Safeguarding Adult Annual Report 2014/15

Safeguarding Adult Annual Report 2014/15 We put patient safety and well being above everything We foster strong partnership working to safeguard our patients from harm

Safeguarding Adults Annual Report 2014/15 1.0 Executive summary This Annual Report 2014/15, on Safeguarding Adults (SA) and the Mental Capacity Act (MCA), activities at UCLH, covers the discussions & outputs of the UCLH Safeguarding Adults Steering Group and the work undertaken to ensure vulnerable adults in the care of the Trust are safe and well cared for by a kind and compassionate workforce. UCLH takes its safeguarding responsibilities extremely seriously, and to that end fulfils the Care Quality Commission s (CQC) principles of adult safeguarding by ensuring that we protect people s health, wellbeing and human rights, and enable them to live free from harm, abuse and neglect. The safeguarding team has successfully achieved and delivered its objectives and initiatives, including training compliance and CQUIN 1 targets. Importantly we have seen a measureable improvement in patient care with the support of two additional staff members with their respective expertise in Domestic Violence (DV) and Learning Disabilities (LD). An overview Major changes in 2014/15 have influenced and affected the safeguarding agenda in the UK. In March 2014, the Supreme Court made significant amendments to the Deprivation of Liberty safeguards (DoLs) to include a new acid test. At the same time, the House of Lords produced a report which was critical about how the MCA and DoLs have been implemented, citing gaps and failings. In May 2014, the Care Act 2014 was passed by Parliament which revokes No Secrets 2000, repeals and cancels 40 pieces of primary legislations and statutory guidance. These changes have a significant impact on how safeguarding patients is managed by local authorities, commissioning, the Police, partner agencies and health with resource, capacity and cost implications. Following the Francis Report, the Cavendish Report recommended the development of a national Care Certificate for all health and social care support workers to be equipped with consistent standards of care. The 15 standards set out explicitly the learning outcomes and competencies to ensure that staff are caring, compassionate and provide quality care. Safeguarding adults is explicitly defined in Standard 10. The Trust is implementing the certificate in April 2015 for all new starters. UCLH has a responsibility to adhere and align itself with these changes by ensuring that systems and processes are in place to support staff and patients. It continues to embed the recommendations of the Francis and Keogh report to ensure that patient safety and wellbeing is considered above everything, underpinned by its Harm Free Care agenda. 1.1 Summary of key achievements - Divisions have achieved training compliance: Level 1= 95%, Level 2=91% - The appointment of a dedicated full-time LD senior nurse - The recruitment of a substantive Band 7 Safeguarding Nurse - Presented a Legal Masterclass for the MCA with the The Department of Health (DH) & Hempson Legal - Achieved CQUIN targets, led by the DV Steering Group - Improved support for people suffering from Domestic & Sexual abuse with the help of a Domestic & Sexual Violence Officer ( joint Partnership with Camden Safety Net) - Raised DV awareness in high risk areas: trained 394 staff (Level 1) and 414 health professionals (Level 2) in early identification and management of patients. 1 Commissioning for Quality and Innovation (CQUIN) payment allows commissioners to reward excellence, by linking a proportion of providers income to the achievement of local quality improvement goals. 2

- Referred 20 DV victims to the Police led Multi Agency Risk Assessment Committee s Identified and provided safe haven for 34 high risk DV victims. - Since January 2015-267 clinical staff (high risk areas) have completed the LD awareness training. - Since December 2014 provided direct support for 104 high-risk in-patients with LD to improve their experience whilst in hospital. - Made 103 DoLs safeguard applications. - Preparedness for the Care Act 2014 and Care Certificate was delivered on time. 1.2 Summary of key risks 1.2.1 Training Compliance for mandatory Level 3 training trust-wide remains red at 75%. Compliance for Medical & Dental training remains at amber: Level 1= 89% and Level 2 = 84% Increasing administration burden on application of DoLs due to increasing number of referrals. PREVENT 2 further work required to embed 2015/16 PREVENT training. Ongoing work regarding full implementation of the DV NICE guidelines. 1.2.2 Specific Impact of changes in DoLs and 2015 Care Act Increasing administration burden regarding application of DoLs due to significant increase in number of referrals. Continued increasing trend in safeguarding referrals, predicted to increase further secondary to the 2015 Care Act legislation. Meet compliance for statutory changes by the Care Act to make enquiries and Making Safeguarding Personal (MSP). 1.3 Recommendations and risk mitigating actions Divisions to target staff who require Level 3 training to meet 90% compliance (24 staff in total identified and action in place) complete end of June 2015. Medical Safeguarding lead identified - July 2015. Develop next stage strategy for the PREVENT agenda by July 2015 with Workforce & Security colleagues. Sustain 2014/15 gains made to meet NICE Domestic Violence guidelines & Domestic Violence CQUIN goals by end of April 2016. Finalise changes on systems, policies and procedures to incorporate the new Care Act by July 2015. Review the safeguarding service to ensure the DoLs and Care Act agenda are implemented effectively with adequate support. Capitalise on the Learning Disability work done to date and continue to increase activity and measure outcomes via patient and carer experience. Review the current e-flagging system for identification of high-risk patients entering our pathways. Assurance: incorporate key safeguarding elements into 2015/16 internal audit programme. 2 PREVENT is a government strategy that focuses support on vulnerable individuals. 3

2. 0 Summary of Safeguarding Adults alerts - Tables A- E Table A: Total Safeguarding Adults Alerts 2014/15 NEGLECT 9 0 3 23 73 122 FINANCIAL PHYSICAL PSYCHOLOGICA L SEXUAL DISCRIMATORY 61 32 INSTITUTIONAL Table B: Location of Alerts at UCH 2012/13 2014/15 4

Table C Location of Alerts at QSD 2012/13 to 2014/15 Table D: The Heart Hospital, Eastman Dental Hospital & Royal National Nose Throat Ear Hospital 2012/13 to 2014/15 Table E: Five Year Summary of safeguarding alerts 2012 to 2015 CATEGORY 2010/12 2011/12 2012/13 2013/14 2014/15 TOTAL ALERTS 126 167 175 243 329 AVERAGE PER MONTH 10 14 15 20 27 INCREASE 93% 5% 39% 39% 35% NEGLECT 38 52 59 73 122 FINANCIAL 8 23 18 35 32 PHYSICAL 15 35 43 45 61 PSYCHOLOGICAL 25 21 10 19 23 SEXUAL 1 10 11 4 9 DISCRIMATORY 2 0 0 2 0 INSTITUTIONAL 7 1 0 19 3 OTHER 30 25 34 46 73 5

2.1 Summary of safeguarding alerts (Tables A-E) The total number of safeguarding alerts for 2014/15 continued to increase steadily (to 329 at year end), with a 35% rise from the previous year. This is consistent with reports by Camden Adult Social Care (ASC), as per Section 10.0. Neglect has the highest category of alerts rising by 66%. Physical and psychological abuse continues to rise with the largest increase in Other by 59%. Financial abuse at UCLH has dropped slightly in contrast to Camden reports. The upward trend continues at the Emergency Department (ED) where A&E alerts have risen by 79%.The ED (A&E & the Acute Medical Unit (AMU)) in total represents 47% of alerts reported. Queen Square Division (QSD) reports 20% of alerts. At UCH, T7 ward alerts have risen by 63% and in the ICU there is an increase by 120%. There is also a rise in alerts from outpatient settings, Chalfont, Hyper Acute Stroke Unit and the Heart Hospital. The five year trend since 2012 demonstrates steady yearly increases, especially over the last three years. This may be due to the successful awareness training delivered which encourages staff to recognise and report abuse. A&E department staff were commended by the safeguarding team as their heightened awareness has led to a 79% increase in alerts. The large increase of Other (defines specific vulnerable groups of self-neglect) by 59% will have a significant impact as the new Care Act has included these groups of patients who require safeguarding enquiries. Colleagues at Camden ASC have recorded a rise of 115% in protection plans. A large number of the remaining cases required social services support and intervention. There is generally a significant rise of patients with highly complex needs who require comprehensive discharge planning with multi agency partners/providers. This factor, which includes challenges on community resources to cope with the increases, has a significant impact on discharge planning and length of stay. Summary of key alerts: Pressure ulcers: 47 Domestic Violence : 44 Allegations against family: 80 There has been an increase in patients admitted to UCLH with serious pressure ulcers - resulting in 47 UCLH referrals categorised as patients suffering neglect. There is a subsequent increase in referrals to the coroner and to inquests. A large percentage of these patients are perceived to have the capacity to refuse or reject care. Several cases have determined that more timely intervention and enhanced multi-agency working within a shared information approach may have reduced the risk of harm in these patients. Recommendations of learning from the investigations have emphasised the urgency for community staff and agencies to raise awareness for the MCA and the vital duty to intervene once patients are identified as high risk. UCLH Case Studies 2014/15 A Serious Case Review (SCR) for Mr A is described below. This was led by Camden Safeguarding Adults Partnership Board & illustrates the challenges. The final report is due to be published in the 3 rd quarter of 2015/16. Another case of Domestic Homicide Review was held by Ealing Social Services. The perpetrator was convicted of murder in February 2015. Lessons were discussed by multi-agency partners for patients at risk from domestic violence, with actions being committed by various agencies. UCLH received two whistleblower reports which were appropriately referred to relevant agencies to ensure patients are protected and safe practices implemented. 6

Serious Neglect case review Mr A Mr A, a 89 year old man was admitted to the Emergency Department. He appeared severely neglected, cachectic, dehydrated & emaciated with 13 multiple (Grade 3-4) pressure ulcers all over his body. Most were necrotic and to the bone. His vital signs were poor. Mr A was immediately transferred to the ICU where he subsequently died within 24 hours on admission with sepsis and multi organ failure. Mr A s estimated weight was 30kg. His case was referred to the coroner. Staff at ED and the safeguarding team took prompt action to ensure that full documentation and medical photography were prepared immediately on admission. The Police were informed. Two inquests were conducted. During a recent AAR it was accepted that most staff who had years of experience had never experienced such a severe case of neglect. 2.2 Alerts against staff or UCLH in 2014/15 There were a total of 31 alerts made against staff and/or the Trust. Investigations of the safeguarding alerts, jointly led by Camden and partner Social Services were carried out in accordance with the Pan-London policy & procedures. These incidents were examined by the Quality & Safety team which referred appropriate referrals for Serious Incident investigations. Some of these were referred to Independent Reviews and were duly notified to the CQC. Alerts were raised from: o Medical Specialties - 14 o Surgical & Cancer - 6 o Specialist Divisions - 11 Outcomes of alerts: o Unsubstantiated 22 o Inconclusive 1 o Substantiated - 4 o Pending - 4 Substantiated cases involved: o Medication error - QSD o Omission of care/pressure ulcer Infectious Disease o Multi-agency failure/poor discharge Infectious Disease o Inappropriate professional behaviour Surgical Specialties As part of the learning, trust systems and processes have been comprehensively reviewed and changes made to ensure that gaps identified have been fully addressed to prevent the incidents from reoccurring. As reflective learning, managers have responded by reassessing and reviewing policies and procedures and acting on recommended action points to learn from incidents, support staff, patients and improve practice. A reflective session is a standing item at the Safeguarding Adults Steering Group Agenda where Matrons from affected divisions discuss actions taken and learning with the multi agency peer group. Additionally, root cause analysis, After Action Reviews (AAR) and Schwartz Rounds 3 have assisted staff to improve patient care and professional practice through reflective exercises. 3 Meetings which provide an opportunity for staff from all disciplines across the Trust to reflect on the emotional aspects of their work 7

3.0 Safeguarding Adults & the Mental Capacity Act Training Table F - Safeguarding Adults & the MCA training compliance by board Board Not compliant Level 1 Corporate Functions 2 98.2% Medicine Board 26 95.9% Specialist Hospital Board 70 93.4% Surgery and Cancer Board 50 95.9% Grand Total 148 95.1% Board Not compliant Level 2 Corporate Functions 4 84.0% Medicine Board 19 93.8% Specialist Hospital Board 133 90.1% Surgery and Cancer Board 12 89.7% Grand Total 168 90.6% Board Not compliant Level 3 Corporate Functions 100.0% Medicine Board 12 61.3% Specialist Hospital Board 9 80.0% Surgery and Cancer Board 3 82.4% Grand Total 24 75.3% Table G Safeguarding Adults & the MCA training compliance by staff groups Staff Group Not compliant Level 1 Not compliant Level 2 Not compliant Level 3 Additional Clinical 97.4% 81.2% Services 14 13 NA N/A Administrative and 93.5% 96.2% Clerical 2 1 NA 100.0% Allied Health 99.4% 96.9% Professionals 2 4 NA N/A Medical and Dental 98 89.5% 33 84.3% NA N/A Nursing and Midwifery 97.6% 91.6% Registered 27 108 24 74.7% Students 2 77.8% N/A NA N/A Grand Total 148 95.1% 168 90.6% 24 75.3% Table H Five year comparison of Safeguarding AdultsTraining Compliance at UCLH Year 2010/11 2011/12 2012/13 2013/14 2014/15 Percentage 62% 84% 89% 61% 95% 8

3.1 Summary of Safeguarding Adults & the MCA training (Table F- H & Appendix A) As demonstrated in Table H, for the first time in five years, compliance for safeguarding training has met 95%. This is due to the commitment of divisions and staff to keep safeguarding a top priority in improving patient care and experience. The efforts of the Learning & Development department and the safeguarding team in continuing to improve the training framework have successfully delivered an efficient and effective training system for staff. Compliance for Level 3 MCA training does remains at amber at 75% (24 staff identified as requiring training). The Nursing Directorate, in particular the Medical Specialties are committed to ensuring that compliance is met in the next quarter. Medical Directors have been asked to identify a clinical lead to champion safeguarding adults and the MCA for medical and dental staff, in an effort to improve its compliance which is at amber. This action requires attention. To assist professionals to embed and apply the principles of the MCA, the Trust organised a Legal Masterclass in December 2014, inviting the DH MCA Lead and legal and psychiatric experts to present case law. It generated an active debate and received positive feedback by staff. To ensure staff knowledge and awareness on safeguarding, the MCA and DoLs, the Trust has implemented specific measures:: Easy guide for DoLs, standardised red drawers across all clinical sites at QSD, QSC Newsletter messages and the appointment of a Band 7 Safeguarding Nurse. The level 2 elearning tool was revised and case scenarios added to make the training more effective and engaging. An impact assessment will be conducted in quarter 3 to evaluate its efficacy. A new national Care Certificate to ensure that all new healthcare support workers receive consistent 15 standards with skillsets and competences will be implemented on the 1 st April 2015. 4.0 Quality Assurance 4.1 External Audit: In October 2014 Baker Tilly (internal auditors during 2014/15) reviewed compliance with the Safeguarding Adults, MCA and Consent Policies. The draft review (issued in April 2015) rated Safeguarding Adults as Green-Amber with the following recommendations: a) Management should ensure that training records are fully and accurately maintained. b) Managers should be reminded of the need for all new starters to complete mandatory training as part of the staff induction process and as part of ongoing training. Regular reports should be produced to identify when mandatory training has not been undertaken so that appropriate reminders and action can be taken c) Managers should be reminded of the need to ensure that all mandatory training is undertaken as required. 4.2 Trust Casenote (Safeguarding Adults) Audit In February 2015 thirty four sets of casenotes from across the Trust were audited. The audit results were mixed and demonstrated that although improved, further work was required to embed Safeguarding across the Trust; this is particularly relevant and timely given the 2015 Care Act. Audit recommendations: Review of (2013 syllabus) training content for clinical staff. Continued leadership by both medical and nursing teams to prioritise safeguarding, and to release staff to participate in the safeguarding investigation process ie completion of forms, attending meetings and providing documents as required by the safeguarding agencies. Further embed the 2014 Staff Responsibilities for Safeguarding. 9

Update the Trust Safeguarding Policy to reflect these changes. 5.0 The Care Act 2014 (Appendix B) The Care Act, effective from the 1 st April 2015, sets out a statutory framework for adult safeguarding and is binding on local authorities, the police and the NHS but it also has relevance and messages for a much broader range of organisations and individuals. Specific safeguarding duties and powers are set out in Sections 42-45, 68 and Schedule 2 of the Act but there are a range of relevant other provisions including the principle of promoting well-being, assessment., care planning, and prevention The message from the DH is that this is not a case of business as usual. Both in terms of statutory duties and the development of practice, the Care Act heralds a new way of working in adult safeguarding, encapsulated by the Making Safeguarding Personal Programme.. 5.1 Statutory guidance The Care Act replaces No Secrets 2000 and repeals/replaces 40 pieces of legislations, under Annex 1. The new definition states: Adult Safeguarding is working with adults with care and support needs to keep them safe from abuse or neglect. Unlike the rest of the Care Act, the safeguarding duties have a legal effect in relation to organisations other than the local authority and are binding on the NHS and the Police. The Care Act requires that each local authority must: a. make enquiries, or ensure others do so, if it believes an adult is, or is at risk of, abuse or neglect. b. set up a Safeguarding Adults Board (SAB) c. arrange, where appropriate, for an independent advocate to represent and support an adult who is the subject of a safeguarding enquiry or Safeguarding Adult Review where the adult has substantial difficulty in being involved in the process and where there is no other appropriate adult to help them; d. cooperate with each of its relevant partners (as set out in section 6 of the Care Act) in order to protect adults experiencing or at risk of abuse or neglect. 5.2 Making Safeguarding Personal (MSP) The statutory guidance requires local authorities to make safeguarding a personalised experience: aiming to achieve the outcomes identified by adults at risk of harm and abuse, rather than a people being taken through a process. The MSP programme originated in sector-led improvement and the identification, through peer reviews, that people were being 'put through a process' rather than engaged in it, and that in many instances families, the individual concerned, professionals, teams and boards were not able to identify what difference the intervention had made. 5.3 There are 10 revised categories of abuse: Physical, domestic violence, sexual abuse, psychological, financial or material, modern slavery, discriminatory, organisational abuse, neglect and acts of omission and self-neglect (new categories in bold) 5.4 Actions taken to implement the Care Act: Develop an FAQ for all staff for dissemination (completed and published on UCLH Intranet) Revise all training content ( completed) Revise & update Safeguarding policies and procedures (P&P) - completed & due for approval May 2015 Inform the Executive Board. Briefing note sent in March. Item is on May agenda 10

Escalate to other partners to revise P&P for the other 40 pieces of legislations and statutory guidance eg Discharge teams (completed) Review resources and capacity to manage predicted increased activities and alerts from DV and Self Neglect groups Collaborate with social services & external agencies to manage increases effectively 6. 0 Pressure Ulcers Incidences of Hospital Acquired Pressure Ulcers (HAPU) are monitored by the Harm Free Care group. There were no Grade 4, 64 Grade 2 and 12 Grade 3 HAPU (a 40% reduction in Grade 3 HAPUs). Indications are that the Trust will achieve its 2014/15 pressure ulcer CQUIN. A trigger system is in the DATIX 4 referral process requires senior nurses to identify & refer any safeguarding concerns from the HAPU s to the safeguarding team UCLH has adopted the principles of the Pan London Pressure Ulcer protocol, which is embedded in trust policies. 7.0. The Mental Capacity Act) & Deprivation of Liberty safeguards In March 2014, the Supreme Court made a ruling which stipulates the application of an acid test: if a person is continuously supervised, controlled and not free to leave, they are deprived of their liberty for people who lack capacity to make decisions As expected, the ruling has resulted in a huge surge of applications across the country. DH has estimated a ten-fold increase to 110,000 for 2014/15. The responses from CQC, ADASS (Association of Directors of Social Services) NHS England and the DH have issued guidance on how organisations and providers meet the capacity to cope with the ruling. DH, in partnership with ADASS and partners has developed a revision and guidance of the application forms. The Court of Protection has made amendments to accept block applications from care homes. The Law Society has written a practical guide Identifying a deprivation of liberty in April 2015 to provide guidance for organisations in the hospital, psychiatric, care home, supported living, at home and under 18 s settings to ensure that staff adhere to correct applications of the test and to ensure patient s human rights are respected. Enclosed link: lawsocietyadvice New DoLs forms and guidance are available to staff on the UCLH website in the Safeguarding Patients section. 7.1 Deprivation of Liberty safeguards applications at UCLH Total: 103 QSD- 36 (largest numbers at John Young= 10) University College Hospital - 67 ( AMU = 12, T7=28) Approved: 52 (50%) Declined: 36 Pending: 12 Local Authorities: 40 (41%) from Camden, 22 from Islington, the others from across London and the rest of England In 2014/15 UCLH made 103 applications compared to 18 the previous year, a rise of 472%. There were 3 applications in 2011/12, 6 in 2010/11 and zero in 2009/10.The sudden increase is a result of greater staff and public awareness, and the Supreme Court rulings and is consistent with national figures. There were 41% of applications sent to Camden 4 Healthcare Incidents, patient Safety and Risk Management reporting system 11

The increase has generated risks for providers, including UCLH: Timely processing of complex applications & meeting requirements of local authorities Applying the correct legal tool to detain patients: interface between the MCA & the Mental Health Act (MHA) Applying the correct acid test to at risk groups at ICU, A&E, Care of the Elderly & neurology settings Timely referral to the Coroner and Local Authorities when patient dies whilst under DoLs or MHA. Resource and capacity of provider teams to manage the increase in applications effectively These are 2014/15 actions UCLH has taken to mitigate the risks above and to ensure we are compliant with the legal requirements: Development of an Easy Guide on DoL s application for Trust-wide leads (completed) Set up a system and database to monitor and manage applications (completed) Up-skilling of existing key staff/champions to Level 3 training. Compliance remains at amber (75%) Revise elearning and face to face training content to align with new ruling (completed). Escalate the risk of not meeting compliance to the trust risk register(completed) Organise a legal Masterclass with experts: lawyers, psychiatrists and the DH to inform staff (completed December 2014) UCLH lead for safeguarding adults & the MCA is a member of the national steering group at the DH developing new national guidance (completed) 8.0 Learning Disabilities UCLH is working jointly together with multi agency partners in Camden and Islington to learn lessons from Death by Indifference- 74 deaths and counting and Winterbourne. A new LD Clinical Nurse Specialist (CNS) was appointed in November 2014. LD progress in year: Developed a 3 level training framework & workplan. Trained and raised awareness for 267 staff on Level 1 (LD specific training). Supported 104 patents through a patient centred pathway across emergency and elective pathways. Increased access to LD services through regular clinical walk rounds. Engaged with local LD users in the local community at Camden and cross London. Developed a bespoke UCLH video for LD patients who may enter our Hospitals via the emergency or elective pathways. 9.0 PREVENT HealthWrap & Counter Terrorism (Radicalisation)Traini UCLH continues to support the PREVENT strategy to raise awareness in the safeguarding agenda. Public organisations are required by the Home Office, the DH and NHS England to raise awareness through staff training by a specifically packaged training, Prevent HealthWrap 3. NHS trusts are required to report monthly to the DH and NHS England. Camden is identified as a high priority borough, with prioritised areas like mental health, A&E & ambulance services, offender and adolescent services as key delivery areas. At UCLH, this initiative is led jointly by, the Trust Lead for SA and Head of Security, who are trained to deliver training, jointly with the London Metropolitan Police. To date, UCLH has trained 138 key staff. The DH has recommended that staff at the emergency department, the mental health and adolescence teams should be prioritised for training. Although the A&E department has trained a significant proportion of their staff (75%) over the past 2 years, maintaining this high level of compliance (due to staff turnover) will continue to be a challenge 2015/16. 12

Four senior staff from the safeguarding and security team have been trained by the NHS England and Prevent team to facilitate training locally using a revised HealthWrap 3 module, this will aid training compliance. Both the Camden PREVENT teams from the Police and ASC are assisting with the UCLH leads to deliver the training for 2015/16. 10.0 Update from Camden Safeguarding Adults Partnership Board Quarter 1-3 2014/15 This is a summary extracted from the Camden Safeguarding Adults Partnership Board report: There has been an increase in the number of safeguarding alerts when compared with the same period last year. There were 1021 alerts for April to February 2015 opposed to 726 for the same period in 2013/14. The screening of alerts continues to be effective in ensuring that cases strictly involving safeguarding proceeding to referrals and investigation. The numbers of referrals were 393, a 38% increase from last year. Referrals leading to protection plans increased to 311, a 115% increase from last year NHS staff are the highest source of referral (206) compared to 113 for ASC. There is a slight increase in alerts from GPs (15) There was a total of 224 cases of abuse allegedly perpetrated by a relative/ carer (including paid domiciliary carers from all sectors) in the victim s own home, and the police were involved in 36 of these cases. Abuse by family and friends continue to rate as the highest (46%). Social Care staff is the second group. Financial abuse ranks the highest, with neglect and physical respectively There were a total of 313 DoLs applications (a fivefold increase) The reason for low numbers for Camden is due to the low numbers of care homes in the borough IMCA (Independent Mental Capacity Advocates) referrals were not recorded. 11.0 Domestic Violence (DV) In February 2014, NICE issued guidelines for trust implementation. The CCG s recommend local CQUIN funding to support and enable the implementation of DV across services. A DV Steering Group (DVSG) was set up to develop a strategic plan to include a 3- level training framework and pilots of screening tools at the A&E and maternity (commenced in December 2014) The DVSG has successfully delivered all targets for 2014/15. The Independent Domestic & Sexual Violence Advocate (IDSVA), in partnership with local Camden Safety Net has received 103 referrals from 33 settings across the trust. A&E are the highest referral source, with maternity as the second source. Twenty victims were referred to the Police led, Multi Agency Risk Assessment Committee (MARAC). Safe haven was identified for 34 high risk victims A total of 394 staff received level 1 training and 414 professionals from high risk areas have received Level 2 training. 12.0 Female Genital Mutilation (FGM) The Female Genital Mutilation Act 2003: Makes it illegal to practice FGM in the UK Makes it illegal to take girls who are British nationals or permanent residents of the UK abroad for FGM whether or not it is lawful in that country Makes it illegal to aid, abet, counsel or procure the carrying out of FGM abroad Has a penalty of up to 14 years in prison and/or a fine 13

The Serious Crime Act 2015 amended sections of the 2003 Act to extend statutory duties. Section 74 inserts a section 5B into the Act which creates a new mandatory reporting duty requiring specified regulated professionals ( healthcare professional, teacher or social care worker) in England & Wales to make a report to the police, if the FGM appears to have been carried out on a girl under 18 (at the time of discovery). The Prime Minister, at the Girl Summit in July 2015 introduced the new measures which state: all acute hospitals must report the prevalence of FGM each month. Mandatory reporting started in September 2014. At UCLH, the adult FGM team is led by a Consultant Obstetrician & Gynaecologist, who submits a quarterly report to the Safeguarding Adults Steering Group: Achievements: Streamlined integrated service with continued support for these women Education & Training regular training sessions for all staff to raise awareness Developed a database to collect & monitor data Challenges: Data collection of all cases from the rest of the hospital Provide psychological support for women The total number of referrals from September March 2015 are: 233, eight were children. Enclosed is a link to the FGM act 2003 and the Serious Crime Act 2015 legislation.gov.uk 13.0 Care Quality Commission There were no inspections in 2014/15 UCLH has implemented the Improving Care Rounds to assist staff to improve practice and to acclimatise them in the new inspection to include the new Fundamental Standards of Care. Recommendations made following these monthly visits have seen improvement in patient care 14.0 Conclusion This report demonstrates that 2014/15 has been an active and productive year for the safeguarding adult and MCA DoLs agenda. The safeguarding team has successfully achieved and delivered its objectives and initiatives, including training compliance and CQUIN targets. Importantly we have seen a measureable improvement in patient care with the support of two additional staff members with their respective expertise in Domestic Violence (DV) and Learning Disabilities (LD). In year changes in legislation have resulted in major revisions to systems and process to ensure that the trust is aligned with national standards and as required by commissioners and regulators. One year on from the implementation of the 2014 Supreme Court Judgement of the acid test, the Law Society, DH, ADASS and the House of Lords have developed plans to help and support organisations and health partners to navigate the complex applications of deprivation of liberty safeguards. The 2014/15 casenote audit of the safeguarding investigation process has highlighted some risks in how the safeguarding policy, procedures and processes are managed. Recommendations have been made with regard to staffs responsibilities. The trust continues to embed the Supreme Court ruling by constantly scanning the horizon with external partners to ensure that when patients who lack capacity to make decisions to leave, appropriate legal tools and appropriate process are applied. The new 2015 Care Act poses new challenges through its now statutory footing. The impact of the Act will be closely monitored by the Safeguarding Team to ensure UCLH meets its legal obligations. Compiled by Betsey Lau-Robinson, Trust Safeguarding Adults & MCA Lead, for the Safeguarding Adults Steering Group - May 2015 14

Appendix A Safeguarding Adults Training Compliance 2014/15 by Clinical Division LEVEL 1 Division not compliant Grand Total Compliance Chief Nurse Division 61 100.0% Clinical Governance 24 100.0% Corporate Services 26 100.0% Education 1 73 97.9% Information & Communication Technology 82 100.0% Research and Development 1 76 96.6% Workforce 96 100.0% TOTAL 2 601 Clinical Support 3 372 97.6% Critical Care 4 199 81.0% Emergency Services 10 265 95.3% Infection 114 100.0% Integration Division 24 100.0% Medical Specialties 6 221 96.1% Medicine Board Central Team 54 100.0% Pathology 3 104 96.1% TOTAL 26 1353 Eastman Dental Hospital 2 329 98.6% Heart Hospital 22 447 90.0% Paediatrics Division 7 243 96.3% Queen Square 8 1404 94.7% RNTNE Hospital 11 285 93.6% SpH Divisional Management 26 100.0% Women's Health 20 591 89.5% TOTAL 70 3325 Cancer Services 17 596 95.3% Gastrointestinal 8 272 96.0% Imaging 5 229 97.1% S&C Management Team 29 100.0% Surgical Specialities Division 14 296 93.4% Theatres and Anaesthetics 6 449 97.9% TOTAL 148 7150 95.1% 15

LEVEL 2 Corporate Functions Division Capital Investment & Facilities Not Compliant Compliance 100.0% Chief Nurse Division 2 87.5% Clinical Governance 100.0% Research and Development 100.0% Workforce 1 66.7% Corporate Functions Total 4 Medicine Board Clinical Support N/A Critical Care 9 94.7% Emergency Services 2 95.9% Infection 7 87.7% Integration Division 100.0% Medical Specialties 1 92.3% Medicine Board Central Team 100.0% Pathology 100.0% Medicine Board Total 19 Specialist Hospital Board Eastman Dental Hospital 100.0% Heart Hospital 16 84.3% Paediatrics Division 4 73.3% Queen Square 77 90.8% RNTNE Hospital 1 95.0% Women's Health 35 89.5% Specialist Hospital Board Total 133 Surgery and Cancer Board Cancer Services 4 86.7% Gastrointestinal 100.0% Imaging 1 66.7% S&C Management Team 100.0% Surgical Specialities Division 3 88.0% Theatres and Anaesthetics 4 87.5% Surgery and Cancer Board Total 12 Grand Total 168 90.6% 16

LEVEL 3 Board Division Not Compliant Compliance Chief Nurse Division 100.0% Clinical Governance 100.0% Corporate Functions Total 100.0% Medicine Board Emergency Services 1 91.7% Infection 1 50.0% Medical Specialties 1 83.3% Medicine Board Central 18.2% Team 9 Medicine Board Total 12 Specialist Hospital Board Eastman Dental Hospital 100.0% Heart Hospital 2 85.7% Paediatrics Division 1 0.0% Queen Square 5 72.2% RNTNE Hospital 100.0% Women's Health 1 90.0% Specialist Hospital Board Total 9 Surgery and Cancer Board Cancer Services 2 66.7% Gastrointestinal 100.0% Surgical Specialities Division 1 87.5% Theatres and Anaesthetics Surgery and Cancer Board Total 3 N/A Grand Total 24 75.3% 17