INDEX 1. INTRODUCTION

The aim of this policy is to ensure all staff understand and adhere to procedures for ensuring the safeguarding of all adults receiving care from, or visiting Cygnet service users. It is the responsibility of local Cygnet units to ensure they liaise with their Local Safeguarding Adult s Board (SAB), and adhere to any local protocols which may be provided in addition to those defined in this policy. It is the personal responsibility of every individual referring to this policy to ensure that they are viewing the latest version; this will always be published on Cygnet s SharePoint. For Cygnet Hospitals Bury, Sheffield and Woking, these will be available on the local network. Table 1 Linked Policies Related Policies RECORDING FORMS (CPF 4.02.1) SAFEGUARDING, PROTECTING AND PROMOTING THE WELFARE OF CHILDREN AND CHILD VISITORS (CPF 4.03) POLICY FOR PATIENT SAFETY: INCIDENT REPORTING AND MANAGEMENT (CPF 4.0) SAFEGUARDING ALLEGATIONS AND UTILISATION OF SUSPENSION (PM 20.9) PREVENT POLICY AND STRATEGY (CH 48) USE OF MOBILE PHONES AND RECORDING DEVICES (CH 22) INFORMATION TECHNOLOGY ACCEPTABLE USE POLICY (CH 24.02.1) INTERNET SOCIAL NETWORKING POLICY (CH 24.02.6) DISCLIPLINE AND DISMISSAL PROCEDURE (CH 39) DBS DISCLOSURE PROCEDURE (CH 06.01) PROFESSIONAL BOUNDARIES AND RELATIONSHIPS BOTH WITH SERVICE USERS AND BETWEEN CYGNET STAFF MEMBERS (CPF 2.11) PROCEDURE FOR RAISING CONCERNS (WHISTLEBLOWING) (CH 34) MENTAL CAPACITY ACT 2005 (MHA 11) PROCEDURE IN THE EVENT OF AN UNEXPECTED DEATH (CPF 4.04) NOTIFICATION OF A SERIOUS INCIDENT (CPF 4.0.1) WORKPLACE OPTIONS EMPLOYEE ASSISTANCE PROGRAMME (EAP) REFERRAL PROCESS (PM 16) DoLS PROTOCOL (MHA 11.01) INDEX 1. INTRODUCTION 2. SAFEGUARDING GOVERNANCE 2.1 Strategic and Organisational Arrangements 3. RIGHTS & RESPONSIBILITIES OF STAFF, SERVICE USERS, FAMILIES AND CARERS 3.1 Key principles 3.2 Safeguarding everyone s responsibility 3.3 A service user-centred approach 4. EQUALITIES STATEMENT 5. RECOGNISING ADULT ABUSE TERMS AND DEFINITIONS 6. PREVENT 7. DOMESTIC VIOLENCE & ABUSE (DVA) Page 1 of 32

7.1 The impacts of domestic abuse on children 8. FEMALE GENITAL MUTILATION 8.1 Response 9. SAFEGUARDING & TECHNOLOGY 10. ADULT SERVICE USERS WHO DISCLOSE HISTORIC SEXUAL ABUSE 11. SERVICE USERS WHO DISCLOSE PERPETRATING ABUSE 12. DEALING WITH DISCLOSURES 13. REFERRAL PROCESS 14. ESCALATION PROCESS 14.1 Medical examinations 15. MANAGING ALLEGATIONS AGAINST PROFESSIONALS (AAP) 16. PUBIC INTEREST DISCLOSURE (WHISTLEBLOWING) 17. RECORD KEEPING GUIDANCE 18. CONFIDENTIALITY AND INFORMATION GOVERNANCE 18.1 Public interests and legal restrictions high risk of serious harm or homicide - MAPPA 19. SUPPORTING CHILDREN WHOSE PARENTS ARE SERVICE USERS 20. MENTAL CAPACITY ACT / DEPRIVATION OF LIBERTY SAFEGUARDS 21. SAFEGUARDING ADULT REVIEWS (SAR) 22. SAFEGUARDING SUPERVISION 23. TRAINING 24. SAFE RECRUITMENT 25. REVIEW PERIOD 26. MONITORING, AUDIT AND GOVERNANCE 1. INTRODUCTION This policy details the actions all Cygnet staff should follow. All staff are legally obliged to report any concerns of abuse, and if unreported abuse is discovered and the concerned staff member has failed to report this, then this will be considered under Cygnet s disciplinary procedure. Cygnet provide services directly to adults of various ages in a number of inpatient units across the country. This policy is in line with the legislative frameworks for health. The key priority of all staff is to always ensure the safety and protection of adults (particularly those with additional needs, vulnerabilities and risks). It is the responsibility of all staff to act on any concerns, suspicion or evidence of abuse or neglect, and to respond and take action regarding these concerns. The Department of Health outline the following key principles for benchmarking safeguarding. These principles underpin Cygnet s systems for safeguarding adults within the services: Empowerment presumption of person led decisions and informed consent. Protection support and representation for those in greatest need. Prevention it is better to take action before harm occurs. Proportionality proportionate and least intrusive response appropriate to the risks presented. Partnership local solutions through services working with their communities. Communities have a part to play in preventing, detecting and reporting neglect and abuse. Page 2 of 32

Accountability accountability and transparency in delivering safeguarding. The safeguarding duties apply to an adult who: Has needs for care and support (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. Care and Support Act Statutory Guidance (October 2014), Chapter 14.2 Safeguarding Adults is defined as; An adult s right to live in safety, free from abuse and neglect. It is about people and organisations working together to prevent and stop both the risks and experience of abuse or neglect, while at the same time making sure that the adult s wellbeing is promoted including, where appropriate, having regard to their views, wishes, feelings and beliefs in deciding on any action. (Care & Support Act Statutory Guidance (October 2014), Chapter 14.7) This should be achieved through working with the adults for them to be included in the decisions regarding their care and wellbeing, but also to work with the professionals to establish what being safe means to them and how this can be best achieved. The following areas must be considered at all times in line with the Human Rights Act (1998). The following are key principles with a particular link to safeguarding of adults (although there are other articles that are not expressively linked to safeguarding): Right to Life this means that you have the right to be protected if your life is at risk. Similarly, public authorities should consider your right to life when making decisions that might put you in danger or which affect your life expectancy. Freedom from torture and inhuman or degrading treatment - Public authorities must not inflict such treatment on you, and they must also protect you from this treatment where it comes from someone else. For example, if they know you are suffering inhuman or degrading treatment, they must intervene to stop it. Torture occurs when someone acting in an official capacity (for example a police officer or soldier) deliberately causes serious pain or suffering (physical or mental) to another person. This might be to punish someone, or to intimidate. Right to Liberty and security - You have a right to your personal freedom. Services cannot take away your freedom by detaining you without good reason - even for a short period. Freedom from slavery and forced labour - The Human Rights Act protects your human right not to be held in slavery or servitude. Slavery is when someone actually owns you like a piece of property. Servitude is similar. You might live in the person s property, work for them and be unable to leave, but they don t officially own you. The law also protects you from forced labour forcing you to work under the threat of punishment that you have not agreed to accept. Respect for private and family life - You have the right to respect for your private life, your family life, your home and your correspondence. But at the same time you must also respect the rights of other people. Page 3 of 32

Freedom of thought, belief and religion - The Human Rights Act protects your right to have your own thoughts, beliefs and religion. This includes the right to change your religion or beliefs at any time. You also have the right to put your thoughts and beliefs into action. For example, public authorities cannot stop you practising your religion, publicly or privately, without very good reason, as outlined in the restrictions. Importantly, this right protects a wide range of religious beliefs and other beliefs including veganism, pacifism, agnosticism and atheism. Freedom of expression - You have the right to hold your own opinions and to express them freely without government interference. This includes the right to express your views aloud or through: Published articles, books or leaflets. Television or radio broadcasting. Works of art. Communication on the internet. However, these cannot be at the expense of impinging on another person s Human Rights. Protection from discrimination in respect of these rights and freedoms - Discrimination occurs when you are treated less favourably than another person in a similar situation and this treatment cannot be objectively and reasonably justified. 2. SAFEGUARDING GOVERNANCE 2.1 Strategic and Organisational Arrangements The key features of the Safeguarding arrangements are as follows: Director of Nursing & Patient Experience Professional Lead for Safeguarding Hospital / Unit Safeguarding Lead Ward Safeguarding Link Professional Page 4 of 32

Director of Nursing Is the identified Executive Lead and the named person at Board level to champion the importance of safeguarding for both adults and children throughout the organisation. The Executive Lead is responsible for: Ensuring that Cygnet managers are aware of adult and child protection policies and procedures, and provide appropriate training and support to clinical staff. Ensuring any adult or child protection case reviews are presented to the Executive Management Board annually. To have managerial responsibility and oversight for the Professional Lead for Safeguarding. Professional Lead for Safeguarding Is the identified professional within the senior management team to support both the Board in executing the statutory responsibilities for safeguarding in the Cygnet group, and supporting frontline staff and Clinical Managers regarding the management of safeguarding matters in our wards and hospitals across the group. The Professional Lead for safeguarding is responsible for: Updating policies as required in line with safeguarding adults and child protection guidance and legislation. Updating training as required in line with safeguarding adults and child protection guidance and legislation. Communicating any changes to the Executive Lead and disseminate relevant safeguarding information to the clinical staff through the aforementioned safeguarding structures within each hospital site. Advising senior managers, where necessary, with regard to adult and child protection issues. Monitoring the recording and handling of incidents and complaints involving adult and child protection issues. Supporting and managing the processes regarding allegations against professionals processes. To be the Independent Management Review author for Cygnet Health Care in the event of a Serious Case Review (SCR) being commissioned by the Local Safeguarding Children s Board and Safeguarding Adult Reviews (SAR) being commissioned from the Safeguarding Adult s Board. Cygnet s Unit / Hospital Safeguarding Lead May be the Clinical Leads (or another nominated person(s) and are designated as having responsibility for co-ordinating safeguarding locally at their particular unit, and supporting the ward / unit safeguarding link practitioner. They would also be responsible for monitoring the actions of their staff to safeguard and promote the welfare of adults and children. The responsibilities include ensuring that adults, children and young people are listened to appropriately and concerns expressed about their own or any other child s welfare are taken seriously and responded to in an appropriate manner. Clinical Professional to champion safeguarding matters across the services at a hospital site, and to support the professional lead for safeguarding execute Cygnet s mandatory safeguarding responsibilities. Page 5 of 32

Unit / Ward Safeguarding Link Professional Each Cygnet inpatient unit / education service should appoint at least one safeguarding link professional, this role is too primarily to provide advice and act as support to the ward based team regarding safeguarding matters. They would also act in a supporting role to the safeguarding lead for the unit. Safeguarding link professionals will receive additional support, training and safeguarding supervision to enable them to carry out this role effectively. Safeguarding link professionals may also wish to support in the delivery of safeguarding training or facilitate safeguarding supervision sessions following the completion the appropriate training. 3. RIGHTS AND RESPONSIBILITIES OF STAFF, SERVICE USERS, FAMILIES AND CARERS 3.1 Key principles Effective safeguarding arrangements in every local area should be underpinned by the following key principles: Stop abuse or neglect wherever possible. Prevent harm and reduce the risk of abuse or neglect to adults with care and support needs. Safeguard adults in a way that supports them in making choices and having control about how they want to live. Promote an approach that concentrates on improving life for the adults concerned. Raise public awareness so that communities as a whole, alongside professionals, play their part in preventing, identifying and responding to abuse and neglect. Provide information and support in accessible ways to help people understand the different types of abuse, how to stay safe and what to do to raise a concern about the safety or well-being of an adult. Address what has caused the abuse or neglect. 3.2 Safeguarding everyone s responsibility No single professional or agency can have a full picture of an adult s needs and circumstances and, families are to receive the right help at the right time, everyone who comes into contact with them has a role to play in identifying concerns, sharing information and taking prompt action. In order that organisations and practitioners collaborate effectively, it is vital that every individual working with families is aware of the role that they have to play and the role of other professionals. In addition, effective safeguarding requires clear local arrangements for collaboration between professionals and agencies. Any professionals with concerns about an adult s welfare should make a referral to local authority adults social care service. Professionals should follow up their concerns if they are not satisfied with the local authority adults social care response, see section 14, Escalation Process. 3.3 A service user-centred approach Effective safeguarding systems are service user centred. Failings in safeguarding systems are too often the result of losing sight of the needs and views of the adults within them, or placing the interests of other people or services ahead of the needs of adult at risk of harm. Page 6 of 32

People want to be respected, their views to be heard, to have stable relationships with professionals built on trust and to have consistent support provided for their individual needs. This should guide the behaviour of professionals. Anyone working with adults at risk should see and speak to them; listen to what they say; take their views seriously; and work with them collaboratively when deciding how to support their needs. 4. EQUALITIES STATEMENT Cygnet Health Care is committed to promoting the ethos and philosophy of respecting diversity with our services regardless of status; whether staff, visitor, service users or their families. Within safeguarding, there has sometimes been evidence and learning regarding missed opportunities to safeguard people due to either assumptions made regarding cultural (CS, Hampshire, 2013), failure to challenge (Winterbourne, 2012, Stafford, 2013). It is the responsibility of all Cygnet staff to clarify concerns regarding practice and culture through either: Researching that community on-line. Speaking to a community / religious leader / specialist regarding that area of concern. Having the courage to speak up and raise the concerns to others in challenging poor or unsafe practice. It is unrealistic for staff to be aware of every cultural norm and value due to the diversity of the UK population therefore if making further enquiries, they should be undertaken in a sensitive and respectful manner. People have a right to autonomy of thought, religion and practice within their communities, however, there is an obligation for this to be challenged if this contravenes UK law. Some themes regarding diversity that link with safeguarding practices may include: Forced marriage (which differs from arranged marriage). Female Genital Mutilation (FGM). Domestic abuse. Belief in spirit possession (and witchcraft). Prevent. If you are in any doubt or concern, seek further advice and support from the Ward or Site safeguarding lead. 5. RECOGNISING ADULT ABUSE TERMS AND DEFINITIONS The Care and Support Act Statutory Guidance (October 2014) identifies the following categories of abuse: Physical abuse including assault, hitting, slapping, pushing, misuse of medication, restraint or inappropriate physical sanctions. Domestic violence including psychological, physical, sexual, financial, emotional abuse; so called honour based violence. Sexual abuse including rape, indecent exposure, sexual harassment, inappropriate looking or touching, sexual teasing or innuendo, sexual photography, subjection to pornography or witnessing sexual acts, indecent Page 7 of 32

exposure and sexual assault or sexual acts to which the adult has not consented or was pressured into consenting. Psychological abuse including 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. Financial or material abuse including 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 encompasses slavery, human trafficking, and 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 including forms of harassment, slurs or similar treatment; because of race, gender and gender identity, age, disability, sexual orientation or religion. Organisational abuse including 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 on-going 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 including ignoring medical, emotional or physical care needs, failure to provide access to appropriate health, care and support or educational services, the withholding of the necessities of life, such as medication, adequate nutrition and heating Self-neglect this covers a wide range of behaviour neglecting to care for one s personal hygiene, health or surroundings and includes behaviour such as hoarding. Concerns may refer to only one or more of the above categories and abuse and may occur in a range of settings including: the family home; day care service; residential home; health or hospital establishment. Abuse may not always present as one incident but could present as a pattern of concern about the welfare of the adult. Abuse may be identified by a variety of sources including: statutory and non-statutory agencies; members of the family; clinical professionals or support staff or the wider community or the adult themselves. 6. PREVENT The Government s Prevent strategy focuses on stopping people becoming terrorists or supporting terrorism. It is part of the Government s counter terrorism strategy CONTEST, which is led by the Home Office. As Prevent is about recognising when vulnerable individuals are at risk of being exploited for terrorist-related activities. Cygnet is a key partner in the Prevent principle of this strategy, in line with all parts of health and the NHS. The Prevent agenda will ensure that: Cygnet staff know how to safeguard and support Page 8 of 32

vulnerable individuals, whether service users or staff, who they feel may be at risk of being radicalised by extremists. Appropriate systems are in place for staff to raise concerns if they have concerns someone maybe at risk of this form of exploitation. Safeguarding and incident reporting policies are integrated with the Prevent strategy. This policy should be read in conjunction with CH 48 Prevent strategy and policy. 7. DOMESTIC VIOLENCE AND ABUSE (DVA) The cross-government definition of domestic violence and abuse is: Any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16 or over who are, or have been, intimate partners or family members regardless of gender or sexuality. The abuse can encompass, but is not limited to: Psychological. Physical. Sexual. Financial. Emotional. The main features of a domestically abusive relationship are based around Coercive and Controlling behaviour. Coercive behaviour is an act or a pattern of acts of assault, threats, humiliation and intimidation used to harm, punish or frighten the survivor. Controlling behaviour are acts designed to make a person subordinate and dependent by isolating them from support, exploiting their resources, depriving them of the means for independence and regulating their behaviour. Since the introduction of the Care Act (2014), Domestic Violence and Abuse has been recognised as a safeguarding category of abuse in its own right for the protection of adults at risk. However, consideration should also be made regarding whether a referral should also be made to Children s Social Care services for any children and young people in the family home that may be witnessing domestic violence and abuse. 7.1 The impacts of domestic abuse on children Children witnessing domestic abuse (which can be both seeing or hearing the abuse), is categorised as emotional abuse due to the harm of seeing or hearing the abuse, or the observed consequences following the abuse situation. Studies have shown the psychological impact of abuse on children can be very damaging in both the short and longer term (Horn, Miller-Graff, Galano, Graham-Bermann, 2016). However, children are also at increased risk of physical abuse and harm when either caught in the cross fire of violence or attempt to intervene to protect one person from another. 8. FEMALE GENITAL MUTILATION (FGM) Female genital mutilation, excision or infibulation (female genital mutilation) is illegal in this country by the Female Genital Mutilation Act 2003 except for specific therapeutic reasons. There are 4 main types of FGM including; Type 1 clitoridectomy removing part or all of the clitoris. Page 9 of 32

Type 2 excision removing part or all of the clitoris and the inner labia (lips that surround the vagina), with or without removal of the labia majora (larger outer lips). Type 3 infibulation narrowing of the vaginal opening by creating a seal, formed by cutting and repositioning the labia. Other harmful procedures to the female genitals, which include pricking, piercing, cutting, scraping and burning the area. It is an offence to: Undertake the operation (except in specific physical or mental health grounds). Assist a girl / woman to mutilate her own genitalia. Assist a non-uk person to undertake FGM of a UK national outside the UK (except in specific physical or mental health grounds). Assist a UK national or permanent resident to undertake FGM of a UK national outside the UK (except on specific physical or mental health grounds). The Serious Crime Act (2015) extends this to non- permanent UK residents as well. Genital piercing. If you become aware of an adult with whom you are working with has experienced the FGM procedure / abuse, you should become vigilant if there are children within the family who may be placed at increased risk of harm as a result of this form of abuse. The adult may also require additional physical and psychological support as a result of the injuries sustained. 8.1 Response Any concerns or suspicions of intended FGM must be referred to Social Care and the Police. There is now a mandatory reporting duty to report FGM to the police in the event of; Those working in regulated professions (for example, teachers, social workers and healthcare workers) to report the discovery of FGM appearing to have been carried out on a girl under 18. (Serious Crime Act, 2015). 9. SAFEGUARDING AND TECHNOLOGY Staff should not befriend with service users and/or their families on any form of social media, or communicating via personal email or personal phones; please see Cygnet s Internet social networking policy, CH 24.02.6. Any staff found breaching this process may be subject to Cygnet s discipline and dismissal procedure (CH 39) and referred to the local authority allegations against professionals processes. If the person/family are known to you prior to them accessing Cygnet services, you should notify your hospital safeguarding lead immediately so a record of this can be made, and a risk assessment undertaken regarding the appropriateness of working in that environment whilst the person is placed in that service. Most modern phones have a range of additional functions including: cameras, internet etc. These should not be brought onto the ward environment. Photographs of service users should be taken (if required for therapy, or ward file information) on a Cygnet Page 10 of 32

hospital camera / phone. For further information, please refer to CH 22, Cygnet s Use of mobile phones and recording devices policy. 10. ADULT SERVICE USERS WHO DISCLOSE HISTORIC SEXUAL ABUSE Many people have disclosed abuse in their own childhood either at the time, or later as adults however, due to many factors including the culture at the time, the lack of understanding of what was being said, or a lack of process for how to action the disclosures in many hundreds of cases, nothing was done. Since the revelations regarding the activities of Saville (and others) came to light in 2012, there has been a significant number of reviews and enquiries conducted across a variety of agencies and services where it has been recognised the past failing, and services across health, social care and the police are committed to supporting assessments (and prosecutions) of these historic crimes. It is important to note that if the offence occurred before the person turned 18, that this is covered by Child Protection processes even if the person disclosing is now an adult. However, the adult may still be at risk and vulnerable to continued exploitation and abuse as an adult, and consideration should also be made in relation to the on-going support needs for the individual that may also include adult social care services. There are several options available to a person making a disclosure which include; Not wishing to take any further action. Reporting the matter to social care / Police for investigation. However, if during your discussion with a person who is disclosing historic abuse it becomes clear that the perpetrator is still alive and has access to children (i.e. grandchildren) or holds a position of trust (i.e. works in a paid or unpaid capacity with children / adults at risk) then there is a legal responsibility to report the allegation to the local authority social care (and in the event of a professional the LADO) so the risks to other children can be assessed to enable them to be protected. Sharing this information may be distressing for the person who has disclosed information of historic sexual abuse, and therefore support and reassurances will need to be provided and on-going. This support should be care planned. The person should be reassured that even though this information is being shared, it should not mean that they are under any pressure to speak to the police or be a part of any wider investigation, but it is simply a matter of ensuring the on-going safety and welfare of children who may be at risk currently. 11. SERVICE USERS WHO DISCLOSE PERPETRATING ABUSE Not all people who perpetrate harm are adult, children can also be abusers of other children for example; physical abuse (bullying), emotional abuse (bullying) or sexually harmful behaviour. If there are concerns that this may be the case, this should be clearly documented in the service user s record and a risk assessment undertaken, with a view to ensuring the safety and welfare of others. If a service user discloses that they have, or may have abused another person, this must be taken seriously and should be clearly documented in the service user s record, and discussed with the multi-disciplinary team. Staff must seek advice from the unit s Page 11 of 32

safeguarding lead / professional lead for safeguarding at Cygnet, and discuss arrangements for making a referral to Social Care and/or the Police as appropriate. 12. DEALING WITH DISCLOSURES If a person make a disclosure, it is important that you remain calm, reassure the person and provide the appropriate support. It is important that you explain clearly what will happen next as a result of the information they have disclosed. It is important that you document in as much detail as possible (and include as many direct quotations of what has been said) into the written record. Include also; non-verbal communication i.e. eye contact, upset, angry, tearful etc. Do not make promises that you will make sure that the abuse stops this is not something that is within your control. Do not also offer to keep the disclosure a secret. It is plausible that sometimes a person may retract (or take back) what has been disclosed. This also need to be recorded, if the initial disclosure met the threshold for referral to social care prior to the retraction then the referral should continue to be made with the subsequent retraction of the disclosure by the person. It is important that following a disclosure the person is adequately supported, and their care plans and observation levels are reviewed. Consideration should also be given for what information is shared with the family / carers. Clear documentation should be made regarding what information has or hasn t been shared and the reasons for this decision. WHAT TO DO IF A PERSON DISCLOSES ABUSE Accept what the person says Keep calm and don t panic Take what they say seriously, even if it involves someone you feel sure wouldn t harm them. Be honest Look directly at the individual Let them know you need to tell someone else Assure them they are not to blame for the abuse. WHAT NOT TO DO IF A PERSON DISCLOSES ABUSE Don t seek help whilst the person is talking to you Try to avoid making too many notes whilst the person is with you this can make the person think you aren t really listening Do not appear shocked or disgusted the adult might interpret that you are disgusted with them. Never ask leading questions (Use the TED model below) Try not to repeat the same question to the adult Never push for information Do not fill in words, finish their sentences, or make assumptions Page 12 of 32

Reflect the statement an adult has made back as a question by changing the intonation of voice Be aware that the adult may have been threatened Take proper steps to ensure the physical and emotional safety of the patient. Make certain you distinguish between what is said and what conclusions you have made accuracy is paramount Let the person know what you are going to do next Do not permit personal doubt to prevent you from reporting this Do not make promises you cannot keep Do not confront the offender Do not keep it a secret (even if the person retracts what they have said) Do not blame the adult you should have told someone before T.E.D. T TELL Tell me what you mean? Tell me what happened? E EXPLAIN Explain what you mean Explain how that made you feel D DESCRIBE Describe what you mean Describe how you felt Describe what happened next TED formulates a part of Achieving Best Evidence (ABE) practice which when having difficult conversations with people i.e. disclosures, reduced the opportunities for the disclosure or conversation to be viewed as the person of being led. Examples of leading questions might include; What did (s)he do to you? whereas by using the TED model it would be better to phrase the question as; Tell me what happened?, Explain what you mean by that. or Describe what happened. Page 13 of 32

In the event of a case getting to court, how the initial disclosure conversation is viewed may compromise the evidence if a defendant suggest that the person was led during that conversation. It is important that the disclosure is documented as soon as possible after the person has finished speaking, whilst the information is fresh in your mind. Go off to a quiet location if possible where you are less likely to be disturbed. Dealing with a disclosure can be a very emotive and emotional event for a professional. It is therefore important that you have the opportunity to debrief soon after the event with a member of the unit / ward management team, and for this to be followed up approximately 4 weeks following the disclosure. The unit safeguarding team should contact the professional lead for safeguarding if additional, specialist safeguarding support and debrief is required. 13. REFERRAL PROCESS All members of staff should be supported in making a referral to social care. The line manager / unit safeguarding links can support a member of staff in this process however, retrospective notification of the Line Manager / unit safeguarding link by the Cygnet employee is acceptable if waiting would cause undue delay in the referral to social care being made. The local authority should be considering whether there are grounds to undertake Section 42 enquiries. These enquiries are the statutory duties the local authority have to investigate and make plans to safeguard adults who have been subjected to, or are at risk of abuse as defined earlier in this policy. Page 14 of 32

Following the referral to social care, they should notify what the outcome of the referral has been. It may be one of the following: No further action. Planned for further information gathering. Passed for s42 enquiries. If you have not heard an outcome of the referral within 7 working day the ward/unit should follow up and request an outcome of the referral from social care. If you disagree with the outcome decision made by the local authority, request a reason for the decision. Consider whether the Escalation Processes should be followed (see section below). Be clear in ensuring what your professional recommendation is regarding the referral and how you have reached that conclusion. Suggestions include: Name the suspected category of abuse. Highlight whether you think this case needs an initial assessment to better understand the facts. Or By referencing the local threshold for referral document, we can be clear as an organisation that social care accept the appropriate referrals for further safeguarding enquiries. Complete incident reporting processes as per organisational policy i.e. Notification of a serious incident, CPF 4.01.1. The following flowcharts highlight the processes following a referral being received by the local authority social care department. Page 15 of 32

Flowchart to describe the safeguarding processes under Section 42 Care & Support Act Statutory Guidance (October 2014), page 251-252 14. ESCALATION PROCESS The aim of the escalation process is that multi-agency disagreements should be resolved as quickly as possible. Each SAB is responsible for having a process for managing disagreements between multi-agency partners. There are generally 5 stages to an escalation process. This was initiated as a result of finding from a number of Serious Case Reviews which indicated that agencies often failed to challenge if partner agencies if in disagreement with them regarding the welfare and safety of an adult. This failure to challenge in many occasions left the adult at further risk of abuse and harm. Stage 1 If you disagree with the outcome / decision made by the local authority, request a reason for the decision. Describe why you disagree with the decision and if possible refer the social worker back to the policy or threshold document for that area. This 1 st stage challenge can be made by any member of staff. Document in the records STAGE 1 escalation challenge and follow up the telephone conversation in writing outlining the concerns raised. If it is unresolved at this stage, speak to the Unit or Ward manager / Nurse in Charge for them to review the case. Stage 2 If the Unit / Ward Manager / Nurse in Charge also feels that this should be accepted by social care following the review of the records and the concerns raised, then they should speak to the social worker s manager within Social Care. Again to outline the Page 16 of 32

concerns and request that social care review the information and reconsider their decision, outlining where we disagree with their analysis. Document in the records STAGE 2 escalation challenge and follow up the telephone conversation in writing outlining the concerns raised. If it is unresolved at this stage, speak to the unit safeguarding lead for them to review the case. Stage 3 If the unit safeguarding lead feels that this should be accepted by social care following review of the record and the concerns raised, then they should arrange to speak with the service manager for that social care team. Again to outline the concerns and request that the service manager for social care review the information and reconsider their decision, outlining where we disagree with their analysis. Document in the records STAGE 3 escalation challenge and follow up the telephone conversation in writing outlining the concerns raised. If it is unresolved at this stage, speak to the Cygnet Professional Lead for Safeguarding requesting them to review the case. Stage 4 If the Cygnet Professional Lead for Safeguarding feels that this should be accepted by social care following review of the record and the concerns raised, then they should arrange to speak with the Director of Children s Social Care. Again to outline the concerns and request that the Director of Children s Social Care for social care review the information and reconsider their decision, outlining where we disagree with their analysis. The Professional Lead for Safeguarding will email the unit Safeguarding Lead details of the conversation and also forward a copy of the escalation letter for inclusion into the service user s record. If it is unresolved at this stage, speak to the Director of Nursing requesting them to review the case. Stage 5 The Director of Nursing will review the information and if the feel that the case should be accepted by social care, they should arrange to speak to the Chair of the SAB and escalate the case there. This should be followed up in writing and copies of the letters sent to be included in the service user s record. The decision of the safeguarding board is final and binding. It is important to note that if any Cygnet staff do not feel that the case should continue to be escalated, their decision should be recorded in the service user s records with a rationale as to why they disagree. If the professional wanting to escalate the case is in strong disagreement, support and advice should be sought from the safeguarding person at the next level for further discussion and support. 14.1 Medical examinations It may be necessary as a part of a safeguarding / protection enquiry that either the Police or social care may request the person receives a medical examination. This may be carried out either by a police surgeon (or their nominated specialist representative for collecting forensic evidence). Cygnet will cooperate fully with any requests for either of these interventions and support facilitation of these examinations. This may require a section 17 (Mental Health Act) being created for detained patients and should be expedited as quickly as possible. Page 17 of 32

15. MANAGING ALLEGATIONS AGAINST PROFESSIONALS (AAP) This section should be read in conjunction with the HR policies and procedures CH 39, CH 37, PM 20.09; Professional boundaries CPF 2.11 and CH 34 Whistleblowing policies. The safety and welfare of our service users is of paramount importance and any concerns regarding staff are viewed with the utmost seriousness. Concerns may be raised through a variety of way in relation to staff including; formal and informal complains, concerns being raised by colleagues from Cygnet or other professionals, young people or their families raising concerns. The Care & Support Act Statutory Guidance (October 2014) is currently under review, and the Department of Health have announced the removal of the Designated Safeguarding Adults Manager (DASM) role this will be phased out over time for authorities that already have a DASM in post to oversee the Allegations Against Professionals process. The safeguarding concerns fitting in with the AAP processes would be that the alleged person has: Behaved in a way that has harmed a person, or may have harmed an adult. Possibly committed a criminal offence against or related to an adult. Behaved towards a patient in a way that indicates s/he is unsuitable to work with adults. There may be up to 3 strands of an enquiry that are running concurrently: A Police investigation of a possible criminal offence. Enquiries and assessment by adult social care about whether an adult is in need of protection or in need of services. Consideration by Cygnet Health Care of disciplinary action in respect of the individual. In the event of a concern being raised regarding a member of Cygnet staff, the Unit Safeguarding Lead should be notified. They should notify and liaise with the Professional Lead for Safeguarding / Director of Nursing for support and advice as appropriate. Referral to the Local Authority will need to be considered as a part of the action plan, and co-ordination regarding who would have this discussion. A discussion should take place to indicate how the safeguarding of the service users is being managed, the HR processes being undertaken as an element of this process, culminating in the development of a plan, next steps and processes to consider (which may also include the police). Many of the actions should be based on the recommendations from the local authority / Police, however, Cygnet Health Care reserve the right to take steps to safeguard the service users prior to these conversations taking place. Any process involving a member of staff is without prejudice whilst the investigations are on-going. Support for the individual member of staff will be provided by Unit Manager / HR. Staff can also seek additional support from the Workplace Options Employee Assistance Programme (EAP) PM 16 and GP/Counselling services. Page 18 of 32

CYGNET HEALTH CARE Under no circumstances should the member of staff speak to friends / colleagues within Cygnet regarding the allegations until such time as the process has been completed. Failure to adhere to this will be subject to disciplinary processes. Under no circumstances should Cygnet Health Care undertake any internal investigation involving interviewing staff until authorisation has been given by the following; Police. Adult Social Care. Crown Prosecution Service. This is because, the potential criminal legal investigations and gathering of evidence takes far greater president over the civil employment processes and safeguarding enquiries. The Professional Lead for Safeguarding / Director of Nursing / Senior HR Manager will attend any multi-agency AAP meetings as required. It is recognised that there may be an impact on colleague from within the team / service. They also should be offered support and debrief, without disclosing details of the ongoing enquiries and investigations. If the concerns raised are in relation to non-cygnet staff (including agency workers), there is still a duty to report and share this information, again liaising with the Designated Safeguarding Adults Manager (DASM), as appropriate. The Unit Safeguarding Lead should be notified. They should notify and liaise with the Professional Lead for Safeguarding / Director of Nursing for support and advice as appropriate. There should also be liaison with the professional s Line Manager in the partner organisation, with the concerns followed up in writing. If a professional that maintains a professional registration, Cygnet Health Care may also make a referral to the registrants body. The Safeguarding Vulnerable Groups Act (2006) and the Protection of Freedoms Act (2012), place a legal duty on Cygnet Health Care of people working with children or adults to make a referral to the Disclosure Barring Service (DBS) in certain circumstances. This is when Cygnet has dismissed or removed a person from working with children or adults (or would or may have if the person had not left or resigned etc.) because the person has: Been cautioned or convicted for a relevant offence. Or Or Engaged in relevant conduct in relation to children and/or adults (i.e. an action or inaction (neglect) that has harmed a child or adult or put them at risk of harm). Satisfied the harm test in relation to children and/or adults. i.e. there has been no relevant conduct (i.e. no action or inaction) but a risk of harm to a child or adult still exists]. The legal duty to refer to DBS applies even when a referral has been made to the local social care safeguarding team or professional regulator regardless of whether that Page 19 of 32

body has made a referral to the DBS about the person. 16. PUBLIC INTEREST DISCLOSURE (WHISTLEBLOWING) This section should be read in conjunction with CH 34, Cygnet s Procedure for raising concerns (whistleblowing) policy. All Cygnet staff have a duty to share concerns regarding culture and practice from within the organisation. Without this challenge and scrutiny, safeguarding concerns may arise for our services users, and their needs go unmet and are at increased risk of significant harm. Staff are encouraged to speak to their line manager regarding concerns; if it is their line manager they have the concerns about or are implicated through friendship with the person of concern, then staff are encouraged to speak to their manager s line manager. If the concerns are purely safeguarding contact can also be made directly to the Professional Lead for Safeguarding or the Director of Nursing. 17. RECORD KEEPING GUIDANCE All staff will keep accurate, contemporaneous records in the service user s clinical record. All entries should provide factual information, timing of events and reasoning behind the decisions made. All contact with the alleged victim in relation to the incident must be recorded in detail, noting exactly the words used and any behaviours etc. All consultation with Line Managers or other senior staff must be recorded, showing the date and time, and indicating the rationale for any decisions which have been made. When making contact with staff or other agencies any questions asked or information given should be recorded. Documentation should also reflect what information has not been shared and why it hasn t been shared. Any action plan provided by Social Care should be noted in the service user s record, and provided to the Unit Manager, Safeguarding Link Professional and Site Safeguarding Lead. Consider using additional tools to compliment good quality record / reviewing of service users records including; Chronology, Body Maps, Genograms, Ecomaps etc. 18. CONFIDENTIALITY AND INFORMATION GOVERNANCE Service users should expect that their contact with/provision of information to statutory agencies will be treated with care and confidentiality, unless disclosure is justified. However, there are occasions when it will be necessary to share information with other agencies including: Concerning an alleged perpetrator of abuse. Best practice highlights the importance of discussing and informing of any information sharing with the person (and their family), however there may be particular circumstances where this would be inappropriate or not permitted i.e. PREVENT, Sexual Page 20 of 32

Abuse, concerns where the person may be trafficked or go missing, or if the person was put at increased risk of harm. Clear documentation should be made in relation to information sharing discussions as well as the final decision as to what information has been shared and why and what information has not been shared and why this information wasn t shared. If there are any doubts regarding whether information should be shared relating to safeguarding, specialist safeguarding advice should be sought from either the unit safeguarding link professional, the unit safeguarding lead, or professional lead for safeguarding or Caldicott Guardian. A record of this discussion should be kept. Sharing information appropriately means that all Cygnet policies on information governance must be complied with (please refer to Cygnet s Information governance policy family CH 24 CH 24.17). Cygnet Health Care follow national guidance on information governance, and all Cygnet units will ensure that when sharing information with others that this is shared using safe and acceptable media to relay information. 18.1 Public interests and legal restrictions high risk of serious harm or homicide - MAPPA There may be other circumstances where the seriousness of the situation involves acting without the consent of a person with mental capacity. The legitimacy of this action must be clearly defined, be proportionate to the circumstances and permissible in law. Sharing information should be done with consent where possible. However this may be done without consent where the seriousness of the risk is such that there is a public interest in sharing information in order to prevent a crime or to protect others from harm. Multi Agency Public Protection Arrangements (MAPPA) is a statutory process for sharing information about people who present the highest levels of risk to their communities. Multi Agency Risk Assessment Conference (MARAC) responds in situations of domestic violence where there is high risk of harm or homicide. The service user s consent to share information should be sought unless there is compelling reason not to e.g. it may put them at a greater degree of risk. There may be exceptional circumstances where a service user who has capacity, makes a decision or intends to act in a way that brings civil or criminal law into play. Examples include: Where their action or intended course of action is unlawful. Where their care may need to be addressed under the Mental Health Act 1983. Where other legislation such as the Environmental Protection Act 1990, may be relevant. Management of such complex situations is likely to include others such as legal services and members of the multi-disciplinary/interagency team in exploring the best way forward. Ultimately, where no alternative solutions can be found, legislation may need to be used in the interests of the person or to protect the rights of others. Page 21 of 32

19. SUPPORTING CHILDREN WHOSE PARENTS ARE SERVICE USERS Staff should always consider the impact a parent s mental health or addiction may have on their parenting capacity. Evidence from studies undertaken following Serious Case Reviews (SCR) across the UK, indicate that in a high percentage of these cases parental mental illness or parental substance misuse were known features to agencies and services prior to the child s death or injury. That is not to say all parents who have mental health problems or use substances are going to harm children however, there should be evidence in the risk assessments, care plans and discussion with partner agencies and services that these factors have been considered. 20. MENTAL CAPACITY ACT [MCA] (2005) AND DEPRIVATION OF LIBERTIES SAFEGUARDS [DoLs] (2007) This section should be read in conjunction with the MCA/DoLs policies, MHA 11 & MHA 11.01. For people over the age of 16, assessments should be in relation to Mental Capacity in line with the MCA. The statutory principles in relation to capacity are: Always assume a person has capacity unless proven otherwise. All practicable steps should be taken to enable a person to make their own decisions. People have the legal right to make unwise decisions and in doing so it should not automatically be assumed they lack capacity as a result of this. Professionals should act or decide in the best interests of the young person is they lack capacity. Always use the least restrictive options. If there are concerns regarding whether someone has capacity, a two part test should be undertaken and clearly documented in the record. Two Stage Test of Capacity DIAGNOSITIC THRESHOLD does the person have a disorder or dysfunction of the mind / brain whether temporary or permanent? TEST OF THE ABILITY TO MAKE THE DECISION are they able to understand, retain, and weigh up relevant information as a result of the condition? Are they able to communicate the decision? Capacity is only impaired if both of the above apply, should this be the case, it is reasonable that a best interest decision may be needed to act on behalf of the young person. There have been recent changes in terms of case law relating to the Deprivation of Liberties Safeguards (DoLs). It has always been the view that this only applies to adults (People who are 18+). However, there have been recent cases that have gone through the court which have left a significant change to the interpretation of the law (Birmingham City Council v D, January 2016), this judgement now required people 16+ to be considered for a DoLs application. Page 22 of 32

21. LOCAL BOARD (LSAB) LEARNING REVIEWS (INCLUDING: SAFEGUARDING ADULT REVIEWS (SAR)) A safeguarding adult review may be commissioned by the Local Safeguarding Adult s Board (LSAB) in the following circumstances: When the adult in the locality dies as a result of abuse or neglect whether known or suspected. And Or Or There is concern that partner agencies could have worked more effectively to protect the adult. If an adult in its area has not died, but the SAB knows or suspects that the adult has experienced serious abuse or neglect. In any other situation involving an adult in its area with needs for care and support. Care and Support Act Statutory Guidance (October 2014), p 266 However, the safeguarding board may commission other forms of multi-agency safeguarding reviews i.e. SILPs (Significant Incident Learning Processes). In the event of Cygnet being notified of a SAB review being commissioned regarding a former / current service user the following need to be immediately notified: Director of Nursing. And Professional Lead for Safeguarding. There is a statutory duty to co-operate with the SAR process and this co-ordination will take place from the corporate leadership team. The aim of a SAR is to ensure multi-agency learning takes place and there will be a full review of Cygnet services involvement and report written that will feed into the wider multi-agency report. This review will be conducted by a member of Cygnet s senior management team who will act as IMR author (Independent Management Review), this will usually be the professional lead for safeguarding. The IMR author will look at written documentation and may also conduct interviews with staff involved in the care of the service user. An action plan will be devised and agreed with the SAB Panel. 22. SAFEGUARDING SUPERVISION This should be read in line with the safeguarding supervision strategy. Skilled and knowledgeable supervision focussed on outcomes for adults is critical in safeguarding work. Care and Support Act Statutory Guidance (October 2014), Paragraph 14.172 For many practitioners involved in day-to-day work with children, adults and their families, effective supervision is important to promote good standards of practice and to support individual staff members. It should ensure that practitioners fully understand their roles, responsibilities and the scope of their professional discretion and authority. It should also help identify the training and development needs of practitioners, so that each has the skills to provide an effective service. Page 23 of 32

Safeguarding Supervision should include reflecting on, scrutinising and evaluating the work carried out, assessing the strengths and weaknesses of the practitioner and providing coaching development and pastoral support. Safeguarding Supervisors should be available to practitioners as an important source of advice and expertise and may be required to endorse judgements at certain key points in time. All staff with a leadership role in Safeguarding should access Safeguarding Supervision (this includes; Ward/Unit Safeguarding Link Practitioners, Unit Safeguarding Leads and the Professional Lead for Safeguarding). This will be facilitated by an appropriately trained Safeguarding Supervisor. 23. TRAINING All staff working at Cygnet will be expected to complete a mandatory safeguarding briefing (including reading the appropriate safeguarding policies), on joining the organisation as a part of their induction this is normally within the first week of employment. Members of staff will then be enrolled onto the next available training course appropriate for their role and function within the organisation within 6 months of starting. All staff are also encouraged to attend local safeguarding board training within their own locality / area to keep themselves up to date with safeguarding training. Evidence of courses attended will be needed and given to line managers for the HR file. Alternatively, staff should attend Cygnet Health care s refresher training as mandated by their role and function within the organisation. 24. SAFE RECRUITMENT Cygnet Health Care is committed to the safe recruitment processes for all staff employed within the organisation. All appropriate checks will be undertaken prior to the commencement of employment. This will include: two written references (and verbal confirmation with one of the references) and a DBS check. It is the responsibility of the employee to notify of any changes to the DBS status at any stage during their employment. The offence will then be subject to risk assessment regarding suitability of continued employment. Any changes not declared, and discovered later will be subject to dismissal from the organisation. Cygnet will DBS checks will be undertaken every three years as recommended by the Lampard Enquiry (2015) and Cygnet HR policies and procedures. For further information, please refer to Cygnet s DBS disclosure procedure (CH 06.01). 25. REVIEW PERIOD This policy has been written by the Professional Lead for Safeguarding and has gone through the appropriate Cygnet Health Care ratification processes including sign off from; Director of Nursing, Corporate Governance Director, Corporate Risk Manager and the Executive Management Board. This policy will be reviewed 12 months following implementation unless there are significant changes in organisational systems and structures, legislation or statutory Page 24 of 32

CYGNET HEALTH CARE guidance. This review will be conducted by the Professional Lead for Safeguarding and any amendments will be reported to the Director of Nursing before implementation. There will be an audit trail of version and amendments retained by Cygnet in case of enquiries and reviews in the future. 26. MONITORING, AUDIT AND GOVERNANCE The Corporate Risk Manager will retain a record on the risk management system of all reported safeguarding concerns. In accordance with CPF 4.0, the policy for Incident reporting and management, an incident form must be completed for all safeguarding children incidents and a serious incident notification form sent to the Corporate Risk Manager who will notify the Professional Lead for Safeguarding. Subject to bank holidays and weekends, the unit s on-call person must be contacted for advice. All internal SI notification forms during weekends and bank holidays must be sent on Monday before midday or, the first working day following a bank holiday, to the Corporate Risk Manager and notify the Professional Lead for Safeguarding Follow up serious incident reports are required by commissioners at 72 hours and 60 working days after the incident (if a root cause analysis report has been instigated). A final report and action plan should be submitted when it has been signed off for approval by the Patient Safety Committee (Members include, Chief Operating Officer, Director of Nursing, Corporate Governance Director and Corporate Risk Manager). All of these reports concerning safeguarding adult incidents must first be sent to the Corporate Risk Manager, Professional Lead for Safeguarding and the Information Governance Manager. REFERENCES Practice issues FAQ for safeguarding adults http://www.scie.org.uk/care-act-2014/safeguarding-adults/adult-safeguardingpractice-questions/ The Sexual Offences Act (2003) http://www.legislation.gov.uk/1983?title=mental%20health%20act The Mental Capacity Act (2005) http://www.legislation.gov.uk/ukpga/2005/9/contents The Safeguarding Vulnerable Groups Act (2006) http://www.legislation.gov.uk/ukpga/2006/47/contents The Protection of Freedoms Act (2012) http://www.legislation.gov.uk/2012?title=protection%20of%20freedom%20act The Mental Health Act (1983 &2007) http://www.legislation.gov.uk/1983?title=mental%20health%20act http://www.legislation.gov.uk/2007?title=mental%20health%20act The Mental Health Act Codes of Practice (2015) https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/435 512/MHA_Code_of_Practice.PDF Forced Marriage http://www.legislation.gov.uk/asp/2011/15/contents Human Rights Act (1998) http://www.legislation.gov.uk/ukpga/1998/42/contents The Serious Crime Act (2015) https://www.gov.uk/government/collections/serious-crime-bill Page 25 of 32

APPENDIX 1 Body chart The following chart is a useful and simple way of recording injuries. It is better to record what is actually observed than to speculate on the cause of the injuries at this stage. If the body chart is to serve as a monitoring tool for minor injuries observed over a period of weeks (or even months), a new body chart should be used on each occasion. It is therefore very important to be consistent in the method of recording injuries so that comparisons can be made with earlier charts. Where several different staff may be completing the monitoring forms, managers should ensure they understand what is required of them. The following points should be covered: Describe any marks, swelling, lacerations or other injuries carefully (cuts, bruises scratches). An arrow should then indicate a written description. Describe the colour (brown/yellow/blue), size and shape of any injuries and indicate their location on the body chart; also describe any pattern if there are several bruises close together. Briefly list any relevant circumstances witnessed, such as anger or aggression or by anyone in contact with the person. Record any explanations of injuries given immediately by the adult and any other witnesses. Ensure that for each chart completed the date and time of examination are clearly entered along with the name of the person and their job title completing the chart. Page 26 of 32

Front and back views - Female Service user or staff initials: Incident Log Number: Please confirm the actual harm caused i.e. cut, bruise, sprain etc. Please confirm both in writing and by marking the picture of the actual body part/s harmed On completion of the above, please tick one of the following to indicate the severity: 1) No harm (negligible) 2) Minor 3) Moderate 4) Severe 5) Catastrophic / Death Completed by: Name: Designation: Date Time Page 27 of 32