SAFEGUARDING ADULTS POLICY

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1 SAFEGUARDING ADULTS POLICY This document may be made available in alternative formats and other languages, on request, as is reasonably practicable to do so. Policy Owner: Approved by: POVA Operational Group Safeguarding Committee Issue Date: 10 th August 2009 Review Date: 10 th August 2011 Policy ID: HB34 Version Number: 1 Page 1/21 1

2 ADULT SAFEGUARDING POLICY CONTENTS PAGE NO. Part 1 Policy Statement 3 Part 2 Partnership Arrangements 3 Part 3 Scope of Policy 4 Part 4 Aims and Objectives 4 Part 5 Definitions 5 Part 6 Responsibilities 8 Part 7 Monitoring 10 Part 8 Staff Training 11 Part 9 References 11 Appendix 1 Adult Safeguarding Process for Complaints 12 Appendix 2 Action Sheets Version Number: 1 Page 2/21 2

3 1. POLICY STATEMENT 1.1 In September 2000, the National Assembly of Wales issued a guidance document entitled In Safe Hands, which called for the development and implementation of multi-agency polices and procedures to protect and support vulnerable adults from abuse and inappropriate care. 1.2 The South Wales Adult Protection (SWAP) Forum, consisting of representatives drawn from all agencies working with vulnerable adults, was established which subsequently compiled a document entitled Inter-Agency Policy & Procedures for Responding to the Alleged Abuse of Vulnerable Adults in South Wales (revised 2004). This is the overarching policy document for dealing with cases of alleged abuse. 1.3 Abertawe Bro Morgannwg (ABM) University Health Board is committed to the fundamental principle of preventing abuse and will seek to achieve this through the development of positive service cultures in providing care, protection and support of vulnerable adults. All persons have the right to live their life free from violence and abuse all citizens should have access to relevant services for addressing issues of abuse and neglect, including the civil and criminal justice system and victim support services. Safeguarding Adults, ADSS The ABM University Health Board Adult Safeguarding Policy reflects participation in a multi- agency approach and has adopted the Inter-Agency Policy & Procedures for Responding to the Alleged Abuse of Vulnerable Adults in South Wales 2. PARTNERSHIP ARRANGEMENTS 2.1 The Health Board will be a partner agency of the South Wales Adult Protection Forum and the Area Adult Protection Committees of Swansea, Neath Version Number: 1 Page 3/21 3

4 Port Talbot, Bridgend and the Vale of Glamorgan and thereby contribute to strategic development and progress. 2.2 South Wales Adult Protection Forum The senior management group made up of representatives from all core agencies subscribing to the Inter-Agency Policy & Procedures for Responding to the Alleged Abuse of Vulnerable Adults in South Wales (2004). Its role will be to provide an over-arching responsibility for co-ordinating policy and practice across the seven local authority areas. 2.2 Area Adult Protection Committees Each local authority has established an Area Adult Protection Committee to be responsible for overseeing and co-ordinating policy and practice relating to vulnerable adults in their area. The Committee will be a multi-agency group chaired by Senior Manager from Social Services with clearly designated formal responsibility. The Head of POVA and nominated Designated Lead Managers & Lead Locality Managers will represent the Health Board on these committees. 2.3 Inter-Agency Policy & Procedures A copy of the Inter-Agency Policy & Procedures for Responding to the Alleged Abuse of Vulnerable Adults in South Wales (2004) is available in each work area either in hard copy or electronically via the Internet and Intranet. This will be held by all line managers and will be the overarching guidance for dealing with all cases of alleged abuse. 3. SCOPE OF POLICY 3.1 This policy applies to all staff and volunteers employed by ABM University Health Board and also independent contractors and providers (e.g GPs, dentists and opticians). 3.2 This policy and procedure applies to all vulnerable adults who access Health Board services or are known to staff. Version Number: 1 Page 4/21 4

5 3.3 When a vulnerable adult is able to make an informed decision regarding his/her personal circumstances where risk has been identified and does not wish to accept the intervention of statutory authorities, then his/her wishes must be respected except where a statutory duty to intervene exists as outlined in the Mental Capacity Act (2005). 4. AIMS AND OBJECTIVES 4.1 All staff employed by ABM University Health Board are aware of their responsibilities in protecting vulnerable adults. 4.2 This will be enacted by full compliance with the Inter-Agency Policy & Procedures for Responding to the Alleged Abuse of Vulnerable Adults in South Wales (2004). 4.3 This will aim to clarify and support the roles and responsibilities of practitioners and managers in all areas of the organisation tasked with caring for and supporting vulnerable adults. 5. DEFINITIONS The following definitions and abbreviations are used throughout this policy:- 5.1 P.O.V.A. stands for Protection of Vulnerable Adults. 5.2 The Health Board is the ABM University Health Board. 5.3 The AAPC refers to the Area Adult Protection Committees of Bridgend, Swansea, Neath Port Talbot and the Vale of Glamorgan. 5.4 Designated Lead Manager (DLM) denotes a designated manager with specific responsibility for co-ordinating the Trust s response to any disclosure or referral made. These are the Heads of Nursing or their nominated deputies. 5.5 A vulnerable adult is defined as: a person who is 18 years of age or over, and who is or may be in need of community care services, by reason of mental or other disability, age or illness Version Number: 1 Page 5/21 5

6 and who is or may be unable to take care of him/herself, or unable to protect him/herself against significant harm or serious exploitation. (Law Commission Who Decides?: Making Decisions on Behalf of Mentally Incapacitated Adults 1997). 5.6 Abuse is a violation of an individual s human and civil rights by any person or persons Abuse of a vulnerable adult may be: Physical Sexual Psychological or Discriminatory Financial Neglect and/or Acts of Omission Institutional 5.8 Capacity and Consent Mental capacity is the term used to describe a cluster of mental skills that people use in their every day lives in making decisions. It includes memory, logic, the ability to calculate and the flexibility to turn one s attention from one task to another. In the context of adult abuse, there are two stages at which the capacity to give consent requires consideration: i. Did the vulnerable adult have the capacity to consent to the act, relationship or situation that constitutes the allegation of adult abuse?, and ii. Does the vulnerable adult have the capacity to give consent to any actions that professionals wish to take to investigate the matter further and to take steps to prevent further abuse? 5.9 Although a person may not have consented to the abusive act, they may not agree to any agency intervention as a consequence. In circumstances where the vulnerable adult is adjudged to lack capacity professionals and others are required to act in the best interests of the individual concerned as outlined in Version Number: 1 Page 6/21 6

7 the Mental Capacity Act (2005). This should apply even when there are doubts about an individual s capacity to make such decisions DEPRIVATION OF LIBERTY SAFEGUARDS The Deprivation of Liberty Safeguards (DOLS) are designed to protect service users who are in hospital and care homes registered under the Care Standards Act The procedures came into force in April 2009 and are a statutory obligation. The law will require a hospital or care home (a managing authority) to seek authorisation from a Local Authority or Health Board (a supervisory body) in order to deprive the liberty of someone with a mental disorder who lacks capacity to consent. This legislation will have an impact on the need for awareness and notification from care homes and hospitals to identify individuals for whom application should be made. They will apply to: people aged 18 and over; and suffer from a mental disorder; and lack the capacity to give consent to the arrangements made for their care or treatment in a care home or hospital, under public or private arrangements; and for whom a deprivation of liberty is considered, after an independent assessment, to be a necessary and proportionate response in their best interests to protect them from harm; and detention under the Mental Health Act 1983 is not appropriate for the person at that time. If a person is at risk of deprivation of liberty because they are subject to frequent, cumulative and ongoing restriction or restraint, consideration should always be given to less restrictive alternatives. If this cannot be achieved, then an application for an authorisation under DOLS must be made Complaints Version Number: 1 Page 7/21 7

8 A complaint is defined as an expression of dissatisfaction or disquiet about the actions, decisions or apparent failings of service provision which require a response. An allegation of abuse will more likely involve a referral of a serious nature indicating possible abusive or criminal practices however complaints are a source of referrals and the Health Board has outlined the referral process when a complaint is identified as having adult protection issues (see appendix 1). 6. RESPONSIBILITIES 6.1 Health Board The Health Board will ensure that appropriate systems are in place for compliance with the Inter-Agency Policy & Procedures for Responding to the Alleged Abuse of Vulnerable Adults in South Wales. 6.2 Executive Board Is responsible for approving this Policy and any subsequent amendments. It may delegate responsibility for approving supporting Policies & Procedures to another Committee. There will be a nominated member of the Executive Board taking a lead role for the Protection of Vulnerable Adults. 6.3 Executive Lead The Director of Nursing is identified as the Executive lead within the Health Board and will ensure the organisation discharges its responsibilities in respect of the Protection of Vulnerable Adults. These responsibilities include: (i) (ii) Supporting and monitoring the implementation of the Inter-Agency Policy & Procedures for Responding to the Alleged Abuse of Vulnerable Adults in South Wales. Ensuring the collation and analysis of information relating to the incidence of suspected abuse and the impact upon organisation Version Number: 1 Page 8/21 8

9 services. Presenting the above information to the Health Board and other appropriate committees within the organisation. (iii) Ensure that the organisation contributes to the strategic development of Inter-Agency Policy and Procedures relating to the protection of vulnerable adults. 6.4 Directorate General Managers and Lead Locality Managers Each Directorate General Manager and Lead Locality Manager must ensure that adequate provision is made for protecting vulnerable adults within their area of responsibility. These specific responsibilities are: (i) (ii) (iii) (iv) Ensuring implementation of this Policy. Ensuring the provision of information, training and supervision as is necessary to ensure compliance with the Inter-Agency Policy & Procedures. Ensure monitoring systems are in place for the recording of incidents, training, supervision and any actions taken. Ensuring the prompt implementation of the inter-agency referral and decision making process when abuse of a vulnerable adult is suspected. 6.5 Designated Lead Managers The Designated Lead Manager is responsible for co-ordinating the Directorate response. They will be fully aware of their responsibilities as outlined in the Inter-Agency Policy & Procedures for Responding to the Alleged Abuse of Vulnerable Adults in South Wales. Specific responsibilities may be delegated. Where a disclosure or referral is received by the Designated Lead Manager (DLM), they must ensure that the VA1 form is completed by the practitioner/line manager, without delay, but within one working day of the disclosure. Version Number: 1 Page 9/21 9

10 The DLM will ensure that the referral is made to the Adult Protection Coordinator in Social Services within one working day. 6.6 Line Manager Details of the responsibilities of line managers on receipt of notification of disclosure from a member of staff as in the Inter-Agency Policy & Procedures for Responding to the Alleged Abuse of Vulnerable Adults in South Wales (2004). 6.7 Staff All staff have a responsibility to fully comply with the Inter-Agency Policy & Procedures for Responding to the Alleged Abuse of Vulnerable Adults in South Wales (2004). Staff will need to familiarise themselves with the issues involved and their roles and responsibilities. 6.8 Policy Owner The policy was reviewed by the Safeguarding Committee in conjunction with the Area Adult Protection Committees of Swansea, Bridgend, Neath Port Talbot and the Vale of Glamorgan MONITORING 7.1 Internal Monitoring The Lead Locality Managers and Head of POVA will produce quarterly reports outlining the number of referrals made, actions taken and lessons learnt. The Trust Safeguarding Committee will meet quarterly and will approve adult safeguarding strategies, policies and procedures. The Designated Lead Managers, as members of the Forum, will be responsible for providing regular reports from their Directorate / Locality External Monitoring 10 Version Number: 1 Page 10/21

11 i) The Area Adult Protection Committees will oversee the development, monitoring and evaluation of the practice of adult abuse procedures within its partner agencies, including the Trust. ii) The Healthcare Inspectorate of Wales will regulate activity through assessment and inspection and compliance with the Healthcare Standards for Wales. 8. STAFF TRAINING The organisation will ensure that appropriate training is made available for all staff working with vulnerable adults (refer to Adult Safeguarding Strategy). 9. REFERENCES In Safe Hands (2000) National Assembly for Wales. Welsh Office Interagency Policy & Procedures for Responding to Alleged Abuse and Inappropriate Care of Vulnerable Adults in South Wales (2004). South Wales Adult Protection Forum Mental Capacity Act (2005). Department of Health. London Healthcare Standards for Wales (2005).Welsh Assembly Government. Author: Head of POVA on behalf of the POVA Operational Group Review Date: Every two years, unless otherwise indicated 11 Version Number: 1 Page 11/21

12 POVA Complaint Process APPENDIX 1 Complaint letter comes into Governance Support Unit (GSU) GSU feel investigation under POVA may be more appropriate than under Complaints Send letter to Directorate Lead DLM (HON) (or Nominated Deputy). Ask to review and respond within 24 hours. POVA investigation not required DLM advise complaints dept of rationale Process through usual complaints procedure POVA strategy meeting to be held GSU send acknowledgement letter identifying that a POVA strategy meeting will be held to identify if complaint will be investigated under POVA or Complaints process. Send usual acknowledgement DLM to hold strategy meeting within 48 hours Complaints investigation to be undertaken DLM advise complaints dept of rationale GSU to advise complainant Complaint process followed POVA investigation to be undertaken DLM to draft a letter to complainant within 24 hrs to advise them that it will be investigated as a POVA. Letter to be sent via chief exec. DLM to identify investigating officer Formal letter in Chief Executive s name at conclusion

13 Appendix 2 ACTION CARD 1 REFERRAL PROCEDURE & OUT OF HOURS ARRANGEMENTS The procedures are set out under four headings, which can be broadly classified as the four stages of the Safeguarding Adults process. 1. Prevention 2. Early Detection 4. Post Intervention/ 3. Protection Debrief Practitioners are expected to incorporate each of these phases into their core practice. These procedures are set out to enable practitioners to employ best and mandatory practice at whatever stage within the process is relevant to the safeguarding of the vulnerable adult(s) with whom they are working.

14 PREVENTION OF ABUSE ACTION CARD 2 This card details mandatory actions and responsibilities that all practitioners who provide services for vulnerable people must incorporate within their own practice to ensure, as far as is possible, that the abuse of vulnerable adults is prevented. The organisation will ensure information about the services they provide and any accompanying eligibility criteria are widely available and can be adapted to meet individual requirements. The organisation will give potential service users comprehensive information about the specific service they will be provided with, in a format that is appropriate to their needs. Thorough assessments of need will be completed and care packages set up that most appropriately meet the eligible needs of the vulnerable adult. All assessments will consider whether there are any potential indicators of abuse and address these accordingly using these procedures. When looking at potential placements, practitioners must consider the possibility of placing a vulnerable adult who may themselves abuse others and address this accordingly. Thorough carers assessments will be completed and appropriate support provided and Service users and carers will be given a copy of their care plan. Thorough and timely reviews will be carried out and provision adjusted to meet changing needs. All reviews will consider whether there are any further potential indicators of abuse and address these accordingly using these procedure within the Inter Agency Policy. The organisation supports service users to lodge complaints and endeavours to support them in this process. Staff will endeavour to inform vulnerable people and their carers about the different types of abuse, enabling them to protect themselves from becoming victims of abuse. Appropriate risk assessments will be completed prior to, or as soon as possible after, the service user starts to receive the service. Risk assessments will be reviewed in line with care plans and whenever there is a significant incident or change of service. The organisation will ensure that staff are subject to a training schedule which includes specific Protecting Vulnerable Adults from Abuse training, appropriate to their level of involvement. The organisation has a well publicised Whistle-Blowing policy that enables staff to report issues of concern without fear of reprisal. 14 Version Number: 1 Page 14/21

15 EARLY DETECTION AND REPORTING OF ABUSE 15 Version Number: 1 Page 15/21 ACTION CARD 3 This card details mandatory actions and responsibilities that must be implemented if potential or alleged abuse occurs. All staff and volunteers working in the organisation who may come into contact with vulnerable adults must gain a good knowledge and familiarity with these procedures. All staff and volunteers working in the organisation who may come into contact with a vulnerable adult must be mindful that the abuse of vulnerable adults does happen and could potentially happen within our own organisation. You may find out about abuse in a number of different ways: A vulnerable adult may tell you that they are being abused You may observe abuse taking place Someone you may work with may discuss their concerns with you A relative or friend of the patient may tell you that they think someone is being abused You may have a suspicion, concern or a hunch that something isn t right Staff and Volunteers must ensure that that all concerns (however minor) regarding a potentially vulnerable adult must be recorded in an appropriate place (e.g. in case notes or by using a VA1 form) so that reference may be made to them should future concerns arise. If the concern appears to involve an allegation of abuse (as defined in these procedures) the Adult Protection Team will complete the VA1 (& VA1a) form. If in doubt about whether a concern could constitute abuse or not then you must discuss the issue with your Line Manager. If you think that your Line Manager is the perpetrator you must contact the Head of Department. If it is clear that the vulnerable adult is in serious danger you must contact the Emergency Services (999) or (medical help in hospital) to seek urgent assistance. If there are any concerns regarding the safeguarding of children, the Line Manager must contact the Children s Safeguarding Team. Any professional who is informed, or is concerned, about the abuse of a vulnerable young adult (aged 18-25) should contact the Safeguarding Children s Service to ascertain if there are any reports of previous concerns about the care of the vulnerable young adult as a child. Upon receipt of the alert and the VA1 the Line Manager will notify the Designated Lead Manager and start the strategy discussion phase. Be aware that any information (verbal or written) gathered through a Safeguarding Adults investigation will potentially need to be disclosed in the event of the case going to court.

16 MAKING A REFERRAL USING THE VA1 & VA1a ACTION CARD 4 If the concern appears to involve an allegation of abuse (as defined in these procedures) you must complete the VA1 (& VA1a) form. If it is clear that the vulnerable adult is in serious danger you must contact the Emergency Services (999) or medical help (in hospital) to seek urgent assistance. Reassurance must be given to the victim of abuse. If the perpetrator is another patient who is also a vulnerable adult then make sure this person is looked after as well. Include as much detail as possible on Section 1 of the form however do not ask the victim or perpetrator or any witness any searching questions ( e.g. who, how, why, where, when etc). You must only document what you have observed or have been told. Anyone can complete a VA1 and VA1a form. This includes, untrained staff, patients, relatives as well as qualified staff. Section 2 of the form must be completed by the Line Manager You must pass the VA1 form onto your Line Manager immediately. If there are any concerns regarding the safeguarding of children (any person under the age of 18 years including young people being treated by adult services), the referrer must contact the Children s Safeguarding Team. Any professional who is informed, or is concerned, about the abuse of a vulnerable young adult (aged 18-25) should contact the Safeguarding Children s Service to ascertain if there are any reports of previous concerns about the care of the vulnerable young adult as a child. Please Note: OUT OF HOURS: In the absence of the identified Designated Lead Manager contact should be made with the appropriate manager, in accordance with existing out of hours arrangements. If any doubt remains or clarification is required contact the Adult Safeguarding Team for advice on or (9am-5pm, Monday to Friday). 16 Version Number: 1 Page 16/21

17 PROTECTION PHASE ACTION CARD 5 THE STRATEGY DISCUSSION/ MEETING PHASE (To take place within 48 hours of the VA1 being received) The purpose of the Strategy Discussion / meeting is to: Start multi-agency working so that all who can protect the vulnerable adult are aware of the allegation and can play a role in addressing it. Obtain the views and wishes of the vulnerable adult and, if appropriate their family and carers. Determine, at an early stage, whether an offence has taken place and put in place measures to address this. Decide whether to investigate the allegation Formalise the protection process and the recording of plans, actions and outcomes Bring together those multi agency colleagues involved in protecting the vulnerable adult. Share information relevant to the allegation Prior to proceeding with the Strategy Discussion phase, it is also the responsibility of the DLM to decide whether legal advice should be obtained and if so to seek this from the organisation s legal team. It is the responsibility of the Designated Lead Manager (DLM) to determine whether achieving the purpose of the Strategy Discussion requires a meeting, a series of meetings or a series of telephone calls. The DLM will use the VA2 paperwork to record the necessary details and actions, and to ensure the outcomes are clear, fit for purpose and defensible. The VA2 documentation will underpin the entire strategy discussion, meeting and investigation stage In order to achieve the purposes laid out above the following process must be adhered to: 1. On receipt of the VA1, the DLM must contact the POVA Co-ordinator in the local Social Services Department for the hospital area (unless the abuse took place at the patient s home and the patient lives in another area, then the DLM should contact the Social Services POVA Co-ordinator for the area where the person lives). 2. If it appears that a criminal offence has occurred the DLM must contact the local Public Protection Police Officer. This will result in one of three possible outcomes; the police will lead on the investigation; the Trust will lead on the investigation, or a joint investigation between the police and a partner agency will take place. 3. If the alleged abuser is a Local Health Board employee or independent contractor in certain circumstances suspension of the member of staff is advised. The Human Resources Department must be contacted for advice and support. If suspension is not 17 Version Number: 1 Page 17/21

18 necessary the employee can be transferred to another department or non-care work may be advised until the investigation is completed. If a member of staff is suspended a referral should be made for counseling to support the member of staff during the investigation period 4. The DLM will ensure that measures have been taken so that the vulnerable adult is supported throughout the investigation and that the need/wish for the support of an advocate has been addressed. 5. The DLM will ensure ongoing liaison with the Head of POVA and provide copies the VA1, VA2 and VA4. 6. Those who should be invited to/ involved in the strategy discussion /meeting are: The DLM Social Worker or Social Services POVA co-ordinator The Police Officer with whom the DLM has liaised The Line Manager Other relevant professional colleagues (e.g. GP, Consultant, Occupational Therapist). The Head of POVA or deputy Minute taker 18 Version Number: 1 Page 18/21

19 ACTION CARD 6 THE INVESTIGATION The purpose of the investigation is to: Determine, as far as is possible, the extent and nature of the allegation. Gather and record information. Identify the expectations of the vulnerable adult for the investigation (and/ or, in appropriate cases, the expectations of their closest family The investigating officer is responsible for undertaking interviews relating to the allegations made. The interview with the vulnerable adult should take place within one working day of the strategy meeting or discussion. The investigation officer must comply with Health Board Disciplinary Policies and Procedures when interviewing staff accused of alleged abuse. The Human Resources Department must be contacted for further advice if required. During the investigation particular attention must be given to gathering information about: The vulnerable adult s account of what has happened or is happening. What other agencies are involved. The vulnerable adult s expectations of the investigation. What support is available (either formal or informal). Any urgent actions that are needed to secure the safety of the adult or to gather more information. Whether the alleged abuser may present a risk to other vulnerable adults or young people. Interviews and related notes may be used as evidence in a case that goes to court. The investigating officer must compile a report on behalf of the Strategy Meeting. As a result of the interview the investigating officer will follow up any information that is checkable. This may involve arranging another interview or gathering other information. If the vulnerable adult has stated that they do not wish to be involved in a police investigation their wish will almost always be respected but, in exceptional circumstances, if the investigation has to continue they should be reassured that the police will treat the matter sensitively. For example, officers could attend in plain clothes, female officers could attend if requested by a female vulnerable adult. Any decision to decline police involvement must be communicated to the police officer who was involved initially and to the Adult Protection Unit by the Line Manager. N.B. It is inappropriate for the alleged abuser to attend a strategy meeting. 19 Version Number: 1 Page 19/21

20 ACTION CARD 7 THE ADULT SAFEGUARDING CASE CONFERENCE The case conference must take place within 8-15 working days of the last strategy meeting or discussion. The Case Conference has the following functions: To devise and agree a multi agency plan that addresses the medium and longterm protection needs of the vulnerable adult. To provide a forum for the exchange of information between multi-agencies, the vulnerable adult, family and carers To continue to fulfil the views and wishes of the vulnerable adult To clarify the roles and responsibilities of professionals The Case Conference will provide recommendations to individual agencies for action to address the identified risks. These will be detailed into an Action Plan designed to protect the vulnerable adult from abuse. A full Case Conference can only be convened following completion of the Investigation and Strategy Discussion Phase of these procedures. When deciding the venue for the Case Conference, the needs of the vulnerable adult and his/her interpreter and/or advocate must be considered and accommodated, where possible. Appropriate transport and care support must also be sought. The DLM is responsible for ensuring an appropriate venue is booked, for attempting to address any identified needs, e.g. communication needs. The DLM will also arrange for a minute taker to be present. Unless there are exceptional circumstances, to be discussed with the Case Conference Chair, the following must always be invited: The Vulnerable Adult and/or their relative/carer/ advocate Investigating Officer General Practitioner or Hospital Consultant Community and Adult Care Services Team Manager Appropriate Health Service Manager Social Worker and Police Officer involved in the case The Vulnerable adult must be given the opportunity to voice any ongoing concern about the action plan or the conduct of the case. When the process is finalised a VA4 form must be completed and sent to Social Service POVA co-ordinator and copied to the Head of POVA. 20 Version Number: 1 Page 20/21

21 ACTION CARD 8 CHANGE OF PRACTICE / REVIEW PHASE The DLMs in conjunction with the Head of POVA and Lead locality Managers will ensure that there is ongoing monitoring of all POVA cases and that wherever possible lessons are learnt as a result of issues raised. Quarterly reports will be produced for the Risk Management Committee and the Trust Safeguarding Committee. The POVA Operational Group will be instrumental in developing polices and procedures to prevent abuse from occurring in the future. 21 Version Number: 1 Page 21/21

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