FIRST SAFEGUARDING REPORT FROM WORCESTERSHIRE CCGs APRIL-OCTOBER 2013

Transcription

1 FIRST SAFEGUARDING REPORT FROM WORCESTERSHIRE CCGs APRIL-OCTOBER 2013 Author: On behalf of: Ellen Footman Designated Nurse for Safeguarding NHS Redditch and Bromsgrove CCG, NHS Wyre Forest CCG and NHS South Worcestershire CCG Page 1 of 19 Last updated: 29/10/13

2 Contents: 1. Introduction -The CCG s role in safeguarding and promoting the welfare of children, young people and in protecting adults at risk from abuse or the risk of abuse Safeguarding Children and Adults Governance and Accountability Arrangements. Maintaining accountability in the new NHS The CCGs Governance and Accountability arrangements for Safeguarding Children and Adults Key Legislation for Safeguarding Children and the role of the CCGs Key legislation for Adult Safeguarding and the role of the CCGs Partnership working with Worcestershire Safeguarding Adults Board, Worcestershire Safeguarding Childrens Board and sub-groups Learning Lessons from Serious Incidents and Child Deaths Child Sexual Exploitation Looked After Children (LAC) Monitoring of Commissioned Services Safeguarding Commissioning Strategy Safeguarding in Care Homes (with Nursing) Supporting Safeguarding Standards in Primary Care Prevent CCGs role in Adult Protection Processes Conclusion Page 2 of 19 Last updated: 29/10/13

3 1. Introduction -The CCG s role in safeguarding and promoting the welfare of children, young people and in protecting adults at risk from abuse or the risk of abuse This is the first safeguarding children and adult report for NHS Redditch and Bromsgrove, NHS Wyre Forest and South Worcestershire Clinical Commissioning Groups (CCGs). CCGs gained statutory status on 1st April 2013, following implementation of the NHS Health and Social Care Act The CCG authorisation process scrutinised safeguarding arrangements within the CCGs prior to transition, and all Worcestershire CCGs were found to be satisfactory in relation to safeguarding arrangements, with no conditions for improvement imposed. A recent external Audit was undertaken in July 2013 with findings of significant assurance that the CCGs were compliant with safeguarding arrangements. Progress against recommendations in the action plan will continue to be monitored on a quarterly basis by the auditors. NHS England, Arden Area Team monitor the CCGs arrangements through biannual reporting to the Board, and through an annual self- assessment process. Worcestershire context Worcestershire CCGs commission health services for over 566,600 people which includes nearly one in five adults aged 65+ and one in forty are aged 85+. In , 1501 Alerts were made to the Access Service (Adult social Care), which is 125 per month. Of these 67% were in respect of older people aged 65+, 17.3% were for people aged with a Learning Disability, 4.6% Mental Health and 9.5% Physical disability. 83.9% of alerts became on-going referrals. Approximately 25% of alerts were made by NHS staff. Out of the total population of Worcestershire almost 128,200, are children 0-19 years. According to the Office of National Statistics in 2012 there were approximately 114,676 children under the age of 18 in Worcestershire. Of these, 37,000 children are aged five or under. A significant minority of these children will be living in circumstances where they are at risk of suffering significant harm from abuse and neglect or are in the care of the Local Authority. 1.1 Purpose The purpose of this report is to provide assurance that Worcestershire CCGs are fulfilling their new statutory responsibilities as commissioners to promote the safety and welfare of children in all of the services they commission (1), and provide assurance of the CCGs commitment to prevent and reduce the risk of abuse and neglect of adults and of continuing to improve safeguarding practice in the NHS. The report also provides an overview of work undertaken during 2012/13 and highlights specific areas requiring development during 2013/14. --Achievements over the past year and priorities for the future are highlighted. 1 Section 11 of the Children Act 2004 and Working Together to Safeguard Children HM Government 2013 Page 3 of 19 Last updated: 29/10/13

4 2. Safeguarding Children and Adults Governance and Accountability arrangements: Maintaining accountability in the new NHS The implementation of the Health and Social Care Bill has resulted in significant organisational transformation. From the 1st April 2013 the CCGs took on new statutory responsibilities and the PCT devolved its responsibilities to new NHS organisations including NHS England, Public Health England, and Commissioning Support Units. Specific roles and responsibilities for CCGs and other NHS statutory bodies around safeguarding are outlined in Safeguarding Vulnerable People in the Reformed NHS Accountability and Assurance Framework issued by the NHS England 31st March This document replaced previous interim guidance and is the benchmark to monitor CCG arrangements. Accountability structures and clarity about certain roles and responsibilities is still under development between the CCGs and NHS England and will be embedded during the coming year. The aim of the NHS Accountability and Assurance Framework is to promote partnership working to safeguard children, young people and adults at risk of abuse, at both strategic and operational levels. The framework clarifies NHS roles and responsibilities for safeguarding, including in relation to education and training. It provides a shared understanding of how the new system will operate and, in particular, how it will be held to account both locally and nationally. The framework ensures professional leadership and expertise are retained in the NHS, including the continuing key role of Designated and Named professionals for safeguarding children. The framework outlines a series of principles and ways of working that are equally applicable to the safeguarding of children and young people, and of adults in vulnerable situations, recognising that safeguarding is everybody s business. It outlines the responsibility of every NHS funded organisation and healthcare professional to ensure that people in vulnerable circumstances are not only safe but also receive the highest possible standard of care and assurance that commissioned services have safe systems to protect children and adults at risk of abuse. Governance and accountability is also maintained in the new NHS through The Mandate: A mandate from the Government to the NHS Commissioning Board: April 2013 to March The mandate sets out for NHS England, (formally NHS Commissioning Board) a specific objective of continuing to improve safeguarding practice in the NHS and reflects the commitment to prevent and reduce the risk of abuse and neglect of adults. NHS England s objective is to ensure that CCGs work with local authorities to ensure that vulnerable people, particularly those with learning disabilities and autism, receive safe, appropriate, high quality care. The Government is clear that, where serious failures of care and treatment have occurred, managers in both the NHS and social care sector will be better held to account. A culture must be developed to ensure learning from patient safety incidents, particularly events that should never happen, such as wrong site surgery, to prevent them from happening again. Patients should be able to expect to be treated in a safe and clean environment and to be protected from avoidable harm. Improving patient safety involves many things: treating patients with dignity and respect; high quality nursing care; creating systems that prevent both error and harm. Page 4 of 19 Last updated: 29/10/13

5 The Governments ambition is to help give children the best start in life, and promote their health and resilience as they grow up; and the Government s commitment to an additional 4,200 health visitors by 2015 will help to ensure this vital support for new families through the NHS working together with schools and children s social services, supporting and safeguarding vulnerable, looked-after and adopted children, through a more joined-up approach to addressing their needs. Since the first mandate there have been some important developments. The government requires NHS England and CCGs to act upon these core priorities. The Francis report highlights the need to detect and expose unacceptable care quickly. The system must take responsibility to address problems urgently and effectively and the actions taken as a result. Care for older people must be improved particularly through reform of primary care given its pivotal role within communities. The refreshed mandate re-emphasised that safeguarding children remains a priority for the NHS and its duties to ensure that appropriate recognition is made to protect adults at risk of harm and to ensure that processes are in place to support practitioners to respond to concerns. 3. The CCGs Governance and Accountability arrangements for Safeguarding Children and Adults The CCG governance arrangements for safeguarding children and adults are through the Quality and Patient Safety (QPS) Committees of Redditch and Bromsgrove CCG and Wyre Forest CCG, which meets bi-monthly, and the Quality, Patient Review, (QPR) Committee of South Worcestershire CCG which meets monthly. The Committees monitor progress on national guidance and strategic priorities, as well as progress on recommendations from previous CQC inspections. These are monitored through the action plans of health providers. External auditors monitor for CCG compliance by quarterly audit. Through this process, CCGs are assured of their readiness to comply with the CQCs Single Inspection Framework. The Safeguarding Children and Adults Commissioning Strategy was presented to the CCGs QPS and QPR Committees in August and October 2013 respectively, in draft form. It will be presented for ratification following minor amendments at the next governing Body meetings. The Strategy is a 3 year rolling strategy with an Annual refresh. The Quality Committees will monitor the strategy regarding progress of the action plan on a quarterly basis. The CCG Quality Committees ratified the Safeguarding Children Policy and the Safeguarding Adults Policy in October Both are due for a refresh in light of national guidance. The Safeguarding Policy clearly outlines individual and organisational arrangements to comply with statutory responsibilities and guidance. The Management of Allegations Policy was also ratified in October 2012 but is due to be updated by end of 2013, to ensure compliance with current national guidance. A Memorandum of Understanding outlines the safeguarding arrangements across the three CCGS. An Executive Nurse is in place for both Quality and Patient Safety teams across the 3 CCGs with responsibility and accountability for quality assurance of NHS contracts, often from the same provider. Redditch and Bromsgrove CCG host the arrangements for Safeguarding Adults and Children on behalf of all 3 CCGs. The host CCG employs a Designated Nurse. This is a full-time substantive post. A Service Level Agreement is in place for the Designated Doctor with Page 5 of 19 Last updated: 29/10/13

6 Worcestershire Health and Care Trust and the CCGs for 1 day per week. The host CCG employs a Safeguarding Adults Lead which is a full-time substantive post. In addition the host CCG employs a Named GP for Safeguarding Children for two sessions per week and the recruitment process is underway to recruit a Named GP for Safeguarding Adults for two sessions per week. However, interest expressed to date has been limited Safeguarding Clinical Leadership and support Clinical leadership for Safeguarding is provided by a full time Designated Nurse and Designated Doctor. The Designated Nurse provides professional advice and has key responsibilities for Safeguarding Children, Looked After Children, Safeguarding Adults and is the Mental Capacity Act Lead, across the health economy. The Designated Nurse offers safeguarding supervision to all Named Nurses, and Safeguarding Leads who work within the two main NHS provider organisations; the Acute Hospitals Trust, Health and Care Trust and the CCGs. The Designated Doctor supervises 5 Named Doctors who work within the three main NHS provider organisations; the Worcestershire Acute Hospitals NHS Trust (2 Named Doctors), the Worcestershire Health and Care NHS Trust (2 Named Doctors) and primary care (1 named GP). The Designated Doctor also supervises the Named Doctor for Looked after Children (LAC). This doctor along with the Named Nurse for LAC ensure that children entering the looked after system have timely health assessments leading to a health care plan for each child. About 1000 children move into the looked after system each year with about 650 being looked after at any time. The Named Doctors have a role, in conjunction with Named Nurses and others in their organisations to ensure that staff have appropriate training, advice and support in safeguarding. The Designated Nurse and Doctor provide expert advice and support to CCGs in safeguarding matters, contributing to the assurance processes to ensure Worcestershire CCGs are fulfilling their new statutory responsibilities as commissioners to promote the safety and welfare of children in all of the services they commission, and its commitment to prevent and reduce the risk of abuse and neglect of adults and of continuing to improve safeguarding practice in the NHS. This includes seeking assurance from health providers that they have robust policies and procedures, that WSCB sub groups and task and finish groups have high quality representation and advice from health professionals, that staff across the organisation have appropriate training and are able to obtain safeguarding supervision and safeguarding advice as required. Furthermore, that recommendations from serious case reviews and other learning processes are implemented, through their agencies action plans. Adult Safeguarding Lead The Adult Safeguarding Lead provides expertise and a point of contact for advice and intelligence regarding adult safeguarding across the health economy. The Adult Safeguarding Lead works in partnership with the Local Authority, particularly around care homes and adult protection processes. Page 6 of 19 Last updated: 29/10/13

7 The Adult Safeguarding Lead represents the CCGs at Worcestershire Safeguarding Adult Board sub-groups as well as some sub-groups of Worcestershire Safeguarding Children Board. Key priorities are, to ensure that prevention of avoidable harm is seen as a priority and to ensure that Worcestershire residents/patients receive safe, quality care. This is achieved by supporting Nursing Homes to understand safeguarding and through Quality Assurance visits as a member of the Quality and Patient Safety teams within the CCGs. Another key priority is to raise awareness of CCG colleagues re the Prevent agenda by cascading knowledge and ensure staff are aware where to take concerns. The Safeguarding Adult Lead ensures dissemination of learning regarding Serious Case Reviews and other learning processes to primary care through training and workshops. Named GP for Safeguarding Children The Named GP is employed for two sessions per week. Key priorities for the Named GP for Safeguarding Children have been raising the profile of safeguarding as a priority within general practice and in particular assisting with the review of practice and implementing learning. This latter element has been specifically via involvement with Serious Case Reviews, Child Death and other reviews as well as working with other safeguarding colleagues to implement a training strategy for primary care staff including general practitioners. Additional work has been to improve the communication and mutual understanding between the wider safeguarding community (such as Children s' services) and general practice. The Safeguarding Children and Adults Commissioning Strategy ( ), next year will specifically look at the systems in general practice that could support safeguarding and in particular how better use of the computer systems in all practices could be better utilised. Improvement in engagement with child protection processes is also a high priority. NHS England directly commissions GPs and is statutorily responsible for ensuring that these services provide a safe system that safeguards children and adults at risk of abuse or neglect. The CCGs support NHS England Area Team in safeguarding and their work with GPs. 4. Key Legislation for Safeguarding Children and the role of the CCGs Sections 11 and 13 of the Children Act 2004 have been amended so that Clinical Commissioning Groups have identical duties to those previously applying to Primary Care Trusts (PCTs) i.e. to have regard to the need to safeguard and promote the welfare of children and to be members of Local Safeguarding Children Boards. The Executive Nurses and Designated Nurse have 100% attendance at the Safeguarding Board. The revised edition of Working Together to Safeguard Children (2013) sets out expectations as to how these duties should be fulfilled. The CCGs have robust systems in place for assuring that the following key features are in place in the services they commission at an organisational or strategic level: senior management commitment to the importance of safeguarding and promoting children s welfare; a clear statement of the agency s responsibilities towards children is available for all staff; Page 7 of 19 Last updated: 29/10/13

8 a clear line of accountability within the organisation for work on safeguarding and promoting the welfare of children ; service development that takes account of the need to safeguard and promote welfare and is informed, where appropriate, by the views of children and families; staff training on safeguarding and promoting the welfare of children for all staff working with or (depending on the agency s primary function) in contact with children and families and safe recruitment procedures are in place. Whilst in the majority of cases the systems in place ensure effective inter-agency working to safeguard and promote the welfare of children and young people and effective information sharing, these are still areas for improvement as these issues have been highlighted in Serious Case Reviews, nationally and locally. The CCGs have established a Communication Task and Finish group to develop these processes across the health economy. 5. Key legislation for Adult Safeguarding and the role of the CCGs The draft Care Bill (July 2013) sets out comparable requirements with respect to safeguarding adults. Section 42 of the Care Bill sets out that enquiries must be made by a local authority where it has reasonable cause to suspect that an adult in its area (whether or not ordinarily resident there): i. has needs for care and support (whether or not the authority is meeting any of those needs), ii. iii. is experiencing, or is at risk of, abuse or neglect, and as a result of those needs is unable to protect himself or herself against the abuse or neglect or the risk of it. The local authority must make (or cause to be made) whatever enquiries it thinks necessary to enable it to decide whether any action should be taken in the adult s case. Section 43 of the Care Bill specifies membership of Safeguarding Adults Boards (SAB). CCGs as statutory members of the Safeguarding Adult Board (SAB) will have a duty to comply with requests by the SAB in order to carry out its functions. This would include to supply information and contribute to conducting a Review where there is reasonable cause for concern about how the SAB, members of it or other persons with relevant functions worked together to safeguard the adult. Other key legislation and guidance are the Mental Capacity Act (2005) and No Secrets (2000) 6. Partnership working with Worcestershire Safeguarding Adults Board, Worcestershire Safeguarding Children s Board and sub-groups The two Executive Nurses from the three CCGs, are members of Worcestershire Safeguarding Children Board. The Designated Doctor and Nurse are members of the Board to ensure professional advice and clinical expertise. The Named GP has also represented the CCGs on WSCB. The Designated Nurse represents the CCGs on the WSCB Serious Case Sub-Group (SCR Subgroup), Page 8 of 19 Last updated: 29/10/13

9 Quality Assurance Group (QAG), and the Performance Sub-Group. (PSG) and Child Sexual Exploitation Panel as required. The Designated Doctor, Designated Nurse and Named GP are members of the Worcestershire Child Death Overview Panel (CDOP). The Named GP attends the Safeguarding Effectiveness Executive (SEE) as required by the group, to discuss issues pertinent to GP Practice. The Safeguarding Adult Lead has also attended various sub-groups and task and finish groups, both to deputise for the Designated Nurse and to develop wider thinking around adult and child safeguarding. The two Executive Nurses from the three CCGs, are members of Worcestershire Safeguarding Adults Board. The Designated Nurse is a member of the Board to ensure professional advice and clinical expertise. The Designated Nurse represents the CCGs on the WSAB Serious Case Review Sub-Group (SCR Subgroup), Policy and Procedures Sub-Group and is Joint Chair of the Mental Capacity Act/Deprivation of Liberty Safeguards (DOLS) Sub-Group, which was aligned as a subgroup of the Board in September The Safeguarding Adults Lead represents the CCGs at the Audit and Good Practice, Communications and Training Sub-Groups. The Designated and Named professionals have attended various Panels in respect of the Serious Case Review Process and other learning processes, such as the Significant Incident Learning Process (SILP) and have contributed to the dissemination of learning from such processes. The Designated Nurse wrote the Health Overview Report from the SCR GW. The Health Overview Report analyses the Independent Management Reviews (IMR), for all health providers across the county. Recommendations from the Health Overview Report are incorporated into the Independent Authors Report and the action plans of individual agencies. The SCR Independent Authors Report is submitted to Ofsted for scrutiny. The Named GP wrote the Authors Report for the Significant Incident Learning Process (SILP) CR6 which was recently undertaken. The Adult Safeguarding Lead has also undertaken 3 Independent Management Reviews (IMR) for Serious Case Reviews (Adults and Children) on behalf of GP Practices in the last 12 months. Through membership of the Board and its sub-committees the CCG has oversight of provider organisations progress in implementing and effecting change as a result of the serious case review process and audit, as well as through the Quality committees of the CCGs and Safeguarding Health Forum. 6.1 Partnership working with Worcestershire Safeguarding Children s Board and Sub-groups Worcestershire Safeguarding Children Board (WSCB) The Board has a statutory scrutiny role. A Section 11 (2) self-assessment audit tool for commissioning and provider organisations is disseminated for completion annually. Completion of this tool will enable the CCGs not only to monitor their own performance against required standards, but also to monitor provider organisations. In WSCBs Annual Report 2013, the Independent Chair has highlighted key areas of improvement for individual agencies. The Implications for Health are: Communication between health workers and GP input to child protection processes e.g. case conference attendance and reports. Action has already commenced to improve GP attendance at case conference by providing alternate means to engage GPs in the process, such as through tele-conferencing for case conferences. The Designated Nurse, Named GP for Safeguarding and Safeguarding Adult Lead are also working with GPs to improve understanding and practice regarding child protection processes Page 9 of 19 Last updated: 29/10/13

10 and the importance of GP engagement, through training, workshops and regular updates. This is particularly important in light of the findings from the Daniel Pelka Serious Case Review, where GPs lack of engagement was highlighted: The SCR Author commented on the GP practices lack of any proactive communication with other agencies. GPs tended to be on the periphery of professional communication which should raise concerns locally as to whether GPs are fully engaged within the multi-agency professional community in endeavouring to address the needs of vulnerable children. The Designated Nurse is facilitating a Communication task and Finish group which has been established with commissioner and provider Safeguarding Leads to improve processes for effective communication within health. (2) Section 11 (s11) of the Children Act 2004 places a statutory duty on key persons and bodies to make arrangements to ensure that in discharging its functions, they have regard to the need to safeguard and promote the welfare of children and that the services they contract out to others are provided having regard to that need. Serious Case Review (SCR) Sub-group The SCR sub-group oversees and quality monitors serious case reviews and individual organisation Independent Management Reviews (IMR s) and associated action plans. SCRs and other learning processes are examined in more detail in Section 8 Quality and Assurance Group (QAG) The QAG undertakes themed Multi-Agency Case File Audits as well as a programme of audit. The QAG scrutinises and evaluates impact evidence of key recommendations from serious case reviews. Performance Group The Performance Group is developing a Dashboard of indicators to measure outcomes, monitor impact and effectiveness. The Performance Task and finish group reviewed the children s safeguarding threshold guidance for staff. The Adult Safeguarding Lead supported this work and helped ensure that the Think Family profile is embedded in the guidance. Think Family should also be considered by staff working in adult services and this is a key theme for safeguarding training across Worcestershire s health economy. Child Sexual Exploitation Panel The Child Sexual Exploitation Panel ensures a co-ordinated approach is taken to concerns about the sexual exploitation of children and to maintain an overview of the emerging picture in Worcestershire. Child Sexual Exploitation (CSE) is examined in more detail in Section 9 (3)House of Commons home Affairs Committee Child Sexual Exploitation and the Response to Localised Grooming 2013 Child Death Overview Panel (CDOP) The WSCB is responsible for ensuring that a review of each death of a child normally resident in the WSCB s area is undertaken by a Child Death Overview Panel (CDOP). The Child Death Review process is examined in more detail in Section 8.1 Page 10 of 19 Last updated: 29/10/13

11 Safeguarding Effectiveness Executive (SEE) The SEE comprises representatives with operational management roles from a various agencies whose role it is to ensure effective implementation and delivery of the Boards priorities and key strategic objectives. Training and Development sub-group. The group s work includes looking at appropriate ways of evaluating safeguarding children training sessions and also staff audit to ascertain if learning is embedded in practice. 6.2 Partnership working with Worcestershire Safeguarding Adults Board and sub-groups Worcestershire Safeguarding Adult Board (WSAB) The Board will move to a statutory function once the Care Bill (2013) is enacted. SAB will seek to achieve its objective to help and protect adults in its area (Care Bill, Section 42) by co-ordinating and ensuring the effectiveness of what each of its members does. The Executive Nurses of the CCGs attend the WSAB and the Designated Nurse was invited to attend from September All representatives have attended over 75% of meetings or have sent a Deputy. WSAB Safeguarding sub-groups Communications sub-group The communications sub-group business plan includes actions to maintain a program of campaigns to raise awareness of Safeguarding Adults issues with the general public, service users and staff across Worcestershire; ensure service user and carer forums are invited to comment on all publicity materials; and create a mechanism for cascading information about safeguarding adults across the partnership. Training sub-group Current Training Strategy (WCC) is under review ( ). Some concerns have been raised regarding the move from face to face level 1 training to e-learning from April It was agreed that although face to face training is preferable, it is impossible to deliver to large numbers. Each organisation is responsible for basic and level one safeguarding adults training. There is a plan to provide access to multi-agency level 2, 3 & 4 adult safeguarding training via the Learning & Development team based at WCC. Good Practice & Audit sub-group This year the group has commenced themed Multi-Agency Case File Audits (MACFA) chosen randomly from safeguarding alerts. The purpose of the audits is to identify gaps in knowledge and practice of health & social care professionals; and address learning needs via supervision relevant training. The Audit & Good Practice sub-group has previously been involved in auditing action plans relating to Serious Case Reviews (SCR); the purpose of this is to establish if learning has been embedded. Policy and Procedures sub-group The group ensures that multi agency policies and procedures are fit for purpose and minimise the risk to vulnerable adults, in line with national best practice guidance. Page 11 of 19 Last updated: 29/10/13

12 Serious Case Review Sub Group The group ensures WSAB learn from national and regional SCRs and other learning processes, as well as relevant children s SCRs and Domestic Homicide Reviews (DHR). It ensures learning is disseminated to improve practice. Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) This group became a sub-group of the WSAB in September The group promotes best practice in the use of MCA/DoLs amongst Statutory and Independent organisations that support people who lack capacity. The Designated Nurse is newly elected as joint chair. 7. Learning Lessons from Serious Incidents and Child Deaths How the CCG enables learning from child deaths and serious incidents, Serious Case Reviews, (Adults and Children), Domestic Homicide Reviews and ensures lessons learned result in sustained improvements in outcomes for children, young people and adults at risk of abuse or harm. The SCR sub-groups of both Boards oversee and quality monitors serious case reviews and individual organisation Independent Management Reviews (IMRs) and associated action plans. The Quality Assurance Group (WSCB) and Good Practice & Audit sub-group (WSAB) scrutinises and evaluates impact evidence of key recommendations from serious case reviews. As well as SCRs the SCR sub-groups utilise other methodologies for learning from serious incidents. For example, the Significant Incident Learning Process (SILP) has been commissioned recently in Worcestershire by WSCB following recommendation from the SCR sub-group. The SILP process engages with frontline practitioners and their managers, throughout the process. SILP looks at the systems and processes within organisations in place at the time of the incident. SILP seeks to examine and understand why something happened, in order to bring about better outcomes for children and vulnerable adults. By improving systems, processes and practice, children and adults at risk of harm and abuse, will be better safeguarded. Recently members of the SCR sub-group for WSAB attended a regional event examining various methodologies used in Serious Adult Reviews and SCRs. The WSAB SCR sub-group will look at national and regional methodologies to improve understanding and learning from serious incidents in Worcestershire. 7.1 The Child Death Review Process CCGs have a statutory duty to secure the expertise of consultant paediatricians whose responsibilities are to organise and provide advice on the commissioning of paediatric services which undertake enquiries into unexpected deaths in childhood, and provide medical investigative services. The LSCB is responsible for ensuring that a review of each death of a child normally resident in the LSCB s area is undertaken by a Child Death Overview Panel (CDOP). The CCG Designated Doctor and Nurse, as well as the Named GP are members of the Worcestershire CDOP. The Child Death Overview Panel (CDOP) is a subgroup of the Worcestershire Safeguarding Children Board (WSCB) and was set up to fulfil the processes set out in Working Together to Safeguard Page 12 of 19 Last updated: 29/10/13

13 Children. The panel has a fixed chair who is a retired GP, a manager and clerical staff funded by the WSCB. There is a standing membership representing all key stakeholders. The panel meets 5 times per year and provides an overview of all deaths up to the age 18. The panel has reviewed 189 deaths since it was set up in A subgroup of the CDOP, the Perinatal group, meets at Worcestershire Royal Hospital 4 times per year in order to review deaths of infants who have never left hospital. The Rapid Response process enables a rapid coordinated response to unexpected childhood deaths. The lead nurse for unexpected death in children and the designated paediatrician for unexpected childhood deaths coordinate a response of professionals to ensure that appropriate enquiries and investigations are undertaken in regard the death and that the family and others receive care and support. In 2011/ out of 34 deaths triggered a rapid response process. The CDOP and the rapid response process have led to a number of findings and key themes. The invariable association of smoking and bed sharing with sudden infant death syndrome has led to a roll out county wide of a safer sleeping strategy. The delay in presentation in some forms of childhood cancer and frequent association in parental consanguinity in some congenital conditions has also been highlighted. The perinatal group have noted the importance of neonatal death and the Acute Hospitals trust are to appoint a bereavement midwife. The CDOP manager currently chairs the regional CDOP/Rapid response network meeting and findings of the Worcestershire CDOP have been included within regional statistics. Details of the work and membership of the CDOP and Rapid Response team can be found in the Child Death Review Process annual report 2011/ Domestic Abuse and Domestic Homicide Review The Worcestershire Forum Against Domestic Abuse (WFADA) aim to ensure that people can feel safe and confident in their homes and communities, as well as aims to improve and develop those services, which are available to victims and survivors During the CCGs received reports from WFADA which outlined the scale and prevalence of domestic abuse across the county and identified opportunities to address the concerns. The Designated Nurse represents the CCGs on the WFADA which is steering local multi agency responses to the issue. The report by Co-ordinated Action Against Domestic Abuse (CAADA) (2013) identifies that there were reduced incidents of Domestic Abuse in the 12 months after the incidents had been to MARAC (Multi-Agency Risk Assessment Conference) compared to the previous 12 months which represented a reduction in police incidents. The numbers of cases discussed at MARAC were 254 across Worcestershire in the last 12 months (April 2012 March 2013). This corresponded to 335 children. Many children subject to a Child Protection Plan are living in households where domestic abuse is a factor. The Quality Assurance Group (QAG) analysed through Multi-Agency Case File Audits (MACFA) particular households with high numbers of DA incidents where children were subject to child protection plans. (MACFA 9). The children and their families were identified by West Mercia Police as living in households where the Police have concerns about the number of incidents of domestic abuse in the home. Agency involvement with 14 children in 7 different families was discussed. 2 Page 13 of 19 Last updated: 29/10/13

14 unborn babies were also considered. Following the MACFA recommendations are made and an action plan developed which is disseminated by members of the QAG. The MACFA reflected the findings of many previous cases audited: decision making without information held on both children and parents by the GP. The GP records are one of the few places where cradle to grave information is held in one place, which makes it a very significant source of information for practitioners, and for the MACFAs. A recommendation from the MACFA that the WSCB be approached to ask for their support in identifying a representative on the MACFA for GPs who can have access to records before the MACFA and then feed the information into the process, and feedback on MACFA concerns. As a result a letter from WSCB will go to the individual GP practices prior to future MACFAs to inform them that information from the records of parents and children would be required. 7.3 Domestic Homicide Reviews (DHR) The scale and prevalence of domestic abuse has been highlighted by recent domestic homicides across the County. Following the completion of the "JH" DHR, which was submitted to the Home Office, the Quality Assurance panel graded the review as "adequate". This was an important learning experience and the hard work and commitment to examine this case was acknowledged by the Home Office. The action plan has been updated by all agencies and the Executive summary and Overview report has been published on the South Worcester Community Safety Partnership website. The DHR sub group met in July to review a further murder which occurred in North Worcestershire (LE) and following that meeting wrote to the Home Office stating that Worcestershire did not intend to conduct a review. This case went to trial in October. A response is awaited from the Home Office. Following a further attempted murder in North Worcestershire in August a Near Miss review meeting was convened to review the case and identify lessons to be learned. Following the meeting Information sharing opportunities were identified and an opportunity to improve the maternity risk assessment form will be progressed. 8. Child Sexual Exploitation The Child Sexual Exploitation Panel ensures a co-ordinated approach is taken to concerns about the sexual exploitation of children and to maintain an overview of the emerging picture in Worcestershire of Child Sexual Exploitation (CSE). Recent cases of CSE including operation Retriever in Derbyshire are revealing the extent of child sexual exploitation across the country. A House of Commons Select Committee 4 reviewed several serious cases including those in Oxford and Rochdale has recently made recommendations that the Local Safeguarding Boards take responsibility for leading strategic plans to tackle the issue, including the development of Multi Agency Safeguarding Hubs. Worcestershire LSCB has been proactive in developing a cross authority Child Sexual Abuse Strategy. Designated and Named Professionals from the CCGs and health providers are Page 14 of 19 Last updated: 29/10/13

15 represented on this group. August 2013 saw the implementation of the strategy which should greatly improve agency responses to this complex issue. (3)House of Commons home Affairs Committee Child Sexual Exploitation and the Response to Localised Grooming Looked After Children (LAC) There are currently 650 children and young people looked after by Worcestershire Children's Services. Most of these young people live with foster carers in Worcestershire. In addition there are more than 200 children and young people looked after by other local authorities who are also placed with carers in Worcestershire. These children require co-ordinated multi agency assessments and planning to ensure appropriate protection plans keep them safe within their family or where this is not possible, to be accommodated by the Local Authority. Health workers across all services play a significant role in this process, from identifying concerns as they arise, referring children at risk to the Local Authority and contributing to multi agency assessments and plans to support children within their families or when they are accommodated into care. The promotion of the health and well-being of Looked After Children is identified as a key priority in the CCGs Safeguarding Children & Adults Commissioning Strategy , by means of the development of a clear strategy for Looked after Children (LAC) and the commissioning of appropriate services. 10. Monitoring of Commissioned Services Through monitoring of Commissioned Services, CCGs gain assurance that staff across all provider organisations safeguard and protect children and protect adults at risk of harm and ensure that processes are in place to support practitioners to respond to concerns. Worcestershire CCGs commission health services from: - Worcestershire Health and Care Trust, (WHCT), Worcestershire Acute Trust (WAHT), Harmoni Out of hours medical services, Continuing Health Care (CHC)/ Funded Nursing Care (FNC),West Midlands Ambulance Service and other health providers. Joint Commissioning Unit (JCU) commission healthcare services on behalf of the 3 CCGs-Child and Adolescent Mental Health Services (CAMHS-Integrated Service for Looked After Children), including the Named Nurse for Looked After Children and 16+ Transitions Nurse Arden Area Team, (NHS England) commission Primary Care Contracts on behalf of the 3 CCGs. These organisations are performance managed via the Quality Committees led by the Chief Operating officer and Clinical Quality Review (CQR) Committees of the CCGs led by the Executive Nurses. This is achieved through: monitoring of Service Level Agreements and Contract Schedules through Quality Committees; WSCB S11 self-assessment tool and WSAB self-assessment tool; monitoring actions arising from Serious Case Reviews and Domestic Homicide Reviews; the Child Death Overview Process; Serious Untoward Incident reporting and monitoring; and announced and unannounced and site visits. Page 15 of 19 Last updated: 29/10/13

16 11. Safeguarding Commissioning Strategy The draft Safeguarding Children and Adults Commissioning Strategy includes a strategic objective regarding commissioning services that demonstrate appropriate safeguarding arrangements and embed learning and continuous quality improvement. Assurance will be sought via visits to Provider services; quality schedules; service specifications; evidence of learning from serious incidents; audits to evidence that staff training is at the appropriate level for their role. Learning from SCRs and MACFA identifies areas of good practice and highlights areas for improvement; including promoting information sharing to minimise risk of harm death. Within CCG Quality & Patient Safety teams, various Service Improvement work streams are currently underway to support the safeguarding strategy. These include targeted work with care homes to include hydration; work to reduce avoidable pressure ulcers; work on falls linking with county-wide falls strategy; partnership working with Local Authority; a health & social care project to improve communication; and embedding a culture of quality. 12. Safeguarding in Care Homes (with Nursing) Concerns in Care Homes, highlighted via safeguarding alerts, are an important aspect of soft intelligence to inform CCGs of the quality assurance of NHS funded care in the Independent sector. Themes of safeguarding alerts The following types of safeguarding concern have been raised with regard to care received in Care Homes: Grade 3 and 4 pressure ulcers Falls resulting in serious injury, particularly fractures Resident assault by another resident Poor or inappropriate manual handling techniques Failure to respond to deteriorating health needs Neglect- poor support of hydration and nutritional need Failure to recognise and document lack of mental capacity and document appropriate best interest responses. Intervention from CCGs regularly includes: An overseeing and supporting role in the completion of root cause analysis investigation, an overseeing and supporting role in the implementation of recommended actions developed from the identification of lessons to be learned. Furthermore, the informing of announced and unannounced quality assurance visits to Care Homes based on themes identified in safeguarding alerts and investigation. Page 16 of 19 Last updated: 29/10/13

17 Key areas of service improvement developed in response to safeguarding concerns and CCG intervention. The following areas of service and practice improvement have been developed in response to CCG intervention following a safeguarding concern: documentation to provide consistent guidance to care staff in the prevention of pressure area lesions care plan templates that prompt the seeking of medical opinion when residents remain symptomatic following the completion of a course of anti-biotics regular equipment calibration to ensure accurate weight surveillance as part of good nutritional support procedures for checking and responding to deteriorating health and physiological vital sign measurement changes procedures for supporting agency staff to sufficiently understand the needs of residents in their care improved application of the Mental Capacity Act. 13. Supporting Safeguarding Standards in Primary Care Accountabilities for CCGs are described in the Safeguarding Vulnerable People in the Reformed NHS as having a duty to support improvements in the quality of primary medical care Achieving and maintaining professional competencies in safeguarding is the responsibility of all clinicians as part of their General Medical Council/Nursing and Midwifery Council professional registration requirements. The GMC has provided guidance to all GPs outlining their individual responsibilities regarding this. As GP contract holders, monitoring of compliance with these professional standards is a function of the newly established Arden Area Team (AT), NHS England through the GP revalidation process. Worcestershire CCGs have continued to provide support for local GPs through the appointment of a Named GP for Safeguarding Children. Furthermore, GP practices should have a lead for safeguarding, who should work closely with Named GPs, Safeguarding Adults Lead and Designated professionals. There will be a named GP for Safeguarding (Adults) in post in the near future. This post-holder will provide support to the GP practices The CCGs are working closely with NHS England, through the work of the Designated Nurse, Named GP and Safeguarding Adults Lead to provide a rolling programme of training and workshops for GPs in respect of safeguarding children and adults. The workshops have been arranged to cascade learning from Serious Case reviews (SCR) and other learning processes. A clear message to general practitioners in particular has been that when requested, the sharing of information on patients is the expected norm unless there are significant reasons not to do so. This has been disseminated by means of training, quarterly newsletters and updates via the webpages of the CCGs. CCGs have also supported primary care clinicians in the following ways: Page 17 of 19 Last updated: 29/10/13

18 Advice and support to frontline staff in respect of safeguarding concerns development of a safeguarding webpage which is a source of information and key local contacts Supervision to Safeguarding Leads via the Named GP. The Safeguarding Health Forum shares best practice, learning from significant events as well as providing the opportunity to network with other safeguarding leads across Worcestershire. GP Safeguarding Leads have been invited to attend future forums as a means of providing additional support. 14. Prevent Prevent focuses on working with individuals and communities who may be vulnerable to the threat of violent extremism and terrorism. The overall principle of Prevent is to safeguard vulnerable individuals. The Executive Nurses for the CCGs have overall responsibility for ensuring the Prevent agenda becomes embedded within the health economy. The Safeguarding Adults Lead acts as the Prevent Lead on behalf of the CCGs and works in partnership with lead organisations for Prevent across Worcestershire and regionally. Awareness sessions for CCG staff have been arranged to highlight the Prevent Agenda. Currently, the Prevent Lead is awaiting clarification from NHS England regarding how the Prevent agenda will be raised with GP and Dental Practices. The CCGs have to complete an annual self-assessment in respect of their response to Prevent. An action plan is in place which is monitored through the Quality Committees in the CCGs. 15. CCGs role in Adult Protection Processes Worcester County Council Safeguarding Service has had two interim Safeguarding Services managers since October 2012; the new (permanent) Safeguarding Services manager commenced in post in August The MOPAR (more than one person at risk) process was introduced to manage cases where multiple concerns affected a number of residents in a Care Home. The process was introduced and piloted earlier this year by one of the interim managers. A Professionals Risk Assessment multiagency meeting (PRAM) was held on a monthly basis to enable health & social care professionals to discuss risks to residents and enabled them to have a strategy to discuss with the Provider Organisations; representation by CCGs at PRAM was at Executive level. The process was not felt to be robust and WCC Safeguarding Team are now considering using the Large Scale Investigation process (LSI) and are in discussion with members of the Policies and Procedures sub-group of the WSAB. The purpose of a Large Scale investigation is to have in place multi-agency arrangements to respond to a complex/large-scale incident, with the local authority, the police, the PCT (now CCG), the CQC and any commissioners of implicated services being key partners (Safeguarding adults: multi-agency policy and procedures for the West Midlands, 2012 p 101). Page 18 of 19 Last updated: 29/10/13