Appendix 1. Safeguarding Children and Adults. Safeguarding Children

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1 Appendix 1 Safeguarding Children and Adults Safeguarding Children Following the presentation of the Safeguarding Children Annual Report by the Designated Nurse for Safeguarding Children at the Salford CCG Board meeting on 29 May 2013, a further detailed Safeguarding Children update report has been requested for the CCG Board meeting on 25 September- this update will provide additional information in respect of specific areas discussed within the Annual Report. There are no ongoing Serious Case Reviews (SCR) in relation to children. These reviews are undertaken if the criteria stipulated by the statutory guidance- Working Together to Safeguard Children (Department for Education, 3013) - is met. This guidance states that LSCBs must always undertake an SCR for cases where abuse or neglect of a child is known or suspected; and either (i) the child has died; or (ii) the child has been seriously harmed and there is cause for concern as to the way in which the authority, their Board partners or other relevant persons have worked together to safeguard the child. The Designated Nurse for Safeguarding Children is Chair of the Salford Safeguarding Children Board (SSCB) Case Review Subgroup. The Subgroup is currently undertaking four Case of Concern Reviews. Any agency can make a referral for a case to be considered by this Subgroup in accordance with the SSCB Case Review Policy. The Subgroup undertakes Case of Concern Reviews for cases which do not meet the criteria for an SCR but the Subgroup identifies that there are lessons to be learnt through undertaking a review. For two of these cases, it has been identified that there are lessons to be learnt for individual partner agencies but not for involved health services or for multi-agency working. The third case is to be discussed in detail for the first time at the Case Review Subgroup meeting on 12 July The fourth case was reviewed through a Multi-Agency Learning Event Methodology and has identified lessons to be learnt for multi-agency working. This case was a complex safeguarding case with multiple agencies involved. The final report and action plan will be presented to the SSCB Executive Committee in September 2013 in order to ensure that SSCB is in agreement with the report and determined action plan. One theme identified was in relation to information sharing. Whilst there were some examples of good information sharing within this case, this did not happen consistently. One action agreed is to develop additional but succinct information sharing guidance which will be cascaded across and within all agencies and included within all single and multi-agency training. A decision is awaited as to whether or not a Domestic Homicide Review is to be undertaken following an incident in Salford on 29 June This decision will be made within 1 month of the date of the incident by the Chairs of the Community Safety Partnership. Working Together to Safeguard Children, 2013, stipulates that LSCBs have to gather data to assess whether partner agencies are meeting their obligations under Section

2 11 of the Children Act 2004 i.e. they conduct their day to day business in a way which takes into account the need to safeguard and promote the welfare of children. For example, agencies ensure that staff have had relevant safeguarding training and have safe recruitment processes in place. SSCB is currently gathering this data by undertaking a Section 11 audit and the Designated Nurse for Safeguarding Children is leading on this audit for Salford CCG. Undertaking this work will identify any required areas of development for the CCG. Salford Royal Foundation Trust (SRFT) and Greater Manchester West Mental Health NHS Foundation Trust (GMW) are also required to complete this audit. The SSCB Performance Management Subgroup reviews all completed Section 11 audit tools and resultant action plans and reports the findings to SSCB. The Designated Nurse for Safeguarding Children is a member of this Subgroup and can therefore gain a good understanding of the key health provider action plans and any areas of concern. The Specialist Nurse Safeguarding Children for Independent Contractors is a member of the SSCB Child Sexual Exploitation (CSE) Subgroup this is currently a very high profile area of safeguarding children practice. Multi-agency guidance is in place and single and multi-agency training is being delivered. One CSE seminar has been offered to GP Practice staff to date and a further seminar will be offered before the end of The first CSE seminar offered was attended by 1 GP and 3 Practice Nurses only. The Safeguarding Team has recognised that the Practices are currently prioritising attendance at the mandatory level 2 safeguarding children training resulting in attendance at the additional seminars offered to date being limited. Further seminars will be offered and the Safeguarding Team will continue to monitor attendance at these. Regular meetings between the Specialist Safeguarding Nurse for Independent Contractors and the Designated Nurse for Safeguarding Children with the Safeguarding Leads within GP Practices are to be convened from September. A first topic for discussion will be Child Sexual Exploitation with the expectation that the GP Safeguarding Leads will have increased knowledge and understanding which they will be expected to share with colleagues. This increased knowledge will also enable the GP Safeguarding Leads to provide initial case advice to Practice colleagues. Further topics will be raised at subsequent such meetings and will provide an additional method for cascading information to Practices. A further method now being utilised is the GP monthly bulletin- as of July the Safeguarding Team has commenced providing safeguarding information for inclusion in each of these bulletins. The Designated Nurse for Safeguarding Children and Designated Nurse for Adult Safeguarding are attending the GM Safeguarding Collaborative Meetings convened by the Area Team since April A key area for discussion has been the division of safeguarding responsibilities between the Greater Manchester Area Team and the Greater Manchester CCGs in accordance with the non-statutory guidance published by the NHS Commissioning Board on 21 March 2013 Safeguarding Vulnerable People in the Reformed NHS Accountability and Assurance Framework. There is a need to clarify responsibilities in relation to primary medical care and in particular to the following:

3 Responsibilities for commissioning GP Individual Management Reviews for Serious Case Reviews (adult and children) and Domestic Homicide Reviews Responsibility for the provision of safeguarding training for primary medical care. These discussions are currently ongoing and have been raised by the Greater Manchester Designated Nurses with Chief Operating Officers. Safeguarding Children Training The continued aim for NHS Salford CCG is to ensure that all practices have access to and have undertaken Safeguarding Children Training appropriate for their role in accordance with the statutory guidance Working Together to Safeguard Children (2013) and the Intercollegiate Document (2010). The training undertaken by staff will feed into the overall mandatory training schedule and strategy for the CCG. It should be undertaken three yearly. Practice based training within General Practices in NHS Salford was commenced in June Level 2 Safeguarding Children Training was primarily offered within practice settings to encourage engagement from all practice staff and GPs (Figure 1). Level 2 safeguarding training will be completed by September An action plan has been agreed in July 2013 by the CCG GP Quality Lead, CCG Safeguarding Children GP Lead, the CCG Designated Nurse Safeguarding Children and the CCG Specialist Nurse Safeguarding Children, Independent Contractors to engage the remaining GPs and practices in completing level 2 safeguarding training. Particular areas of reduced uptake from GPs are Ordsall /Langworthy cluster and Broughton. These are particularly significant given the numbers of children subject to child protection plans (CPP) within these areas- see Table 1 which indicates the areas where there are higher levels of vulnerable families and highlights the need for engagement and completion of training within these areas. Ordsall & Claremont/ Little Total Broughton Langworthy Weaste Eccles Swinton Irlam Hulton Walkden GPs 77% 56% 82% 93% 97% 100% 80% 90% 86% PN 73% 67% 80% 95% 91% 73% 100% 90% 93% Other 34% 55% 85% 86% 83% 48% 100% 90% 78% No of Children on CPP 31/03/ Figure 1 shows the % of GP s, practice nurses (including other nurse clinicians) and other staff by Cluster who have received face to face safeguarding children training up until July 2013.

4 Figure 2 demonstrates the progression of GPs trained in % from June 12 Jul 13. Jun-12 10% Jun-Sept-12 34% Dec-12 55% Apr-13 84% Jul-13 86% Level 3 safeguarding children training for GPs has already commenced. 33% of GPs have completed level 3 training which will be offered via seminars and cluster groups. The aim is to complete this training by June Domestic Abuse and Multi agency Risk Assessment Conferences (MARAC) The provision of GP feedback form MARAC meetings has commenced from May Information is disseminated from the Specialist Nurse Safeguarding Children,

5 Independent Contractors to indiviual GP practices after each MARAC meeting following liaision with the SRFT Safeguarding Team Domestic Abuse lead. This includes detailed information about the domestic abuse, the perpetrator, the victim and any children. It also includes an action plan from MARAC detailing specific agency responsiblities and ongoing work to promote the safety/protection of the victim and the children. The purpose of this is to alert the GPs to the victims and children who are high risk cases of domestic abuse within their practice in order to inform their treatment and management of this vulnerable client group. There are approximately 20 cases per fortnight sent out to GP Practices across the city. Within the last two months 7 of these recent cases have required direct discussion with the GP regarding the management of specifically high levels of risk either to the victim, to the staff within the practice or both. Examples of these cases are if the perpetrator poses a risk to life as they are known to carry a weapon and have extensive violent history including custodial sentences, pose a risk to lone female workers/health staff, particularly violent attacks on a pregnant victim requiring more intensive monitoring from the GP. Work has been undertaken with the practices in relation to secure storage of this information and placing standardised alerts on the systems to ensure each healthcare professional who is treating these clients within the practice setting is fully aware of the circumstances of this client/family and any risks that may be present. As a result of this process it has been identified that training for GPs on Domestic Abuse and MARAC is required to improve their knowledge and skill base. A training event has been organised by NHS Salford CCG on the 18 th September this is to be supported by the Greater Manchester Police MARAC Lead and the SRFT Safeguarding Team Domestic Abuse Lead. Domestic abuse is also discussed briefly within the Level 2 safeguarding children training. Intial Case Conference report completion Work has continued with GPs in relation to their provision of reports for initial child protection case conferences via the developed report proforma specifically for GP practices. GPs have a critical role to play in safeguarding and promoting the welfare of children (Working Together to Safeguard Children 2013, GMC 2012) The Safeguarding LES ended on March 31 st On analysis of the figures for completion on intial case conference reports this does not seem to have had a direct impact. However the number of reports provided has fallen to 46% in May See table 2. Table 2- % GP reports completed for Intial Case Conference Aug 12 May 13 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 70% 65% 44% 60% 70% 54% 42% 40% 34% 46% Figure 3 represents the % of competed GP Intial case conference reports from Aug 12 May 13

6 Further analysis of the figures has identified several themes in relation to completion of the reports. Firstly, there are inconsistencies in the provision of reports from some practices whilst it is noted that others are consistent. A 50% increase in the numbers of initial child protection case conferences taking place has been indentified in the month of April 13 and therefore an increase in the number of reports requested from GP practices has taken place possibly leading to a reduced timeline for their completion. There is a correlation between those areas that have undertaken training and the clusters who have completed the highest numbers of initial case conference reports (Table 3). Therefore the practices who have not completed intial case conference reports have been identified and further work is in progress to address this. However, there has been a significant level of support for GPs from the Specialist Nurse Safeguarding Independent Contractors which has continued consistently throughout this time period. An action plan has been agreed in July 2013 by the CCG GP Quality Lead, CCG Safeguarding Children GP Lead, the CCG Designated Nurse Safeguarding Children and the CCG Specialist Nurse Safeguarding Children, Independent Contractors to progress this issue through the Neighbourhood Clinical Commissioning Groups (NCCG) where individual practice figures will be discussed with a view to increasing compliance. The governance process for this will be that the NCCGs will feed into the Quality and Outcomes Group through to the Programme Management Group where this will be fed the CCG Board. Table 3 GP reports completed for Intial Case Conference Aug 12 May 13 by cluster Clusters No of Reports Requested No of Reports Completed % of Reports Completed Broughton Ordsall & Langworthy Claremont / Weaste Eccles Swinton and Pendlebury Irlam Little Hulton Walkden % 40% 30% 60% 59% 10% 40% 54%

7 The quality of the reports provided will be reviewed via an audit commencing in August 2013 for six weeks. The findings and individual feedback will be reviewed and disseminated accordingly to identify changes or developments that ensure the delivery of best practice in relation to the safeguarding initial case conference reports. Adult Safeguarding The role of the Designated Nurse for Adult Safeguarding in the CCG is developing and differs from that of the established role of the Designated Nurse for Safeguarding Children. Predominantly, cases of adult abuse often have complex health care requirements and therefore, the Designated Nurse for Adult Safeguarding regularly represents health at safeguarding strategy and case conference meetings and provides direct support with safeguarding investigations to support social services. In conjunction with this the Designated Nurse for Adult Safeguarding has strategic oversight of the adult safeguarding agenda. Ultimately, the Designated Nurse and the CCG envisage that the role of the Designated Nurse for Adult Safeguarding moves away from a predominantly reactive approach to adult abuse and moves towards preventative measures. Training update From December 2012, Adult Safeguarding training has been introduced and rolled out to all general practice staff including administrative staff. This training was developed in conjunction with the North West Core Skills Framework guidance to ensure standardization and consistency of training delivered to independent practitioners. Figure 1 shows the % of GP s, practice nurses (including other nurse clinicians) and other staff by Cluster who have received face to face adult safeguarding training up until July Figure 1

8 Between 2011/ 2012, 17.6% of referrals into adult safeguarding were from Healthcare staff. Between 2012/ 2013, this has risen to 25.3%. It is suggested that the instigation of adult safeguarding training across independent contractors and other provider services by colleagues within SRFT may anecdotally have influenced this. However, it has been recognized that current data collated within the Local Authority does not provide an explicit split between providers and independent contractors, particularly since the change from PCT to CCG. This has been raised and action to coordinate more accurate data is scheduled. Further development with training is still required in respect of adult safeguarding. Figure 2 shows the latest data obtained from the Adult Safeguarding Unit detailing the alerts for adult safeguarding within individual Integrated Care Teams. Figure 2: The table below highlights the no. of alerts made from each of Salford s Integrated Care Teams 1 st April 2011 to 31 st March st April 2012 to 31 st March 2013 Integrated Team (I/T) Total alerts Total alerts Broughton I/T Claremont I/T Eccles I/T Irlam/ Cadishead I/T Little Hulton I/T Ordsall I/T Swinton I/T Walkden I/T The figures in red show where there has been a decrease in alerts in these areas and will form the basis of areas (practices) to target further adult safeguarding training. The data also provides us with possible higher risk areas in relation to adult abuse cases. Care Homes update There are currently no care homes within the serious concerns process. Regular meetings with the Care Quality Commission (CQC) are in place and attended by the Designated Nurse Adult Safeguarding. This provides an opportunity to share any low level concerns and will instigate further health and social care reviews or an inspection from CQC. Furthermore, intelligence is also gathered via the CCG Quality Lead who attends the system wide Quality Surveillance Group. Trends in respect of alerts within care homes are currently monitored and concerns specific to health are investigated by the Designated Nurse for Adult Safeguarding. Concerns in respect of Heartly Green Residential Home were raised around the care of residents with pressure ulcers. An investigation eliminated these concerns though highlighted issues in relation to: Poor record keeping

9 Poor communication between Care Staff and District Nurses.

10 Good Practice example As a result of this, the Designated Nurse for Adult Safeguarding in conjunction with Heartly Green has adapted the Intentional rounding tool (renamed as Comfort in Care) to improve the quality of care provision and record keeping. Since implementation of this tool, the Care Home Manager has highlighted that Comfort in Care has proved invaluable in safeguarding investigations in respect of providing evidence. This pilot will be expanded to further residential care homes. Residential Care Home Intentional Rou Following over a month of completing the Care in Comfort tool, Heartly Green have been able to utilize the tool to provide evidence within a safeguarding investigation. Records of food and fluid intake are now recorded in greater detail and provide a more personalized approach to the care of their residents. In addition to this, a leaflet developed by the NHS Institute of Innovation and Improvement around Harm Free Care has been adapted by the Designated Nurse for Adult Safeguarding and now provides information for carers/ care staff on how to prevent harms to residents including, catheter related UTI s, pressure ulcers and falls. This leaflet is being shared with the Designated nurses across Greater Manchester to ensure consistency of good practice information. Final Draft March 13.pdf Adult Safeguarding Strategy and Case Conference meeting developments Within the remit of the Designated Nurse for Adult Safeguarding is to attend both safeguarding strategy meetings and case conferences to represent health. Attendance at these meetings has enabled appropriate sharing of expertise and supported social services to complete thorough safeguarding investigations and eliminate barriers around information sharing. In order to capture data to support the level of input required from the Designated Nurse (as well as NHS Funded Care), a request form has now been developed to provided an audit trail of any input required at adult safeguarding meetings. This will also endeavour to capture areas of concern specific to health.

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