SOMERSET PARTNERSHIP NHS FOUNDATION TRUST SAFEGUARDING ADULTS AT RISK POLIC Report to the Trust Board 16 September 2014 Sponsoring Director: Author: Purpose of the report: Director of Nursing and Patient Safety. Head of Safeguarding. The purpose of this report is to ask the Board to approve the updated Safeguarding Adults at Risk policy. Key Issues and Recommendations: This policy is aimed at all staff and gives an outline of the safeguarding service that the Trust provides whilst signposting staff to follow the appropriate course of action following safeguarding concerns or disclosure. The Safeguarding Adults at Risk policy has been amended: to reflect organisational changes that incorporate previous mental health and community health safeguarding services; to reflect legislative changes and the implementation of the Care Act 2014; to reflect closer working together arrangements with partner agencies; to simplify and clarify operational practice for staff giving a clear referral pathway and operational flow charts. The appendices included in the previous policy have been removed and updated versions are available via the safeguarding intranet pages to ensure up to date versions are readily available for staff to access. Actions required by the Board: The Board is asked to approve the policy. September 2014 Public Board
SAFEGUARDING ADULTS AT RISK POLIC Version: Ratified by: Trust Board Date ratified: Title of originator/author: Head of Safeguarding Title of responsible committee/ group: Clinical Governance Group Date issued: May 2014 Review date: May 2016 Relevant Staff Groups: All Staff Groups This document is available in other formats, including easy read summary versions and other languages upon request. Should you require this please contact the Equality and Diversity on 01278 432000 September 2014 Public Board - 1 -
DOCUMENT CONTROL Reference Number RP/April14/vol4SA ar Amendments Version 4.0 Status Author Head of Safeguarding Reflects changes in Somerset Safeguarding Adults Board & Procedure November 2012 Reflects New Somerset Partnership Safeguarding Adults at Risk Referral Pathway April 2014. Reflects integration of Somerset Partnership NHS Foundation Trust with Somerset Community Health. Document objectives: To provide information to staff and the public regarding the Somerset Partnership. Intended recipients: All Trust staff and members of the public Committee/Group Consulted: Safeguarding Steering Group Safeguarding Champions and Team Leads Group, Mental Health Act Group. Monitoring arrangements and indicators: Safeguarding Steering Group to review in light of any changes to local or national policies and procedures and in response to significant learning from serious case reviews. Training/resource implications: Somerset County Council provides inter-agency Safeguarding Adults training for levels B & C. Level A and A+ training is provided by the Somerset Partnership Training & Development Team and the Trusts Safeguarding Team. Clinical Governance Approving body and date Date: Group Formal Impact Assessment Impact Part 1 Date: Clinical audit standards No Date: NA Ratification Body and date Trust Board Date: Date of issue Review date Contact for review Lead Director Head of Safeguarding Director of Nursing and Patient Safety September 2014 Public Board - 2 -
CONTRIBUTION LIST Key individuals involved in developing the document Name Richard Painter Vanda Squire June Childs Laurence Perrett Safeguarding Steering Group Clare Woodhead & Debbie Bunce Nick Woodhead Somerset County Council South West One Designation or Group Head of Safeguarding Team Leader for Safeguarding Adults MARAC, MAPPA & PREVENT Lead Information Governance Manager Membership CMHT Managers MHA Lead Safeguarding Adults Team Somerset Direct Adults Team Leader September 2014 Public Board - 3 -
CONTENTS Section Page Summary of Section Doc Document Control 2 Cont Contents 4 1. Introduction 5 2. Purpose and Scope 5 3. Duties and Responsibilities 6 4. Explanations of Terms used 8 5. Somerset Partnership Referral Pathway 9 6. Safeguarding Adults Practice Guidance 11 7. Flow Charts for Safeguarding Adults at Risk Community Mental Health Teams Only 14 All Services Apart From Community Mental Health Teams 15 8. Safeguarding Training Requirements 16 9. Equality Impact Assessment 16 10. Counter Fraud 17 11. Monitoring Compliance and Effectiveness 17 12. Relevant Care Quality Commission (CQC) Registration Standards 18 13. References, Acknowledgements and Associated Documents 19 September 2014 Public Board - 4 -
1. INTRODUCTION 1.1 This policy fully support and reflect the core principles and content contained within the Somerset Safeguarding Adults Board Safeguarding Adults at Risk in Somerset Policy - November 2012. (INSERT HPERLINK CLICK HERE FOR LINK TO THE Somerset Safeguarding Adults Board- and Procedure) 1.2 Somerset Partnership NHS Foundation Trust is an active member of the Somerset Safeguarding Adults Board and its sub-groups. 1.3 Somerset Partnership NHS Foundation Trust shares the commitment of partner agencies to Safeguard Adult at Risk by; respecting and upholding their human rights; always giving full consideration to their needs, interests and wishes; working together to reduce the likelihood of abuse or neglect of adults at risk; co-operating in the provision of a professional response to any concerns raised which is robust, proportionate and timely. 1.4 The procedures also aim to make sure that each adult at risk maintains: choice and control; safety; health; quality of life; dignity and respect. 1.5 An Adult at risk is defined as a person aged 18 or over who is or may be unable to protect themselves from harm or exploitation. 1.6 Practice Guidance and Safeguarding information referred to in this Policy is available on the Trust Safeguarding Adults intranet pages. All relevant reporting and recording forms are available within the forms section under Safeguarding. 2. PURPOSE & SCOPE 2.1 This policy ensures all Trust staff are clear regarding their duties and responsibilities to safeguard adults at risk. 2.2 This policy refers to detailed guidance and forms for Safeguarding Adults at risk available on the Trusts intranet. 2.3 Up to date safeguarding adults at risk guidance is available on the Trust s Safeguarding intranet pages or by contacting a member of the safeguarding team. September 2014 Public Board - 5 -
2.4 Up to date forms are available on the Trust s Safeguarding intranet pages. 2.5 This policy provides detailed guidance on the process for both the identification and the reporting of adults at risk of abuse concerns. The ultimate aim is to provide the safest possible care for adults at risk of abuse through consistent application by all staff of the principles within this document. 2.6 This policy reinforces the importance of inter-agency working with the aim of achieving the best possible outcomes for those who we are aiming to protect from risk of abuse. 3. DUTIES AND RESPONSIBILITIES 3.1 The Trust Board has a duty to ensure that it fulfils its statutory duties to safeguard adults from risk of abuse in accordance with the Care Bill 2014. Following publication of this policy the Care Bill with amendments will become the Care Act 2014 later this year. 3.2 The Director of Nursing and Patient safety is the Executive Lead for Safeguarding Adults with the Trust. 3.3 The Trust has a Non-Executive Director for Safeguarding who is also a member of the Trust Safeguarding Steering Group. 3.4 The Head of Safeguarding is responsible for reviewing this policy at least every two years or more frequently if there are changes in legislation. 3.5 The Heads of Division are members of the Trust Safeguarding Steering Group and within their role ensure that operational staff incorporate Safeguarding Policies and Procedures within their practice. 3.6 The Safeguarding Team provides a single point of contact for staff requiring safeguarding adults advice and guidance. Please see Safeguarding intranet pages for up to date contact numbers. Non urgent enquiries only should be made via: safeguardingadults@sompar.nhs.uk 3.7 The Trust Safeguarding Steering Group undertakes a strategic and development role across the Trust and report to the Clinical Governance Group and Trust Board. Please see Safeguarding intranet pages for up to date membership list. 3.8 Each ward or team across the Trust have either a Team Leader (Community Mental Health Teams - CMHTs only), who holds specific safeguarding responsibilities or a Safeguarding Champion who provides local advice and support and a link to the safeguarding team. September 2014 Public Board - 6 -
3.9 Team Leaders (CMHTs only) undertake Level B and C inter-agency safeguarding training in order to equip them to manage the safeguarding adults at risk investigation process. 3.10 Safeguarding Champions undertake inter-agency Level A+ training to assist them in their role to support local staff. 3.11 Professionally Qualified staff within CMHTs undertake level B inter-agency safeguarding adults at risk training to equip them to undertake safeguarding investigations. 3.12 All Trust staff undertake safeguarding training in order to raise their awareness of their responsibilities to safeguarding adults and children at risk of abuse. 3.13 All Trust staff have a responsibility to ensure their safeguarding training is up to date and they conversant with the principles of this policy and are competent to be able to identify safeguarding concerns and ensure appropriate action is taken to safeguarding adults and children. 3.14 All new employees undertake safeguarding adults and children induction training. The aim of this is; to raise their awareness of safeguarding, advise them of their own responsibilities, the principles of this policy, the role of the safeguarding team and the practice guidance and forms available on the intranet.. 3.15 All staff must clearly document all safeguarding concerns and subsequent actions in accordance with trust guidance available on the safeguarding pages of the intranet. 3.16 All Trust Staff must work within the Trust Information Sharing Protocol, available via the safeguarding intranet pages. It should be noted personal information relating to and held by Trust staff is subject to a duty of confidentiality and would not normally be disclosed without consent. However, the Data Protection Act allows for disclosure of confidential information when it is deemed necessary to safeguard the welfare of children, adults at risk and the general public. 3.17 If staff have concerns or doubts about sharing information with any key partner agency, they should discuss this with a member of the Trust s Safeguarding Team and/or the Information Governance Manager based at Mallard Court (01278 432000). September 2014 Public Board - 7 -
4. EXPLANATIONS OF TERMS USED 4.1 An Adult at risk is defined as a person aged 18 or over who is or may be unable to protect themselves from harm or exploitation. (Somerset Safeguarding Adults Board - & Procedure - November 2012) (INSERT HPERLINK- CLICK HERE FOR LINK TO Somerset Safeguarding Adults Board & Procedure) 4.2 An Adults at Risk may also abuse a carer, abuse other vulnerable people, neglect him or herself or deliberately harm themselves. 4.3 Safeguarding Adults means all work which enables an adult to retain independence, well-being and choice and live a life that is free from abuse and neglect. It is about preventing abuse and neglect as well as promoting good practice for responding to concerns on a multi-agency basis. 4.4 An adult at risk may be a person who: is elderly and frail due to ill health, physical disability or cognitive impairment*; has a learning disability; has a physical disability and/or a sensory impairment; has mental health needs including dementia or a personality disorder; has a long-term illness/condition; misuses substances or alcohol; is limited in their capacity to make decisions and is in need of care and support. This list is not exhaustive 4.5 Please note: *This does not mean that just because a person is old or frail or has a disability they are inevitably at risk. For example, a person with a disability who has mental capacity to make decisions about their own safety could be perfectly able to make informed choices and protect themselves from harm. In the context of Safeguarding Adults, the vulnerability of the adult at risk is related to how able they are to make and exercise their own informed choices free from duress, pressure or undue influence of any sort, and to protect themselves from abuse, neglect and exploitation. It is important to note that people with capacity can also be vulnerable. 4.6 An adult at risk s vulnerability is influenced by a range of interconnected factors including personal characteristics, factors associated with their situation or environment and social factors. Safeguarding an adult at risk and positive September 2014 Public Board - 8 -
interventions by staff can have a positive impact on outcomes. The role of the Trusts Safeguarding Team is to compliment and advise the work of other Trust to positively impact on these factors that staff have an opportunity to influence. Some of these are described below; 4.7 Vulnerability Influences Negative Influences Personal or social factors increasing vulnerability Limited mental capacity to make decisions about their own safety including fluctuating mental capacity associated with mental illness Poor physical or mental health Communication difficulties Being dependent on others for basic personal care and activities of daily life Low self-esteem Experience of abuse as a child or in adult life Social isolation, limited range of positive relationships Limited understanding of own rights Positive Influences Personal or social factors decreasing vulnerability Having mental capacity to make decisions about their own safety Good physical and mental health Able to communicate effectively using aids if required Limited dependency upon others or able to self-direct care as needed Self-confidence and high self- esteem Positive life experiences Socially engaged, several positive relationships Good understanding of own rights 5. SOMERSET PARTNERSHIP REFERAL PATHWA FOR SAFEGUARDING ADULTS AT RISK. 5.1 The referral pathway (6.3) on page 10 of this policy has been devised with commissioners and partner agencies in order to give clarity to the process that will be followed within Somerset Partnership and our partner agencies. 5.2 Prior to referrals being made, it is an expectation that staff will seek advice and guidance from their line manager and/or the safeguarding team. 5.3 It is clear in the referral pathway on page nine and in the flow charts on pages 13 and 14 that the process for safeguarding adults at risk is different in the CMHTs compared to all other services. This is because the Trust has delegated responsibility to manage the entire safeguarding process within the CMHTs. 5.4 Health staff that work within the community adult teams for people with learning disabilities, would follow the process and system specific to those teams. These teams are managed and led by the local authority. A significant difference is that referrals are generally received as incidents on open cases. These are then looked at within the teams by the care manager/team manager who will agree the action to be taken looking at the safeguarding threshold. Referrals are rarely received via Somerset Direct. September 2014 Public Board - 9 -
SOMERSET PARTNERSHIP NHS FOUNDATION TRUST SAFEGUARDING ADULTS AT RISK REFERRAL PATHWA Prior to referrals being made, it is an expectation within each organisation that staff will seek advice and guidance from their line manager and from the respective safeguarding team. New safeguarding adults at risk referrals CMHT previous care coordination/management by CMHT Somerset Direct passes referral to Sompar Safeguarding Team to review previous involvement and make a judgement on current concerns. If current concerns not relevant/appropriate the referral will be discussed with SCC Safeguarding Team and consideration for ASC referral will be made by SCC safeguarding team. All referrals go to Somerset Direct 0845 345 9133 adults@somerset.gov.uk Concerns where adult may have significant mental health difficulties but not known / care managed by CMHT Somerset Direct will forward the referral to the Sompar Safeguarding Team who will liaise with the SCC Safeguarding Team to decide which service should accept the referral CMHT open cases The CMHT will inform Sompar Safeguarding Team following the initial judgement (IDR) with the Team Manager whether safeguarding or other processes will be utilised. Sompar Safeguarding Team will advise Somerset Direct to enable logging of information only. Other safeguarding adult concerns Somerset Direct will pass referral to local Adult Social Care Team to lead safeguarding decision-making and any subsequent investigation. If relevant to previous involvement Sompar Safeguarding Team will pass concerns to CMHT for follow up. CMHT Team Manager leads initial discussion, threshold decision (IDR), and investigation. Outcomes to be notified to Sompar Safeguarding Team via (SAMF) at end of the September process 2014 who Public will Board then advise SCC - 10 - Safeguarding Team. Individuals known to Somerset Partnership in services other than a CMHT The Sompar Safeguarding Adults Team will be asked to identify appropriate workers to support the safeguarding process being led by ASC. Continuing Health Care and Funded Nursing Care For safeguarding adults at risk cases the CHC/FNC teams will be notified directly by the ASC Social Work Team. Outcomes must be notified to ASC. Nursing and Care Homes May be requested to undertake their own investigation and feedback outcome to ASC/Sompar.
6. SAFEGUARDING ADULTS PRACTICE GUIDANCE 6.1 The Somerset Safeguarding Adults Board (SAB) - Safeguarding Adults at Risk Policy & Procedure sets out the process for the investigation and monitoring for safeguarding adults at risk. (INSERT HPERLINK- Link here to the Somerset SAB Policy and Procedure.) 6.2 Practice Guidance for all Trust staff not working in CMHTs is available on the safeguarding pages of the intranet. The Referral Pathway on page ten covers all safeguarding adult cases. 6.3 Practice Guidance for staff working in CMHTs is available on the safeguarding pages of the intranet. This has been developed in partnership with the Somerset Safeguarding Adults Board to support managers/staff responsible for leading on and investigating adult protection issues. The Referral Pathway for Safeguarding Adults at Risk on page ten of this policy outlines the process of how to make a report if abuse of a vulnerable adult is suspected and to whom this should be reported. The flowchart on page 13 of this policy gives a clear outline of the safeguarding process for CMHTs to follow. The forms required for the safeguarding process when conducting a safeguarding adult investigation are available in the forms section of the intranet under safeguarding. 6.4 Mental Health Act and Safeguarding. Where actions under the Mental Health Act 2005 & 2007 take fully into account meeting the needs of patients, the safeguarding policy and procedure is not required. When considering the needs of patients who may be at risk of abuse or self-neglect the Safeguarding Adults at Risk Policy and Procedure should be considered alongside the Mental Health Act. For further advice and guidance staff should contact the Mental Health Act Lead for the Trust based at Mallard Court (01278 432000) or the Safeguarding Team. Up to date safeguarding team contact details can be found on the Safeguarding intranet pages. 6.5 Mental Capacity and Safeguarding. The Somerset SAB Policy & Guidance explains the links between Mental Capacity and Safeguarding. (Insert Hyperlink to page 103 of SAB policy. CLICK HERE TO LINK TO The SAB Policy and Procedure.) All staff need to consider a patients mental capacity in terms of the Mental Capacity Act and undertake capacity and best interest assessments where appropriate. Safeguarding procedures are not required unless the needs identified in a mental capacity or best interest assessment suggests that the adult is at risk. For further advice and guidance staff should contact the Mental Health Act Lead for the Trust based at Mallard Court (01278) 432000 or the Safeguarding Team. Up to date safeguarding team contact details can be found on the Safeguarding intranet pages 6.6 Deprivation of Liberty Standards (DoLS) and Safeguarding. The SAB Policy & Guidance explains the links between DoLS and safeguarding. (Insert hyperlink to page 109 of the SAB policy. CLICK TO LINK TO The SAB Policy & Procedure.) All staff need to consider whether DoLS applies to patients with whom they are working. DoLS applies when a patient has a mental disorder and does not have the capacity to make decisions. DoLS needs to be considered when the actions that staff are proposing to make in the patients best interests may be considered as depriving them of their liberty. For further advice and guidance staff should contact the September 2014 Public Board - 11 -
Mental Health Act Lead for the Trust based at Mallard Court (01278) 432000 or the Safeguarding Team. Up to date safeguarding team contact details can be found on the Safeguarding intranet pages 6.7 Domestic Abuse and Safeguarding. The SAB Policy & Guidance explains the links between domestic abuse and safeguarding. (Insert Hyperlink to page109 of the SAB policy. CLICK TO LINK TO The SAB Policy & Procedure.) The Multi-Agency Risk Assessment Conferences (MARAC s) explained in the SAB policy are an important part of the Trusts work. The Trust has a Domestic Abuse Policy for Patients available on the Trusts safeguarding pages. All staff have a duty to ensure the safety of patients and their families, undertake specific risk assessments and make appropriate referrals as specified within the Domestic Abuse Policy. Further information, risk assessments and referral details are available on the Trust safeguarding intranet pages. For further advice and guidance staff should contact the Trusts lead for MARAC via the Safeguarding Team. Up to date contact details can be found on the Safeguarding intranet pages. 6.8 Multi- Agency Public Protection Arrangements (MAPPA) and Safeguarding. MAPPA is designed to ensure that there is a co-ordinated approach to the management of dangerous offenders and sexual offence offenders. The safeguarding intranet pages contain information and guidance for staff regarding the management of offenders. For further advice and guidance staff should contact the Trusts lead for MAPPA via the Safeguarding Team. Up to date contact details can be found on the Safeguarding intranet pages. 6.9 PREVENT (Counter Terrorism Strategy) and Safeguarding. PREVENT is part of the governments CONTEST- counter terrorism strategy. The Trust has a duty to ensure that all staff are aware of our responsibilities under the PREVENT strategy. The principle of PREVENT is to identify those with whom staff may be working who are in danger of being radicalised into potential terrorist activity. The aim is to work with partner agencies, primarily the police, to divert people away from what could be considered to be linked to terrorist activity. Further information is available on the Trusts intranet safeguarding pages. For further advice and guidance staff should contact the Trusts lead for PREVENT via the Safeguarding Team. Up to date contact details can be found on the Safeguarding intranet pages. The Trust provide Health WRAP training as part of the safeguarding training package to all appropriate staff to inform them of how to recognise and respond to potential PREVENT cases. 6.10 Whole Service Concerns relating to care settings where there are safeguarding concerns for more than one individual. The Trusts Safeguarding Team are represented at regular inter-agency meetings where whole service concerns are discussed and a Special Placements List is updated. This is available to CMHT managers when considering placements. Whole Service Concerns are managed by Somerset County Council Safeguarding Team colleagues. There are guidance notes and Performa s that are available but it is important to remember that the individual safeguarding process for patients (see page 13) still needs to be followed to ensure individual needs and responses to risk are managed in consultation with the Trusts Safeguarding Team. For Whole Service Concerns please contact the Safeguarding Adult Team Leader. Up to September 2014 Public Board - 12 -
date safeguarding team contact details can be found on the Safeguarding intranet pages. September 2014 Public Board - 13 -
7. FLOW CHART FOR SAFEGUARDING ADULTS AT RISK 7.1 COMMUNIT MENTAL HEALTH TEAMS (CMHTs) Safeguarding concern identified and recorded in RiO progress note with appropriate RiO alert being added. (Ensure Care coordinator advised if not person identifying concern) Care Coordinator/Allocated Worker gathers information and after discussion with line manager and Safeguarding Team (01823 346694) completes Safeguarding Adults - Initial Discussion Record (IDR) (INSERT HPERLINK) to allow Safeguarding team to make a safeguarding RiO notes and formal decision making process to begin. Team Manager and worker decide action to be taken. 1. Always record decision making on Safeguarding Adults - IDR. 2. Email copy to safeguardingadultsteam@sompar.nhs.uk 3. Upload document on RIO under "SAFE" code and cross reference in a Progress Note. 4. Ensure Rio risk alert and risk assessment updated. 5. Safeguarding issue needs to be evaluated in care plan and care plan updated accordingly. Datix report may suggest SIRI process needs to be triggered. Safeguarding Adults Team Leader/ Head of Safeguarding Adults will lead this decision in consultation with Director of Nursing & Patient Safety If Team Manager has decided the safeguarding concern meets the threshold for the Safeguarding policy to be followed. Safeguarding Action Plan (INSERT HPERLINK) to commence. Worker leads the investigation & ensures completion of Datix form identifying Safeguarding. Is a Safeguarding Strategy Meeting required? ES Team Manager ensures safeguarding investigation commences. NO Review RCPA NO ES Within 2 working days set date for a Safeguarding Strategy Meeting inviting partner agencies and IMCA/ Advocate if required. Record in progress The Safeguarding Strategy meeting should be held within 10 working days where practicable and should consider the safeguarding investigation to date, the views of the patient, with support of an advocate if necessary, alongside the professionals actively involved. The meeting needs to follow the agenda (INSERT HPERLINK) & be recorded using the template. (INSERT HPERLINK). A review Safeguarding Strategy Meeting may be required in complex cases with multiple actions to ensure actions are fully met. Following each strategy meeting/review strategy meeting the following must be updated: safeguarding action plan, RiO progress notes, care plan, risk screen, risk assessment. A Safeguarding Outcome Monitoring form must be completed at the end of the process. September 2014 Public Board - 14 - Update RCPA and cross reference in a Progress Notes to reflect influence of safeguarding concerns. The Safeguarding Outcome Monitoring Form ensures that outcomes are always recorded. (Insert Hyperlink) email to the safeguardingadultsteam@so mpar.nhs.uk N.B It is essential this always done to avoid the Trust under reporting to the Somerset Safeguarding Adults Board.
7.2 ALL SERVICES APART FROM COMMUNIT MENTAL HEALTH TEAMS (CMHTs) AND LEARNING DISABILIT HEALTH STAFF (See 5.4) WORKING IN THE COMMUNIT LEARNING DISABILIT TEAMS Safeguarding Concern Identified and discussed with patient if appropriate. Refer to an advocate if required. Discuss your concerns with your line manager and/or Local Safeguarding Champion and seek further advice from the Safeguarding Team if required. See Safeguarding intranet pages for contact numbers. safeguardingadultsteam@sompar.nhs.uk Complete Safeguarding Adults alert form (Insert Link to form) and complete DATIX incident form (Insert link). Email copy of completed alert form to adults@somerset.gov.uk and copy to safeguardingadultsteam@sompar.nhs.uk and patient s social worker if known. If the safeguarding concern relates to a criminal matter copy alert form to southernscu@avonandsomerset.pnn.uk Somerset Direct will pass referral to Adult Social Care Team for threshold decision whether referral accepted as safeguarding. Any immediate Sompar actions required will be notified to the Sompar Safeguarding Team and the referrer. Within 2 working days, Sompar worker raising referral should contact patient s social worker if known, or Somerset Direct on 0845 345 9133 to obtain outcome of safeguarding referral, the planned actions and Sompar involvement required. If safeguarding procedure to be followed, Adult Social will lead this and liaise with the Sompar Safeguarding Team to request the referrer continues to be involved with the safeguarding plan alongside other Sompar colleagues that it may be appropriate to involve. Be sure to play an active part in the multi-agency safeguarding process and inform decision making. Seek advice / guidance from your line manager, safeguarding champion and the Sompar Safeguarding Team at any point you need to. No further action required continue with care pathway but be vigilant and report any further safeguarding concerns. Safeguarding investigation will be undertaken, led by Adult Social Care and will clarify whether safeguarding process needs to continue. If safeguarding concerns continue a safeguarding case conference will be convened by adult social care. An action plan will be agreed and is likely to require ongoing Sompar involvement. No further action required continue with agreed care pathway and continue to record and liaise with Somerset Direct/ adult social care. Re-refer if required. Continue with this process until all actions are complete and the patient is no longer at risk as agreed with adult social care. September 2014 Public Board - 15 -
8. SAFEGUARDING TRAINING REQUIREMENTS 8.1 The Trust is committed to ensuring all staff are appropriately trained in line with the Trusts Training Matrix. 8.2 There are five levels of training, which reflect roles within the Trust. 8.3 Basic awareness raising undertaken at mandatory induction for all new staff - covers recognition and response to abuse - mandatory for all staff. 8.4 Level A Recognising and responding to abuse. This is provided by the Sompar Safeguarding Team and the Sompar training and Development Team. This is recommended for all staff not working in CMHTs who have direct contact with adult patients. Accessed via nomination through the Sompar Learning and Development Team. Three yearly refreshers recommended. 8.5 Working together (formally known as Level A+) For all staff not working in a CMHT who may support the safeguarding investigation led by adult social care. This is multi-agency training provided in a partnership between the Sompar Safeguarding Team and the Adult Social Care Safeguarding Team. Accessed via nomination through the Learning and Development Team, three yearly refreshers recommended. 8.6 Level B - Safeguarding Adults at Risk. This is mandatory for all staff working in CMHTs who may undertake safeguarding investigations. This training is accessed via nomination through the Sompar Learning and Development Team and is multi-agency provided by adult social care. The three full days training must be completed. Three yearly refreshers required. 8.7 Level C - Managers and Deputy Team Managers of CMHTs mandatory training in addition to Level B for managers. This training is to equip managers to lead and manage safeguarding investigations and to chair safeguarding adult at risk conferences. This can be accessed via the Sompar Learning and Development Team. Three early refreshers recommended. 9. EQUALIT IMPACT ASSESSMENT 9.1 All relevant persons are required to comply with this document and must demonstrate sensitivity and competence in relation to the nine protected characteristics as defined by the Equality Act 2010. In addition, the Trust has identified Learning Disabilities as an additional tenth protected characteristic. If you, or any other groups, believe you are disadvantaged by anything contained in this document please contact the Equality and Diversity Lead who will then actively respond to the enquiry. September 2014 Public Board - 16 -
10. COUNTER FRAUD 10.1 The Trust is committed to the NHS Protect Counter Fraud Policy to reduce fraud in the NHS to a minimum, keep it at that level and put funds stolen by fraud back into patient care. Therefore, consideration has been given to the inclusion of guidance with regard to the potential for fraud and corruption to occur and what action should be taken during the development of this document. 11. MONITORING COMPLIANCE AND EFFECTIVENESS 11.1 The Trusts Safeguarding Adults at Risk Best Practice Group and the Sompar Champions and Leads Group both report to the Trusts Combined Safeguarding Adults and Children Steering Group. 11.2 The Trusts Combined Safeguarding Steering Group reports to the Clinical Governance Group. 11.3 The Clinical Governance Group reports to the Trust Board. 11.4 The Trusts Head of Safeguarding has a responsibility to monitor performance of the Trusts safeguarding adults at risk arrangements and report to the Somerset Safeguarding Adults Board as required. 11.5 Methodology to be used for Monitoring periodic reports to the Somerset Safeguarding Adults Board for inclusion in the Safeguarding Adults Board annual report; statistical quantitative and qualitative data; serious incidents requiring investigations review group reporting; Safeguarding DATIX Reporting; Safeguarding RIO Reports; Safeguarding Adults Board and sub-groups; Trusts Combined Safeguarding Steering Group; Safeguarding Adults Monitoring Forms. 11.6 Frequency of Monitoring annual reports to Somerset Safeguarding Adults Board; quarterly updates provided to the Somerset Safeguarding Adults Board; September 2014 Public Board - 17 -
quarterly Best Practice Group; quarterly Team Leads and Champions Group; quarterly reports to the Clinical Governance meeting; quarterly reports to the Trusts Combined Safeguarding Steering Group. 11.7 Process for reviewing results and ensuring improvement in performance occur. the Somerset Safeguarding Adults Board discusses multi-agency safeguarding adults at risk matters. This includes deciding the safeguarding agenda for developing safeguarding in Somerset in line with national and local directives, identifying good practice, highlighting areas for improvement, discussing Serious Case Reviews and lessons learnt. Lessons learnt from the Serious Case Reviews are fed into the Trust via the internal safeguarding groups. 11.8 Lessons learnt will be forwarded to the Trusts Head of Risk who will add to the Lessons Learnt Quarter Report to the Risk Group meeting. Following each meeting the report will be accessible to all staff on the Trust Intranet and hyperlinked into newsletter to raise awareness. 12. RELEVANT CARE QUALIT COMMISSION (CQC) REGISTRATION STANDARDS The standards and outcomes which inform this procedural document are as follows: Section Outcome Information and involvement 1 Respecting and involving people who use services 2 Consent to care and treatment Personalised care, treatment and support 4 Care and welfare of people who use services 5 Meeting nutritional needs 6 Cooperating with other providers Safeguarding and safety 7 Safeguarding people who use services from abuse 8 Cleanliness and infection control 9 Management of medicines 10 Safety and suitability of premises 11 Safety, availability and suitability of equipment Suitability of staffing 12 Requirements relating to workers 13 Staffing 14 Supporting workers Quality and management 15 Statement of purpose 16 Assessing and monitoring the quality of service provision 17 Complaints 18 Notification of death of a person who uses services September 2014 Public Board - 18 -
19 Notification of death or unauthorised absence of a person who is detained or liable to be detained under the MHA 1983 20 Notification of other incidents 21 Records Relevant National Requirements Care Act 2014 Department of Health guidance NICE and other clinical guidance 13. REFERENCES, ACKNOWLEDGEMENTS AND ASSOCIATED DOCUMENTS 13.1 References Department of Health, (1998), Modernising social services, partnerships in action. DOH, London Department of Health, (2000), No Secrets: Guidance on developing and Implementing multi-agency policies and procedures to protect vulnerable adults from abuse. DH, London Home Office, (1998), Speaking up for justice. Home Office Justice and Victims Unit, London Somerset County Council (2012) Safeguarding Adults at Risk Somerset Safeguarding Adults Policy and Procedure. The Association of Directors of Social Services (2005), Safeguarding Adults: A National Framework of Standards for good practice and outcomes in adult protection work. Edited by, Fiennes S, Ingram R, Pell J, Quigley L, Robinson J. ADSS, London 13.2 Cross reference to other procedural documents Clinical Assessment & Management of Risk of Harm to Self and Others Policy Confidentiality and Data Protection Policy Counter Fraud Policy DATIX Risk Reporting Guidance DATIX, Untoward Event Reporting Guidance Escalation Policy Information Sharing Protocol Learning, Development and Mandatory Training Policy Managing Allegations against Staff Policy PALS and Complaints Policy Recovery, Care Programme Approach Policy September 2014 Public Board - 19 -
Record Keeping and Records Management Policy Risk Management Policy and Procedure Risk Management Strategy Safeguarding Adults Strategy Trust Board Paper Safeguarding Children Policy Serious Incidents Requiring Investigation (SIRI) Policy Somerset and Procedure Staff Training Matrix (Training Needs Analysis) Training Prospectus Untoward Events Reporting Policy and Guidance Whistleblowing Policy Work force Development Strategy (2008-2013) All current policies and procedures are accessible to all staff on the Trust intranet (on the home page, click on Policies and Procedures ). Trust Guidance is accessible to staff on the Trust Intranet (on the home page, click on Information, then Local Guidance). The Safeguarding intranet pages contain all of the up to date contact details and other useful links. September 2014 Public Board - 20 -
Links to Strategic Themes: Identify to which of the Somerset Partnership NHS Foundation Trust strategic themes this report relates by including a cross behind the relevant theme(s) Quality and Safety X Innovation X Viability and Growth Integration Service Delivery X Culture and People Links to the Assurance Framework: Links to the NHS Constitution and Trust Values: Links to CQC Domains: Identify to which risks of the Assurance Framework this report relates not relevant to any specific risks on the Assurance Framework but safeguarding underpins all risks of the Assurance Framework Identify the Values to which the issues raised in this report relate by including a cross behind the relevant value(s) Working together for patients Respect and dignity Commitment to quality of care X X Compassion Improving lives X Everyone counts Identify which of the CQC domains are covered by this report by including a cross behind the relevant domain(s) X Is it safe? X Is it caring? Is it well-led? Is it effective? Is it responsive to people s needs? Legal or statutory implications/ requirements: Public/Staff Involvement History: Previous Consideration: Care Act 2014; Not applicable. Not applicable. September 2014 Public Board - 21 -
CHECKLIST FOR APPROVAL AND RATIFICATION OF PROCEDURAL DOCUMENT Key Questions /N Comments Title Document Title and Version: Safeguarding Adults at Risk Is the title clear and unambiguous? Is it clear whether the document is a guideline, policy, protocol or standard? Rationale Are reasons for development of the document stated? Development Process Is the method described in brief? Are people involved in the development identified including consultation Groups? Equality Impact Assessment Has an Equality Impact Assessment been completed? 14/7/14 Approval and Review Does the document identify the approval group? Document Author: Rich Painter Date: 14.7.14 Part B: To be completed by the approving Governance Group Part A: To be completed by the Document Author: Development Process Has a reasonable attempt been made to ensure relevant expertise has been used in document development? Is there evidence of robust consultation with key stakeholders? If appropriate have the JMSCC (or equivalent) agreed the document? Content Is the objective of the document clear? Is there a clear policy statement? Is the target population clear and unambiguous? Evidence Base Does the document clearly signpost to the relevant national guidance, standards and/or legislation checklist September 2014 Public Board - 1 -
Does the document correspond to NHSLA Risk Management standards? If so are the relevant minimum requirements clearly described? Does the document correspond to CQC standards? If so are the relevant standards clearly identified? Are key references cited in full? Does the document make explicit cross reference to other supporting procedural documentation? Dissemination and Implementation Is there an outline plan to identify how this will be done? Does the plan include the necessary training/support to ensure compliance? Process to Monitor Compliance and Effectiveness Are there clear and measurable standards which identify how and when monitoring of compliance with the document will be undertaken? Does the monitoring section of the document identify whether there is a plan to audit compliance with the document? Review Date Is the frequency of review identified? If so is it acceptable? Overall Responsibility for the Document Is it clear who will be responsible for co-ordinating the dissemination, implementation and review of the documentation? Launched via What s on in Sompar and promoted via Divisional meetings. Supported by staff training explained in the policy. Compliance monitoring occurs via audit and through the Somerset Safeguarding Adults Board Will be more frequent if required. Governance Group Approval Group Clinical Governance Date of meeting 24 July 2014 Name (Chair) Sue Balcombe Signature Following document approval this fully completed form should be provided alongside the approved documentation for final ratification by Senior Managers Business Group (or Board if required). Part C: To be completed by the Ratification Group Senior Managers Business Group (or Trust Board where required) Ratification Complete below and send to the Document Author Group Name (Chair) Date of meeting Signature checklist September 2014 Public Board - 2 -
Equality Impact Screening Assessment Form PART ONE Document/Activity being assessed: Safeguarding Adults at risk Policy Name of person completing screening assessment: Rich Painter 1. What is the main purpose of the document/activity being assessed? To replace the existing Safeguarding Vulnerable Adults at Risk Policy. New policy reflects legislative, organisational and Somerset Safeguarding Adults Board Developments. 2. Who will be affected or will benefit most from the document/activity and how? All patients deemed to be an adult at risk in accordance with the policy. Staff will have a more concise policy to follow that incorporates referral pathway and operational flowcharts. 3. Is the activity consistent with European Human Rights legislation? ES If NO, please indicate in what areas it is not consistent. (if in doubt- note this and confirm advice has been sought) 4. Is the activity consistent with the Trust s obligations under the Equality Act? ES If NO, please indicate in what areas it is not consistent. (if in doubt- note this and confirm advice has been sought. 5. Is responsibility for the activity shared with another agency or organisation? ES If ES, please indicate other agency or organisation. Safeguarding activity is undertaken with partner agencies and commissioners. 6. What impact is the document/activity likely to have on the Equality Act s protected characteristics groups (including staff)? ou may wish to use the table below as a prompt. The document will give updated clarity to the existing arrangements. - 1 -
Compliant AND Needs Considered Suggested amendments or additions to document or activity. Age ES NO Disability ES NO Gender Reassignment ES NO Marital Status/Civil Partnership ES NO Pregnancy and Maternity ES NO Race ES NO Religion or Belief ES NO Sex (Gender) ES NO Sexual Orientation ES NO Learning Disabilities ES NO - 2 -
If unsure how to answer, please seek further guidance from the Equality and Diversity Lead before proceeding. Signature of person completing Screening Assessment: Date Screening Assessment completed: 14/7/14 PART TWO For completion by the Equality and Diversity Lead: As a result of this Screening Assessment are further amendments and additions required? ES If ES, please see below. Additions or amendments which need to be made A number of formatting and spelling issues noted; document should be in Arial 12 pt throughout. Information on the protected characteristics (of the Equality Act 2010) of these patients should be included in the monitoring information. Are there other ways the activity could be adapted so it further promotes equality? Not at this time. Signed: Date: 16 July 2014 (Equality and Diversity Lead) - 3 -