Safeguarding of Vulnerable Adults. Annual Report

of Vulnerable Adults Annual Report 2011-2012 April 2012

DOCUMENT CONTROL Version Author Date Change V0.1 Veronica Flood 20 April 2012 First draft V0.2 Mary Sexton 24 April 2012 Second Draft V0.3 Mary Sexton 9 May 2012 Third Draft Version Reviewer Role Date 2 Governance Review and suggest changes 30 April 2012 and Risk Management Committee 3 Trust Board For information and approval 28 May 2012 2

Contents Page 1. Introduction 4 2. Adults at Risk National Policy Context 4 3. Local Context 5 4. Summary 5 5. Key Achievements 6 6. Infrastructure 6 7. Training 7 8. Quality Assurance 8 9. Multi Agency Case Reviews 13 10. Mental Capacity Act (2005) 14 11. Prevent 16 12. Data Management 16 13. Progress from Work Plan 2010-11 17 14. Priorities for 2012-13 18 15. Conclusion 18 Appendix 1 - Work plan 2012-2013 19 3

1. Introduction This Annual Report provides details of Adult activity in Barnet Enfield and Haringey Mental Health NHS Trust (BEHMHT) and Enfield Community Services (ECS) during 2011/2012. The Annual Report covers the national policy context and describes how this has been transferred into local practice. The report also describes the work that has been carried out under the multi-agency arrangement for Adults. During 2011/12 there was a continued drive to ensure that people who use services in BEHMHT and ECS are safeguarded from abuse and any reported abuse was dealt with as per the Protecting Adults at Risk: London Multi-Agency Policy and Procedures to Safeguard Adults from Abuse (Pan- London Procedures). The Annual Report concludes with a detailed work plan for 2012/2013. 2. Vulnerable Adults National Policy Context The document No secrets: Guidance on Developing and Implementing Multi-Agency Policies and Procedures to Protect Vulnerable Adults from abuse was issued by the Department of Health in 2000. This document gave Health and Social Care organisations guidance and a framework on how to recognise, deal with and prevent abuse to vulnerable adults. This document is under review and although final guidance has not been issued there is a suggestion that there needs to be stronger national leadership and that local arrangements should be placed on a statutory footing. In addition, a further policy initiative was the development of The Pan London Adults Procedure. www.scie.org.uk/publications/reports/report39.pdf The policy Protecting adults at risk: London Multi-agency Policy and Procedures to Safeguard Adults from abuse has been implemented by Local Authorities across London, to ensure that adults at risk are protected from abuse and that organisations such as the Police and NHS in London follow one Multi-Agency Procedure. The policy has put forward the role of the NHS in as: To prevent harm occurring Responding effectively when harm occurs Supporting adults at risk within their own communities and other services Developing effective systems for protecting adults at risk. In May 2011 the Government issued a statement in which it described its policy on safeguarding vulnerable adults. The Government set out the following principles and outlined the Government s objective to prevent and reduce the risk of harm to vulnerable people. The principles are: Empowerment supporting people to make decisions and have a say in their care; Protection support and representation for those in greatest need; Prevention it is better to take action before harm occurs; 4

Proportionality safeguarding must be built on proportionality and a consideration of people s human rights; Partnership local solutions through services working with their communities; and Accountability safeguarding practice and arrangements should be accountable and transparent. 3. Local Context During 2011/2012 work had been carried out via the Adults Boards to plan and ensure the implementation of the Pan London Procedures. In September 2011 a launch event was held at Enfield Council organised by Enfield Adults Board. Each partner agency was represented and gave a presentation on how their organisation will support and implement the new procedures. The for Adults represented the Trust and did a presentation on behalf of the Trust. Following the Launch all the revised templates and Practice guidance was circulated. Similarly, the Barnet Adults Board undertook the work to ensure revised forms and practice guidance was developed with the advent of the Pan London Procedures. In Haringey, the Pan London Procedures have been implemented, however the revised forms have not been issued. To ensure that the policy was circulated widely the for Adults circulated a copy of the procedures during the early part of 2011 for Managers to start familiarising themselves with the policy. The policy was implemented in the Trust during September/October 2011.. At a national level the Government has developed a number of supporting documents to offer further guidance to staff in working with vulnerable adults. The following document, Adults: The Role of Health Service Practitioners, has been a valuable resource for health service staff. This document has been circulated to all ward and team Managers. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalass et/dh_125233.pdf 4. Summary During 2011/12 there was a continued drive to ensure that people who use services in BEHMHT and ECS are safeguarded from abuse and any reported abuse was dealt with as per the Protecting Adults at Risk: London Multi-Agency Policy and procedures to Safeguard Adults from Abuse (Pan-London Procedures). This is demonstrated in the achievements the Trust attained as set out on the following page. 5

5. Key Achievements A service user booklet developed and implemented which give service users written information about abuse and how to report abuse. The booklet was distributed to all wards and teams. A Trust Self-Assessment was carried out by the for Adults using the Adult Assurance Framework for Healthcare Services. This allowed for a benchmark against the given standards in the Framework. The actions from the assessment have been taken forward by the Adults and service managers. A balanced scorecard has been developed which will be used to report on safeguarding activity to the Trust Board. It is planned that a report will be presented three times per year. A Adult Audit Tool has been developed and is now on Meridian. The tool will enable team managers to audit one safeguarding case per month. The Trust Level 1 training slides has been updated to include the changes as set out in the Pan London Procedures and to draw on local learning from safeguarding alerts. The Trust has implemented compliance inspections against the criteria in Outcome 7 (safeguarding) of the CQC s new regulatory framework on all inpatient units and Community Teams. Case File Audits have been carried out as part of a quality assurance measure. 5.1 Key Challenges A drive to ensure quality in practice has seen increased inspections by external bodies such as the Care Quality Commission (CQC). This has come at a time of the development and implementation of the new Adults policy and procedures. A further demand on the Trust staff has been in the efforts to offer representation at multi-agency sub groups and other multi agency groups. A gap analysis has highlighted where those resources can be targeted. 6. Infrastructure The Trust has a Board Lead for Adults, the of Nursing, Quality and Safety. 6

The Trust has an for Adults who reports to the of Nursing, Quality and Safety. Adult and Children administrator post is shared between the s for Adults and Children (0.25 safeguarding adults). In BEHMHT the management of safeguarding cases is co-ordinated by the Community Mental Health Team Managers and Team Managers in integrated Teams. This arrangement has been reached with Barnet and Enfield local authorities. The process for Enfield Community Services is different as all safeguarding alerts are sent to and managed by the London Borough of Enfield. In Haringey the process for managing alerts differs from the other boroughs in that all alerts from BEHMHT are sent to the Integrated Access Team/ Adults Team. These are then screened and co-ordinated via the Adult Team. The Board receives an Annual Report and work plan on the Trust s Adults arrangements. The Trust has an internal Adults Committee that meets on a bi monthly basis which reports to the Trust s Clinical Governance Sub Committee. The Committee meeting is chaired by the of Nursing, Quality and Safety. Other members of the committee are assistant directors from each Service line or their representative, Local Authority representative and the Trust Designated Doctor. There is also a bi monthly practice development group co-ordinated by the Enfield Adults team. 6.1 Challenges With the reorganisation in the psychosis service line the role of Clinical Lead Nurse has been deleted. This was a pivotal role in link with the Haringey Adult Team and the Trust. This has been identified as a gap in service. The benefits to the Trust to have this role is about the close working with the Adults Team, involvement in Multi Agency Risk Assessment Conference (MARAC), and close working with staff in the Haringey sector of the Trust. Other challenges that have been brought about due to reconfiguration of services is a reduced amount of resources to offer input to the Adults sub groups which is held at the three local authorities. The for Adults attends some of the subgroups but this places further demands on the role in trying to balance the Multi-Agency input and the strategic and operational needs of the Trust. 7. Training The way in which staff apply for Multi Agency training has changed over time. This has presented a challenge for staff in Workforce Development Department in the tracking of all applications from BEHMHT staff for level 2 and 3 training. 7

Both Enfield and Haringey Councils have changed the way in which staff can book on a course. To book a place for training each staff need to create an account on the Learning and Development Website which will enable them to apply electronically. Level 1 safeguarding adult training continues to be offered as part of the mandatory training day. As of 31 st March 2012, 75% of staff has been trained in level 1 training as seen in table 1. Service Line Common Mental Health Problems Total Compliant Total Noncompliant % Compliance 91 37 71% Corporate 130 62 68% Crisis and Emergency Dementia and Cognitive Impairment Enfield Community Services 292 27 92% 217 31 88% 311 267 54% Estates and Facilities 57 32 64% Forensic 288 30 91% Psychosis 138 26 84% Severe and Complex Non Psychotic Disorders Overall Trust Compliance 237 86 73% 1761 756 75%. (Table 1: Adult Level 1 training from 1 st April 2011 to 31 st March 2012) During 2011/2012, 82 staff from BEHMHT attended Multi Agency Adult training which included level 2 and 3 training at the three local authorities. This means that the Trust met its compliance levels agreed in the 2011/2012 work plan. Bespoke Adult Training has been delivered by the for Adults to staff within the wards in the Dementia and Cognitive Impairment Service Line. This training was undertaken as part of the actions and learning lessons from a safeguarding investigation. 8. Quality Assurance A Trust self-assessment was completed using the Adult Assurance Framework for Healthcare Services. This allowed for a benchmark against the given standards in the Framework. The actions from the assessment have been taken 8

forward by the Adults in partnership with Service Line leads. A Balanced Scorecard has been developed which will be used to report on safeguarding activity to the Trust Board. It is planned that a report will be presented three times per year. A Adult Audit Tool has been developed and is now on Meridian. The Tool will enable Team Managers to audit one safeguarding case per month. 9

Audit Activity When Undertaken Key Findings of Internal monitoring within the Trust BEHMHT Adults Case File Audit-Barnet Barnet Case file Audit (Internal)May 2010 5 case files audited. Strengths: service user/carer involvement Areas for development: Recording on RIO Quality of paperwork in some cases BEHMHT Adults Case File Audit-Haringey October 2010 Timescales 10 case files audited. 9 of the 10 files were found not to have paperwork on RIO. Lead to a review of SoVA Process in Haringey during February-April 2011. BEHMHT Case File Audit- Enfield BEHMHT Case File Audit- Barnet May 2011 October 2011 10 case files audited. Good indication of the process. Areas for development-recording on RIO. Whilst progress has been made in recording on RIO there were in some cases information being found in progress notes and minutes of meeting not in clinical documentation on RIO. CQC Standard 7 Adults audit of clinical and community teams Bi-Monthly Practice Standards Leads An example of which is: In October 2011, eight wards, two Community Teams and two assessment units were assessed on Outcome 7. It was found that: Written information on the safeguarding process were not accessible to staff during the Lead Nurse assessment (7A). 10

Teams were not maintaining a mandatory training matrix which shows the dates when mandatory training was provided to all staff members. The matrix is designed to show at a glance the outstanding mandatory training for staff that can then be booked so that they fulfil all training requirements (including safeguarding training (7A). Staff requires Deprivation of Liberty Safeguards training which is provided through Workforce Development Department. Ward managers are to book their staff on the necessary training and feedback via the Service Manager once the training has been provided (7G). The recording of the safeguarding process on RiO is inconsistent. Ward managers are to ensure all documentation around safeguarding alerts is uploaded to RiO (7C). 11

8.1 External Monitoring Month External Agency Area of Trust Result Type on monitoring Outcome activity September 2011- November 2011 CQC Across the Trust announced inspection Compliant for Outcome 7 January 2012 CQC Inpatients wards in Enfield. March 2011 London Borough of Barnet Barnet Community Teams Unannounced inspection in Enfield. Outcome 7- people who use services from abuse () A sample check of 20 cases (13 for LBB and 7 for the MHT) Compliant For Outcome 7 MHT Issue: plans are being reviewed by team managers during case supervision, but outcome of the review is not being recorded in RIO. May 2011 April 2012 Enfield Adult Team Barnet and Enfield Adult teams is currently undertaking a Case File audit in the Trust Enfield Community Teams Community teams Planned audit by Enfield Adults Team of files which had been audited by Team Managers. Audits have not yet been completed There was evidence to show that improvements had been made by Teams in providing advocacy, undertaking investigations, using protection plans undertaking reviews and general recording. 12

9. Multi Agency Case Reviews A Fire Death Review was undertaken in Barnet in March 2011. The review was regarding a Service User who was known to the Trust and the Local Authority. The review was attended by staff from BEHMHT, the Fire Service and the Local Authority. A Domestic Homicide Review in Haringey found that staff needed to increase their knowledge and understanding of Domestic Violence and the use of MARAC. To address this, a number of training/raising awareness sessions were carried out by the Clinical Lead Nurse for Haringey. Sessions were held in each borough in the Trust. 9.1 Alerts in the Dementia and Cognitive Impairment Service Line (DCI) In May 2011 there were a number of safeguarding allegations made in respect of the then Cornwall Villa ward. There was a joint investigation in line with multi agency safeguarding process. A final report was received from London Borough of Enfield in December 2011 and a completed action plan to address all findings was implemented and is being closely monitored by the Governance and Risk Management Committee. In addition to the safeguarding investigation the Trust commissioned an independent internal review of its governance processes to ensure that how we assess, monitor and review standards is robust. There had been a cluster of alerts in the DCI Service Line in November/December 2011. Two of the alerts were related to Cornwall Villa and was received on 25th November and 30th November 2011. One alert was related to a service user in Silver Birches and was received on 25th November 2011 and one related to a service user in The Oaks on 2nd December 2011. All the alerts were managed through the safeguarding process and regular feedback was given to the of Nursing, Quality and Safety and Service Line management. The meetings related to the alert regarding the environment on Cornwall Villa was chaired by the Local Authority staff. The rest were managed under the Trust safeguarding arrangements. Following investigation three of the allegations were not substantiated. The allegation of abuse of a Service User on the Oaks by two staff members was substantiated. 9.2 Organisational Learning from the Above Alerts One of the requirements in the new Pan London procedures is to capture the learning following a safeguarding case and demonstrate how the learning will be fed back into practice and across the organisation. The list below are areas of learning that have been highlighted following two of the 4 safeguarding cases in the DCI Service line. All the staff to undertake awareness training. Communication - staff to understand the communication needs of people with dementia. To understand what information needs to be communicated to patients and relatives. For all staff to attend Mental Capacity Act Training. Ward Manager to ensure that all patient care plan and risk assessments were reviewed and updated within 8 weeks. 13

Ward Manager to develop a nursing management system that is visible and clear to all the patients during each shift about who their allocated worker is and how to approach him/her. leaflets and information to be easily available to each patient and family on the ward, clearly explaining what to do and how to report a concern. Ward Manager to ensure that clinical supervision was up to date with all the staff and that safeguarding is part of the supervision agenda. This was to be in place by February 2012. Each of the above learning points have been taken forward by the Ward Manager and the for Adults. Some of the actions are still ongoing. A further learning point was highlighted following a Fire Death Review in Barnet. The review found the need for home safety checks for those service users who are a known fire risk due to being a smoker or other fire risk factors. The Fire Brigade have developed a referral form to be used by partner agencies. The referral form has been circulated to all team managers. 9.3 How Will the Above Organisational Learning be Shared? 1. Through supervision 2. Through practice development meetings 3. Ward meetings 4. Through Trust meetings i.e. Adult Committee, Clinical Governance Sub Committee. 10. Mental Capacity Act (2005) 10.1 Uses of the Mental Capacity Act by Borough It is not possible to measure all the uses of the Mental Capacity Act in the same way as it is for the Mental Health Act. Much of the capacity assessment and subsequent best interests decision making, where appropriate, is undertaken by clinicians throughout their working day on many levels from making decisions about what a patient may wish to wear or eat right up to key decisions about their treatment and accommodation. For most instances of assessing capacity and decision making under the MCA 2005 the most appropriate place to evidence this is in the progress notes and it is clear from the RiO progress notes of most inpatients that these considerations are being recorded. For more decisions about serious medical treatment or accommodation which are to be taken in the best interests of the patient under the MCA 2005 there are specific forms in RiO where the process is recorded (and associate crib sheets are available to support staff in completing them). There is currently no report available from RiO/SSRS which allows for the identification of the uses of the Mental Capacity Act in this way. The MHA office staff are currently looking at audit tools that will provide a clearer understanding of the 14

quality and quantity of evidencing under the MCA and Deprivation of Liberty Safeguards (DoLS). 10.2 Uses of the Deprivation of Liberty Safeguards by Borough since April 2010 The Mental Capacity Act Deprivation of Liberty Safeguards (MCA DOLS) was introduced, as part of the Mental Health Act 2007, by the Department of Health in April 2009 to prevent deprivations of liberty without proper safeguards including independent consideration and authorisation. Deprivations of liberty in hospitals or care homes, other than under the Mental Health Act, should now follow the MCA DoLS process and all affected patients and residents should benefit from the new safeguards where appropriate or relevant. Table 2 shows a breakdown of applications since April 2010. Borough Number of applications Number of applications authorised Barnet 0 0 Enfield 5 2 Haringey 1 1 (Table 2) All DoLS applications from Enfield came from the DCI Service Line which is what might be expected. The closure of Haringey DCI wards and overall consolidation may explain the figures. All DoLS requested and granted are reported to the Care Quality Commission (CQC) in line with their regulatory requirements. Numbers of patients on DoLS currently is zero. 10.2.1 Resources available on RiO: MCA / DoLS crib sheet Memo circulated from of Nursing on 'Evidencing Patient Involvement, Capacity and Consent to Treatment' to be updated and recirculated later in March to include more on community and some amendments. This is useful for all clinical staff to understand the expectations of the organisation in respect to evidencing the use of the MCA, DoLS and other related mental health legislation. 10.2.2 MCA Resources available generally: Mental Capacity Act 2005 Policy and Procedures document BEH website MCA 2005 Deprivation of Liberty Safeguards Policy BEH website Information for staff and patients plus downloadable booklets BEH website DoLS guidance and booklets for staff and patients BEH website DoLS tools, contacts and access to support information BEH website 15

11. Prevent The aim of Prevent is to stop people becoming terrorists or supporting violent extremism. The Prevent objectives that relate to healthcare services are to: 1) Support individuals who are vulnerable to recruitment, or have already been recruited by violent extremists. 2) Disrupt those who promote violent extremism and the places in which they operate. 3) Address the grievances which the radicalisers are exploiting. Healthcare workers will be key to the success of Prevent as the NHS is one of the world s biggest employers and deals with vulnerable individuals who may be at risk of being exploited by radicalisers and violent extremists. The Lead for PREVENT in BEHMHT is the Head of Non Clinical Risk and Local Security Management Specialist. Under the PREVENT agenda a two day training course has been developed by the Department of Health and it is a requirement that those staff who will deliver PREVENT training attend this course. Currently there are 4 staff from BEHMHT who have attended the 2 day training including the for Adults. A raising awareness/prevent training has now been added on the Mandatory Training Day and is delivered by the Head of Non Clinical Risk and Fire Safety Officer. Prevent course will give staff the awareness and confidence to respond appropriately if they are concerned about a vulnerable individual. 12. Data Management Table 3 shows the number of alerts raised during 2010/2011 and 2011/2012. The data for 2011/2012 is incomplete as at the time of writing this report the data for March 2012 had not been received from the local Authorities. The data also does not include alerts from ECS. However what can be deduced from the data below is that there has been an increase in the number of Adult referrals in 2011/2012. In Haringey there appears to be a decrease in the number of referrals in 2011/2012. One possible explanation for this is that the Adult Team changed the way referrals are screened at the point of referral. There is now a duty worker in the Integrated Access Team who screens referrals and passes on those that are of a safeguarding nature. 16

12.1 Allegations of Abuse by Staff in BEHMHT Abuse can occur in any relationship. It can be by family members, other service users and care professionals. It could also take place in inpatient settings or in the community. Table 4 shows a breakdown of the disciplinary cases in 2010/2011 and 2011/2012 of staff in BEHMHT as a result of an allegation of abuse of a patient. Date No Case to Answer First written Total warning 1 April 2010-31 March 2011 3 0 3 April 2011-29 February 2012 10 2 12 (Table 4) Overall, there has been significant progress in the work of Adults in the Trust. One of the challenges identified is regarding the collating of safeguarding adult data. Some Managers are not completing the monitoring forms fully to enable the Local Authority and the Trust to have all the information about the safeguarding case. A further challenge has been that once the data is received from the Local Authority, having the right administration support to analyse and present the data in a way that supports the quality improvements in all aspects of safeguarding. 13. Progress from Work Plan 2010/2011 1. Attendance at three boards has continued during 2010/2011. 2. Training have been amended in June 2011 to reflect the Pan London Procedures. 3. All the actions from the audits have been followed through to completion during 2010/2011. 17

4. The Pan London procedures were implemented in the Trust in September/ October 2011. The revised templates have been received from Barnet and Enfield. The revised templates from Haringey have not been received. 5. The Clinical Lead Nurse carried out a review of the work of the Adult Team in Haringey. The outcome of the review enabled the management of the team to change the way referrals are dealt with. A duty worker now screen referrals in the Integrated Access Team and send the appropriate referrals to the Adult Team. Since this change has been implemented the process for managing referrals has been working much better and therefore the need to change the process of the management of safeguarding alerts from BEHMHT to Haringey Team was not necessary. 14. Priorities for 2012-13 Continue to raise awareness amongst staff in the practice of Adults. To ensure that 60 key staff attend level 2 and level 3 Multi Agency Adult Training across the three boroughs. To develop practice in the Trust regarding domestic abuse by ensuring a jointly developed protocol and adequate domestic abuse training for staff across the Trust. To have a continued programme of level 1 Adult training with 85% compliance achieved. With the increased activity in the number of referrals being reported services to ensure that adequate resources are available to support and respond to alerts in a timely way. 15. Conclusion This report presented an overview of the work that has been carried out regarding Adults in BEHMHT from April 2011 to end of March 2012. The report shows that whilst improvements have been made, challenges in the management of safeguarding data and recording on RiO continue to be present. During 2012/2013 the Trust will endeavour to maintain standards of practice and ensure effectiveness in the work of Adults. This will be guided through the work plan in Appendix 1. 18

Appendix 1 Work Plan 2012-13 Area Action Time Scale 1 Multiagency Partnership Working Health System Leadership Continue to represent the Trust at the three Boroughs Partnership Boards Ensure that the Trust is represented at the safeguarding adults subgroups. March 2013 Lead s for Service Line/ Adults Outcome measure Staff in each Borough identified to attend Multi-agency meetings Progress Ensure the Trust has representation at Multi Agency Risk Assessment conference (MARAC) 2 Training Ensure that training in Domestic violence is delivered to staff in BEHMHT to raise awareness and gain further understanding of the referral process. March 2013 March 2013 s Adults/Children Training is delivered and staff knowledge increased Ensure that a planned programme of Bespoke Adult training is undertaken and delivered to managers and staff in the Forensic service. May July 2012 Forensic Service/ Lead Forensic Training is delivered and staff knowledge increased 19

Area Action Time Scale Ensure that 60 key members of staff receive level 2 and 3 Adult training in 2012/13 March 2013 Lead Service/ director Adults Outcome measure That the Trust reach the required target Progress Link with Workforce Development to ensure the training needs of BEHMHT staff in safeguarding adults is achieved. March 2013 That the Trust is Compliant with Adult Training.3 Audit and Monitoring to maintain quality standards regarding safeguarding adults in the Trust Team Managers to audit 1 case file per month on Meridian. By doing this Managers will get instant results of the audit. Attend Team/staff meetings and find out areas of concern they may have regarding the practice of safeguarding adults also to communicate key messages. March 2013 Adults/ s for Service Lines/ Team Managers Audit is fed into the quality assurance process of the Trust Continue awareness raising and check staff understanding of safeguarding adult process Carry out internal case file audits and report to the Adult Committee on a quarterly basis. Adults/ DATIX Manager 20

Area Action Time Scale Complete actions plans following evidence drawn from these audits. Lead Outcome measure Progress 4 Data Management Ensure the maintenance of the adult database Receive regular data updates from the Local Authority. Present a data update at the Bimonthly Adult Committee. March 2013 Adults. /Team Managers/ Local Authority staff Up to date data is maintained. Regular data reports is developed and presented at the required committee meetings or Trust Board. 5 Implementation of the Bournemouth Adult As part of the implementation the Bournemouth Competency Tool to ensure that the Trust has a system that gives consistency in the use of the tool March 2013 Adults s/ Team Managers/ System for assessment completed Integration into current practice such as supervision /appraisal 6 Further develop closer working links with the Serious Incident and Complaints Manager to ensure the continued integration of the three processes at the time To collect information on Serious Incidents that were investigated as Cases and present at the adult Committee. March 2013 Adults/Serious Incident Manager/ Complaints Manager Cases presented at Adult Committee 21

Area Action Time Scale an incident happens Lead Outcome measure Progress 7 Use of the Adults Self-Assessment and Assurance Framework for Healthcare Services To review the outcomes on a yearly basis to ensure that standards in practice are maintained. Link the actions from the Self- Assessment to the Trust work plan for 2012/2013. August 2012 Adults/ s in Service Line Actions link to Trust Work plan. Gaps identified are communicated to relevant personnel to address the issue 8 Learning Lessons from Investigations 9 Establish a domestic abuse protocol across the Trust 10 Update Adult information on the new Trust Website 11 Embedded Pan London Procedures in practice. Ensure learning lessons from safeguarding cases are feedback into practice Work jointly with the for Children to develop a protocol Link with staff in Communications department. Ensure relevant protocols and forms relating to Adults are easily accessible to all staff Ensure Pan London Practice Guidance is circulated across the Trust March 2013 March 2013 April 2012 December 2012 Adults/Ward and Team Managers s/ Domestic Abuse Co-ordinators/ Committee members Adults Adults/Team Demonstrate how the learning lessons have been taken back into practice Trust Domestic Abuse Protocol completed and disseminate across the Trust. Staff aware of Protocol Staff have access to relevant policies and paperwork needed in managing safeguarding cases Staff aware of policy and guidance 22

Area Action Time Scale 12 Update Adults Poster to reflect changes including Enfield Community Services Adults to collate information to be included in the update May 2012 Lead managers Adults/Team managers Outcome measure A3 Poster issued with updated information Progress 13 Establish DATIX system that promotes appropriate recording of safeguarding cases To get regular reports from the DATIX Manager to enable for the tracking of incidences on DATIX that has been reported as a safeguarding case. Adults/ DATIX Manager Memo to Staff Appropriate reporting on DATIX 23