Safeguarding and Protection of People at Risk of Harm ANNUAL REPORT

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1 Safeguarding and Protection of People at Risk of Harm ANNUAL REPORT Purpose This Report serves to inform the Health Board of the Safeguarding People at Risk of Harm activity undertaken in relation to Safeguarding Children, Young People, Looked After Children, Safeguarding Adults, Domestic Abuse, Sexual Violence and the overarching Safeguarding activities under the remit of harm for the period from April 1 st 2014 to 31 st March Introduction Betsi Cadwaladr University Health Board must safeguard vulnerable persons in accordance with the legislative framework of the Children Act 1989, Children Act 2004, Social Services Well-being (Wales) Act 2014, Criminal Justice & Courts Act (2015) and key principles and core values arising from In Safe Hands, All Wales Interim Policy & Procedure for the Protection of Vulnerable Adults from Abuse (2013) and Violence against Women, Domestic Abuse, Sexual Violence (Wales) Act (2015) within the guiding principles of the European Convention on Human Rights and the Human Rights Act 1998 Safeguarding Adults, Domestic Abuse, Honour Based Violence and Modern Slavery/Human Trafficking, Sexual Exploitation and Female Genital Mutilation are key strategic target areas for the National and Regional Safeguarding agenda with the addition of the Counter Terrorism Prevent strategic activities. During this period the Safeguarding agenda has been undergoing a period of change and consultation for a number of significant activities, namely forthcoming legislation. Including the implementation of Child Practice Reviews Adult Practice Reviews and Domestic Abuse Homicide Reviews. The continued growth in activity and complexity is significant within all spheres of the agenda. The political agenda is acutely positioned at a very high level with regulatory and media interest indicating no signs of abating in its interest to expose failing NHS care environments. The implementation of the Social Services and Well-being (Wales) Act (2014) places Adult Protection firmly on a statutory footing, making it a duty to safeguard, report, protect, co-operate and share information. The legislation continues to strengthen Multi-agency and collaborative partnership engagement. This report has been compiled with reference and information obtained from a number of reports identified within the Safeguarding Reporting Framework which assumes a Safeguarding Annual Report FINAL V.5 Page 1

2 human rights based approach and promotes fairness, respect, equality, dignity and autonomy (FREDA) principles. Title of Sub-Group: Safeguarding and Protection of People at Risk of Harm Sub-Group Dates covered by this Report: Assurance/s that the Safeguarding & Protection of People at Risk Sub-Group is designed to provide: The Safeguarding Reporting Framework and the Safeguarding Assurance Framework support and drive the Safeguarding agenda. This provides a platform to enable safeguarding activities to be embedded within operational and clinical teams within Clinical Programme Groups and Corporate Teams. 3.1 Assurance The Terms of Reference were formally agreed by the former Quality & Safety Committee to provide assurance to the Board, provide evidence of compliance and progress the identification of barriers and risks with evidence of actions to support development and progress. 3.2 Governance & Accountability Legislation, National Inquiries and Reviews provide evidence to drive the Safeguarding Agenda and hold statutory organisations to account for example; Rochdale Child Abuse Inquiry 2013/2014 Trusted to Care (2014) Orchid View (2014) Learning the Lessons: Operation Pallial (2015) Driving Change for Older People, Impact & Research (Older Peoples Commissioner) Donna Ockenden: BCUHB Investigation Report (2014) Increase in activities, challenges and findings from National, Regional and Local inquiries, an Options Appraisal Structure and Skill Mix Implementation Report was presented to the Board on The paper supported and reflected growth recognising that the Safeguarding Adult Clinical Team had an identified workforce of 2.6wte which, due to absence was reduced to 1.6wte during the period identified by this report. Mitigation of risk Safeguarding Annual Report FINAL V.5 Page 2

3 Implement revised organisational Safeguarding reporting arrangements to ensure the Safeguarding Reporting Framework has a Scrutiny and Performance function with alignment with the organisational reporting and Governance framework. Develop and strengthen quality assurance, governance and clinical reporting arrangements. The Safeguarding Assurance Framework will be revised to ensure the statutory and legislative framework of Safeguarding is embedded and reported within Secondary Care, Area Teams and Divisional performance indicators. Actions outstanding since All CPG s and Corporate Departments to record and review training data/statistics and complete Annual Training Needs Analysis Dec 2015 Not all Clinical Programme Groups and Corporate Teams have been able to report their Training Needs Analysis or Training Compliance. This has had an impact upon the Training Programme for 2014/2015, as it inhibits strategic planning and the identification of key risk areas within the organisation. Formally consider the appointment of a Named Doctor for the Protection of Vulnerable Adults March 2014 Appoint to the position of a Named Doctor for Safeguarding Adults Dec 2015 The Safeguarding Team and the Office of the Medical Director has formally considered the benefit of the appointment of a Named Doctor for Safeguarding Adults/Adult at Risk. This post is not included within any current guidance however the benefits to support the corporate strategic vision and engage the clinical workforce will be key for this post. Mitigation of risk Discussions remain ongoing with the Office of the Medical Director Actions from Out of twenty six (26) actions for the period identified all were completed except for four (4) that remain amber and within a revised time frame and a further four (4) that have been superseded by the revision of the organisational structures and lines of accountability. Actions from Identified activities as recorded in the Annual Report Status Safeguarding Annual Report FINAL V.5 Page 3

4 Audit the implementation of the Deprivation of Liberty Safeguards Action Plan for the implementation of the Cheshire West Judgement. Ensure the implementation of the identified actions and recommendations from the Safeguarding People at Risk event and Safeguarding Children Internal Audit. Review and enhance engagement with Primary and Community Care Service provision and Independent Contractors considering the role of Practice Development Nurses in; Nursing Home Settings/commissioning provision GP and Independent Contractors Jan 2016 Dec 2015 Superseded This is the responsibility of the Area Nurse Director, however, Safeguarding will still be engaged for areas within our portfolio. Receive from each identified Corporate Department /CPG an annual Safeguarding Report to evidence: Governance Arrangements; Training needs analysis and training data; Incidents and recommendations from Adult/Child/Homicide Review; Safeguarding Datix Incidents; Evidence to comply with National, Regional and Local audit activities; Annual Action Plan with evidenced compliance Ratify, and implement the revised and updated BCUHB Adult Protection Policy and Procedures ( due to regulatory amendments). For Tissue Viability Nursing Team to provide assurance and evidence that Welsh Government incidents (Grade 3 and 4) are recorded and embedded within practice in line with procedures. Superseded Nov 2015 Superseded Ratify, evaluate the implementation of the MAPPA Operational Protocol. Dec 2015 To work in collaboration with workforce and Organisational Development and Clinical Programme groups to improve training compliance and recording. Superseded 3.3 Four (4) Key Organisational Priorities: Safeguarding People at Risk of Harm Team Structure and Skill Mix Safeguarding Annual Report FINAL V.5 Page 4

5 The fundamental and overarching objective of this period and the period of is to implement the identified and agreed posts within a framework which ensure review and evidence of improvement or ongoing risk. Since the reconfiguration of the NHS Services in North Wales the Safeguarding Adult Team has had an allocated clinical staffing provision of 2.6 wte. On the 10 th February 2015, the Board endorsed the findings and recommendations presented within the Safeguarding People at Risk of Harm Team Structure and Skill Mix Implementation Report and this paper provided an update position of the current activity. The increase in activity driven by legislation, statutory regulation, statutory multiagency and single agency activities is a direct consequence of the awareness and evidence from National, Regional Reviews, and incidents of poor care, lack of knowledge, poor organisational governance and limited safeguarding specialist workforce resulting in an ill equipped workforce. Although there are many examples that Betsi Cadwaladr University Health Board are leading on aspects of this agenda, with political and national recognition, the current safeguarding corporate provision cannot fully engage or sustain the required pace to undertake all of the legislative, statutory and best practice duties and responsibilities, or execute its vision for a greater emphasis on the prevention and promotion of dignified and compassionate care. Mitigation of risk The full 3 year recruitment plan will be reviewed and evaluated in light of the additional workforce for the identified period. It is recognised that the review establish and evidence benefits and or weaknesses in the provision after additional resources have been allocated at each stage. The vision is to move into a proactive, seven day service with a Safeguarding on-call facility Named Doctor Safeguarding Adult: Since the reorganisation of BCUHB and evidenced in the Annual Report 2011 a key action was to both consider and identify a Named Doctor Adult Safeguading to support the Associate Director Safeguarding and to ensure the full engagement of clinical colleagues with the appropriate provision of protected time. Mitigation of risk Implementation of a Named Doctor Safeguarding Adults/Adults at Risk Safeguarding Training: The Safeguarding Reporting Framework identifies a Regional Training Task & Finish Group which is ideally positioned to drive and facilitate training across the organisation and enables the flow of activities between the Regional Safeguarding Boards Training Forums. Mitigation of risk Safeguarding Annual Report FINAL V.5 Page 5

6 To enable the workforce to be appropriately trained and to have an effective training schedule supported by the Safeguarding Training Strategy, each Area Team, Secondary Care Team, Division and Corporate function must identify their training needs analysis on an annual basis Deprivation of Liberty Standards/Mental Health Act/Mental Capacity Act: During the period of 2015, significant change has occurred regarding the legislative framework of the Deprivation of Liberty Safeguards. The portfolio of this service provision will be formally transferred to the Executive Director of Nursing, Midwifery, Therapies and Health Sciences with the Office of the Medical Director maintaining professional accountability for medical clinicians. From December 2015, the Legacy Statement and funding stream will be finalised ensuring the clear identification of progress, risk and financial position. A full review of the service will be undertaken to ensure full integration within the function of Safeguarding Adults. 3.4 Audit and Assurance NHS Wales Shared Services Partnership Audit and Assurance Service The assignment originates from the 2013/2014 internal audit plan and the subsequent report was submitted to the Chief Executive and Audit Committee on 11th December 2014 Although this audit concentrated upon Safeguarding Children, as the Safeguarding organisational framework, and the governance framework incorporates both Safeguarding Children and Safeguarding Adults the audit findings reflect both areas. Scope The audit review of Safeguarding Children Act 2004 seeks to provide the Health Board with assurance that they are compliant with the requirements of the Act and Child Protection Procedures and have up to date Corporate Policies that reflect compliance. Opinion and Key Findings The level of assurance given as to the effectiveness of the system of internal controls in place to manage the risks associated with Safeguarding Children is Limited Assurance. A review of the systems and controls in place within the corporate service was conducted. Safeguarding Annual Report FINAL V.5 Page 6

7 Good practice was identified in the following areas: A Corporate Safeguarding structure is in place with all but one position filled. The structure is supported by a Corporate Reporting Framework; Representation has been secured from within the Health Board on the Safeguarding structure for Nursing, Safeguarding Children, Adults and Domestic Abuse; Effective multi-agency engagement at local, regional and national level; Comprehensive safeguarding information is available on the Health Board intranet with e-learning modules available for training purposes; A safeguarding Annual Report was submitted to the Board for the period 12/13. It was noted in this Report that Corporate Safeguarding identified the risk stating, Clinical Programme Groups are not fully engaged with the Safeguarding Quality Assurance Framework and Governance arrangements to ensure the implementation of the Strategic directives and National, Regional and Regulator priorities, including statistical data relating to training compliance; Evidence to support Corporate Safeguarding is leading the way nationally with a framework for a combined structure for Safeguarding for Children and Safeguarding Adults; Evidence to support Corporate Safeguarding is leading the way nationally with regards to Domestic Abuse, Modern Slavery/Human Trafficking, the Prevent Strategy and Sexual Exploitation. In addition BAWSO (Black Association of Women) and WG relating to Human Trafficking/Modern Slavery have adopted a referral document developed by the Corporate Safeguarding Team; Evidence to support that Corporate Safeguarding were the only Health Board to initially develop and implement an e-learning training package. On receipt of the Draft Report findings an urgent Safeguarding event/workshop was convened with attendance from senior staff within CPG s and Corporate functions. The event was well attended and fully supported by the Chief Executive, Chair, Executive Directors and Independent Members. The event focussed on discharging statutory duties, governance, roles, and responsibilities with a key purpose to address concerns raised. Assurance Summary The summary of assurance given against the individual objectives is described in the table below: ASSURANCE SUMMARY 1 Audit Scope Review of corporate policies/procedures 2 Safeguarding children activities and responsibilities are embedded within Safeguarding Annual Report FINAL V.5 Page 7

8 ASSURANCE SUMMARY Audit Scope the Corporate framework. 3 Corporate structure and reporting lines 4 Corporate Multi-agency engagement 5 CPG management, operational compliance and governance arrangements 6 CPG staff training Corporate Governance Review of Corporate Policies The Health Board has a number of Safeguarding policies and procedures in place for the control of Safeguarding Children. Two Health Board procedures were due for review at the time of the audit. Evidence was provided to identify that one procedure was awaiting review based on the very first National guidance. This has progressed following completion of the audit. The second procedure was under review within a multi-agency forum and will be developed as a Multi-Agency Regional Procedure and is no longer the remit or responsibility of the Health board to manage the review of this document. Corporate Operational compliance with legislation Evidence was provided to support operational compliance with legislation (Children Act 2004 and Children Act 1989) and All Wales Child Protection Procedures within the Corporate Team. Corporate Structure for Safeguarding Evidence was provided to confirm that a corporate structure for Safeguarding Children is in place. Evidence was provided to support the escalation of the Safeguarding agenda to the Board and working arrangements of Operational Forums and Task Groups within the structure. Multi-agency Engagement The Corporate Team provided high level and substantial evidence to support statutory multi-agency engagement with safeguarding groups and forums. CPG Management and Governance Arrangements There were examples where CPG arrangements for Safeguarding Children did not provide assurance that robust systems were in place - these are highlighted in the table of findings to the rear of the report. A number of CPG s are in the process of developing a Governance Structure for Safeguarding Children and establishing reporting systems in order to engage with Corporate Safeguarding. Safeguarding Annual Report FINAL V.5 Page 8

9 It is evident from the audit findings that the MHLD CPG are able to engage in the Safeguarding agenda due to the identification and implementation of a Safeguarding Senior Lead post within the CPG structure. CPG staff Training Information provided by some CPG s indicated that they were not achieving training targets. Compilation of training data was not provided consistently across the CPG s and numerous systems are being used to collate data. Some CPG s were unable to provide all the data required to support training at the required levels. Audit Recommendations A range of recommendations have been made to address the issues identified and these have been accepted. A numerical data. Priority H M L Total Number of recommendations Mitigation of Risk The Safeguarding Audit action plan will be reviewed in light of the revised organisational structure with a requirement for a current position from the each Director to support a revised implementation plan. 3.5 Service Redesign relating to Legislation and National Guidance Social Services & Well-Being (Wales) Act 2014 The Social Services and Well-Being Act (Wales) 2014 will have significant influence on Health Board to ensure full compliance with new statutory duties from April 2016, these include, but are not exhaustive: Co-ordination of Adult Protection Support Orders, these co-ordinators will require additional specialist training and flexibility to undertake these duties at short notice, these powers are unlikely to be exercised frequently, but identified Health staff may be required to have the relevant competencies; (b) The Act will also impose a duty on staff to report alleged abuse; failure to do so may result in a breach of statutory duties; (c) The new legal definition of adult at risk is proving difficult to regulate and runs The risk of widening the door to more groups being categorised as Adult Protection. We await Welsh Government guidance documentation to clarify and support this definition. Mitigation of Risk: Safeguarding Annual Report FINAL V.5 Page 9

10 Full implementation and engagement at National, Regional and Local level by the Corporate Safeguarding Team and the Organisation. Multi-Agency Engagement at Safeguarding Adult and Safeguarding Children Boards (sec 132,133,134). Social Services & Well-Being (Wales) Act 2014, Part 7, also requires under legislation the development and implementation of Safeguarding Adults Boards and Safeguarding Children Boards. Regional & Sub Regional Structures The North Wales Regional Safeguarding Children Board used the findings of the ADSSW/WLGA evaluation study and the Independent Safeguarding Panel s Report to inform discussion and decision making at its development day on the 4 th April North Wales will have a new Regional Safeguarding Board Structure, with statutory responsibility placed at the Regional Adult Safeguarding Board, and Regional Safeguarding Children Boards both engaging with the National Safeguarding Board. There will be a number of other groups, including six local Multi-Agency Delivery Board of which, an Adult Delivery Board and a Children s Delivery Board supports two Local Authority Areas, with a further 5 to 6 Regional Sub-Groups. Representation will be at the level directed in statute and; Local needs, culture and language are supported via the Local Safeguarding Delivery Groups; Statutory Directors of Social Services can continue to report to Elected Members in Local Authority Areas; Local and Regional structures will be supported by representatives at different levels, reducing the pressures on very senior representatives; The regional Board will be able to make decisions and promote swifter progress G&A 26, , , , , Conwy & Denbighshire 17, , , , , Regional Funding to be agreed Flintshire Wrexham 4, , , , , , , TOTAL 53, , , , , Regional Structure April 2014 Safeguarding Annual Report FINAL V.5 Page 10

11 Regional & Sub Regional Safeguarding Adult Protection Boards The reconfiguration of the Regional Safeguarding Adult Board is a mirror image of the Safeguarding Children Boards arrangements and structure. Appropriate membership and expertise is fundamental to ensure our organisation has a voice, and ultimately represents and acts on behalf of the Board and the organisation in line with legislation and guidance. Ongoing discussions are taking place to review the financial position and consider the funding implications for the Regional Adult Safeguarding Boards. 3.6 Effectiveness and Quality Assurance Task and Finish Group The Task and Finish Group is designed to assure the Safeguarding People from Harm Scrutiny and Performance Sub Group Ongoing activity required to complete the Quality Outcome Framework is carried out in a timely manner and timescales for submission are adhered too; Ongoing activity required to complete HCS 11 and other relevant audits/data collections are carried out in a timely manner and timescales for submission are adhered too; Monitoring of any relevant Safeguarding Children/Adult Audits is carried out and action plans monitored. 3.7 Quality Outcome Framework Safeguarding Annual Report FINAL V.5 Page 11

12 In his Report, Safeguarding and Protecting Children in NHS Wales (Cardiff University, 2010), Professor Sir Mansel Aylward identified the need for robust monitoring and evaluation in order to improve and develop services. This led to the recommendation: Evaluation of the efficiency and efficacy of child protection and safeguarding arrangements and interventions must rest on outcome-based monitoring. This is an area that requires further attention. Consideration should be given to the inauguration of a National outcomes development and quality assurance group to establish standards, to set tangible objectives and to drive improvement on an all-wales basis (Rec 6.16). Measuring the effectiveness of Health Services in the contribution to safeguarding children and young people is difficult and complex. The Outcome Based Accountability TM (OBA TM ) model, informed by the work of Mark Friedman 2, has assisted the National Safeguarding Children s Network to develop a tool. The Tool incorporates Section 28 Audit (Children Act 2004). The purpose of the framework is to deliver good quality information on outcomes for children for use by Health Boards and Trusts. Where relevant, data will be collated, analysed and presented in a report to the Chief Nursing Officer and to Health Boards and NHS Trusts. The findings and comparison data must be considered with caution as it is recognised that Health Boards measurements are inconsistent and cannot be truly believed as a benchmark or increased/decreased compliance. The document is supplementary to this Report. 3.8 Health Care Standards There has been little activity regarding HCS 11 as the Welsh Government proposed to review the Health Care Standards in This has currently been delayed until BCUHB have agreed to use the existing Health Care Standards for Corporate Safeguarding has continued to collate evidence which is transferrable for monitoring purposes. 3.9 Multi Agency Safeguarding Hub (MASH) The Wrexham MASH was set up as a pilot project to deal initially with CID 16s (Police referrals). It was supported by Welsh Government funding for 2 years. The Multi Agency Safeguarding Hub (MASH) is a partnership approach with statutory agencies such as Police, Heath, Social Services, Education and Probation being involved. The Team achieved an award for partnership engagement from Winston Roddick Police and Crime Commissioner. Welsh Government funding for the 3 rd year was withdrawn, BCUHB took this opportunity to temporarily withdrawing the Health Post whilst they considered future role and responsibilities for the Health team member. During this time, BCUHB remained committed to the MASH by attending the Project Steering Board and the MASH Operational Group. In December 2014, Children s Services moved their services back to a Local Authority building and since this time the MASH has been operating on two sites. Safeguarding Annual Report FINAL V.5 Page 12

13 Mitigation of risk Full engagement is required to maintain this Multi-Agency service provision. A review of service provision will be required to support any possible service redesign Policies and Procedures The purpose of the Safeguarding Policies and Procedures Task Group is to review and support implementation of Policies, Procedures and Guidance in relation to Safeguarding Children and Adults across Betsi Cadwaladr University Health Board (BCUHB) to ensure equity and consistency in a Human Rights Based Approach and improve the protection of children and adults accessing our services The Work-plan indicates that there are 19 protocols/procedures which are being developed, reviewed and /or out for consultation. However, there are 6 policies/procedures which are noted at amber status which are currently under the process of review and ratification During the last 12 month period, 5 BCUHB Policies/Procedures have been ratified showing a slight increase from 4 over the last year Safeguarding Adults/Adult Protection Key Activities and Assurance In January 2015 the Safeguarding People at Risk Training Strategy, SCH08 was reviewed and is awaiting ratification due to the review of Betsi Cadwaladr University Health Boards Mandatory Training; Consultation with the NHS leads took place in this reporting period for the level 1 E-learning package and this has now been ratified and agreed by the Chair of the group. This package will be available for commencement proposed for June Consultation continues with the Level 2; The BCUHB Corporate Safeguarding Team has continued to be engaged with Welsh Government consultation events across the region in the development of the statutory guidance for part 7 of the Social Services and Well-Being (Wales) Act (2014); The BCUHB POVA procedures were revised due to significant changes in regulation and guidance changes - including; new Pressure Ulcer All Wales Guidance, the Dementia Care Action Plan, the 2013 HIW Inspection Action Plan and the All Wales Interim Adult Protection Policy revision (2013). The BCUHB Procedures where ratified in July 2014; Safeguarding Annual Report FINAL V.5 Page 13

14 The BCUHB Corporate Safeguarding Team has engaged in a consultation to develop a pathway to improve communication between Continuing Health Care and Safeguarding to escalate concerns within the Protection of Vulnerable Adults arena; The BCUHB Corporate Safeguarding Team supported the BCUHB Concerns team following the Andrews Report and Trusted to Care (2014) recommendations to improve the escalation of safeguarding issues when identified within raised concerns. This Pathway will feature in the revised Concerns Procedures; The BCUHB Safeguarding Team have (with the support of the Quality Assurance Lead for Continuing Health Care) supported the development of an Embargo Policy for Escalating Concerns with Care and Closure of Care Homes (when concerns are raised in relation to quality of care/safeguarding within care homes); The Corporate Safeguarding Team has supported the Mental Health Division to Review the POVA Level 3 packages to ensure it meets its standard as an enhanced level package; Additional training packages have been developed which include a work book and DVD; POVA Level 2 training package was comprehensively reviewed and changed in line with new CSSIW data and changes in legislation, to include an endorsed section on MCA and DOLS (in the reporting period) National Picture : Welsh Government Statistics for Wales: The following information is taken from the second annual data collection for the period 1 April March 2014 collated by the Welsh Government Statistics Office using revised guidance. A total of 10,135 referrals were reported. Of these, 5,295 (52 referrals received met the threshold of significant harm and 1,510 (15 referrals received were deemed inappropriate. 3,330 referrals, reported by 21 Local Authorities, did not meet the threshold of significant harm. Number of completed referrals by place of alleged abuse, 31 March 2014: The alleged abuse was more likely to occur in the vulnerable adult s own home in the community, accounting for 34% of all locations cited, or Care Homes (Residentia l and Nursing Homes) accounting for 36%. Betsi Cadwaladr University Health Board Audit Data: In line with the National Trend, the overall pattern of referrals has increased over the last four years. Safeguarding Annual Report FINAL V.5 Page 14

15 Status over 3 years National Data (CSSIW pre- 2013) and statistical first release data (Welsh Government) BCUHB Figures Due to the poor reporting arrangements from Clinical Programme Groups and Departments, the Corporate Safeguarding Team included within their local policy that all POVA Referrals to Local Authorities or Police are copied and forwarded to the Safeguarding Hub in Ysbyty Glan Clwyd. This is a clear attempt to identify trends, areas of concern and educate and support staff on the quality of reporting. This activity is not included within the National All Wales Interim Safeguarding Adult Policy & Procedures and although this has been in place for three years, only recently has other Welsh Health Boards implemented this idea. Unfortunately, due to the findings from ongoing activities, it must be reiterated that we cannot confirm that the collation of data is 100% accurate. We continue to detect situations where the Corporate Team has not received any information. A key area of targeted concern is the identification of POVA referrals within Community setting, Care/Nursing Homes and by Independent Contractors. We can therefore assume the number of actual POVA referrals is higher. Place where alleged abuse occurred: n=618 (more than one answer per respondent is possible) Not stated Other Education establishment Home of alleged perpetrator Hospital Independent Sheltered warden accommodation Care home respite place Hospice Day care Relatives home Public place Hospital NHS Supported tenancy Care home nursing place Care home residential place Own home in community 23 (3.7 7 (1.1 1 (0.2 3 (0.5 6 (1 6 (1 1 ( (0.3 1 (0.2 9 (1.5 3 ( ( ( ( ( There is a correlation between age, gender and the classification is consistent with the National profile. The pattern of referrals breakdown per Authority is unchanged, Conwy consistently having the highest activity. Safeguarding Annual Report FINAL V.5 Page 15

16 National data for NHS establishments as the place of alleged abuse is approx 6%; BCUHB recorded 20%, this requires further exploration. It must be recognised that during this period, an Independent Investigation was commissioned by the Health Board which has resulted in professional allegations. Breakdown of Referral activity BCUHB per Local Authority area Local Authority Conwy Denbighshire Flintshire Wrexham Mon & Gwynedd Total Breakdown of the pattern of referral per BCUHB localities is also unchanged and is c consistent with the National picture. To support the Corporate Teams activities to enable the ability of challenge and interrogate the data and organisational activities a reporting outcome arrangement was agreed with the Six Local Authorities 3 years previously. We have received significantly less POVA outcome activity forms per month from each of the Local Authority during this reporting period. We can confirm that Local Authorities have explained the rationale for this, however, this was addressed by the Associate Director Safeguarding at the Regional Safeguarding Adult Board and Local Authority Directors have prioritised this as an activity to work with Betsi Cadwaladr University Health Board to support this activity. Due to this deficit, we cannot interrogate the outcomes of POVAs to compare the National profile. The highest source of referral over the last two years has been within Secondary Care. This alone may not be of concern as it may indicate the positive identification of a concern, and may reflect the increase of referrals due to significant investigations, however, it is of concern for BCUHB. Mitigation of Risk The findings from the Betsi Cadwaladr University Health Board audit require further exploration and research which will include the identification and escalation of detailed analysis relating to referrals, including trends and outcomes. Standard Operating Procedures have been developed to support this activity. The Local Authority reporting arrangements will be reviewed and re-established as agreed by the Regional Safeguarding Adults board. The Local Authority Monthly Reporting Arrangements are to be re-established and audited as agreed. An Internal Governance Framework to improve the quality of POVA investigations by BCUHB, and develop a training package to ensure BCUHB have clear guidance and a framework for referrals, investigations and report writing. Monitor the BCUHB Operational engagement with the recently developed POVA Strategy and Case Conference Summary Report process. Safeguarding Annual Report FINAL V.5 Page 16

17 Standard Operating Procedures have been developed for the identification of risk and professional allegations. They will be ratified and implemented and compliance audited Pressure Ulcers Reported under Adult Protection The All Wales Pressure Ulcer Reporting and Investigation Guidance (2014) have been fully endorsed by the BCUHB. A component of this guidance involves reporting safeguarding concerns. 21 POVA Referrals were generated and were directly linked to Pressure ulcers during this period. The All Wales Guidance on Pressure Ulcers was not fully introduced into operational practice until October Therefore the data needs to be considered in this respect. Mitigation of Risk Area Teams, Secondary Care Teams and Divisions to fully engage in the Regional activities. On appointment Safeguarding Teams to strengthen reporting and working arrangements with the Tissue Viability Teams. Classification of alleged abuse: (34.3 n=618 (m ore t han one answer per respondent is possible) 159 ( ( ( (33 97 ( (3.4 Physical Domestic Violence Neglect Pr essur e Sor e/s 38 ( Mental Health Learning Disability Division Safeguarding Children & Vulnerable Adults Group Remit This Group within the MH & LD Division and meets on a quarterly basis, however, following a Clinical Governance Review from April 2015 this group will meet on a bi- Safeguarding Annual Report FINAL V.5 Page 17

18 monthly basis. The group provides the MH & LD Division with accountability and governance around its safeguarding arrangements both for Vulnerable Adults and Children. The Group is a forum used for wider dissemination of safeguarding information and activity being delivered at a national, regional and local level. It is also the responsibility of the group to ensure the Reporting Framework is implemented and monitored. Following the Clinical Governance review membership and Terms of Reference of this group have been revised. The Group will be chaired by the Director for Mental Health & Learning Disabilities from April Terms of reference for the group are approved by the Divisional Quality and Safety Committee. Due to the increase in meetings the limited staffing levels and increased activity of the Corporate Safeguarding Team it was agreed that the minutes would always be shared and attendance would be on a needs basis within a period of review based upon the recruitment of workforce to the Safeguarding Team. Referral data The table below shows the number of referrals made by staff working within the MH & LD Division. These referrals are received from all sectors within the Division. Adult, Older people, Substance Misuse, Learning Disability and Continuing Health Care. Number of POVA Referrals in April 2014 March 2015 The below table shows the number of referrals made by staff working in the MHLD Division broken down into Local Authority areas Flintshire Conwy Denbighshire Gwynedd & Mon Wrexham Total Classification of Alleged Abuse Area Physical Financial Neglect Emotional Sexual Denbighshire Conwy Wrexham Flint Gwynedd Safeguarding Annual Report FINAL V.5 Page 18

19 Ynys Mon Total POVA Referrals continue to increase, this is in line with the National trend, however greater analysis will be achieved during Investigations/High Profile Incidents: 1 Large scale investigation and police enquiry into Tawel-fan Ward, Mental Health; There have been several hotspots of POVA activity in this reporting period; this involves a number of different locations across the Mental Health Division, which accounts for the highest number of POVA activity; Wrexham DGH had a number of high profile cases including Coroners Inquests and Police Investigations; Within the Continuing Health Care (CHC) and Mental Health Nursing Homes at the time of this report there were 29 homes with several POVA cases across North Wales. Mitigation of Risk: There are notable variances in practice within various divisions for alerting the Safeguarding office of any allegations of professional abuse. A POVA tracker was sent to all divisions to request an update on all allegations of abuse. This information will be triangulated with professional regulation, departments and divisions to identify themes to provide additional independent challenge to obtain assurance that safeguards are in place. Corporate Safeguarding have introduced a traffic light system to identify from the number of copies of POVA referrals they receive into the office in an attempt to identify areas, wards, units with raised activity. A Standard Operating Procedure which identifies levels of escalation and intervention from the Corporate Safeguarding Team has been developed and is to be fully implemented. The Audit template has been amended to ensure allegations of professional abuse can be sourced to Betsi Cadwaladr University Health Board registered professionals/commissioned services and non-regulated staff (i.e. Health Care Support Workers). This information will be readily available for the 2015/16 Annual Report and will withhold further scrutiny. Develop a Manager s guidance pack in collaboration with Workforce and Organisational Development, unions and Managers to deal with Safeguarding concerns and allegations relating to Professional Abuse. Consideration will be given to support the development of a Professional Allegation Panel to ensure consistency and reduce delay. Safeguarding Annual Report FINAL V.5 Page 19

20 The Corporate Safeguarding Team will have renewed engagement within the revised BCUHB structures to implement a joint Corporate Governance and reporting framework with the Governance and Communication Corporate Team to strengthen links between POVA/Safeguarding, Concerns, Clinical governance and quality improvement within each Area, Secondary Care and Division Nursing and Residential and Independent Sector (As provided from the Nursing Home reports from Continuing Health Care and Practice Development: March 2015) There are 11 Nursing Homes under Escalating Concerns; 4 of these Homes currently have embargoes in place; Bed capacity of 11 Homes under escalating concerns, a reduction in capacity of 416 beds; Bed capacity of 4 homes with embargos reduction of capacity of 182 beds. Mitigation of Risk The additional resource to the Safeguarding Adult Team will support the enhanced scrutiny required upon the commissioning and provision of care and services within Nursing and Care Homes. Development and Implementation of an escalation of concerns pathway from Nursing Home/Commissioned Care setting which will incorporate the activities of Commissioners, providers, CHC reviewers, incorporating fundamentals of care Deprivation of Liberty Safeguards (DoLS)Mental Health Act / Mental Capacity Act Care and Social Services Inspectorate Wales ( CSSIW) and Healthcare Inspectorate Wales ( HIW) completed a National Review of the use of Deprivation of Liberty Safeguards (DoLS) in Wales Within North Wales Gwynedd Local Authority and BCUHB took part in the fieldwork of the review. The review was to look at monitoring arrangements, review actions and decisions in light of the code of practice and look at inconsistencies and practitioners awareness. Eight recommendations were identified which required the review of the management of arrangements, reporting framework and to develop a robust quality assurance mechanism. Supreme Court Judgement Cheshire West Health Boards and Social Services in Wales received a letter from Welsh Government providing an update on the judgement of the Supreme Court in Cheshire West. They are aware of the significant increase in applications for DoLS authorisations and wish to support organisations in taking an integrated approach to addressing the implications of the Supreme Court Judgement. Safeguarding Annual Report FINAL V.5 Page 20

21 The Health Board is responsible for ensuring that systems and processes are in place for the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (DoLS) in order to discharge their functions as both the Supervisory Body (SB) and a Managing Authority (MA). A House of Lords Post legislative Scrutiny Report on the Mental Capacity Act (MCA) 2005 published on the 13 th March 2014 has called for a root and branch review of DoLS to be completed within a year. The Supreme Court Judgement will have huge implication on the workforce, particularly for staff supporting the Supervisory Body functions and the Best Interest Assessors (BIAs) and section 12(2) Doctors of the Mental Health Act (MHA) The Board was asked to support and agree the proposed plan, which includes additional funding for the next six months for dedicated BIA and section 12(2) Doctor time and additional DoLS Lead and administration time. A General Risk Assessment has been completed highlighting all the risks to the Health Board of the impact of the case law reinterpreting the definition of a deprivation of liberty. The Office of the Medical Director reviewed the information with an emphasis upon the identification of a process for Corporate escalation. Mitigation of Risk Due to the revised organisational structure as noted previously the professional portfolio of the Deprivation of Liberty Safeguards would be under the Director of Nursing and Midwifery, the accountability of the Mental Capacity Act and the Mental Health Act would remain with the Office of the Medical Director with collaborative accountability. It is imperative that these functions do not become disjointed or fragmented. The DoLS/MCA/MHA will be clearly reported within the 3 Area/secondary Care Safeguarding Delivery Boards with ultimate reporting to the Safeguarding Performance and Scrutiny Sub- Group and Mental Health Act Committee and ultimately to the Board. The Forums will ensure that the Health Board fulfils its operational responsibilities and complies with the relevant national legislative guidance. It will also provide assurance on clinical governance issues related to the implementation of the DoLS across the Health Board. Full engagement with the Welsh Government who were scoping the requirements of National training in both the new requirements of the DoLS and the MCA, work is also underway to assess the current model of delivery Dementia It must be recognised that the Nurse Consultant Dementia leads this service and continues to be managed within the Mental Health and Learning Disability Division. In 2013 a Dementia Operational Forum was established and positioned within the existing and robust, safeguarding governance structure. The Dementia Operational Forum works to two specific annual action plans. Safeguarding Annual Report FINAL V.5 Page 21

22 The BCUHB Dementia Action Plan, this is set following outcomes from the National Audit of Dementia in the General Hospital and is reportable to Welsh Government. However, that plan covers a twelve month period whereas the National audit occurs every two years. Historically this has left no plan in place every other year. The Forum has acted to address this by drafting an outcome focussed Dementia Strategy that may be edited following each round of National audit. For this period the overall status is AMBER as executive approval to raise the status of the strategy beyond draft was delayed awaiting the progress of the Flynn Eley Review and the move towards an integrated Dementia Strategy for North Wales. This approach has been approved by Welsh Government that acknowledges that many of the outcomes within the draft Dementia Strategy have been completed. Secondly is the Master Plan which identifies all other dementia related objectives and work streams. It is a live document that is monitored by the Forum and its current status is anticipated to always be AMBER. Clinical Audit During this year a more formalised dementia audit group has been established under authority from the forum. That group has responsibility for setting the annual dementia audit plan, 50% of which will be set by people with dementia and their carers. Clinical Effectiveness Across a large organisation there is considerable diversity in the scope of clinical practice associated with dementia care. Whilst the forum oversees programs of work such as the Butterfly Scheme and the acute care dementia pathway that are aimed at improving quality of care generally it also has supported more specialist activity and developments, for example, Palliative Care Services have developed a toolkit to educate and identify common symptoms, Audiology Services have been involved in establishing national (UK) clinical recommendations regarding audiology services and hearing assessments for people with dementia, Older Person s Mental Health Services have introduced a Nursing Development Strategy for dementia wards with an emphasis on changing culture. Mitigation of Risk Proactively the forum had identified a number of areas that will require attention during the coming year. This will be reviewed in light of the revised Reporting Framework with a clear agreement regarding the footprint and integration of this provision within Areas and Secondary Care. A third round of the National Dementia Audit is being commissioned by the Royal College of Psychiatrists for This commences with a pilot of the methodology and the Health Board has been invited to be one of the sites involved, the Forum will manage this on behalf of the organisation. The Forum will develop a clear mechanism for capturing carer/service user opinions and comments on dementia care. Safeguarding Annual Report FINAL V.5 Page 22

23 The first dementia audit plan will be launched. This will be co-produced with carers/service users ensuring full dissemination and the implementation of key lessons and actions Safeguarding Domestic Abuse Domestic Abuse, Violence against Women, and Sexual Violence/Honour Based Violence are key strategic target areas for the Safeguarding agenda. This strand of the safeguarding agenda also consists of other areas associated with vulnerability that include Counter Terrorism PREVENT, Child Sexual Exploitation, Human Trafficking, Honour Based Violence (HBV) Female Genital Mutilation (FGM and Forced Marriage (FM). The Domestic Abuse, Violence against Women, and Sexual Violence agenda has a direct impact on both Adult Protection and Child Protection. White Ribbon Campaign 2014 White Ribbon UK is a global campaign to end violence against women. Corporate Safeguarding engaged with external partners and carried out an awareness raising events during the week to staff and members of the public in the three district general hospitals Multi-Agency Assessment Conferences (MARAC) MARAC guidance requires monthly meetings in each Local Authority areas to manage and co-ordinate multi-agency protective measures for victims of Domestic Abuse. Multi-Agency Assessment Conferences (MARAC) data: 1. Between the reporting periods of , 281 high risk individuals were identified by Betsi Cadwaladr University Health Board staff as having met the threshold for referral to MARAC. In October 2014, the helpline reported that they had received 1000 MARAC referrals from Betsi Cadwaladr University Health Board staff. Victim Gender Female 267 Male Safeguarding Annual Report FINAL V.5 Page 23

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