Quality & Safety Committee. Safeguarding & Protection of People at Risk Sub-Committee

Transcription

1 Betsi Cadwaladr University Health Board Committee Paper Item QS14/ Name of Committee: Subject: Summary or Issues of Significance Quality & Safety Committee Safeguarding & Protection of People at Risk Sub-Committee Situation: Significant Issues: 1. Single Electronic Record: Due to a recommendation from a Safeguarding Children Serious Case Review the issue of multiple children s records was highlighted and remains a concern. The subject of introducing a single electronic record has been raised previously by the Safeguarding Children Operational Forum in multiple arenas and is considered to be an issue which continues to warrant discussion at Board level. Issue of significance. 2. CPG Representation on Safeguarding Forums and Task Groups: LG has recently written to Chiefs of Staff and Associate Chiefs of Staff requesting that they review their CPG representation on the identified Safeguarding groups to ensure that they are appropriately represented. The appropriate CPG representative will be responsible for the dissemination of information to and from the CPGs. The concerns relating to CPG engagement with the Safeguarding agenda was noted in the Annual Report. 3. Social Services & Well Being Bill Update: This Bill will have significant implications for the NHS. It is extremely important that we ensure the organisation is fully engaged arising from the impact of proposed legislation. The new legislation will require additional resource to ensure implementation and engagement. 4. Training Strategy & Sub Group link with N Wales Sub Training Group: There is no doubt that HIW will request from the Board a position statement with regard to the training compliance level. The organisation needs to be able to demonstrate a high level of training compliance through a training sustainability plan. The engagement of Doctors and Nurses is desirable and also essential. The North Wales Sub Training Group is yet to reconvene on which the Health Board has representation. KM noted that the Workforce & Operational Development Committee has concerns with regard to the quality of the training data. At the last meeting the Acting Chief Executive referred to the accuracy of the data arising from OLM and ESR. NR has indicated that so far Mental Health & Learning Disabilities as well as Anaesthetics, Critical Care/Pain Management CPGs have fully responded to the information necessary to develop an Annual Training Report for 2013/14.

2 Pathology has also responded and further information is awaited from other CPG s who have only partially responded. Action: CPGs and departments to respond appropriately with the relevant data; NR to prepare a report based on the current data provided by CPGs/Departments. 5. Pressure Ulcers: It was noted that pressure ulcers was a significant challenge for the Health Board following a number of cases escalated through the POVA process, one of which is subject to an ongoing SCR and a further likely to be referred also. Revised system and process; The Pressure Ulcer policy and procedures have been amended to incorporate the changes arising from the All Wales Guidance for Reporting and Investigation (August 2013) KM noted that at a recent Board meeting it was established that Pressure Sores will be discussed monthly at Q&S as well as considered monthly at Board level; Tissue Viability report to ann-marie Rowlands, Deputy Director of Nursing. Strategic Theme / Priority addressed by this paper Healthcare Standard addressed Equality Impact Assessment (EqIA) Making it safe Health Care Standard 11 & 22 Has EqIA screening been undertaken? N/A Recommendations: The Committee accepts the Report Author(s) Presented by Michelle Denwood, Deputy Director of Nursing & Safeguarding Angela Hopkins, Executive Director of Nursing & Midwifery Date of report Date of meeting Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board

3 Safeguarding and Protection of People at Risk Sub-Committee Minutes of Meeting held on 27 th September Boardroom 2, Wrexham Headquarters, Wrexham VC: The Boardroom, Llandudno Hospital VC: PHW, Pontypool Present: Michelle Denwood (MD) Chair Lindsay Groves (LG) Keith McDonogh (KM) Sue Williams (SW) Chris Weaver (CW) Fiona Giraud (FG) Rachel Shaw (RS) Pauline Galluccio (PG) Lynne Joannou (LJ) Meinir Williams (MW) Mr N Ramessur (NR) Lin Slater (LS) Sue Owen (SO) Matthew Winter (MW) Manon Williams (MW) Ian Walker (IW) Katherine Williams (KW) Apologies: Angela Hopkins (AH) Christine Lynes (CL) Julie Smith (JS) Lynne Joannou (LJ) Rachel Shaw (RS) No Apologies or Representatives from: Yvonne Harding (YH), Hywel Meredydd Davies (HMD) Minute Taker: Jan Holland () 1 Apologies: Apologies noted. The Chair welcomed Keith McDonogh to his first attendance at this Safeguarding Sub-Committee. The Chair informed the group that KM is the BCUHB Independent Member for Children who has a great deal of experience having been the Safeguarding Co-ordinator for the Diocese of Wrexham aswell as Director of Education and Children s Services for Flintshire Local Authority before his retirement. ACTION Introductions given 2 Attendance List: Not discussed Updated Meeting Procedure: MD informed the group that whilst she was aware of the demographics of holding a meeting with membership taken from across the whole of BCUHB, she was now taking the position of limiting the number of areas who VC into the meeting due to the extreme difficulties encountered in previous meetings, where there were constant interruptions from later arrivers and early leavers which made the meeting difficult to progress. The meeting will now be held in Wrexham Headquarters with VC arrangements available from Llandudno Hospital. In future in order to reinforce our professionalism we will as usual review the minutes for accuracy, however, we will not go into great detail before proceeding directly to the actions. 1 Minutes S&PoPaR Sub-Committee FINAL

4 3 Minutes agreed and accepted as a true account with one correction:- Previous Minutes: Page 13: Due to the apology tendered by RS, LS (PHW) had been requested to address the minute regarding RS s premature departure. RS asked for the minute to be reviewed to reflect the incident accurately. There was a consensus that the minute was an accurate account, hence no changes were necessary, except for the time when RS left the meeting to be accurately recorded, however, given that the exact time could not be provided, it was estimated to be around 12 noon. Ongoing Actions from Previous Minutes Meeting to discuss how Children can bypass ED and go straight to Children s ward forwarded to CL and YH on the 20 th August 2013 CL and YH not in attendance at today s meeting, however, KW stated that this initiative was still not progressing and Paediatrics appeared to be unaware that they should be bypassing A&E MD requested feedback to be made available at the next meeting. YH/CL/ KW Flow Chart: Concern or Allegation raised in PCC and Independent Contractors: Not finalised to date. Meeting arranged for MD and Chris Lube to finalise this guidance document. 4.3 Booking of Glan Clwyd Lecture Theatre: HMD forwarded contact details regarding possible booking of the Welsh Assembly Building, Conwy. This issue was a submitted to the Q&S Committee as an Issue of Significance who are now regarding it as a BCUHB concern. 5.1 SBAR: Domestic Abuse Women No response as yet update requested from Lorna Burdge. Practice Development Team to be represented at this meeting request to be forwarded to Marianne Walmsley. LB/MW 6 & 8 Safeguarding Training Event: With regard to the possibility of a one day North Wales Domestic Abuse Conference facilitated by Alison Griffiths, Clinical Nurse Specialist Domestic Abuse, PG reported that she had spoken to staff in Telford and Wrekin- and the Assistant Designated Nurse who has expertise in this area, and the Designated Nurse are willing to be part of this and be involved in discussions - a venue nearer the border would be appreciated. This information was relayed to AG. 14 HIW: A key action from HIW Inspection 2012 was that the Health Board should seek to expand the implementation of Safeguarding Forums across all relevant CPG s. A request was disseminated to ACoS Nursing, David Fletcher, Pathology and 2 Minutes S&PoPaR Sub-Committee FINAL

5 Alison Kemp, Radiology for completion of the template for the CPG Safeguarding Reporting and Governance Framework with a submission date of no later than the 20 th September Women s and Mental Health CPGS complied, PCSM gave notification of the process being moved forward and were awaiting their first meeting before submitting the requested information. Anaesthetics, Critical Care & Pain Management also reported that the Safeguarding Framework had been reviewed by the CPG and that they had reviewed their membership agreeing membership of the various Safeguarding Task & Finish Groups and Forums. MD noted that there were still a number of CPGs with outstanding template submissions and a request was again made for this information to be forthcoming, as this was just the first part of the process as MD would be drilling deeper in order to gain the initiative. MW (ACoS) informed the group that the Surgical & Dental CPG structure was under review; however MD requested that a current position was necessary and should be submitted via the template, any changes could be made at a later date. NR stated that the view coming from HIW was that Safeguarding should form part of the Governance Framework and CPG s need to embed a Safeguarding Forum within their Reporting Framework as this information will be required when he makes his October submission to HIW therefore demonstrating that BCUHB is moving forward. KW assured the group that the PCSM CPG had placed Safeguarding as a standing agenda item for most meetings within the CPG and that she was working closely with the safeguarding nurses ensuring that they rotate their attendance at T&F Groups/Forums within the Safeguarding Reporting Framework. A meeting to agree the Terms of Reference for their CPG Safeguarding Forum has taken place and the first meeting of this Forum will be in October. MD further reiterated that the Children & Young People CPG without doubt required a Safeguarding Forum to be formed and she has shared this request at their CPG meetings. NR thanked SW for the Anaesthetics CPG Adult Protection Training data return which was an excellent and comprehensive return given that it is the largest CPG with a significant amount of risk. 5. PG agreed that the Powys Safeguarding Annual report could be disseminated to the membership with these minutes. 4a Significant Issues: Children: 1. Single Electronic Record: The issue of multiple children s records is concerning and the subject of introducing a single electronic record has been raised before by the Safeguarding Children Operational Forum in multiple arenas and is considered to be an issue which continues to warrant discussion at Board level. Issue of significance. 2. Lead Doctor Safeguarding Children for Wrexham Maelor Hospital: Dr Philip Minchom was the Lead Doctor for Safeguarding Children for the Wrexham Maelor Hospital before his retirement in March 2013, and many discussions have taken place with Dr Brendan Harrington regarding Dr 3 Minutes S&PoPaR Sub-Committee FINAL

6 Minchom s replacement as this has been identified as a risk to the organisation until an appointment for his replacement is made. Dr Harrington has passed this issue to Paula Knight, Clinical Director Acute, C&YP CPG for resolution; MD has also spoken to Paula regarding this issue. 3. Representation by the CPGs at the SCOF and at the Safeguarding Training Task Group: LG has recently written to Chiefs of Staff and Associate Chiefs of Staff requesting that they review their CPG representation on the identified Safeguarding groups to ensure that they are appropriately represented. The appropriate CPG representative will be responsible for the dissemination of information to and from the CPGs. 4b Significant Issues: Adults: 1. Social Services & Well Being Bill Update: This Bill will have significant implications for the NHS. It is extremely important that we ensure the organisation is fully engaged arising from the impact of proposed legislation. 2. Training Strategy & Sub Group link with N Wales Sub Training Group: There is no doubt that HIW will request from the Board a position statement with regard to the training compliance level. The organisation needs to be able to demonstrate a high level of training compliance through a training sustainability plan. The engagement of Doctors and nurses is desirable and also essential. The North Wales Sub Training Group is yet to reconvene on which the Health Board has representation. KM noted that the Workforce & Operational Development Committee has concerns with regard to the quality of the training data. At the last meeting the Acting Chief Executive referred to the accuracy of the data arising from OLM and ESR. NR has indicated that so far Mental Health & Learning Disabilities as well as Anaesthetics, Critical Care/Pain Management CPGs have fully responded to the information necessary to develop an annual Training Report for 2013/14. Pathology has also responded and further information is awaited from others who have only partially responded. Action: CPGs and departments to respond appropriately with the relevant data; NR to prepare a report based on the current data provided by CPGs/Departments. CPGs NR 3. Pressure Ulcers: It was noted that pressure ulcers was a significant challenge for the Health Board following a number of cases escalated through the POVA process, one of which is subject to an ongoing SCR and a further likely to be referred also. Revised system and process; 4 Minutes S&PoPaR Sub-Committee FINAL

7 The Pressure Ulcer policy and procedures have been amended to incorporate the changes arising from the All Wales Guidance for Reporting and Investigation (August 2013) KM noted that at a recent Board meeting it was established that Pressure Sores will be discussed monthly at Q&S as well as considered monthly at Board level; NR to write to Anne-Marie Rowlands for the current position update. NR 4. Healthcare Standards: Not discussed 5. Feedback from APC: Not discussed 6. HIW Monthly Returns: Agenda item 5 HIW Review of Patient Care (Standing Agenda item) Rolling submission template completed monthly by NR and Sean Page, Consultant Nurse, Dementia August 2013 submission. a) The Health Board needs to strengthen arrangements to ensure that as many staff as possible receive the minimum level of training: During August significant number of POVA training sessions were delivered across the Health Board: Level 2 10, Level 3 1 The quality of the compliance data is subject to a high level of scrutiny for accuracy based on information recorded on OLM and also at local level on ESR. b) Action needs to be taken to ensure that POVA training is targeted appropriately at both nursing and medical staff:- The training compliance data suggest that of the total number of training sessions: 3 were specific to Medical staff 2 for Consultants and 1 for Junior Doctors. Predominantly, the attendance at the other 8 sessions were Nursing Staff. c) Training Levels in respect of POVA need to be maintained and improved:- This remains a key priority for the CPG s and at Corporate level to ensure that staff has undertaken the appropriate level of training. A sustainable training plan has been developed to maintain the overall compliance level up to the end of the year. The number of training 5 Minutes S&PoPaR Sub-Committee FINAL

8 sessions average between 7 10, at Level 1 and 2 at Level 3 every month. d) The Health Board should seek to expand the implementation of Safeguarding Forums across all relevant CPGs: In addition to the progress highlighted in the July return, Safeguarding remains a key Governance item at local level. e) The POVA Training being provided should seek to emphasi9se the varying circumstances that may constitute a POVA referral, with a focus on neglect issues that may arise within the hospital environment: Neglect remains a key component during Adult Protection training at the Varied level to increase staff awareness as to what constitutes neglect And their role and responsibility to instigate the POVA process. e) The Health Board should undertake an audit to ensure that all appropriate members of staff received CRB checks: This remains a prerequisite during staff recruitment to ensure that staff working with Vulnerable Adults and Children in regulated activity do not pose a risk of harm. 6 Feedback from All Wales Safeguarding Leads Group (Standing Agenda item): Short overview from meeting held 12 th August 2013, key themes arising from the meeting were:- Draft Professional Concerns Guidance: The guidance was initially developed by the All Wales Co-ordinators Group to provide guidance to Designated Safeguarding Leads where professionals are implicated in the abuse. It was referred to the All Wales NHS Leads Group where there was a consensus for this to be rolled out as a reference document. Awaiting a response from MW, WOD, to ensure that it complies with current policy. Mental Capacity Act: This guidance was issued by the All Wales Co-ordinators Group specific to the role of the Independent Mental Capacity Advocate also known as IMCA, underpinning the MCA. The current status of the document remains guidance for frontline staff requiring to call upon the services of an IMCA. From a BCUHB point of view the guidance was reviewed by the Best Interest Assessors and Deprivation of Liberty Standards leads which has highlighted some inaccuracies. David Parsonage is taking the lead to revise the guidance which will incorporate DoLS and on completion this guidance will be available on the Safeguarding Web Page. Francis Report: The Welsh Government has responded swiftly arising from the Francis Report (January 2013) by publishing the Delivery of Safe Care, Compassionate Care document in July 2013, the main reason being Learning for Wales from the 6 Minutes S&PoPaR Sub-Committee FINAL

9 Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry which has wider implications at Board level as well as significant implications for Safeguarding. Social Services and Well-Being (Wales) Bill Stage 1 and Committee Report: The Social Services and Well Being (Wales) Bill has concluded stage 1 of the legislation process and the key themes and challenges arising from the discussions are outlined in the Stage 1 Committee Report (July 2013). The Welsh Government is yet to respond, however, a response is imminent from the Minister. The Safeguarding Advisory Panel has embarked on a number of work streams under 4 groups to iron out the high level details that may be included in the legislation, which will form the basis for any future discussion around regulation and codes of practice. Work plan (2013) and an interface between complaints and Adult Protection: A Task & Finish group is in progress to clarify the link between complaints and Adult Protection, which formed an integral part of the Inspection by HIW across Wales. It is anticipated that when this piece of work is concluded, it could be implemented across BCUHB to ensure consistency of practice. Update on the Social Services & Well-Being Bill:- The Social Services and Well Being (Wales) Bill published in January 2013 is designated to place Adult Protection firmly on a statutory footing arising from the Adult Support and Protection (Scotland) Act Currently, the Bill is progressing through the various stages of the legislative process leading the Royal Assent prior to becoming law. The current position is that it has gone through Stage 1 and a response is awaited from the Welsh Government before being escalated to the next level. The legislation will create a statutory duty for all agencies working with an adult at risk to safeguard and protect whilst providing a legal definition of adult at risk and wider powers for the authorising officer under the Adult support order to enter, assess and intervene where an adult is a t risk in their own home. Arising from the Bill, the Welsh Government has indicated that there will be a National Independent safeguarding Board and 6 Regional Safeguarding Adult Boards following on from the footprint of the Health Boards coterminous. Details of the interface between adult and Child Protection are still subject to further discussion at National, Regional and Local levels. Discussions are ongoing between MD, NR and Emily Warren, Policy Lead for Health & Social Services to consider in greater depth some of the background and opportunities for the NHS to contribute to the final plan whilst ensuring a joint approach to key areas of deliver. 7 SBAR: Training Compliance: The recording of staff training attendances is firmly established on OLM for Child 7 Minutes S&PoPaR Sub-Committee FINAL

10 Protection and Domestic Abuse over the last 3 years and longer, however, Adult Protection training attendances has only been included on OLM since April 2012 Lengthy discussion ensued covering the following key issues: - The need to standardise the interface between OLM, ESR and Local Sharepoints to create a single system to ensure consistency and accuracy of data; To identify a Safeguarding Lead within each CPG as a contact point for the source of Mandatory training data; CPGs to take ownership of the quality of their training data ensuring the figures are scrutinised before submission; CPG Leads to be engaged at the relevant safeguarding Forums for updates and continuity at a time of significant change impacting on Safeguarding; Currently no provision for recording/capturing training information on staff PADR Forms. MW to take forward; MW CPGs responsible for ensuring that staff have attended the appropriate level of training with regard to Safeguarding, MD aware that Women s CPG will undertake set block training days in 2014; How is the training data captured for Primary Care/Independent Contractors, as currently a BCUHB employment number is required to record data on ESR? It was noted that as an organisation it is essential that we have safe services and due to the different systems used to capture the training data and levels of compliance it is essential that all the variables are captured in CPG responses and forwarded to the Safeguarding Task & Finish Group. NR to take to the Safeguarding Task & Finish Group. KM stated that if the Board had an ongoing issue regarding the training data, he would raise the issues identified in NR s SBAR in order to give assurance of compliance; MW, Surgery & Dental requested that KM made it known at Board Level that the releasing staff from Acute Wards to attend training had been impossible due to recruitment issues; NR KM Agreement made that MW, WOD would be a standing member on the Safeguarding Task & Finish Group and feed back to Mark Sykes; Ongoing issue regarding provision for booking large training venues in the Central area. LG noted that the Royal Alex Hospital might be a solution, however, provision for seating and a projector would have to be found. MD stated that this had been an issue of significance at the last Q&S Committee Meeting and that the Board would take this forward; 8 Dementia Update: MD informed the Committee that NR had undertaken significant work on the Dementia agenda prior to Sean Page coming into post. Dementia has now been positioned within the Safeguarding Governance Framework and the Dementia Operational Forum Terms of Reference is on this 8 Minutes S&PoPaR Sub-Committee FINAL

11 agenda for ratification. The following recommendations were noted:- That the current hypotheses be tested through a programme of audit and evaluation; That a formal Dementia Strategy (currently in DRAFT) be submitted for executive approval; That a third round of National audit be undertaken in the three main General Hospitals; That further training opportunities are identified and made available; That the Butterfly Scheme be launched in all Community Hospitals by the end of 2013 as well as Butterfly Champions being identified; That resources be sourced to support the work around Dementia friendly wards. 9 Deeside Press Statement: There is an ongoing progression of Safeguarding activities following the POVA Process. Significant work has been undertaken by CL and KW, PCSM CPG. One hundred percent compliant in work already undertaken/going forward and regular briefing papers evidencing this have been submitted to the Welsh Government, the Chief Medical Officer, Chief Nursing Officer and the Health Board Executive. MW, Surgical & Dental excused herself from the meeting having made apologies for an early departure at the onset of the meeting. 10 Child Death Review: This report has been shared with the LSCBs however this Sub Committee will ensure that it is also shared with the Community Safety Partnership. MD Significant for BCUHB as in North Wales concerns have been identified in relation to child overlay. A Task & Finish Group has been set up chaired by Ann Walker, Safeguarding Midwife, working with Women s and C&YP CPGs, to look at what advice and guidance we share with parents, guardians and acute wards. It was noted that it was important to identify national guidance and implement it at a local level to ensure we are on the correct course. 11 Child Sexual Exploitation, Task & Finish Update Report: Sexual Exploitation Risk Assessment Framework (SERAF) sits within the Working Together under the Children Act 2004 and also within Part 5 of the All Wales Child Protection Procedures. Heath assessments are key to safeguarding children and young people to assess and consider risk. BCUHB, the Local Authority and the Police have set up a regional Missing Children & Child Exploitation (CSE) Task Group split into three groups covering two Local Authority areas Flintshire & Wrexham, Conwy & Denbighshire and Gwynedd & Môn. Alison Griffiths, Clinical Nurse Specialist Domestic Abuse, managed by NR, has been tasked to sit on all three groups as part of her portfolio and to feed back to this Sub-Committee, however these groups are in their infancy, however, there are positive signs going forward. PHW are currently working with GPs to attempt to simplify the SERAF Tool to make it more user friendly and effective for them. 9 Minutes S&PoPaR Sub-Committee FINAL

12 12 Safeguarding Structure: This has been a standing agenda item for Safeguarding due to the delay in the banding of the new structure Job Descriptions following the OCP process which has taken 2½ yrs. Most positions have now been appointed to, however, MD reported that she is on track for appointing to outstanding posts, Senior Nurse Safeguarding Adults 8A, Head of Nursing Safeguarding Children/Deputy Named Nurse 8B and Clinical Nurse Specialist Conwy area Band 7. Thanks and appreciation is given to WOD and the interview panel for their valuable input. MD further noted that in light of the Social Services and Well Being Bill, there will be significant issues for Adult Protection due to the amount of activity being generated and driven by the POVA agenda which is significant and therefore the appointment to the 8A post of Senior Nurse Adult Protection will be extremely welcome. It was also noted that Multi-agency participation was also growing at an alarming rate generating huge strategic activity and input by the Safeguarding Team and therefore this would have to be monitored to ensure this was achievable whilst remaining compliant. MD further emphasised that the new structure was the leanest structure safeguarding has had to date and in reply to a question whether the organisation was safe given this structure, MD replied that the organisation was currently safe, however, the situation would have to be re-evaluated when the full safeguarding team was in place to reduce risk to the patients, staff and the organisation. 13 CPG Reporting Framework: The Safeguarding Reporting Framework has been changed slightly in order to reduce duplication of groups and activities. The new SCR, Homicide & Child Practice Review Task & Group has been set up in order to feed into regional LSCB SCR/CPR/Homicide Groups. First meeting to take place shortly. 14 DoLS: The Deprivation of Liberty Safeguards (DoLS) provides a legal framework for safeguards under the Mental Capacity Act (2005). DoLS is very much a safeguarding issue underpinning the Human Rights Act and is embedded within the Health Boards Quality & Safety agenda as well as incorporating the DoLS agenda into the BCUHB Safeguarding structure providing opportunities to introduce DoLS into the Corporate systems and processes. A recent KSF meeting agreed to link into the Safeguarding Structure which could actively influence care delivered across the General and Community Hospitals; DoLS activity is reported to and monitored by HIW (Health Inspectorate Wales) and CSSIW (Care and Social Services Inspectorate Wales). The Welsh Government have given notice to the Health Boards in Wales that HIW & CSSIW will be undertaking an in depth piece of work over the next year, to monitor the use of DoLS and will be reporting their findings to the Minister for Health and Social Services. Reports for 2011 and 2012 showed that a less than anticipated volume of DoLS authorisation applications nationally which corresponds with local activity which may be due to a low level of knowledge of DoLS on ward areas across BCUHB; Training needs identified for a detailed knowledge of the Mental Health 10 Minutes S&PoPaR Sub-Committee FINAL

13 Act and the Mental Capacity Act as well as for new legislation; SO and MD will be attending a DoLS Stakeholder Event on the 9 th October 2013 facilitated by CSSIW & HIW which will cover issues such as inconsistencies in DoLS applications across Wales, wide variations in the approval of DoLS applications across Wales as well as the differential between England and Wales legislation; DoLS representation on the appropriate Safeguarding Strategic and Operational Forums/Task Groups has been addressed; Access to and capacity of Best Interest Assessors (BIA s) was discussed. Currently only 3 BCUHB staff who have completed the course providing a narrow band of expertise and capacity resulting in a potential risk for the Health Board therefore escalated to the Risk Register as well as a paper submitted to the MHA Committee. It is recommended that a review is undertaken of the options of increasing the specialist BIA role within BCUHB and/or commissioning BIAs from Local Authorities where appropriate; Discussed concerns regarding clear under reporting and it was noted that in its next inspection Healthcare Inspectorate Wales will ensure that DoLS will become an integral part of its inspection under Safeguarding; In order to establish closer links with the Concerns Department SO has written to Brian Tehan and Dr Peter Lepping requesting a meeting to discuss communication, advocacy and DoLS. MD requested an update from this meeting; Following a Court of Protection case, the Health Board was advised by their legal representative to use the MCA proforma when it is required, to provide a rational for the decision rather than a tick box proforma. It was noted that the Health Board needs to consider this advice in order to meet any legal challenge. NR formally raised this issue today and SO has raised this issue with the Health Board. Discussion ensued regarding the form and its completion. MD requested that this issue be discussed outside of the meeting. DoLS now linked with the Dementia Butterfly Scheme ; CW informed the Sub-Committee that she has added a half hour slot on to their training sessions in order to give staff a little more understanding of DoLS; SO to submit the DoLS Risk Assessment to the next meeting of the Sub- Committee in order that DoLS can be supported with a collective voice from a safeguarding perspective. PART 2 - CONFIDENTIAL SO 15 G&A LSCB SCR Overview given by LS on behalf of RS:- A Serious Case Review (SCR) was commissioned by Gwynedd and Mon Local Safeguarding Children Board (LSCB) and a Domestic Homicide Review (DHR) was commissioned by the Community Safety Partnership (CSP). Following discussion between Gwynedd and Mon LSCB and the CSP it was agreed to undertake a combined approach to these reviews. 11 Minutes S&PoPaR Sub-Committee FINAL

14 BCUHB were simultaneously undertaking an internal Mental Health Review following discussion with Healthcare Inspectorate Wales (HIW) as the perpetrator was a Mental Health service user. Due to confidentiality a verbal update was given of key/ongoing issues as this case is not yet in the public domain. Recommendations will be shared with the relevant CPG s in the first instance via the Safeguarding SCR, Homicide & CPR Task Group. 16 CPR/Multi Agency Review 2 cases: Due to confidentiality a verbal update was given regarding these cases by MD and LG, as again these cases are not yet in the public domain. Recommendations will be shared with the relevant CPG s in the first instance via the Safeguarding SCR, Homicide & CPR Task Group. For Ratification 17 Safeguarding Training Strategy: Changed and amended to follow the Intercollegiate document. Eleven comments were received and considered, responded to and incorporated as necessary. It was also noted that BCUHB Board members inclusive of independent members would require Annual Safeguarding Training and that this should be incorporated into the Safeguarding Training Strategy. The Training Strategy was ratified by the Sub-Committee; however, a request was made that it should be brought back to this meeting in 12 months time for an overview to ensure compliance. 18 Domestic Abuse Procedures: A letter received on the 26 th September 2013 identified the following guidance: - The Welsh Government 10,000 Safer Lives Project has sought to improve the response of the public service in Wales to victims of Domestic Abuse and this week the Minister for Local Government & Communications will seek confirmation from all Public Service Leads in Wales that organisations have put in place a workplace Policy for dealing with Domestic Abuse, Violence against Women and Sexual Violence. The framework that was provided by Welsh Government to develop and review this Policy identified a role for Domestic Abuse Link Staff. Link Staff do not investigate Domestic Abuse, they provide support and sign post victims, although they may be expected to make disclosures in certain circumstances and where this is necessary. It was therefore decided to ratify the BCUHB Domestic Abuse Procedures with the caveat that this guidance is incorporated into the Policy. Alison Griffiths, Clinical Nurse Specialist, Domestic Abuse, managed by NR will be tasked with the identification of BCUHB Link Staff and liaise with North Wales Police with regard to a North Wales Regional Link Staff Practice Event Workplace Policies on Domestic Abuse to take place on the 16 th October Terms of Reference: Dementia Operational Forum: AG Ratified to be forwarded to the Quality & Safety Committee 12 Minutes S&PoPaR Sub-Committee FINAL

15 Any other Business: Request from NR that the Welsh Government s response to the Francis Report be included on the December agenda; Noted that the March 2014 meeting falls on the same day as the Health Board meeting AH/MD to decide if the meeting date for this sub- Committee is to be changed. All Wales Disclosure and Barring Service (DBS) Policy NOT YET AGREED. MW, WOD to bring back to the next meeting. to disseminate to the membership. MD Future meetings: 20 th Dec th March th June th Sept th Dec 2014 Venue/Time: 9:30am 12:30pm: Meeting Room 2, Medical Institute, Wrexham 9:30am 12:30pm: Boardroom 2, Wrexham Headquarters 9:30am 12:30pm: Boardroom 1, Wrexham Headquarters 9:30am 12:30pm: Boardroom 1, Wrexham Headquarters 9:30am 12:30pm: Boardroom 1, Wrexham Headquarters VC will be available from The Boardroom, Llandudno Hospital 13 Minutes S&PoPaR Sub-Committee FINAL

16 Safeguarding & Protection of People at Risk Sub-Committee ACTIONS Actions from Previous Minutes:- ACTION By Whom Meeting to discuss how Children can bypass A&E and go straight to Children s Ward MD requested feedback to be made available at the next meeting. YH/KW 5.1 SBAR: Domestic Abuse Women Practice Development Team representatives to be members of the Safeguarding Sub-Committee, Safeguarding Operational Forum (SCOF) and the Domestic Abuse and Vulnerable Adults Forums. Invitations to be forwarded again to Marianne Walmsley, Lead Nurse for Community and Primary Care, and she will identify representatives. 14 HIW: A key action from HIW Inspection 2012 was that the Health Board should seek to expand the implementation of Safeguarding Forums across all relevant CPG s. It is accepted that it is not appropriate for all CPG s to have Safeguarding Forums, however, it is extremely important that if Safeguarding is aligned to your internal Committee s you need to have evidence of this and be able to provide key information and evidence of sharing information. Second request to be made for submissions of evidence. CPGs who have not yet responded 4a Significant Issues: Children: Single Electronic Record: The issue of multiple children s records is concerning and the subject of introducing a single electronic record has been raised before by the Safeguarding Children Operational Forum in multiple arenas and is considered to be an issue which continues to warrant discussion at Board level. Issue of significance. 4b Significant Issues: Adults: Training Strategy: CPGs and departments to respond appropriately with the relevant data; NR to prepare a report based on the current data provided by CPGs/Departments. CPGs NR Pressure Ulcers: NR to write to Anne-Marie Rowlands for a current position update. 5 Powys Safeguarding Annual Report: Permission given for the Powys Safeguarding Annual Report to be disseminated to the membership of this Sub-Committee for information. NR 14 Minutes S&PoPaR Sub-Committee FINAL

17 7 SBAR: Training Compliance: Currently no provision for recording/capturing training information on staff PADR Forms. MW to take forward. Process of capturing CPG training data NR to take this issue to the Training Task & Finish Group. MW, Surgical & Dental CPG requested that KM made it known at Board level that the releasing of staff from Acute Wards to attend training had been impossible due to recruitment issues. MW, WOD NR KM 10 Child Death Review: 14 DoLS: This report to be shared with the Community Safety Partnership. MD SO to submit the DoLS Risk Assessment to the next meeting of this committee. 18 Domestic Abuse Procedures: Alison Griffiths to identify BCUHB Link Staff and ensure that Link Staff Guidance is embedded within the Policy as well as to liaise with North Wales Police in relation to a North Wales Regional Link Staff Practice Event on the Terms of Reference: Dementia Operational Forum: to forward to the Quality & Safety Committee. AOB March 2014 Sub-Committee Meeting: MD/AH to decide if the date is to be changed. SO NR/AG All Wales Disclosure & Barring Service (DBS) Policy: All Wales Disclosure and Barring Service (DBS) Policy Not yet agreed. MW, WOD to bring back to the next meeting. to disseminate to the membership. MW 15 Minutes S&PoPaR Sub-Committee FINAL