Wiltshire Safeguarding Adults Board Recommendations from SCR Report Recommendation Action Agreed Lead Responsibility Timescale Recommendations on medication 1. Every effort should be made to reduce psychotropic medication unless there is a clear diagnosis of mental ill-health in a person with learning disabilities that warrants its use: positive behavioural support and behavioural approaches should always be the first approach to challenging behaviour and where it is deemed appropriate it must be properly monitored. 2. Where PRN medication is prescribed, not only the amount but the triggers for, and appropriateness of, its use should be monitored regularly, and carefully, by the prescribing physician and the community pharmacist in relation to each individual, and in relation to the service as a whole. This information should be used to evaluate whether there are instances of underuse or overuse: monitoring should be tailored to explicit individual parameters and used to support clinical decisionmaking. Where its use exceeds safe prescription practice, the GP should put additional monitoring in place and/or require the service to review practice with help from CTPLD or other relevant health professionals. Address through the appropriate application of guidance: Audit awareness and application of the national guidance available in relation to the use of lithium. National work is underway on wider psychotropic medication, arising from the Winterbourne View report, with NICE guidance due in 2015-16. The WSAB will contribute learning from this SCR to that review and learn from it. Identify current advice on PRN medication and send alert specifically about PRN anti-psychotic medication. Liaison between NHS England Area Team and CTPLD to agree advice that can be issued about links to behaviour support services. 1 NHS England Area Team WSAB NHS England Area Team AWP NHS England Area Team CTPLD
3. Community pharmacists also currently monitor the use of PRN medication and they should support GP s to replace this with regularly prescribed medication wherever possible. Overuse of PRN medication should be brought to the notice of prescribers and care providers and, if it persists after an appropriate process of review, reported to the local safeguarding adults team. 4. Lithium is a potentially toxic drug: it can be prescribed by a GP, as opposed to a Consultant Psychiatrist, if a person is stable, provided that blood levels are monitored every three months. Where it is possible for a person to move from lithium to a lower risk medication this should be prioritised even though it is acknowledged that all psychoactive medication carries risk. Identify current monitoring arrangements and raise awareness of community pharmacists about these risks. Safeguarding Manager to liaise with CCG safeguarding lead to propose means of identifying persistent overuse and whether it has met the significant harm threshold. Persistent overuse below the safeguarding threshold to be pursued through CCG quality assurance pathways. See 1 and 2 above NHS England Safeguarding Manager CCG CCG Safeguarding lead 5. Whichever medical practitioner prescribes lithium should also take the primary responsibility for monitoring and evaluating its potential side-effects. See 1 and 2 above 6. CCG s and NHS England should be mindful of the need to commission services that are well integrated so that people with dual and multiple diagnoses can receive a coherent and well thought through approach in the most appropriate setting Letter from the Board to the relevant commissioners to highlight the issues about fragmented services that have arisen in this case. WSAB Chair 2
Recommendations on mental health care 7. Bi-polar disorder is difficult to diagnose in a person with learning disabilities and the Panel therefore recommends that thorough assessment and regular review be used to support such diagnosis and to inform carers about the condition as stipulated in Ensuring Quality Services core principles for the commissioning of services for children, young people, adults and older people with learning disabilities and/or autism who display or are at risk of displaying behaviour that challenges http://www.local.gov.uk/documents/10180/12137/l14-105+ensuring+quality+services/085fff56-ef5c-4883- b1a1-d6810caa925f 8. Psychological assessment and intervention, including comprehensive functional analysis and a focus on engagement should always be considered alongside psychiatric input and the subject of shared consultations within the CTPLD conducted in line with recent government guidance issued as part of the Positive and Safe Initiative [DHApril 2014] (https://www.gov.uk/government/speeches/positiveand-safe-reducing-the-need-for-restrictiveinterventions) 9. Commissioners of both learning disability and mental health services in this area should work together to clarify clinical pathways for people with dual diagnoses and set out quite clearly when they expect a person with a dual diagnosis to receive their psychiatric care in a mainstream setting; where care is shared there should be a clear protocol and a clearly specified individual health action plan spelling out exactly which elements of their care should be provided from which service. In In relation to bi-polar disorder in this group of service users, alert assessment teams to the findings of this review. The Ensuring Quality Services guidance about services for people with behaviour that challenges to be brought to the attention of commissioners and operational teams. The CTPLD now has a challenging behaviour/mental health work stream and these staff support people the team are made aware of who are prescribed PRN. The CTPLD will continue to forge stronger links with our own Psychiatry team and G.P surgeries to identify everyone who is being treated for behavioural/mh issues This links to the Winterbourne View Concordat and the action plan between the Council and CCG which is monitored by the Health and Wellbeing Board and the JCB. Work streams include: A Care Programme Approach is currently being piloted in CTPLD. This includes a clear protocol for where care is shared and a clearly specified individual health action plan spelling out exactly which elements of their care should be provided 3 WSAB Chair Operations / Head of Locality, SARUM, GWH Wiltshire Council Head Of Service Operations / Head of Specialist Commissioning CCG
complex cases the Care Programme Approach or a similar mechanism should be used as a mechanism for planning and reviewing their care. from which service. A Crisis pathway is being developed to address the needs of people with learning disabilities and challenging behaviour A new health specification is being developed for CTPLD which will clarify clinical pathways for people with dual diagnoses and set out quite clearly when they expect a person with a dual diagnosis to receive their psychiatric care in a mainstream setting. Recommendations on management of client finances 10. Financial arrangements for clients monies should always be stipulated in the contracts and/or care plans that are drawn up by placing authorities and overseen by an independent professional, family member or by the placing authority in the interests of a person who lacks capacity to manage their own finances Wiltshire Council to stipulate that placement providers whether in care homes or supported living are no longer able to hold appointeeships or lasting powers of attorney (LPAs). Where alternative arrangements cannot be made via families or friends, the Council s Court of Protection Team (COP) to take on the role. Business case to be produced to enable consideration of additional cost of expanded staffing in COP team by September 2014. Social work teams to identify where arrangements need to change and refer to COP team where necessary. Change to be phased in over the year to 1/10/2015. Wiltshire Council Head of Safeguarding and Quality Assurance Wiltshire Council COP Team Manager Operational Heads of Service 11. Owners or staff in residential homes should not hold appointee-ships or powers-of-attorney to manage the financial affairs of residents, this responsibility should be managed by family members, impartial professional WSAB to write to all placing authorities about this and all other recommendations relevant to their practice. This issue has already been raised in a presentation to the Learning Disability Provider Forum and the information circulated to LD Providers. Similar actions will also be taken with other providers including 4 WSAB Chair Wiltshire Council Head of Specialist Commissioning/ Head of
advisers, advocates or by the host or placing local authority on behalf of a person who cannot manage their finances without assistance. Residential home staff may help the person to manage day-to-day expenses and routine spending but not to manage savings or inheritances. 12. Staff contracts in provider agencies should make clear that staff should not be handling significant amounts of client money, and should spell out the fact that no staff should handle benefits or gain from wills 13. Placing authorities should oversee the arrangements in place to manage the finances of people who lack capacity to manage their own affairs and where a person s money is being managed on their behalf they should ensure that it is neither overspent, nor that it is left unspent, but used appropriately in the best interests of the person concerned. through Wiltshire Care Partnership. Wiltshire Care Partnership to propose guidance to issue to providers. Confirm how this issue is reflected in CQC new inspection arrangements. Clear advice to customers, families, service providers and professionals on who is the appropriate person to act as the LPA or appointee of a person s finance when they do not have the capacity or wish to do so themselves. This will be produced and widely circulated by December 2014. Commissioning Care Support & Accommodation WCP WCP / Provider Agencies CQC Operations Recommendations on Primary Care for GP Practices, District Nurses, Community Dentists and CCG s 14. Where a GP Practice has an unusual concentration of patients with learning disabilities (as happens where there have been historical closures of large institutions) the Practice should designate a particular clinician to take the lead in keeping up-to-date knowledge and networks to underpin their work with this client group. Identify the population breakdown for these groups and write to GP practice safeguarding leads and provide CTPLD contact details NHS England Area Team 15. Non-attendance at appointments must always be seen as an omission by the service and not a choice of the individual: GP s should follow up missed consultations on behalf of clients who do not have capacity and if they meet with non-co-operation they should inform the person s placing authority Raise awareness in GP practices through newsletter and training. 5 NHS England Area Team
16. People with learning disabilities, and/or their carers, when registering with a GP practice should inform the GP about their placing/ responsible authority. 17. The GP liaison nurse in the CTPLD should be proactive in making contact with every surgery in their area and ensure that all GP s know how to access their expertise 18. Where clients and staff of a service use the same GP or Dental Surgery it is important that wherever possible they are assigned to separate practitioners and staff care kept as separate as possible from that of their clients. Ideally staff would attend a different surgery but it is acknowledged that this is not always possible especially in rural areas. Each practice should manage any such conflicts of interest explicitly and the person responsible for the care of patients with a learning disability or other additional needs, should remain at all times independent and impartial in relation to staff of a residential service so that at no time do they lose the ability to advocate for vulnerable patients. 19. CCG s should issue guidance to GP s operating in their areas about potential conflicts of interest and dual relationships, including registering staff or colleagues as patients, or for example accepting a retainer in respect of providing a service to a residential home, reminding them of the need to remain impartial so that they can fulfil their responsibility to the person with a NHS and local authority commissioners can follow this up through the consistent implementation of the out of area placement protocols that are in place. Health Action Plan/Hospital Liaison nurses in the CTPLD to be more proactive in their contact with G.P surgeries. The Nurses will use a training pack they have developed to promote with GP surgeries who and what the team can offer giving the option for them to attend G.P surgery meetings on a regular basis, this will involve the team making initial contact with all 56 surgery managers to set up meetings or agree to send information. Letter to the various bodies identified (GMC and other professional bodies) about this recommendation asking for them to reinforce awareness of this issue with their membership. Letter as above 6 NHS Local Authority Commissioners CCG Operations WSAB Chair with advice from CCG and NHS England Area Team As above
learning disability or older person who is their primary patient. 20. GP s should be included in, and make strenuous efforts to take up, safeguarding training so that they know when to make an alert, such as if they observe Injuries such as bruising Poor practice such as overuse of PRN An absence of appropriate psychological input resulting in punitive lay explanations of, and responses to, challenging behaviour Failure on the part of a residential service to engage with specialist heath care practitioners including the CTPLD and/or to adhere to consistent use of Positive Behaviour Support as a response to challenging behaviour as stipulated in NICE guidelines Carry out local audit to get a baseline for training participation by GPs. (Noted that CQC regulation of practices is helpfully raising awareness of safeguarding.) Training leads to note the proposed content for inclusion in training events. NHS England Area Team WSAB L&D subgroup 21. GP s are gatekeepers to the wider system of health care on behalf of people with intellectual disabilities and especially so where a person lacks capacity to instigate referrals for their health care and/or to attend appointments on their own: at all times the GP should not be dissuaded by non-medically qualified staff from seeking appropriate health care or from exercising appropriate caution on their behalf. To be incorporated by NHS England Area Team into the work programme over the next 12 months on MCA/DoLS in primary care, based on the House of Lords recommendations. CCG are developing a Training programme with UWE on MCA/DoLS for delivery across Health Community. NHS England Area Team CCG 7
Recommendations for commissioning bodies responsible for the CTPLD and GP surgeries whose role it is to manage the interface between mainstream primary care and specialist learning disability services 22. In the CTPLD, multi-disciplinary working should be strengthened and within team referrals, from one profession/discipline to another, should be easy to effect and properly recorded. Build on the current CTPLD referral meetings that are arranged requiring Health and Social care staff to be involved at the earliest stage of a request for a multi disciplinary approach. All customer/patient information to be stored on one electronic system to be in place by January 2015 Operations / Head of Specialist Commissioning 23. Management of the local network of specialist health care professionals working within the CTPLD should be strengthened and structures to facilitate and embed proper multi-disciplinary referral meetings, shared assessments and evidence based interventions should be improved. It should not be possible for a residential service to bypass psychological interventions and rely heavily on medication as an alternative to evidence based psychological approaches to challenging behaviours. 24. CTPLD should liaise with all GP surgeries in their geographical area and ensure that they know what specialist resources and expertise are available locally and how to access them. As above Operations As response in point 17 above Operations 25. Commissioners must clarify and publicise routes for referral and consultation to ease the coordination of service provision across the complicated interfaces between the different agencies providing health care in the county. 26. When asking, or requiring, a residential service to monitor a particular aspect of a person s health or behaviour, the person s responsible clinicians should set out exactly what is to be observed, how it is to be This issue will be raised with the CCG and also with health liaison staff and in partnership meetings A single case management storage system will assist all professionals to check, update and follow up on actions relating to an individual customer/patient s health and social care plan. This will be in place by 8 Head of Specialist Commissioning Operations
recorded and what thresholds should trigger a rereferral: they should take a close interest in, and periodically inspect, this documentation to ensure that it is used to make clinical decisions or changes in the person s care plan or immediate environment so that monitoring does not become bureaucratic or diluted over time but is seen to be useful and contributing to the development of capable services. 27. Health care practitioners should consult with informal or paid carers when making best-interests decisions about a person who lacks capacity but they should not allow that person(s) to act outside of their areas of expertise or responsibility. 28. It should be the role of the CTPLD to work with services as well as with individual clients to build the capability and knowledge base or local services in the interests of service users: this requires them to plan interventions that go beyond, and sit outside, individual assessment or discrete episodes of clinical care. January 2015 To be followed up by CCG Head of Adult Safeguarding. Wiltshire Council to consider extending advice available through DoLS helpline to complex cases. This already happens to some degree and is also the responsibility of commissioners. This issue will be raised with the CCG to incorporate in the revised specification for CTPLD and in partnership meetings CCG Wiltshire Council Head of Specialist Commissioning / CCG Recommendations for secondary care clinicians and referring GPs 29. Even if a referral comes via an unorthodox route, for example if provider agencies refer directly to secondary health care specialisms instead of going through their GP s as gatekeepers, feedback should be communicated to, and or copied to, the person s GP and they should receive discharge notes as they would for any other patient: that way the person s GP builds up a complete picture of their care and a comprehensive health record is held at the surgery: if an episode of treatment continues for more than three months, the GP should be provided with a quarterly review. This recommendation applies to other parts of the NHS and to the CTPLD as well as provider agencies. CCG to issue guidance 9
30. Primary care teams and all consultants in secondary care should know how to apply the Mental Capacity Act 2005 to complex situations and they should be clear that they are the primary decision-makers (and not staff of residential homes) in relation to the health care of a person with learning disabilities who lacks capacity to make their own health care decisions. In primary care the GP should take the lead and in secondary care the consultant will assume the responsibility as decisionmaker in matters such as hospital admission 31. All health, and related, professionals in mainstream services should be clear about where to seek advice about how to apply the MCA and Deprivation of Liberty safeguards (DoL s) from learning disability specialists, but they in turn must be clear about how to apply the Act sensitively and in an appropriately nuanced way especially in situations of high risk or contention. The test of capacity should be formal and apply the two stage criteria of making information accessible wherever possible and then assessing whether the person is properly weighing up the information in making their decision; clinicians and service providers should not hide behind untested assumptions that a person is making a choice when this is improbable. NHS England Area Team & CCG to lead as per Recommendation 21 above, linking with primary and secondary care. As above 21 and 30, and with support from MCA/DoLS team. A letter detailing advice as follows and supplying the contact details for the Wiltshire Council DoLS helpdesk to be sent to all providers in Wiltshire and to the Care Skills Partnership: any test of capacity should be formally recorded and decision specific, clearly evidencing the 4 stages of assessment. Service providers should not use untested assumptions about a person making a choice or unwise decision without evidence of this. Any visit to a provider from the Quality Assurance Team to include in all circumstances a review of the provider s application of the MCA. An updated briefing on the use of the MCA including the points above to be disseminated to all Wiltshire Council operational teams. NHS England CCG with support through MCA/DoLS project NHS England CCG with support through MCA/DoLS project Wiltshire Council Head of Safeguarding and Quality Assurance / MCA & DoLS lead Recommendations for residential home providers, their advisers and regulators 32. Residential services should not rely on PRN medication in the management of challenging behaviours as an alternative to psychological input and approaches. Wiltshire Council and CCG to inform all contracted providers. 10 Wiltshire Council Commissioning and Contract Lead Disabilities /
CCG 33. Proper legal frameworks should be in daily use, thoroughly understood and formally recorded in relation to all deprivations of liberty, uses of restraint and best-interests decision-making 34. A service that is not formulating challenging behaviour in professional, evidence based and ethically informed, ways should not in future be considered compliant with standards when inspected by CQC: positive behavioural support has been advocated for people with intellectual disabilities and challenging behaviour since the early 1980 s, set out in successive government reports (Mansell 1993 and 2007) and is currently stipulated in NICE guidelines Wiltshire Care Partnership to alert members to this issue Through contract expectations. Establish whether CQC standards address this. WCP Commissioning and Contract Lead Disabilities CQC CQC Responsibilities of placing authorities, commissioners and regulators 35. Placing authorities reviews must in future, scrutinise strategies for dealing with challenging behaviour, over time as well as during crises, expect and receive information about the regular monitoring of such behaviour and engage with the service about its understanding of the causes and triggers of such behaviour. 36. Placing authorities should also require notice of formal best-interests decision-making in relation to serious medical treatment and other significant issues in a Wiltshire Council to write to all providers in Wiltshire asking them to inform the council when they offer and provide a placement to a person being placed by another Local Authority. Wiltshire Council to make contact with that Council and request them to provide this information Recommendations 35-37 - WSAB to coordinate WSAB advice to other local authorities reference better practice when placing out of area. As above 11 Operations
person s life and challenge any decisions that are not in the best interests of the person concerned. 37. Placing authorities should review the way that PRN medication is given, recorded and reviewed and scrutinise its management by provider agencies in order to promote and ensure adherence to the principle of following the least restrictive option when working to keep the person safe: where it is used to excess they should seek input from health care professionals to revise a person s regular medication and/or to introduce psychologically informed strategies for managing difficult behaviour and/or distress and agitation. 38. Commissioners should have robust mechanisms for auditing services against national agreements and protocols to ensure that service users are receiving care that has been paid for, including waking night staff if these have been stipulated in the contract, day services or transport that has been itemised, all meals unless these are specifically excluded from the costings and holidays if these are included within the total fee. These placements are paid for out of public money and it should be regularly accounted for. Wiltshire Council to write to all providers in Wiltshire asking them to inform the council when they offer and provide a placement to a person being placed by another Local Authority. Wiltshire Council to make contact with that Council and request them to provide this information and include the appropriate health professionals in Wiltshire in this discussion This to be a requirement within a customer s reassessment. This needs both commissioning and care management input to ensure placements deliver what required by both contract and care plan, as it is about individual reassessments and ensuring people are getting the support they require/is being funded. Commissioning role is to ensure operational staff/processes do this through service specification work. Operations/ Commissioning and Contract Lead Disabilities Operations Wiltshire Council Operations/ Commissioning and Contract Lead Disabilities Recommendations for safeguarding teams 39. Poor reporting of incidents including falls and incidents of aggression between one resident and another should be challenged by safeguarding teams at the earliest possible juncture: failure to report an incident that later comes to light should be taken seriously as a breach of good practice and reported back to placing authorities, to CQC and if serious or repeated, to the Police as a The Council s Safeguarding Adults and Mental Capacity Team (SAMCAT) considers as part of Large Scale Investigation (LSIs) whether service providers are reporting as safeguarding alerts incidents arising in their services. Investigating managers to ensure that this is done routinely and to report back to Adult Safeguarding Conferences and Review so that multi- 12 Wiltshire Council Safeguarding Adults Manager
potential indicator of neglect as defined within the Mental Capacity Act 2005 section 44. 40. Commissioners should clarify in contracts and training the thresholds around what should be reported as abuse or neglect under safeguarding protocols and they should monitor services that have historically high levels of reporting and/or improbably low levels of accidents or incidents referred through formal routes. 41. Primary care teams should receive high quality safeguarding training with other disciplines and health care professionals. They should know how to identify abuse and poor practice and how to raise concerns with local safeguarding and/or health care professionals. 42. Safeguarding training should not only consist of content about recognition and reporting but should focus on positive and preventative practice in difficult areas of care including challenging behaviour, management of finances and medication. 43. The protocol for Whole Service Investigation currently under review, should be strengthened by introducing routine exploration of safer recruitment practice within the home and reviews of practice in relation to other individuals who were or are potentially at risk in this and other settings. agency action can be taken with the Police and CQC where there are serious or repeated failures to report abuse incidents. SAMCAT triage to create a spreadsheet recording all safeguarding alerts received from providers in order to identify those that have a high number of alerts and those where there may be under-reporting. QA team to propose arrangements by which the safeguarding policy and practice of providers who are not in touch over a 12 month period can be audited. All providers to be given a copy of the threshold guidance tool to support the decision on what should be reported. SAMCAT triage direct helpline for provider to continue It is agreed that this recommendation reflects best practice, but in reality, workload patterns mean that much of the training is done individually on line. Learning and Development sub-group to consider how this can recommendation can be addressed. Sub-group to keep training content under review The Large Scale Investigation (LSI) procedure has been updated, so that the following enquiries will normally be included: Understanding of MCA and individual capacity 13 Head of Safeguarding and Quality Assurance WSAB L & D Subgroup WSAB L&D sub group WSAB Policies and Procedures subgroup
44. Where an allegation is made that cannot be substantiated because of the nature of the circumstances and vulnerability of the alleged victim, proper multi-agency consideration should be given as to how to manage the intelligence gleaned from the alleged incident and how to put in place effective investigation strategies in case of further incidents. Whether the service provider is appropriately reporting safeguarding concerns Whether staff have been recruited and vetted in accordance with safer recruitment practice Ensuring the wider group of customers is screened where there is reason to believe the risks are wider ranging. There are plans to implement a QA database that will gather in one place intelligence about care services in order to determine what action to take where services fall short of required standards. There will also be a robust escalation process for decisions in response to concerns. This may be linked to the development of a local Quality Surveillance Group. Head of Safeguarding and Quality Assurance. 14