Safeguarding review to assist Walsall Healthcare NHS Trust

Transcription

1 [Type text] [Type text] [Type text] Safeguarding review to assist Walsall Healthcare NHS Trust A report for Walsall Clinical Commissioning Group April 2014 Buckley- Gray Consultancy Ltd Author: Sandra Gray

2 Contents 1. Executive summary 3 2. Purpose of the report Scope of the review 5 4. Terms of reference Approach and structure.9 6. Key findings Strategic leadership and governance.10 Clinical and operational effectiveness 11 Training and supervision..12 Looked after children Collaboration with other agencies...13 Engaging service users.14 Outstanding areas of concerns Recommendations.15 Appendices Appendix A Biography...19 Appendix B Documents reviewed.20 Appendix C Staff involved in the process 22 2

3 1 Executive summary Key findings Walsall Clinical Commissioning Group commissioned a review of safeguarding in partnership with Walsall Healthcare NHS Trust, following the identification of issues that needed attention to ensure the provision of continued safe and effective care for vulnerable people. The overall aim of the review was to focus on the Trust s strategy, leadership and governance arrangements in discharging their statutory responsibilities to safeguard and promote the welfare of children, young people and adults. The Trust was exceptionally open, honest and transparent in their attitude towards the review and their co-operation and support was valued. All staff consistently demonstrated their commitment and enthusiasm in supporting the safeguarding agenda, which clearly included collaborative working with other relevant agencies. However, there were some clear indications for improving strategic leadership, governance, driving performance and innovation; the details of which are outlined in section 6 of this report. During reviews it is important to focus on improvements that can be made and identify good practices, which are also detailed in section 6 of this report. Some examples of good practice included: Clinical practitioners and senior staff were professional, open, honest, enthusiastic and committed to the safeguarding agenda Leadership and talent strategy in place across the trust alongside a good external partnership, to continue to be exploited to benefit and progress staff in key roles of the safeguarding agenda A strong governance framework in Women and Children Division, which includes good leadership, a quality risk manager post and staff well versed in developing and improving effective services Health Visitors six month induction programme with supervision LAC team have transformed and made huge improvements to their service, this includes health assessments, audits and training Good leadership for adult safeguarding alongside effective engagement with Wolverhampton University, who provide a yearly learning zone for students Good engagement, commitment and contribution by health to the local services of MARAC (multi-agency risk assessment conference) and DART (domestic abuse referral team) Accident & Emergency Consultant attends regular meetings with ADDAC to identify any safeguarding issues for vulnerable alcoholics 3

4 Key recommendation Overall it is clear that the Trust should ensure safeguarding is part of core business in terms of strategy, operational plans and structures. In addition, an appropriate level of scrutiny should be in place concerning the trust s safeguarding performance and board assurance. There are a total of thirty-seven recommendations detailed in section 7 of this report; twenty-five of the recommendations require immediate attention and a further twelve require attention within three to six months. 4

5 2 Purpose of the report 2.1 This report sets out the findings of an independent snapshot review commissioned by Walsall Clinical Commissioning Group (WCCG) with full co-operation of Walsall Healthcare NHS Trust (the trust). It aims to clarify and better understand the form and function of service provision for safeguarding Adults, Children and Young People within the trust, in order to fulfill safeguarding responsibilities, provide assurance on the current position, compliance with quality governance, and identification of any deficits and or risks. 2.2 The trust and WCCG agreed that a formal three day review should be undertaken to explore a number of issues, which were jointly identified, that would assist in strengthening existing arrangements, on-going development and/or improvement. 3 Scope of the review 3.1 The visit was not intended to be a formal inspection (as would be undertaken by a regulator) nor was it a full clinical service review but a three day rapid assessment that sought to gain the views of Directors, a Non Executive Director, lead Doctors/Nurses, Designated Nurse, Heads of Nursing / Midwifery, Clinical Practitioners, Senior Staff and direct observation in a clinical setting. The limitations of this approach should be acknowledged for example anecdotal comment and observations may or may not reflect the reality of the situation and therefore proportionality was key in terms of the visit and considerations contained within this report. 3.2 The principle aim of the visit was to undertake a rapid assessment of the trust s overall position on the provision and governance of clinical services associated with safeguarding for children, young people and adults, giving due consideration to the healthcare service provision for looked after children; making recommendations for the trust to consider going forward. 3.3 The visit focused on: individual and group interviews with a cross section of clinical staff a desk top analysis including triangulation of relevant documents and information strategy, leadership and governance arrangements within the trust responsibilities of the trust to safeguard and promote the welfare of children, young people and adults other matters that arose from the review 5

6 3.4 The initial visits took place on Tuesday 18 and Wednesday 19 March 2014, with a further two half days on the 2 and 9 April 2014, which included preliminary verbal feedback to the interim Director of Nursing, Director of Governance, Head of Nursing and Midwifery and Lead Nurse for WCCG. 4 Terms of reference 4.1 Purpose The scope of this independent snapshot review aims to assist Walsall Healthcare NHS Trust (WHT) and the commissioning body, Walsall Clinical Commissioning Group (WCCG), to better understand the form and function of the Safeguarding Children Service that serves to support the provider organisation to fulfill its Safeguarding responsibilities for both Children and Adults. In addition, the review is to afford consideration to the internal arrangements for healthcare service provision for looked after children and young people. Findings are to inform the associated governance and quality assurance agenda across the provider site with particular reference afforded to accountability, leadership and effectiveness of service provision. Recommendations are to be made from any findings as identified areas that require further development and improvement and by which existing arrangements can be strengthened. 4.2 Background As acknowledged within the national Assurance and Accountability Framework (Safeguarding Vulnerable People in the Reformed NHS Accountability and Assurance Framework, NHSCB, 2013): NHS organisations whether as commissioners or providers of NHS funded care must demonstrate strong local leadership, work as committed partners and invest in effective co-ordination and robust quality assurance of safeguarding arrangements. As key, health service providers: must ensure that those who use the services are safeguarded and that staff are suitably skilled and supported, are required to demonstrate that they have safeguarding leadership and commitment at all levels of their organisation and that they are fully engaged and in support of local accountability and assurance structures, in particular via the LSCBs, are required to have effective arrangements in place to safeguard vulnerable children and adults and to assure themselves, regulators and their commissioners that these are working, 6

7 are required to employ named professionals, who have a key role in promoting good professional practice within their organisation, supporting the local safeguarding system and processes, providing advice and expertise for fellow professionals, and ensuring safeguarding training is in place. They should work closely with their organisation s safeguarding lead, designated professionals and the LSCB. 4.3 Objectives To undertake a rapid assessment of the form and function of provider safeguarding services for both Children and Adults, including looked after children service arrangements and service association with the local Multi-Agency Screening Team (MAST) To agree and undertake an on-site two day programme in order to meet the requirements of the rapid assessment To focus on leadership, governance arrangements and effectiveness for the safeguarding children and adults functions across the Trust To ensure that the review includes engagement with members of the Safeguarding Children and Looked After Children Services (LAC), strategic leads for safeguarding and governance across both the provider and commissioning sites, and as relevant managers and practitioners within field across both hospital and community settings. 4.4 Stakeholders The review process will include communication with the Director of Nursing, WHT, the Lead Nurse Quality Improvements and Partnerships WCCG, the Designated Safeguarding Children health personnel (Doctor and Senior Nurse) and a cross section of staff identified in the above objective. 4.5 Method The objectives will be delivered through facilitation and communication with relevant stakeholders, a two-day rapid assessment of safeguarding functions and discussions with key stakeholders and possible observation in the clinical setting. In addition, access to relevant documents and information concerning the Trust and WCCG. 4.6 Deliverables A report will be collated regarding the outcomes of the review alongside clear recommendations for the Trust to consider, the details of which are to be reported to WCCG. 7

8 4.7 Dependencies Access to appropriate members of staff across both organisations and the timely provision of relevant documents and information from the Trust and the WCCG. 4.8 Key Milestones Agree Terms of Reference with the Director of Nursing, WHT and WCCG Lead Nurse: 25 February 2014 Confirm on site visit dates with the Director of Nursing, WHT and the Designated Nurse for Safeguarding Children 7 March 2014 Undertake the visits by: 10 April 2014 First draft of the report for factual accuracy: 17 April 2014 Final report with recommendations: 30 April

9 5 Approach and structure 5.1 The independent snapshot review took the form of an initial two -day rapid assessment, with a further two half days undertaken by Sandra Gray, Buckley-Gray Consultancy. Biography is included in appendix A. 5.2 Documentary evidence including policies, procedures, strategies, frameworks, annual reports, quality accounts, job descriptions and objectives from the trust and WCCG, including the notes from a recent development session between the children s safeguarding team within both organisations was examined. Full details in appendix B. 5.3 The review focused on leadership, governance and effective coordination of robust quality assurance of safeguarding arrangements across the trust and WCCG. 5.4 Individual and group discussions were held with Directors, a Non- Executive Director, Consultants, Senior Leads and a cross section of Practioners from the trust and WCCG; a total of 25 interviews took place. Staff involved in the process is included in appendix C. 5.5 All evidence received was analysed. Findings and recommendations were made to progress and improve services in line with the national Assurance and Accountability Framework (Safeguarding Vulnerable People in the reformed NHS Accountability and Assurance Framework, NHSCB 2013) and the core legal requirements outlined in Working Together (2013), which came into force from April In addition, the recently published Intercollegiate Document, Third edition March 2014, Safeguarding Children and Young People: roles and competencies for health care staff, by the Royal College of Paediatric and Child Health (RCPCH) on behalf of the contributing organisations, Walsall Safeguarding Children Board, Learning and Improvement Framework This report includes a detailed analysis s of findings and suggested recommendations, which are outlined in sections 6 and 7. 9

10 6 Key findings 6.1 Good Practice Examples of good practice are as follows: Clinical practitioners and senior staff were professional, open, honest, enthusiastic and committed to the safeguarding agenda Leadership and talent strategy in place across the trust alongside a good external partnership, that should continue to exploited in order to benefit and progress staff in key roles of the safeguarding agenda A strong governance framework in Women and Children Division, which includes good leadership, a quality risk manager post and staff well versed in developing and improving effective services Regular professional leads meetings held by the Care Group Manager, Women and Children Division Health Visitors six month induction programme with supervision LAC team have transformed and made huge improvements to their service, this includes health assessments, audits and training LAC team have re-written administration and clerical guidelines in order to sustain the service in the absence of staff Training and development for adult safeguarding has been reviewed by external partners at Walsall Local Authority Good leadership for adult safeguarding alongside effective engagement with Wolverhampton University, who provide a yearly learning zone for students The trust has good student induction and a proforma in place for students to escalate concerns for adult safeguarding In November 2013 a member of staff was awarded the Queen s Nurse recognition for continued commitment to improving current standards of care, learning and leadership mainly for her role as school nurse within the community Good engagement, commitment and contribution by health to the local services of MARAC (multi-agency risk assessment conference) and DART (domestic abuse referral team) Accident & Emergency Consultant attends regular meetings with ADDAC to identify any safeguarding issues for vulnerable alcoholics There is an effective professional relationship between the trust and WCCG. 6.2 Immediate issues for action Strategic leadership and governance: There is no evidence of a declaration for safeguarding on the trust s website 10

11 There is no trust wide safeguarding strategy for children, young people and adults There are no clear objectives set by the board and/or quality & safety committee to support and promote good practices in safeguarding It is not clear how the board and the quality & safety/safeguarding committees are assured in terms of key issues and risks facing the trust, for example the governance framework for delivery of SCR (serious case review) action plans in terms of progress, impact and sustained changes in practice There is no approved audit programme for safeguarding children, young people and adults The terms of reference for the trust s safeguarding committee excludes the current children and young people s structure and arrangements Leadership for the safeguarding team needs grip and pace, in terms of structure there appears to be a distinct gap between the trust lead director and the lead named nurse for children s safeguarding There appears to be a lack of understanding of the role and responsibilities of the named doctor for safeguarding children and young people There is some confusion within the trust about using the risk register and what s expected of staff within the safeguarding team The safeguarding children and young people policy is out of date and in need of considerable revision Despite good leadership for safeguarding adults there is a need to ensure the job description for the lead nurse reflects the expected role, responsibilities and accountabilities The safeguarding adult policy needs an update to reflect the changes in the 2012 Health and Social Care Act, which came into force 1 April 2013 There is no approved policy for children and young people presenting with self harm and no evidence of robust processes in A & E that identify and screen for mental health issues with associated risks such as substance misuse The safeguarding children annual report is not comprehensive and falls short of providing the appropriate level of assurance to the Board Clinical and operational effectiveness: There are concerns about the some members of staff not clearly understanding their role and responsibilities for the safeguarding agenda The children and adult safeguarding functions are operated separately, however, it is recognised that efforts are made to communicate and join forces on relevant issues There are concerns that the children s safeguarding team have lost funding of approximately three days following the retirement of the 11

12 previous post holder who undertook the role of the lead named nurse within the trust There is much scope for improving the safeguarding team s performance in terms of improved outcomes of quality and efficiency, taking a systemized approach to strategic and operational management and ensuring delivery of an agreed programme of work for all individuals The fundamentals of appraisals, setting objectives and performance management for staff appears to be inconsistent within the trust and particular concerns were raised regarding senior staff not adhering to the trust policy A sample of job descriptions (JDs) were reviewed and all found to be out of date, no evidence that this process is accommodated as part of staff appraisals. The JDs would benefit from a review against the RCPCH 2014 competency document The lead consultant for adult safeguarding has no agreed sessional commitment for his role and responsibilities Training and supervision: The strategy for training is out of date and in terms of content appears weak and not relevant to the trust s current position There has been no external review of training for safeguarding children and young people There are concerns regarding the level 3 training, which appears to be undertaken predominately by health instead of multidisciplinary. The evaluation process across the trust has highlighted some negative feedback and staff said the training is not fit for purpose. However, overall the recent improvements on staff completing safeguarding training has been noted There appears to be no provision of training for staff who undertake safeguarding training, for example train the trainer courses The supervision policy is out of date and needs considerable improvement, alongside a review of documentation There were concerns that the case managers who undertake supervision do not have access to supervision themselves There are concerns that no supervision is available for acute trust staff and also a perceived lack of supervision for the lower bands of health visitors The supervision for lead medical staff in particular the named doctor for children and young people needs strengthening to comply with national guidance Looked after children: The form and function of the team operates very well and has strong leadership and effective management by the LAC Head of Service, albeit small in workforce number There is likely to be value in some form of integration across LAC and safeguarding teams for mutual support 12

13 The administrative member of staff working within this team has no cross cover for annual leave or other periods of absence Collaboration with other agencies: MAST (multi-agency screening team) Issues raised regarding the need for a review of the model, alongside the roles and responsibilities for each organisation involved in this activity Consideration needs to be afforded to the most effective form and function of a healthcare service contribution into the operation of the MAST. It is acknowledged that the trust and CCG are considering a plan to address this issue Youth Justice System There are clearly issues regarding permanent funding of this service, currently a service level agreement is in place for 2014/2015 only The service is managed through school nursing and will be picked up by these members of staff as part of LAC assessment should the funding remain unresolved Consideration is being given to health and CCG representation for the work being undertaken with relevant agencies SCR (serious case review) There was no evidence of trust guidance or an individual lead with responsibility for orchestrating the IMR (individual management review) process Some staff raised concerns about training and the approved process for IMR. However, it is acknowledged that training was offered from WSCB and taken up by some healthcare staff. In addition, further support was offered but only partly taken up. Staff also raised an issue about the lack of improvement in documentation No evidence that the trust has learned specific lessons that feed back into policy, practice and training MARAC and DART There is a need for the trust to set out its agenda in relation to Domestic Abuse that goes beyond engagement in MARAC and DART, which relates to both vulnerable children and adults Midwifery would benefit from better recognition of their role in respect of the potential impact of domestic violence on the unborn child, in particular the current information sharing methods in place within DART. Consideration should also be given to implementing a more streamlined process A local review of the form and function of the MARAC and DART has been recently conducted. Healthcare services need to note the recommendations that emerge and review future contribution in light of any necessary change 13

14 There is no explicit process that has been produced to inform on the engagement process of WHT with regard to MARAC and DART. This work is extremely overdue and needs to be viewed as a priority alongside reference to the outcome of the MARAC / DART review Engaging service users: There was no evidence of an overarching trust strategy or process for engaging service users, in particular, children, young people, parents, carers and adults. However, it is acknowledged that there are pockets of activity for example, a project with the British Youth Council on how children and families perceive the service. 6.3 Outstanding areas of concerns identified to be addressed within three to six months: From discussions with the Acting Director of Nursing, the Director of Governance, and the Head of Nursing & Midwifery, it was apparent that the trust itself had already identified it needed to take action on a number of the following areas. However, it is recommended that the trust accelerate its action on the following: There is a shortfall for accessing the reporting system for safeguarding adults via a database which needs attention Some concerns were raised by staff regarding the potential resource implications aligned to a review of the case managers role There is no clear training needs analysis that links directly to the trust s safeguarding agenda and /or objectives There were concerns raised about the funding for the transitional leaving care post (which is placed under LAC but not really part of this service), currently its funded non recurrently for 12 months by the local authority, however, there is currently no plan for sustainability Concerns were raised regarding the release of staff for training and attendance at meetings in respect of safeguarding within the Accident & Emergency department (A&E) due to the constant pressures of workload There is currently an audit of safeguarding documentation within the A&E department due to shortfalls identified in a recent CQC visit, outcomes should be reported to the safeguarding committee and form part of a trust wide audit programme There is no assessment section for safeguarding adults on the A & E casualty card There are concerns regarding the insufficient feedback from safeguarding referrals to local authority for both children and adults There are a number of safeguarding children network meetings that are operating within the trust. They should all undergo prompt review in terms of form, function and governance in particular objectives and impact 14

15 Some staff shared concerns regarding access to meetings that impart appropriate information concerning the overall national nursing professional agenda, which includes safeguarding and the wider knowledge of issues / strategic plans within the trust The named consultant for safeguarding children and young people has one session for his role and responsibilities, this is less than the guidance published by RCPCH which is based on local child population In midwifery concerns have been identified from a documentation analysis regarding the voice of the child not being considered and recorded There are concerns that the mandatory training undertaken by midwives is not updated regularly on electronic staff record (ESR) due to the absence of relevant information being forwarded to workforce colleagues in a timely manner There is no trust learning and development policy or strategy in place There were some concerns expressed regarding the access of funding for continuous professional development. 7 Recommendations Immediate issues for action The trust needs to: 1. Consider developing an improvement plan with clear timescales to address the issues raised from the findings of the independent review. 2. Publish and communicate a yearly safeguarding declaration on the trust s website as evidence of the board s commitment to safeguarding children, young people and adults. 3. Consider a joint safeguarding strategy for children, young people and adults; this should be underpinned by a dynamic work plan based on clear objectives to support realization of the strategy. It should also include the Government s Prevent strategy, and robust systems and processes for reporting through to the Board. 4. As part of the strategy the trust should consider a quality assurance framework that includes an audit programme, which is responsive to issues faced by the trust and practitioners; ensuring it also meets the commissioners requirements. 5. Review the terms of reference for the safeguarding committee to reflect the current trust structures in place for children, young people and other local agencies. In addition, the review should update the membership and make explicit the expected standards for delivery of trust objectives, comprehensive reports, assurance and attendance. 6. Review the safeguarding team, giving due consideration to the provision of sound strategic leadership, operational management, performance, roles and responsibilities and staffing requirements; in 15

16 order to bring together the safeguarding of children, LAC and adult teams, enabling a strong effective interface between all three. 7. Ensure that the role and responsibilities of the named doctor for safeguarding children and young people is communicated and understood by all relevant practitioners and senior staff. 8. Review previous work undertaken concerning the corporate risk register and ensure the safeguarding team has a comprehensive knowledge of risk management and responsibilities as individual practitioners. 9. Revise the trust s safeguarding children and young people policy to ensure it is comprehensive and complies with national, regional and local guidance and procedures. 10. Review the job description of the Lead Nurse for Elderly People and Vulnerable Adults to ensure that the role, responsibilities and accountabilities of the adult safeguarding agenda are clear. 11. Update the adult safeguarding policy to align with the 2012 Health and Social Care Act. 12. Ensure the trust has an approved policy for implementing good practices for children and young people presenting with self-harm, allowing the A & E department to implement an approved process that engages them in the relevant Child and Adolescent Mental Health Services (CAMHS). 13. Review the structure and content of the safeguarding children s annual report to ensure the Board has a wide-ranging update and vigorous assurance, providing an overview on arrangements to discharge the trust s statutory responsibilities, current provision of services and the challenges ahead. Due consideration should be given to including commissioner requirements. 14. Revisit the appraisal system and processes to ensure all staff have clear objectives and relevant performance management for delivering the safeguarding agenda, which should be linked to the improvement plan and /or the agreed annual work programme. 15. Update all pertinent job descriptions and ensure the process of appraisal includes this function on a yearly basis. 16. Review the sessional commitment for the lead consultant for adult safeguarding and agree key role, responsibilities and accountabilities. 17. Undertake a review of the training strategy to ensure it addresses the needs of the organisation; this should include an external assessment of training provided, in particular level 3. It ought to be aligned to the RCPCH recently published intercollegiate document cited in section 5.5 of this report. In addition, ensure staff delivering the training are suitably qualified, developed and supported. The impact and outcome of the application of learning into practice should be evidenced. 18. Review the supervision policy and documentation to ensure all staff fully understand their roles, responsibilities, development needs and the necessary sound practice that is consistent with trust and LSCB organisational procedures. In addition, make provision for a strong supervision process, which addresses the needs of case managers, 16

17 lower band health visitors, and the named doctor for child protection. As part of the review consider a range of reflective practice activities that could be programmed, including more opportunity for case study reflection via peer review and possible learning sets. Ensure evaluation is undertaken to inform ongoing training programmes. 19. Consider some form of integration between the well-managed LAC team and the safeguarding teams as part of the suggested review outlined in recommendation 6 of this report. The administration and clerical staff for safeguarding and LAC should also be part of the review in order to provide cross cover and work as part of an integrated team. 20. Finalise plans for addressing the strategic and operational issues of MAST, ensuring appropriate representation from both health and commissioning. 21. Assist WCCG in resolving the funding for the youth justice system (YJS), commissioners taking the lead role with the local authority. 22. Ensure that the SCR process has a trust lead, guidance and relevant training, in order to embed the appropriate processes that enable lessons learnt to be aligned to training, development and improved practice outcomes. Action plans should be explicitly understood and operational arrangements robust. 23. Set out its agenda for the service of Domestic Abuse, which goes beyond current engagement in MARAC and DART; this should apply to both vulnerable children and adults. The recent local review of these services should be noted and the recommendations that emerge need to be addressed in terms of healthcare services contribution to any necessary changes. 24. Ensure that the integrated strategy mentioned in recommendation 3 of this report includes a section on engaging service users in order to deliver real goals of change. 25. Undertake discussions with mental health colleagues in Dudley and Wallsall to address the issue of accessing relevant information, to facilitate the trust in adding a module to their IT system for safeguarding adults. Outstanding concerns 3-6 months: 26. Communicate the outcome of the case managers review to all relevant staff and address any resource implications and ensure any revised model of working undergoes periodic review to evaluate productivity, impact and outcome. 27. Consider collating training needs analysis that links directly to the trusts strategic objectives for safeguarding. 28. Discuss with WCCG the future-funding requirement for the transitional leaving care post in order to resolve and provide a sustained service. 29. Undertake a more in depth analysis of the issues raised on behalf of A & E in section 6.3 of this report; given their constant pressures and difficulties in releasing staff for training and meetings directly linked to the safeguarding agenda. In addition, due consideration should be 17

18 given to the Paediatric Liaison Service that supports the hospital and community practices and the corporate safeguarding children and adults agenda. 30. Ensure that the A & E Consultant s input to ADDAC meetings (outlined as part of good practice in section 6.1) takes the opportunity to identify and respond to safeguarding children s needs or concerns. 31. Address the issues raised regarding safeguarding referrals to the local authority in terms of the quality and regularity of feedback. 32. Review network meetings relevant to the safeguarding agenda within the trust in terms of form, function and governance giving due consideration to objectives and impact. 33. Ensure that all staff are cognisant with the national professional nursing and safeguarding agendas in order to drive change, improvements, innovation and keep at the forefront of the latest developments. 34. Review the sessional commitment of the named consultant for safeguarding children and young people to ensure he is able to fulfill his roles and responsibilities within the allocated time. 35. Review the issues raised for midwifery outlined in section 6.3 of this report namely: clear documentation to account for the voice of the child and the recording of mandatory training on ESR. 36. Consider developing a trust wide strategy or policy for learning and development. 37. Ensure all staff are aware of the process to access continuous professional development funding. 18

19 Appendix A Biography Sandra Gray Sandra is a professionally qualified and experienced independent clinical management consultant. She has held senior positions at regional and local levels in the NHS, including executive director of nursing and operations, project director and associate director of nursing for West Midlands Strategic Health Authority and NHS Midlands and East. Sandra regularly advises trusts and clinical commissioning groups on strategy, the provision and governance of effective clinical services associated with leadership, quality, patient safety and experience. She is currently a clinical faculty member of the NHS Trust Development Authority. 19

20 Appendix B Documents reviewed: Walsall Clinical Commissioning Group Safeguarding Assurance Strategy for Children and adults Safeguarding Quality Assurance and Performance Framework Walsall Healthcare NHS Trust Integrated Safeguarding Committee - Terms of Reference Minutes of Safeguarding Meetings, September & November 2013, January 2014 Safeguarding Children Training Strategy February 2011 Development Session Safeguarding Children Team February 2011 Terms of Reference for the Integrated Safeguarding Committee Sample of Job Descriptions Child Protection Supervision Policy April 2012 Staff Questionnaire pre supervision Child Protection Supervision Form Training Template of information 0 19 year olds Level 3 Training Schedule Draft Terms of Reference Child Sexual Exploitation/Missing Operational Group Safeguarding Children Induction programme Health Visitors Safeguarding Children Policy and Procedures (2011) Version 1.1 Safeguarding Children Report August & September 2013 Annual Safeguarding Report June 2012 & July 2013 Safeguarding Adults Policy (2013) Version 1.1 Board Development Session November 2013 Evidence of Corporate Risk 22 Non -compliance with level 2 & 3 children s safeguarding training Corporate Objectives linked directly to the quality and safety agenda 2013 /14 Management of Correspondence from Acute services and Notifications for Children and young people Attending A & E Paediatric Liaison, Health Visiting & School Service Management of Children and Young People following an incident of self harm Minutes of the Specialty Quality Team meetings for Children & Family Services National Assurance and Accountability Framework (Safeguarding Vulnerable People in the reformed NHS Accountability and Assurance Framework, NHSCB 2013) Intercollegiate Document, Third edition March 2014, Safeguarding Children and Young People: roles and competencies for health care staff, by the Royal College of Paediatric and Child Health (RCPCH) on behalf of the contributing organisations Standards for Children and Young People in Emergency Settings (RCPCH) Performance and development Review & Gateway Policy (2011) Health Assessment Activity Report LAC 20

21 Appendix B Job Plan Named Doctor Safeguarding Children Quality Account 2013/14 Walsall Safeguarding Children Board Learning and Improvement Framework : Draft 1: 08/05/13 21

22 Appendix C Staff involved in the process: Walsall Clinical Commissioning Group Designated Nurse for Safeguarding Children Lead Nurse Quality, Improvement and Partnerships Walsall Healthcare NHS Trust Executive Director of Nursing Deputy Director of Nursing Director of Governance Executive Director of Strategy, Head of Communication & Marketing, HR and OD Named Doctor for Safeguarding Children and Young People A & E Consultant - Safeguarding Lead for Paediatrics and Adults Non Executive Director Chair of Safeguarding Committee Head of Nursing and Midwifery Women and Children / Clinical Support Services Head of Nursing Division of Medicine and Long Term Conditions Lead Named Nurse for Safeguarding Professional Lead for Health Visiting Care Group Manager/ Professional Lead Children and Family Care Group Health Coordinator/Designated Nurse for LAC Named Nurse Safeguarding Children Named Midwife for Safeguarding Children Named nurse for Domestic Abuse/Safeguarding Children Paediatric Liaison Nurse Lead Nurse for Older People and Vulnerable Adults Professional Lead for School Nursing Senior Sister /RSCN A & E Department Junior Sister A & E Department Matron Emergency and Acute Care Group Head of Learning and Development Workforce Training Manager 22