going developments in this Team are as follows: Service Key Achievements 2016/17 Children s Community Safeguarding Team Development of a CMFT Early Help Sub-group Key partnership with Manchester City Council in the implementation of the Signs of Safety model for delivery engagement with families. Update of Safeguarding Supervision Policy and Safeguarding Consultations to include Signs of Safety model for identifying risk. Child Protection process - increased focus on CMFT staff attendance, contribution and quality of engagement in Strategy Meetings, Initial and Review Case Conferences and legal processes. Participation in the MSCB programme of multi-agency audit and implementation of learning from the findings Safeguarding staff have, during 2016, obtained access to Manchester City Council Children and Families Micare IT system. Access to Micare has contributed to more efficient contact with Social Care Children s Services. General Dental Practitioners work continues to improve communication pathways between dentists and community health services regarding attendance and concerns about dental neglect. Safeguarding Supervision compliance has remained over 90% for both Group and Individual Supervision The Preventing and Managing Missed Health Appointments for Children and Young People Policy was updated during 2016 and was re-launched at a Community ACE event in July 2016 before finally being ratified in October Integrated Sexual Health Services bespoke training provided for 69 members of staff in March 2017 Advice, guidance and support. As additional activity was taking place within the Early Help Hubs and MASH the management of contact with the team by telephone changed during to triage-based contact in the afternoons. This has improved efficiency within the team. During 2016, the pro-forma for safeguarding consultations was updated to reflect the Signs of Safety model; it also reflected the Page 36

37 What is working well On-going developments Plans for 2017/18 outcomes and the reasons for referral were made clearer so that improved analysis could take place. The reasons for referral now include the diverse and ever evolving categories of safeguarding concerns which includes child death, Fabricated and Induced Illness, FGM, Forced Marriage/ Honour Based Violence, Private Fostering, Radicalisation and Criminal Activity. The impact of this change will be evident in 2017/18. Strategy Meetings and Child Protection Conference analysis - In 2016 work commenced on analysing attendance by community children s staff at child protection case conferences. This has allowed gaps to be identified and has provided assurance that the Trust is meeting statutory requirements to contribute to the section 47 process, which in turn has been provided to the MSCB. Court report analysis - There has been a significant rise in Court Report writing activity in with a total of 323 reports submitted relating to 486 children. This represents a 91% increase from the and corresponds with the work undertaken locally in pre-proceeding work in achieving decisions about children s future in a more reasonable and measured timeframe of 26 weeks from the start of proceedings, which is being achieved. Early Help Commitment to develop CMFT involvement and response to the Early Help Strategy. Child Protection Case Conferences development of a single local system to monitor and report attendance by CMFT staff at child protection strategy meetings and case conferences. Need to increase attendance at Level 3 Safeguarding Training for community services as this has been less than 90% for last 2 quarters. There has been a 27% increase in advice and support given by the Safeguarding Team regarding parental drug and alcohol issues. This coincides with the disestablishment of the Community Drug and Alcohol service across the city. Therefore there is no representation from Drug and Alcohol services at Child Protection Case Conferences, leaving a significant gap in services and support available. Signs of Safety Briefing to include: (Please see point 19.4 for details of the Signs of Safety approach) - Child protection processes - Strategy meetings, - Case conferences - Briefings to be delivered dates planned Training - Dates and packages to be developed to ensure learning from Serious Case and Domestic Homicide Reviews Review of escalation processes, particularly how CMFT staff work with partners to address any concerns. Community Children s Safeguarding team activity 2016/ Chart 6 and Table 17, below, set out the referral activity for this team. Table 18 shows that there has been a year on year reduction in the number of referrals over the past three years. This is likely to be the result of the focus on proactive support to frontline staff, including: Page 37

38 Increased visibility in the locality clinics by the Senior Specialist Nurses providing face to face support. Increased attendance of frontline staff at single and multi-agency agency training, resulting in increased knowledge which is evidenced in training evaluations. Both one to one and group supervision sessions being well attended. Chart 6: Categories of Referral 2015/16 and 2016/17 Consultations 2015/ / Physical Abuse Emotional Abuse Sexual Abuse/ CSE Neglect Domestic Abuse Substance Misuse Parenting / Mental Health Table 17: Other Categories Missed Appointments 58 Private Fostering 3 Self-Harm 41 Forced Marriage & HBV 14 Fabricated & Induced Illness 15 Female Genital Mutilation 20 Criminal Activity 14 Table 18: Comparison with Previous Years Referral Data 2014/ / / Analysis of Referral Data The number of referrals with a category of physical abuse has increased from 2015/16, within which there has been a recognised increase in physical chastisement figures. There are plans for Manchester City Council (MCC) to work with Afruca (Africans Unite against Child Abuse) to further understand physical chastisement with a cultural context Sexual abuse figures have reduced, however CSE referrals have almost doubled from previous years. This suggests that CSE cases may have been Page 38

39 categorised in previous years as sexual abuse, but may also be suggestive of increased recognition in response to raised awareness Self-harm referrals have increased significantly from previous years; this may be due to increased awareness and training on signs of self-harm in schools. There has also been an increase in referrals where Drug and Alcohol concerns feature. This may be due to changes in how drug and alcohol services are provided across the city The number of referrals relating to emotional abuse and neglect has remained consistent with previous years. Parenting and parental mental health have significantly increased and could be attributed to learning from SCRs prompting a higher recognition Domestic abuse referrals have reduced, which may be relating to implementation of the Delivering Differently strategy, which focuses on Early Intervention and support at an early stage to support victims of domestic abuse in a proactive way. Court Reports Court reports are requested from health professionals for children subject to proceedings. In 2016/17 there was a significant increase in the number of court reports requested, which is set out in Chart 7 below. This has had an impact on both the Safeguarding Team and frontline community staff. Work is on-going with the MCC legal team to establish ways to streamline the process. Chart 7: Court Report Activity 600 Court Report Activity 2016/ / / /17 No Court Reports No of Children Family Court Statements A Family Court template and guidance, which was formulated with the approval of Manchester City Council Legal Services was embedded in practice during Such reports show a high level of analysis and new and Page 39

40 experienced community staff have attended training on the legal processes and the completion of statements during The template has now been adapted for use within the acute hospital setting and specific training continues to be provided to nursing and other staff as needed CMFT community health staff (particularly the Vulnerable School Child Team) have continued to provide significant numbers of statements for the Family Court. The Safeguarding Team advise, guide and support staff during this process and communicate to ensure timescales are met. Each report is quality assured prior to submission to MCC Legal Services. CMFT statements continue to be judged by legal services as being of a very high quality resulting in few staff being called to court to give evidence and therefore not being required to take time away from their clinical roles. On the occasions that CMFT staff attend Family Court, this is because they have been identified as a key witness or as being instrumental in the case progression. During 2016/17 this has taken place on two occasions with the staff members supported throughout the process by the Safeguarding Children Team. Criminal Court Activity The Community Safeguarding Children Team support CMFT staff with the writing of statements and preparation and giving of evidence in criminal court with regard to disclosures of domestic abuse to health staff. During 2016/17 one member of staff gave evidence in Criminal Court relating to a CSE case. Given the significant increase in requests for and the completion of court statements, it has been identified that a review of the process is required. This work is being undertaken with Manchester City Council Legal Services and is currently at an exploratory stage. Maternity Acute and Community Safeguarding Team Safeguarding services for the Trust s maternity services are led by a Named Midwife/Matron for Safeguarding supported by Specialist Midwives for Safeguarding. Achievements and on-going developments in this Team are as follows: Service Maternity Acute and Community Safeguarding Team Key Achievements 2016/17 Following on from the success of receiving the Royal College of Midwives Team of the Year award (in March 2016) for working with Potential Victims of Trafficking (PVoT), Safeguarding Midwives have presented their findings at the North-West Head of Midwifery Conference (Birchwood); Royal College of Midwives Annual Conference (Harrogate); CMFT Nursing and Midwifery Conference; and Manchester Safeguarding Children Board. Page 40

41 What is working well Learning has also been presented, by request, to Pennine Acute Trust Midwives and the Professional Advisory Sub group. The 25 th November 2016 saw the launch of the International 16 Days of Action Against Violence Against Women. Safeguarding Midwives marked the launch by facilitating a half day professional development forum, focusing entirely on recognition and response to disclosures of domestic violence and abuse. Outside speakers delivered presentations on Honour Based Violence and Forced Marriage; and the IRIS project. (IRIS is Identification and Referral to Improve Safety. It is a general practice-based domestic violence and abuse (DVA) training support and referral programme which includes training and education, clinical enquiry, care pathways and an enhanced referral pathway to specialist domestic violence services for GPs). Safeguarding Midwives presented development and learning sessions on: - Routine Enquiry; - Coercion and Control; - Learning from a Domestic Homicide Review; and Serious Case Review- both of which focused on the impact of Domestic Violence. - The on-site Independent Domestic Violence Advisor (IDVA) also delivered a session on the Risk Indicator Checklist (RIC) for Domestic Abuse Stalking and Harassment (DASH) and MARAC process. Uptake was high, with over 30 midwives, health care support workers, students and divisional staff attending. In line with Intercollegiate Guidance for Safeguarding competencies and the St Mary s Divisional Safeguarding Work Plan, between November 2016 and March 2017 training has been delivered to a further 37 midwives and divisional frontline staff, with regard to completion of the RIC/DASH and the MARAC process. Safeguarding Midwives provided information and presented an information stand relating to domestic abuse, trafficking and FGM on the International Day of the Midwife in Training continues to be provided for all staff requiring Level 3 Safeguarding Children on a monthly basis and bespoke sessions to divisional representatives, specialist midwives and managers has been delivered with regard to Managing Allegations of Abuse and lessons learned from local Domestic Homicides and Serious Case Reviews. To ensure that staff are competent in working within the Safeguarding Policy and processes, two audits have been completed, providing assurances in both: o Compliance with Maternity Safeguarding Plans; Documentation and Information Sharing within the Postnatal Period and o Maternity compliance with Routine Enquiry of Domestic Abuse and Response to Disclosure. Safeguarding Case holders have been trained to engage with Strengths Based Conversations and the use of Signs of Safety Page 41

42 On-going development Plans for 2017/18 model to ensure that assessments and referrals are in line with MSCB processes. The Named Midwife/Matron for Safeguarding and Specialist Midwives for Safeguarding now have access to Manchester City Council social care records through the MiCare system. This has improved the timeliness of discharge of women from the hospital and enabled more robust information sharing. The Specialist Midwife for Refugees and Asylum Seekers has, as part of the planning team, presented at the Refugee Conference to inform professionals on the vulnerabilities and safeguarding of Refugee and Asylum seeking woman and their children. The Specialist Midwife chairs the Refugee Midwifery Network meeting, held quarterly to improve referrals across boundaries and improve outcomes. The Named Midwife/Matron for Safeguarding also facilitates safeguarding training for 2nd year Midwifery students at Manchester University as part of their Safeguarding Module. Safeguarding Midwives are members of the Vulnerable Babies quarterly group meeting and the DV and DA/FGM subgroup The Named Midwife/Matron for Safeguarding chairs the bimonthly Divisional Safeguarding Operation Group for Saint Mary s Division. Midwives based off site in Salford require more visible support; it is envisaged that a specialist Midwife for Safeguarding will attend Salford Community Midwives on a regular basis from 1 st April This should help in the improvement and accuracy of referrals to Children s Social Care and ensure that the safeguarding agenda, policies and processes are being embedded robustly. There will be an audit to demonstrate the accuracy and standard of referrals to Children s Social Care, to ensure that referrals are completed correctly and followed up in a timely manner. Safe Sleeping education needs to be reintroduced to maternity mandatory training sessions, to ensure correct and consistent advice is being given to parents when leaving the hospital. The Safeguarding Midwives have negotiated with the Manager of Antenatal Services and it has been agreed that from April 2017 the Vulnerable Babies Team will facilitate an hour session during the mandatory yearly Breastfeeding Study day for staff. Provide support on-site for Salford based Midwives. This will be rostered into the Safeguarding Midwives work pattern, to commence in April It is also anticipated that electronic, read-only databases will be available in Salford and Trafford Hospital-based clinics for designated staff. This is currently under discussion with the administration team and IT Department. Electronic Guidance for Divisional staff will also be made available and is currently under development; this will provide support with processes during out of hours and weekends and bank holidays. A specialist midwife will continue to develop the Specialist Perinatal Mental Health Pathway, alongside the Specialist Midwife for Mental Health; Perinatal Consultant Psychiatrist and CMFT and NHS England Mental Health Services. Page 42

43 The Specialist Midwife for Refugees and Asylum Seekers will be piloting a support parenting session for Arabic Women, to ensure vulnerable women from this minority group receive the best maternity care. Maternity Safeguarding Team activity 2016/ The activity for this service is set out in Chart 8 and Tables 19 to 22, below, which show that 3783 referrals were made to the Maternity Safeguarding Service between 1 st April 2016 and 31 st March 2017, demonstrating an increase of 113 referrals when compared to the previous year. Chart 8: Maternity Safeguarding Referrals No of Referrals No of referrals Table 19: Other Categories of Referral Concealed pregnancy 9 Private Fostering 1 Hidden Male 18 Forced Marriage & HBV 4 Learning Disability 18 Vulnerable Babies 6 Criminal Activity 28 Unbooked (no maternity care) 310 Analysis of Referral Data The majority of referrals received were for Early Help or for specialist midwifery support in areas such as: Mental Health, Drugs and Alcohol, Young Parents, and Asylum Seekers and Refugees referrals were at child protection level resulting in a referral being made directly into Children s and Families Social care. Of these referrals: Page 43

44 471 families were referred as they were already known to social care or had a current social worker; 277 families were referred due to on-going Domestic Violence and Abuse; 232 families were referred due to high risk safeguarding concerns regarding their mental health; 97 unborn children were referred due to maternal substance misuse. Many women were referred due to more than one category of concern During 2016/17, 305 women were identified as victims of FGM and have discussed their awareness of illegality of the procedure. All FGM data has been shared with Health Visitors. Also during this time period, 395 women disclosed domestic violence; 21 of whom were referred to the MARAC as high risk cases. Table 20: Case Conference Activity Initial and Review Case Conference reports submitted 151 Number of Case Conference attendances 134 Number of safeguarding Care plans created with Police 645 and social care Table 21: Court Report Activity Number of Court Reports submitted 71 Number of children removed following court procedures 70 Number of Court attendances 3 Table 22: Other Safeguarding Activity Professionals Meetings 81 Discharge Planning Meetings 96 Core Group attendances 122 Child in Need Meeting attendances 41 Safeguarding Supervision Safeguarding Supervision is provided in accordance with the Trust Policy and supervision activity is monitored by the Safeguarding Team. 9 Safeguarding Group Supervision sessions have been held for Safeguarding case-holders. In addition, Community Midwives continue to receive bi-monthly group supervision as well as case supervision daily as needed. The Named Midwife/Matron for Safeguarding also facilitates one to one supervision for Specialist Midwives for mental health and substance misuse, Young Parents, Asylum Seekers and Refugees, and the NICU Pathway Co-ordinator and Neonatal Outreach/In reach Team Manager. Page 44

45 12 Safeguarding Training Mandatory Safeguarding Training 12.1 This section of the report provides assurance regarding compliance with the following statutory and mandatory training requirements during 2016/17: Level 1 and 2 Safeguarding Adults Level 1 and 2 Safeguarding Children Level 3 Safeguarding Children Level 3 Safeguarding Adults Mental Capacity Act training (MCA) Deprivation of Liberty Safeguards training (DoLS) Level 1 Safeguarding Adults and Children 94% of staff in the Trust completed Level 1 training along with MCA and DoLS training as part of Corporate Mandatory Training 1% increase from 2015/16 This has exceeded the Trust compliance target of 90% and the CQC target of 80% compliance Level 2 Safeguarding Adults and Children 93% of staff in the Trust completed Level 2 training along with MCA and DoLS training as part of Clinical Mandatory Training 4% increase from 2015/16 This has exceeded the Trust compliance target of 90% and the CQC target of 80% Level 3 Safeguarding Children Training 99% of eligible staff in the Trust have completed Level 3 Children s training 5% increase from 2015/16 This above the Trust target of 90% compliance and above the CQC target of 80% compliance Safeguarding Adults Training 1st April st March staff in the Trust has completed Level 3 Adults training (No compliance target is set) Page 45

46 Subject-specific Training Child Sexual Exploitation (CSE) Training 12.2 The provision of CSE training has continued in 2016/17 with bespoke work taking place within key areas such as Adults and Children s Emergency Departments and Sexual Health Services. Detail of this training is set out in Table 22 below. Table 22: CSE Training Delivered Training Numbers attended Services Half-day training 61 School Nursing Adult Safeguarding Sickle Cell Centre LAC Team Trafford TEDS A&E Learning Disability School Nursing Contraception & Sexual Health 1 hour briefings 89 Midwifery A&E Paediatric Emergency Department Walk-in Centre Integrated Sexual Health Services Total Training numbers were significantly lower in 2016/17 when compared with 2015/16. The reasons for this are as follows: In 2015/16 there was a drive to ensure that staff in key areas were trained to recognise CSE and 681 staff received CSE training, therefore in the past 2 years 831 staff across CMFT in key areas have received CSE training. The CSE sub-group is now well established and divisional representatives take key messages and learning back to their divisions for implementation. The changing role of the CSE nurse and the changing model of delivery of CSE services means that the CSE nurse now spends more time supporting young victims of CSE leaving less time for training to be delivered directly An evaluation was completed in April 2016 to examine the impact of CSE training on practice. The evaluation showed the following: Marked improvements in practitioners ability to define CSE (increased from 67% pre-training to 98% post training), Ability to identify vulnerabilities (increased from 70% pre-training to 100% posttraining), Ability to identify indicators of CSE (increased from 55% pre-training to 100% posttraining) Understanding of the referral process (increased from 55% pre-training to 83% post-training). Page 46

47 The evaluation also identified that practitioners were less confident in providing prevention work with young people and this will be considered further and the training programme developed to reflect this identified need. Forced Marriage and Honour Based Violence (HBV) Training 12.5 Chart 9 shows that there has been a 26% increase in the uptake of Forced Marriage and Honour Base Violence training in 2016/17. This reflects increased awareness and focus on this safeguarding issue. Chart 9: Forced Marriage Training Comparison 2014/15 to 2016/ Forced Marriage & HBV training / / /17 Forced Marriage & HBV training Domestic Violence and Abuse (DVA) Training 12.6 During the period 1st April 2016 to 31st March 2017, 648 members of staff took part in 49 courses/sessions including awareness courses and refresher update courses, which were delivered across the Trust. Although this is a slight decrease (5%) when compared to 2015/16, high volumes of training continue to be achieved. Chart 10: DV&A Training Comparison 2013/14 to 2016/ DV&A Training DV&A Training / / / /17 Page 47

48 Developments in Domestic Abuse Training 2016/ In order to maintain a focus on this key priority, a number of developments have taken place this year, as follows: Bespoke training for midwives was developed and delivered. In collaboration with Divisional Safeguarding Leads, a Domestic Violence and Abuse Training Plan has been developed identifying the priority areas and services with learning needs in relation to domestic violence and abuse. A new full day course: Domestic Violence and Abuse Impact on the Child was developed in response to the need for staff to recognise the interconnectedness of DVA and the safeguarding of children. The course was delivered in March 2017 and was designed to deliver the following learning objectives: - Appreciate what Domestic Violence Abuse (DVA) is and its prevalence; - Reflect on social, agency and individual attitudes to DVA; - Know how DVA can impact on children from birth to adolescence; - Know how to recognise and respond appropriately to indicators of DVA; - Consider learning from Serious Case Reviews; - Know the range of DVA specialist services and how to work with them to ensure the best outcomes for victims and their children There was significant interest in the course from staff. The evaluations were very positive and included the following comments: Really effective and well prepared Fantastic! Excellent! Very effective balanced on content and interaction Much better understanding of the impact on the child, it was excellent Excellent course and trainers Feel more confident, I cannot think of how it needs improving- exactly what I needed Domestic Abuse Training Evaluation 12.9 In August 2016, a detailed evaluation of the DVA courses run by the Safeguarding Team was completed. The results showed that participants increased their knowledge and understanding across all learning objectives as a result of completing the course. Participants also reported a significant increase in confidence in asking about domestic violence and abuse, which was the most commonly identified key learning participants identify. This is an encouraging finding as it is known from local domestic homicide reviews that victims/survivors rarely attend health services immediately disclosing abuse, but often attend with other healthcare needs and will only disclose if asked. Asking more frequently and changing the way they ask is also the most Page 48

49 common behaviour participants say they will do differently as a result of completing the course. 13 Child Sexual Exploitation (CSE) 13.1 CSE is a form of sexual abuse that involves the manipulation and/or coercion of young people under the age of 18 into sexual activity in exchange for things such as money, gifts, accommodation, affection or status. Although the victim can be tricked into believing they are in a loving relationship, no child under the age of 18 can ever consent to being abused or exploited. (Barnardos 2012). CSE Multi Agency Work 13.2 The Phoenix Protect Team is Manchester s multi-agency CSE team, supporting 100+ young people at any one time. Referrals remain at approximately 25 per month and 40% of the work carried out by the Team is preventative. CMFT employs a specialist nurse for CSE, located with the Protect team, she provides a key role in identifying health needs of young people at risk of or being sexually exploited and she supports and signposts these young people to access services such as sexual health and the Sexual Assault Referral Centre (SARC) as appropriate. 2017/18 will see some changes to how the Protect team functions and part of this will be to review the role of the specialist nurse to ensure her role aligns to these changes. CMFT CSE Sub Group 13.3 CSE continues to have a high profile across CMFT and the sub-group is well established with representation from across the Trust s divisions. The subgroup reports to the Trust Safeguarding Group (TSG) and is aligned to the Multi- Agency CSE strategic and operational groups so work is streamlined and connected with MSCB priorities. The CSE sub-group has grown and developed with increased participation from key areas. The training plan has been adapted to reflect a more pragmatic and flexible approach to ensure that awareness is raised as broadly as possible across the Trust CSE guidance has been ratified and a risk indicator checklist has been piloted and is being rolled out across the Trust to provide a tool to assist practitioners to identify children at risk of, or experiencing CSE. A pilot of the CSE risk indicator checklist was completed in September 2016 in the emergency acute settings which gave limited assurance. However, this is a newly developed tool and will require time to firmly embed within the Trust and will be promoted through the representatives attending the CSE subgroup. Page 49

50 13.5 The Trust s CSE sub-group has participation from across the divisions and continues to develop the CSE agenda across the Trust. This group meets every two months and is chaired by a Named Nurse. The group focuses on the following key work streams: Implementing the CSE training plan including targeting key areas for training Working with divisions to embed CSE across all departments. Roll-out of CSE risk indicator checklist and guidance. Co-ordinating Trust CSE Audit. Work to embed the CSE risk indicator checklist in practice CSE Specialist Nurse 13.6 In 2016/17 work has progressed with the CSE nurse raising her profile in key areas across the Trust and ensuring staff are trained and aware of their role and responsibility regarding CSE identification and escalation. The CSE Specialist Nurse continues to be co-located in the Protect multi-agency CSE team, offering consultation and support to staff working with children at risk of, or experiencing CSE and provides direct input with young people who are not able to access a school nursing service The Protect multi-agency CSE team has undergone a review of processes and significant changes are in place. The referral process has been changed and the referral route is now via the Multi-Agency Safeguarding Hub (MASH). The threshold for input from Protect has changed so that the team now focus work on young people at highest risk Safeguarding supervision has been developed for the integrated sexual health services, including Stockport, Tameside and Trafford, which will be delivered via group supervision sessions and one to one sessions for outreach nurses. There have been improved information sharing between the CSE Specialist Nurse and sexual health services, as understanding of safeguarding issues has developed The CSE Specialist Nurse undertakes the following work streams: Member of the Missing from Home Panel in recognition of links between missing from home and CSE. Training and awareness-raising across the wider health economy e.g. GPs and student nurses. Involvement in Phoenix Week of Action awareness raising with the general public on CSE at Piccadilly Station Input into Protect team s peer review Page 50

51 14 Forced Marriage & Honour Based Violence (HBV) 14.1 Forced Marriage and HBV is included in the Manchester Delivering Differently: Manchester s Domestic Violence and Abuse Strategy and is also included in the Trust Domestic Abuse policy, which aligns to this strategy Work continues across the Trust through training and information sharing to ensure frontline practitioners are skilled in recognising and responding to Forced Marriage and HBV. In 2016/17 there have been many events across Manchester to raise the profile of Forced Marriage and HBV in the wider context of safeguarding and protection along with legal rights and responsibilities Bespoke training is on-going across CMFT to support frontline staff to be aware of these issues and identify and escalate any concerns and provide safe support for victims identified or when disclosures are made. 15 Female Genital Mutilation (FGM) 15.1 FGM is a medically unnecessary, harmful, illegal act to which a child is unable to resist or consent. FGM places a child at risk of significant harm under section 47 of the Children Act (1989 and 2004) and it is deemed as physical child abuse and therefore must be addressed within the framework of child protection FGM is practised by families for a variety of complex reasons, but often in the belief that it is beneficial for the girl or woman, essential for their economic, and social survival and marriage. In many practising communities, not to circumcise one s daughter is considered bad parenting and neglectful. However, there are no health benefits to FGM; removing and damaging healthy and normal female genital tissue interferes with the natural functions of girls' and women's bodies Female Genital Mutilation in the UK 15.3 It has been estimated that over 20,000 girls under the age of 15 are at risk of FGM in the UK each year. An estimated 66,000 women in the UK are living with the consequences of FGM, however, the true extent is unknown due to the 'hidden' nature of the crime. Female Genital Mutilation in Manchester 15.4 Greater Manchester has one of the highest number of cases in Britain and this illegal procedure appears to be increasing. Every year thousands of school girls Page 51

52 across Greater Manchester could, therefore, be at risk of mutilation at the hands of their families. FGM Training 15.5 This year, new FGM training has been developed by CMFT and has been rolled out to staff. This training builds on previous training to continue raising awareness of FGM. The training includes assessment and management of health care needs, legal duties around mandatory reporting and recording of FGM and safeguarding women and girls at risk of FGM. Multiagency Working 15.6 Greater Manchester has been identified as one of the hot-spots for Female Genital Mutilation. Greater Manchester Police regard FGM as a form of HBV. They conduct outreach work amongst communities who carry out FGM to raise awareness of the practice and encourage more people to report it. The Police also intend to do more outreach work within Manchester schools to raise awareness. The Safeguarding Team and community-based staff have continued to work closely with GMP to support this complex work The school holidays are known to be one of the riskiest times for girls as they may be taken on extended holidays abroad where the procedure and the long healing process can take place. CMFT staff have worked closely with the Police in their operations at Manchester airport in summer 2016 to raise awareness of FGM and provide advice to passengers travelling to and from countries where FGM is prevalent in order to raise awareness should they have any concerns. This was a successful operation and the Safeguarding Team will continue to support the police in their work identifying FGM CMFT staff also work closely with voluntary organisations such as Afruca and many have been invited to speak at the FGM sub-group to further raise awareness about communities and cultural issues The Trust is part of the Greater Manchester FGM Professionals Forum and also has representatives on the FGM Strategic Group in Manchester. The work of these groups is disseminated across CMFT via the FGM sub group. FGM Policy The Trust s FGM policy is well embedded and is aligned with Multi Agency and Statutory Guidance on FGM. In line with this policy, mandatory reporting continues and the Trust s Information Management Team are now compiling regular data for CMFT. Chart 11 below shows the number of cases identified Page 52

53 and reported in 2016/17. In 2017/18 this data will be more detailed and will be accessed via the Central Intelligence system. Chart 11: Mandatory Reporting and the FGM Data Collection Tool FGM - CMFT Numbers Reported FGM - CMFT Numbers Reported Domestic Abuse Domestic Abuse Policy 16.1 Following the development of the Trust s Domestic Violence and Abuse policy in 2015/16, this policy was updated in 2016/17 to incorporate the Delivering Differently Domestic Abuse Strategy for Manchester. CMFT Domestic Violence and Abuse sub group 16.2 CMFT Domestic Violence and Abuse and Female Genital Mutilation sub group has been refreshed in 2016/17 and meetings are now held quarterly. The terms of reference and membership were reviewed and membership now includes representation from all divisions and from key priority areas identified in NICE 2014 Domestic Violence and Abuse guidance. The sub group meets quarterly with representation from Divisions, priority areas identified in NICE domestic violence and abuse guidelines, the Safeguarding Team and specialist services. The group work plan ensures that national and local learning, policy and practice are reviewed and developed to influence frontline practice in CMFT. Training 16.3 In 2016/2017 the Domestic Violence and Abuse subgroup explored how the Safeguarding Team can work with Divisions to ensure that appropriate staff are being offered, and are attending, Domestic Violence and Abuse training. The Named Nurses for Safeguarding Children and Adults met with Divisional adult services to establish Domestic Abuse training needs across divisions. Page 53

54 Multi Agency Domestic Violence and Abuse Work Streams Domestic Violence and Abuse Strategy The Manchester Domestic Violence and Abuse Strategy was launched on 17 th June 2016 by Councillor Sue Murphy. The launch included input from Women s Aid, End the Fear, Relate, Big Manchester, Manchester Council and CMFT Delivering Differently calculated that 24.5 million was spent by Manchester City Council on reacting to Domestic Violence and Abuse with only 5% of this sum being spent on interventions to tackle domestic abuse. The Strategy defines Domestic Abuse using the Home office definition and identifies the different forms that can present, such as, Coercive Control, Violent Resistance, Situation Couple Violence, Forced Marriage, Female Genital Mutilation, Elder Abuse and Young People (under 18 years) perpetrating violence to parents The Strategy identified the following pledges: Supporting people to seek help Managing safety Training and developing the workforce Adapting delivery models in response to changing need and demand 16.7 CMFT committed to the Training and Developing the Workforce Pledge, which was presented by the CMFT Domestic Abuse Project Manager/Specialist Trainer. Domestic Homicide Reviews (DHR) - Lessons Learned 16.8 CMFT took part in a multi-agency event in May 2016 to look at lessons learned from DHRs. Manchester presented learning from a recent DHR, with lessons as follows: Consideration of Honour Based Violence Face to face contact with victim generates more disclosure Multi-agency information sharing is key - different agencies had different information Consider children living in DV Importance of housing agencies having DV information Separation and child contact - need to consider victims and children s safety in relation to these issues Manchester Domestic Abuse Forum 16.9 CMFT is represented on the Manchester Domestic Abuse Forum. The work of the forum in 2016/17 included: Development of victim/survivor and perpetrator programmes Specialist services for the homeless (due to DV) Publicity campaigns and media events Page 54

55 CMFT agreed to involvement in the Training and Development and Supporting People to Seek Help work streams Multi Agency Risk Assessment Conferences (MARAC) Domestic Abuse MARAC is the process that manages risk assessment and safety planning of all high-risk referrals. CMFT continues to be represented at the 3 Manchester MARACs, which are held 5 times each month. Chart 12 shows that in 2016/17, the majority of CMFT MARAC referrals continued to be from the MRI Emergency Department and Children s Community Services, identifying the key priority areas for the delivery of Domestic Violence and Abuse training within the Trust Appropriate quality referrals to specialist services are an important outcome of CMFT policy guidance and practice. One measure of success is the number of referrals for high risk domestic violence and abuse made by healthcare professionals CMFT makes a significant contribution to the MARACs. Local statistics identified that Manchester s health economy makes 10% of all referrals into MARAC, compared with the national rate of 4% for health referrals. This demonstrates a high level of awareness of domestic abuse. Chart 13, shows the variation in the number of referrals over the past three years, however, CMFT referrals consistently account for between 7 and 8.5% of total referrals. Chart 12: Source of CMFT MARAC Referrals 1st April st March Number of referrals Chart 13: MARAC Referrals Comparison Total Referrals / / / Page CMFT Referrals / /16 April /17 March 2017

56 17 Deprivation of Liberty Safeguards (DoLS) and Mental Capacity Act (MCA) Summary of Progress in 2016/17 Second phase of DoLS portal completed New DoLS/MCA training developed, piloted and rolled out Audit commenced of MCA and DoLS processes and documentation Further guidance developed for staff Supported Divisions to take responsibility for management of DoLS in their clinical areas Closer links with MCC DoLS teams More robust data collection of DoLS activity /16 saw significant focus across the Trust on embedding the DoLS and MCA policy and process and responding to legislative requirements. In 2016/17 this has continued, with further development of the Trust DoLS portal and divisions taking responsibility for managing DoLS applications for their patients, with less reliance on the Safeguarding Team Also, during 2016/17 the Law Commission undertook a public consultation 4 on MCA and DoLS. It has been well documented that many aspects of the DoLS authorisation process are not fit for purpose, with huge impact on resources across a range of organisations. The Law Commission made detailed proposals for a revised system, and the Government response was published on 25 May On 13 March 2017, the Law Commission published its final report and accompanying Draft Mental Capacity (Amendment Bill 2017) 5, proposing reforms to the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS). A response is now awaited from the Government The Chief Coroner also reported that one of the unanticipated and unwanted consequences of both the Mental Capacity Act 2005 (as amended by the Mental Health Act 2007) and the P v Cheshire West case 6,which resulted in the acid test, was that anybody who died while subject to a Deprivation of Liberty Safeguards (DoLS) authorisation, must be notified to the Coroner for inquest. This guidance is despite the fact that the majority of patients subject to a DoLS die from natural causes. 4 Law Commission (2015), Mental Capacity and Deprivation of Liberty, Law Commission, Mental Capacity and Deprivation of Liberty 5 Law Commission (2017), Mental Capacity and Deprivation of Liberty, 6 Supreme Court (2014) P v Cheshire West and Chester Council, Page 56

57 17.4 Amendments to the Mental Capacity Act (2005) and Coroners and Justice Act (2009) have been proposed by Baroness Finlay of Llandaff after warnings by the Chief Coroner and complaints from bereaved families that the automatic requirement for inquests had caused distress and created unnecessary pressure on services. These proposals have been supported by the House of Lords and by the Government and legislative changes are awaited From 3 rd April 2017, the Policing and Crime Act 2017 will come into effect to amend the Coroners and Justice Act 2009 and relieve coroners of the current duty to hold an inquest into every death where the deceased was subject to a Deprivation of Liberty Safeguards (DoLS) authorisation or was deprived of their liberty through provisions in the Mental Capacity Act No other changes have been made to the current DoLS process and final changes are not expected before 2018 at the earliest. 2016/17 DoLS Activity 17.6 Chart 14 shows that there has been just over a 30% increase in DoLS referrals in 2016/17 compared with 2015/16. This follows on-going training and support from the Safeguarding Team in ensuring that frontline staff are correctly identifying patients who require a DoLS. The application process has also been streamlined with further development of the DoLS portal allowing electronic applications to be made which go directly to the Local Authority. This process has allowed divisions to manage and monitor DoLS applications more closely, as the application requires a quality assurance check by a senior nurse in the division before being sent. Chart 14: Comparison of the total number of DoLS referrals 2015/16 to 2016/17 DoLS referrals 325 DoLS referrals / / It is also evident from analysis of the monthly data, set out in Chart 15, that there are seasonal variations in DoLS applications, with the majority of DoLS applications made during winter months, which reflects the increased activity across the medical wards within the Trust. Page 57

58 Chart 15: Number of DoLS applications made to MCC by CMFT from April 2016 to March There have been on-going challenges in managing the volume of DoLS applications in all Local Authority areas since the application of the law changed in Work is on-going with the MCC DoLS team to work in partnership to address these issues, however this has been affected by frequent changes in staff in the MCC DoLS team and limited Best Interest Assessors available. To mitigate this risk CMFT have a process in place whereby an incident form is completed if a patient has not been assessed by Day 15 following the DoLS application. This process is managed within Divisions, ensuring senior nurse review of patients subject to DoLS, monitored by the Safeguarding Team and reported through the Trust s safeguarding governance structure. All DoLS applications where an outcome is known are notified by a bespoke CMFT portal to the CQC. 18 Prevent 18.1 Prevent is one of the four elements of CONTEST, the Government s counterterrorism strategy, and aims to stop people becoming terrorists or supporting terrorism. This strategy relies on vigilance and members of the public reporting concerns The Prevent lead for CMFT is the Trust Assurance Manager, who sits within the Medical Director's Clinical Effectiveness Team. The Safeguarding Team supports Prevent training across the Trust and manages referrals to Channel, which is a multi-agency programme, focusing on providing support at an early stage to people who are identified as being vulnerable to being drawn into terrorism. Chart 16 shows that number of referrals is small, but, this nevertheless remains an important responsibility. The NHS continues to be a key player in supporting the Prevent strategy, as healthcare staff are considered to be well placed to help to identify concerns and protect people from radicalisation. Page 58

59 Chart 16: CMFT Referrals to Channel Channel Referrals 18.3 CMFT is committed to ensuring that all staff are trained in recognition and response in cases where there are suspicions of radicalisation or engagement in acts of terrorism. In doing so, CMFT comply with Prevent requirements. Between 1 st April 2016 and 31 st March 2017: 2,459 staff undertook basic prevent training (levels1-2) via e-learning 1,556 staff attended a face-to-face WRAP session (levels 3-5) 19 CMFT Contribution to Multi-Agency Safeguarding Priorities Early Help 19.1 The MSCB Multi-Agency Levels of Need and Response Framework were launched in 2015 along with the Manchester Early Help Strategy , with the aim of assessing and offering coordinated intervention at an early stage. Three Early Help Hubs were established in the city, with contributions by a range of multiagency partners, including CMFT. The work of the Hubs is grounded in a strengths-based model entitled Signs of Safety The Trust s Safeguarding Team has been instrumental in the rollout of this approach to CMFT staff, who now contribute to a range of Early Help activity including undertaking Early Help Assessments with children and families and the delivery of packages of support. A MSCB Early Help audit focusing on the MASH and Early Help was undertaken in 2016 to which CMFT contributed; the findings are due to be published in May 2017, and will be embed into practice. CMFT Early Help Subgroup 19.3 This internal group was established in 2016 to raise the profile of the Early Help agenda across CMFT. There is representation from community, acute and midwifery services. An Early Help Hub Manager also contributes to the group; Page 59

60 providing service updates and promoting resources. On-going work is of this group includes: Improved communication from strategic and operational working groups; Assessment of the training and develop needs within specific services; Promotion of this work within the acute hospital-based services including specialist services; Better understanding of range of involvement in Early Help Assessments and Request for Services. Signs of Safety 19.4 Signs of Safety is an evidenced-based model and framework for working with children and families. The framework underpins principles for practice and has a range of tools for assessment and planning, decision making and engaging children to improve outcomes for children and families and to be more resilient and therefore less reliant on social care as they grow up The CMFT Safeguarding Team and Manchester City Council Children and Families Service have worked in partnership in the implementation of this model. Implementation commenced in February 2016 and will take time to be fully implemented. The aim is to have a consistent case practice model, common language across agencies, families owning their own plans and the plans actively involving the family s network Two Senior Specialist Nurses and a School Health Team Leader have received additional training to become Signs of Safety Practice Leads. The training has involved attending 7 study days in 2016 and the programme requires Practice Leads to attend workshops every 6-8 weeks. CMFT staff have been recognised as being fully engaged in this process The Safeguarding Teams within CMFT have also attended multi-agency training. In addition, the Practice Leads have planned and delivered briefings at regular team and wider team meetings. Signs of Safety specific briefings for health staff have been delivered to the Safeguarding Team (midwifery, acute and community staff were offered the training) with 26 staff attending the Page 60