SAFEGUARDING ADULTS POLICY

SAFEGUARDING ADULTS POLICY NHS East and North Hertfordshire Clinical Commissioning Group Page 1 of 19

DOCUMENT CONTROL SHEET Document Owner: Director of Nursing & Quality Document Author(s): Head of Adult Safeguarding Version: Version 1 FINAL Directorate: Nursing & Quality Approved By: Quality Committee Date of Approval: March 2016 Date of Review: March 2018 Change History: Version Date Reviewer(s) Revision Description v1.0 December 2015 Implementation Plan: PA to Director of Nursing & Quality FINAL Development and Consultation Dissemination Nursing and Quality Directorate Staff can access this policy via the intranet and will be notified of new/revised versions via the staff briefing. This policy will be included in CCG Publication Scheme in compliance with the Freedom of Information Act 2000. Senior and line managers have responsibility to support staff in implementing good safeguarding practice. Training Staff training will be linked to the competency framework agreed by the HSAB and will be part of mandatory training The CCG s as commissioners must ensure that all commissioning and contract arrangements clarify the need for a training work plan following an annual training workforce analysis, in accordance with national guidance. This should be provided as part of their performance management data collection in terms of evidence of attendance. All staff within the CCG in order to enable compliance with this policy, will be required to attend mandatory safeguarding adults training at the commencement of their employment and then as a refresher every three years. Key members of staff such as the Director of Nursing, Accountable Officer and Chair of the CCG will receive a refresher every year NHS East and North Hertfordshire Clinical Commissioning Group Page 2 of 19

Monitoring Review Equality, Diversity and Privacy The CCG will seek assurance from providers by a broad range of quality monitoring mechanisms drawing from qualitative and quantitative data including: The completion of the annual Self-Assessment Assurance Framework. Quality monitoring/site visits. Individual development work with providers and by attending a range of provider meetings, regional forums, steering groups and public safety initiatives (Prevent, MAPPA and MARAC) in the local area. Clinical Governance The CCG will apply the principles of sound clinical and corporate governance in relation to safeguarding adults which takes account of the corporate governance framework for NHS organisations. The CCG will ensure that safeguarding and promoting the welfare of adults at risk is integral to clinical governance and audit arrangements. The CCG s staff members are responsible for recording near misses, incidents or serious incidents in relation to safeguarding adults according to the organisations reporting policy. The Quality Committee will receive a safeguarding adults report on a six monthly basis including exception reporting and information on the progress of domestic homicide reviews and safeguarding adult reviews and their action plans. The CCG will produce an annual report for safeguarding adults which will be a public document. The CCG will also contribute to the Hertfordshire Safeguarding Adult Board Annual Report. This policy will be subject to 2 yearly review and will also be subject to alteration if required through the creation of additional policy, legislation or guidance and / or local guidance. If revised, all relevant staff/stakeholders will be alerted to the new version when ratified by the Quality Committee. 17/12/2015 - Equality Impact Assessment 17/12/2015 - Privacy Impact Assessment NHS East and North Hertfordshire Clinical Commissioning Group Page 3 of 19

Associated Documents This policy should be read in conjunction with the Hertfordshire Safeguarding Adults from Abuse Procedure issue 9(2015) and the CCG is committed to implementing these procedures in order to comply with relevant legislation and policy. References Association of Directors of Social Services - ADASS(2005) Safeguarding Adults: A National Framework of Standards for Good practice and Outcomes in Adult Protection Work Care Act (2014) Data Protection Act (1998) Department of Health (2000) No Secrets : Guidance on Developing and Implementing Multi- Agency Policies and Procedures to Protect Vulnerable Adults Department of Health (2004) Standards for Better Health Department of Health (2005) National Standards, Local Action Department of Health (2006) Our Health, Our Care, Our Say Department of Health (2006) Safeguarding Vulnerable Adults Group Act Department of Health (2007) NHS Information Governance Department of Health (2010) Equity and Excellence : Liberating the NHS Department of Health (2010) Clinical Governance and Adult Safeguarding Department of Health (2011) Safeguarding Adults: the role of Health Services Deprivation of Liberty safeguards (2009) Domestic Violence, Crime and Victims Act (2004) Equality Act (2010) Freedom of Information Act (2000) Health and Social Care Act (2012) Home Office Prevent Strategy (2011) Human Rights Act (1998) Law Commission Report (2011) Adult Social Care Mental Capacity Act (2005) Safeguarding Vulnerable Groups Act (2006) NHS East and North Hertfordshire Clinical Commissioning Group Page 4 of 19

Table of Contents Section No. Section Name Page No. 1.0 Introduction 6 2.0 Scope 7 3.0 Policy Statement 7 4.0 5.0 4.1 4.2 4.3 5.1 5.2 5.3 5.4 5.5 5.6 Definitions Adult at Risk Abuse Categories of Abuse Roles & Responsibilities Governing Body Chief Executive/Accountable Officer Quality Committee Director of Nursing and Quality Head of Adult Safeguarding & PREVENT Line Managers 8 8 9 9 10 10 10 10 11 11 12 6.0 Process 13 6.1 Safeguarding Adult Reviews 13 6.2 PREVENT and CHANNEL 13 6.3 6.4 6.5 Domestic Homicides Information Governance Recruitment and Employment 14 14 15 Appendix 1 Key Contacts 16 Appendix 2 Hertfordshire Safeguarding Adults from Abuse Procedure 17 Appendix 3 Equality Impact Assessment Stage 1 Screening 18 Appendix 4 Privacy Impact Assessment Stage 1 Screening 19 NHS East and North Hertfordshire Clinical Commissioning Group Page 5 of 19

1.0 Introduction 1.1. NHS East and North Hertfordshire Clinical Commissioning Group (ENCCG) is committed to working with partner agencies to support the identification and prevention of all forms of abuse and mistreatment so that everyone is able to make a full and positive contribution to society within Hertfordshire. 1.2. The Government White Paper, Liberating the NHS (2010), puts patients at the heart of the NHS. 1.3. The Supporting Vulnerable Groups Act 2006 states that a vulnerable adult will be a person aged 18 or over who is in a specific situation, one of which is receiving any form of healthcare AND who needs to be able to trust the people caring for them, supporting them and/or providing them with services (s59 Supporting Vulnerable Groups Act 2006). 1.4. In 2011 the Department of Health issued a number of documents describing the contribution health services can play in achieving positive outcomes for safeguarding adults. These documents describe the role of Health Service Managers and Boards, Commissioners and Practitioners. 1.5. The Care Act 2014 replaces the No Secrets guidance and states - Safeguarding means protecting an adult s right to live in safety, free from abuse and neglect. 1.6. The Care Act (2014) reports that the aims of adult safeguarding are: To prevent harm and reduce the risk of abuse or neglect to adults with care and support needs. To safeguarding individuals in a way that supports them in making choices and having control in how they choose to live their lives. To promote an outcomes approach in safeguarding that works for people resulting in the best experience possible. To raise public awareness so that professionals, other staff and communities as a whole play their part in preventing, identifying and responding to abuse and neglect. 1.7. Hertfordshire has in place The Hertfordshire Safeguarding Adults from Abuse Procedure issue 9(2015) and Hertfordshire County Council are designated as the lead agency. The procedures can be accessed via the intranet. 1.8. This policy applies to ENCCG commissioned services. The organisation has the responsibility to ensure that the health contribution to safeguarding adults is discharged effectively across the health economy through the CCG s commissioning arrangements. NHS East and North Hertfordshire Clinical Commissioning Group Page 6 of 19

1.9. The policy details responsibilities within health services at both strategic and operational level, in keeping with national policy and related statutory guidance, such as the Human Rights Act 1998, the Mental Capacity Act 2005 and Deprivation of Liberty Safeguards 2009. It supports the ethos of safeguarding adults is everybody s business and in particular rights relating to dignity, freedom from abuse, equality, respect and fairness. 1.10. The CCG must ensure that service specifications for commissioned and contracted services include clear service standards and monitoring arrangements for safeguarding adults, the Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (2009). 1.11. The CCG must also ensure that all health agencies and providers with which they have commissioning / contracting arrangements are linked to Hertfordshire Safeguarding Adult Board and have robust policies and procedures which are in accordance with the Hertfordshire Safeguarding Adult Board Inter-agency Safeguarding Adults procedures issue 9(2015). This includes robust operational guidance informed decision making, external referral and multi-agency collaboration. 2.0 Scope 2.1. This policy applies to all CCG staff members, including Governing Body Members and Practice Representatives, involved in the CCG s policymaking processes, whether permanent, temporary or contracted-in (either as an individual or through a third party supplier). 2.2. Everyone has an individual responsibility for the protection and safeguarding of adults, in both their professional and home lives. 2.3. The CCG is required to have appropriate contract monitoring arrangements in place to ensure all providers and commissioners are meeting their contractual responsibilities in ensuring they are providing safe adult patient care and taking action to promote the safety and wellbeing of any adult at risk of abuse. 3.0 Policy Statement 3.1 The CCG is committed to ensuring that services that are commissioned meet recognised national standards in safeguarding adults and that there are clear arrangements for contract monitoring between commissioner and provider where quality, service user outcomes and value for money are discussed and improvements agreed, as necessary. NHS East and North Hertfordshire Clinical Commissioning Group Page 7 of 19

3.2. The CCG champions the rights of adults at risk to be happy, healthy, safe and productive in their contribution to society and not to be abused, neglected or exploited. 3.3. In safeguarding and promoting the welfare of adults at risk, the CCG is committed to creating an ethos which values working collaboratively with others, respects diversity (including race, religion, disability, gender, age and sexual orientation) and promotes equality. 3.4. This policy focuses on responsibilities for the CCG staff, both in their capacity as commissioner of health care and where they may have direct involvement in concerns relating to adult abuse. It is recognised that responsibilities in safeguarding and promoting the welfare of adults at risk also extends to an individual s personal and domestic life. The CCG has adopted HSAB multi- agency policy and procedures which are available on the intranet with link to HCC website. 3.5. The CCG aims to design and implement services, policies and measures that meet the diverse needs of their services, population and workforce, ensuring that no one is placed at a disadvantage over others. It is recognised that some people can suffer disadvantage as a result of discrimination and this can increase vulnerability. 3.6. Abuse and neglect of adults is not a socially acknowledged phenomenon. The complexities of abuse can significantly compromise a victim s ability and motivation to seek support and redress. This is particularly pertinent for people whose disability impacts upon their ability to inform others. The CCG has a clear intention through this policy to have a positive impact on vulnerable adults and to protect all adults who may become vulnerable. 3.7. The CCG is committed to ensuring that it treats both employees and services fairly, equitably and reasonably and that it does not discriminate against individuals or groups on the basis of their ethnic origin, physical or mental disabilities, gender, age, religious beliefs or sexual orientation. 3.8. All policies and procedures are developed in line with the CCG s equality and diversity polices and takes into account the diverse needs of the community that is served, which included an Equality Impact Assessment. 4.0 Definitions 4.1 Adult at risk Historically the term vulnerable adult was used to describe this cohort. The 2014 Care Act now identifies adults as experiencing or at risk of abuse or neglect. NHS East and North Hertfordshire Clinical Commissioning Group Page 8 of 19

The duties apply to adults who have care and support needs (whether or not the local authority is meeting any of those needs) and is experiencing, or at risk of, abuse or neglect; and as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect who may be: living in their own home in hospital in a residential care and / or nursing home attending a Day Centre attending a Social Club attending a GP Surgery without a permanent home (The above lists are not intended to be exhaustive.) 4.2. Abuse: Abuse is the violation of an individual s human or civil rights by any person or persons. An individual, a group or an organisation may perpetrate abuse. Abuse can be passive or active; it can be an isolated incident or repeated. 4.3. Categories of Abuse: Physical Abuse - Assault, hitting, slapping, pushing, misuse of medication, restraint or inappropriate sanctions. Domestic Abuse - Psychological, physical, sexual, financial, emotional abuse, Female Genital Mutilation (FGM); so called honour based violence. Sexual Abuse - Rape, indecent exposure, sexual harassment, inappropriate looking or touching, sexual teasing or innuendo, sexual photography, subjection to pornography or witnessing sexual acts, sexual assault or acts to which the adult has not consented or was pressured into consenting. Psychological Abuse - Emotional abuse, threats of harm or abandonment, deprivation of contact, humiliation, blaming, controlling, intimidation, coercion, harassment, verbal abuse, cyber bullying, isolation or unreasonable and unjustified withdrawal of services or supportive networks. NHS East and North Hertfordshire Clinical Commissioning Group Page 9 of 19

Financial Abuse - Theft, fraud, internet scamming, coercion in relation to an adult s financial affairs or arrangements, including in connection with wills, property, inheritance or financial transactions, or the misuse or misappropriation of property, possessions or benefits. Modern Slavery - Slavery, human trafficking, forced labour and domestic servitude. Traffickers and slave masters use whatever means they have at their disposal to coerce, deceive and force individuals into a life of abuse, servitude and inhumane treatment Discriminatory Abuse - Forms of harassment, slurs or similar treatment; because of race, gender and gender identity, age, disability, sexual orientation or religion. Organisational Abuse - Neglect and poor care practice within an institution or specific care setting such as a hospital or care home, for example, or in relation to care provided in one s own home. This may range from one off incidents to ongoing ill treatment. It can be through neglect or poor professional practice as a result of the structure, policies, processes and practices within an organisation. Neglect and acts of omission - Ignoring medical, emotional or physical care needs, failure to provide access to appropriate health, care and support or educational services, the withholding of necessities of life, such as medication, adequate nutrition and heating. Self-neglect - Covers a wide range of behaviour neglecting to care for one s personal hygiene, health or surroundings and includes behaviour such as hoarding. 5.0 Roles and Responsibilities 5.1. Governing Body The Governing Body is responsible through the Accountable Officer and line management structure for ensuring that the health contribution to safeguarding and promoting the welfare of adults at risk is discharged effectively across the local health economy through the CCG s commissioning arrangements. 5.2. Chief Executive / Accountable Officer The Accountable Officer of the CCG is responsible for ensuring that the health contribution to safeguarding and promoting the welfare of adults at risk is discharged effectively across the local health economy through the CCG s commissioning arrangements. 5.3. Quality Committee NHS East and North Hertfordshire Clinical Commissioning Group Page 10 of 19

The Quality Committee is a sub group of the Governing Body and the Designated Committee for this policy. The committee has an assurance role regarding quality matters including safeguarding 5.4. Director of Nursing and Quality The Director of Nursing and Quality is the identified Lead Executive for this policy and Governing Body Champion for safeguarding. 5.5. Head of Adult Safeguarding & Prevent The Head of Adult Safeguarding Is responsible for ensuring effective training and education is provided to CCG staff. Monitors provider organisations Provides supervision to Named Nurses within provider organisations 5.6. The CCG has signed up to and accepts the principles laid down within Hertfordshire s Safeguarding Adults Board procedures, in that: Hertfordshire is a safe place for all adults at risk to live and work and that they are cared for and supported in an environment free from abuse, harassment, violence or aggression. The HSAB comprises the following statutory partners: East & North Hertfordshire CCG Herts Valleys CCG Hertfordshire Constabulary Health & Community Services Hertfordshire Partnership University NHS Foundation Trust and; Senior management representatives from, West Hertfordshire Hospitals NHS Trust, East and North Hertfordshire NHS Trust, Hertfordshire Probation Service, and District Councils and is responsible for the implementation of the Hertfordshire Safeguarding Adult procedure. 5.7. ENCCG and the serious concerns process In addition, to its commissioning responsibilities the CCG will deliver its responsibilities to the serious concerns process by: The Head of Adult Safeguarding being informed of all serious concerns meetings. The Head of Adult Safeguarding attending serious concerns meetings where patient care and patient safety is of primary concern. The Head of Adult Safeguarding providing nursing advice to the serious concerns process. The Head of Adult Safeguarding will work with the Clinical Quality Manager and the Continuing Health Care Service Manager regarding any concerns relating to quality within care homes to ensure that these concerns are taken forward and monitored. NHS East and North Hertfordshire Clinical Commissioning Group Page 11 of 19

The Continuing Health Care Team will review patients receiving full continuing health care funding, as part of the serious concerns investigations to care homes registered for nursing. 5.8. Line Managers Line Managers are responsible for supporting implementation of this policy: By ensuring staff are aware of this policy and comply with it Escalate safeguarding adult concerns to Assistant Directors, highlighting those that are potentially serious. Consider the need for a debrief session for staff / team involved in complex or difficult cases to ensure actions are implemented and lessons learned following a safeguarding adult investigation. 5.9. All staff are to be: Aware of the Hertfordshire Safeguarding Adults from Abuse Procedure issue 9 (2015). Aware of the importance of listening to adults at risk, particularly when they are expressing concerns about either their own or other people s welfare. Know how to act on concerns that an adult at risk may be at risk of significant harm through abuse or neglect in line with local guidance. Know who to contact to discuss, access support or to report any concerns about an adult at risk. Aware of own roles and responsibilities and recognise limits and boundaries to role. Maintain accurate, comprehensive and legible records if working with adults at risk and store securely in line with local guidance. Take part in training, including attending regular updates so that they maintain their skills and are familiar with procedures aimed at safeguarding and promoting the welfare of adults at risk. Recognise the impact of the Care Act (2014) Mental Capacity Act (2005) and the Deprivation of Liberty Safeguards (2009). Contracts of employment, professional codes of conduct, require all healthcare staff to exercise a duty of care to patients and, where necessary, take action for safeguarding and crime prevention. 5.10. The CCG will regularly receive information relating to: Safeguarding adult reviews from Hertfordshire Safeguarding Adult Board. Interim progress reports on large scale investigations, multi-agency reviews or safeguarding issues that require the Board s awareness and be in a position to anticipate and plan for risks which could affect the reputation of the CCG. Reports and papers regarding any specific issues requiring Board approval or decision. NHS East and North Hertfordshire Clinical Commissioning Group Page 12 of 19

6.0 Processes 6.1. Safeguarding Adult Reviews The CCG has a duty to work in partnership with Hertfordshire Safeguarding Adult Board and /or any other Safeguarding Adult Boards, by participating in safeguarding adult reviews and multi agency serious incident reviews. The purpose of a safeguarding adult review is: To establish whether there are lessons to be learned from the incident about the way local professionals and agencies work together to safeguard adults at risk. To use the review of the case as a learning process to trigger recommendations that specifically identify where systems and practices might be improved to contribute to more effective interagency working and to better outcomes for vulnerable adults. To ensure that any urgent issues that require immediate actions are dealt with as soon as they are identified. The CCG must ensure that the review and subsequent actions following the review are carried out according to the timescale set out by the Safeguarding Adult Review Panel scoping and terms of reference. Both examples of good practice and lessons to be learned should be disseminated across all levels of the organisation. The Quality Committee will monitor the progress of identified recommendations and supporting action plans for issues relating to the CCG. 6.2. PREVENT and CHANNEL PREVENT and CHANNEL are a statutory part of the Government Contest Strategy led by the Home Office that focuses on working with individuals and communities who may be vulnerable to the threat of violent extremism and terrorism. Supporting vulnerable individuals and reducing the threat from violent extremism in local communities is a priority for the health service and its partners. The CCG Head of Adult Safeguarding will ensure that there are robust Prevent arrangements in place across the health economy and form part of quality contracting monitoring. CCG staff will participate in PREVENT basic awareness training at induction. The Head of Adult Safeguarding and the Designated Nurse for Safeguarding Children will participate in any CHANNEL activity as required. NHS East and North Hertfordshire Clinical Commissioning Group Page 13 of 19

6.3 Domestic Homicides Domestic Homicide Reviews (DHR s) were established on a statutory basis under Section 9 of the Domestic Violence, Crime and Victims Act 2004 and came into force in April 2011. A domestic homicide review means a review of the circumstances in which the death of a person aged 16 or over has or appears to have, resulted from violence, abuse or neglect by: A person to whom they were related or was/has an intimate relationship. A member of the same household. This legal requirement has been established to ensure agencies are responding appropriately to victims of domestic abuse by offering and putting in place appropriate support mechanisms, procedure, resources and interventions. The aim is to avoid future incidents of domestic homicide and violence. The CCG has a duty to have regard to the guidance and to ensure that providers across the health economy have the necessary arrangements to respond to this statutory guidance. This will be monitored by the Self- Assessment and Assurance Framework for Safeguarding Adults and form part of quality contracting monitoring. 6.4. Information Governance The Care Act 2014 states that in order to carry out its functions, SABs will need access to information that a wide number of people or other organisations may hold. Some of these may be SAB members, such as the NHS and the police. Others will not be, such as private health and care providers or housing providers/housing support providers or education providers. If someone knows that abuse or neglect is happening they must act upon that knowledge, not wait to be asked for information. A SAB may request a person to supply information to it or to another person. The person who receives the request must provide the information provided to the SAB if: The request is made in order to enable or assist the SAB to do its job. The request is made of a person who is likely to have relevant information and then. Each agency holds information that in the normal course of events is regarded as confidential and will have their own safeguards and procedures for dealing with the same. Personal information is subject to the principles of the Freedom of Information Act 2000, the Data Protection Act 1998, the Human Rights Act 1998 and the common law doctrine of confidentiality. NHS East and North Hertfordshire Clinical Commissioning Group Page 14 of 19

Wherever possible, the adult at risk should be asked to give their consent for their information to be shared, if they are considered to have the capacity to consent to information sharing. If consent is not given, the person lacks capacity to consent, or it is felt not appropriate to tell the adult at risk, then it is possible to share information without the consent of the patient in certain circumstances. Concern about the abuse of an adult provides sufficient grounds to warrant sharing information on a need to know basis and /or in the public interest in accordance with established data protection principles. Unnecessary delays in sharing the information should be avoided, where there is a risk of harm to an individual/ individuals. The CCG s will follow the Information Sharing guidance in Chapter 11 of the Hertfordshire Safeguarding Adults from Abuse Procedure issue 9 (2015) which provides guidance to staff as to when and with whom information can be shared: 6.5. Recruitment and Employment The CCG has a duty to ensure that safe recruitment processes are complied with and act in accordance with the NHS employer s regulations, and the Disclosure and Barring Scheme of the Independent Safeguarding Authority as within the Safeguarding Vulnerable Groups Act 2006 statutory guidance. The CCG has a statutory duty to ensure that appropriate action is taken efficiently and effectively, if an allegation is made, or a suspicion or concern arises about an employee, student or independent contractor. NHS East and North Hertfordshire Clinical Commissioning Group Page 15 of 19

Appendix 1 - Key contacts Contact by direct line or via the Health & Community Services Customer Service Centre: 0300 123 4042 Client Services are open: Monday to Friday 8.00 am to 8.00 pm Saturday 9.00 am to 4.00 pm Outside of these times the Hertfordshire Emergency Duty Team can be contacted using the same telephone number for the Customer Service Centre. Police The Police should be contacted directly in an emergency by dialling 999. If there is a serious incident that requires a prompt police response but is not an emergency dial 101 CCG Head of Adult Safeguarding & Prevent Contact Tracey Cooper, tracey.cooper@hertsvalleysccg.nhs.uk Care Quality Commission, National correspondence, Citygate, Gallowgate, Newcastle upon Tyne NEI 4PA Telephone: 03000 616161 Fax: 03000 616171 National Response Line Action on elder abuse provide a confidential response line concerning all vulnerable adults. The helpline number is 0808 808 8141 The IMCA (Independent Mental Capacity Advocate) service in Hertfordshire is provided by POhWER. Telephone 0300 456 2370 NHS East and North Hertfordshire Clinical Commissioning Group Page 16 of 19

Appendix 2 - Hertfordshire Safeguarding Adults from Abuse Procedure A summary for public agencies and organisations providing services to adults at risk Any member of the public, public service or service provider could become aware of the possible or actual abuse of a vulnerable adult. There are seven categories of abuse: physical, sexual, neglect, psychological, financial, institutional or discriminatory. Any person who is concerned about the possible or actual abuse of a vulnerable adult must share this with a manager/team leader. The manager/team leader must contact one of the investigating teams local to their service within one working day: Community Learning Disability Team (CLDT), Older People Physical Disability Team (OPPD), Community Mental Health Team (CMHT), Hospital Social Work Teams, Specialist Mental Health Team for Older People (SMHTOP), Community Drug and Alcohol Team, Sensory Service, Early intervention in psychosis service, Assertive outreach teams or the Community eating disorder service. Contact should be made within one working day. You can make contact by direct line or through the customer service centre on 0300 123 4042, open Monday to Friday 8am to 8pm, Saturday 9am to 4pm. At all other times including public holidays calls to this number will be dealt with by the Emergency Duty Team. The police can be contacted in an emergency by dialling 999. If a serious incident occurs that requires a prompt police response telephone 101. The investigating team will liaise with the police in all other safeguarding adult matters. The Care Quality Commission (CQC) should be advised of all safeguarding incidents (registered care homes, domiciliary services and health services only) telephone 03000 616161. The investigating team is responsible for the management of all safeguarding adults from abuse investigations. Allegations of possible or actual abuse should not be investigated without an agreement with the investigating team, the service provider and the police where relevant. This includes interviewing staff, the vulnerable adult, family/carers and others. Alleged abusers should NOT be informed of any allegations until a plan of action has been agreed with the investigating team and the police. Investigations can be planned by telephone when prompt action is required or at a safeguarding adults from abuse strategy meeting. At the meeting information is shared and actions agreed which will include an investigation and protection plan. HCS 666 Issue 9 Hertfordshire Safeguarding Adults from Abuse Procedure 2015. NHS East and North Hertfordshire Clinical Commissioning Group Page 17 of 19

Appendix 1 Equality Impact Assessment Stage 1 Screening 1. Policy EIA Completion Details Title: Proposed Existing Date of Completion: Names & Titles of staff involved in completing the EIA: Review Date: 2. Details of the Policy. Who is likely to be affected by this policy? Staff Patients Public 3. Impact on Groups with Protected Characteristics Age Probable impact on group? Positive Adverse None High, Medium or Low Please explain your answers Being married or in a civil partnership x Disability, inc. learning difficulties, physical disability, sensory impairment etc. Having just had a baby or being pregnant Race, ethnicity, nationality, language etc. Religion or belief Sex (inc. being a transsexual person) Sexual Orientation Other: No impact on any of the groups above. Please explain and provide evidence 4. Which equality legislative Act applies to the policy? Human Rights Act 1998 Equality Act 2010 Health & Safety Regulations Mental Health Act 1983 Mental Capacity Act 2005 5. How could the identified adverse effects be minimised or eradicated? 6. How is the effect of the policy on different Impact Groups going to be monitored? NHS East and North Hertfordshire Clinical Commissioning Group Page 18 of 19

Appendix 2 Privacy Impact Assessment Stage 1 Screening 1. Policy PIA Completion Details Title: Proposed Existing Date of Completion: Names & Titles of staff involved in completing the PIA: Review Date: 2. Details of the Policy. Who is likely to be affected by this policy? Staff Patients Public Yes No Please explain your answers Technology Does the policy apply new or additional information technologies that have the potential for privacy intrusion? (Example: use of smartcards) Identity By adhering to the policy content does it involve the use or re-use of existing identifiers, intrusive identification or authentication? (Example: digital signatures, presentation of identity documents, biometrics etc.) By adhering to the policy content is there a risk of denying anonymity and de-identification or converting previously anonymous or de-identified data into identifiable formats? Multiple Organisations Does the policy affect multiple organisations? (Example: joint working initiatives with other government departments or private sector organisations) Data By adhering to the policy is there likelihood that the data handling processes are changed? (Example: this would include a more intensive processing of data than that which was originally expected) If Yes to any of the above have the risks been assessed, can they be evidenced, has the policy content and its implications been understood and approved by the department? NHS East and North Hertfordshire Clinical Commissioning Group Page 19 of 19