Pam Jones, Associate Director Safeguarding.

NHS BOLTON CLINICAL COMMISSIONING GROUP Public Board Meeting AGENDA ITEM NO: 16 Date of Meeting: 23 rd September 2016 TITLE OF REPORT: AUTHOR: PRESENTED BY: PURPOSE OF PAPER: (Linking to Strategic Objectives) LINKS TO CORPORATE OBJECTIVES (tick relevant boxes): RECOMMENDATION TO THE BOARD: (Please be clear if decision required, or for noting) COMMITTEES/GROUPS PREVIOUSLY CONSULTED: REVIEW OF CONFLICTS OF INTEREST: VIEW OF THE PATIENTS, CARERS OR THE PUBLIC, AND THE EXTENT OF THEIR INVOLVEMENT: OUTCOME OF EQUALITY IMPACT ASSESSMENT (EIA) AND ANY ASSOCIATED RISKS: Safeguarding Annual Report Pam Jones, Associate Director Safeguarding. Mary Moore, Chief Nurse NHS Bolton Clinical Commissioning Group has a statutory duty to make appropriate arrangements to safeguard children and adults at risk. The Safeguarding Annual Report for 2015/16 aims to provide assurance to the Governing Body as to how NHS Bolton CCG has discharged those responsibilities. The report also provides an overview of national and local developments during the reporting period. Delivery of Year 1 Locality Plan. Joint collaborative working with Bolton FT and the Council. Supporting people in their home and community. Shared health care records across Bolton. Regulatory Requirement Standing Item To receive and note the content of the report. Quality and Safety Committee Conflicts of interest are reviewed throughout the safeguarding processes. Not considered necessary for this report. Not considered necessary for this report. x 1

NHS Bolton Annual Safeguarding Report 2015/16

Table of Contents 1. Introduction... 2 2. Safeguarding governance and accountability arrangements... 2 2.1 Safeguarding Vulnerable People in the NHS... 2 2.2 NHS Bolton CCG Governance arrangements... 2 2.3 Safeguarding arrangements within NHS Bolton CCG... 2 2.4 Safeguarding assurance in relation to commissioned services... 3 2.5 External audit of Bolton CCG Safeguarding arrangement... 4 2.6 Greater Manchester Collaborative arrangements for safeguarding... 4 2.7 Safeguarding and General Practice... 4 3. Safeguarding Children... 5 3.1 The Child Protection Information sharing project (CP-IS)... 5 3.2 Child Sexual Exploitation... 5 3.3 Female Genital Mutilation (FGM)... 6 3.4 Post Savile... 6 3.4 Bolton s Multi-Agency Safeguarding and Screening Service (MASSS)... 7 4. Bolton Safeguarding Children Board... 7 6. Looked after Children... 8 6.1 CCG responsibilities for looked after children... 8 7. Safeguarding Adults... 9 7.1 Making Safeguarding Personal... 9 7.2 Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS)... 9 8. Bolton Safeguarding Adult Board... 10 9. Prevent... 11 10. Conclusion... 11 11. Contributors to this Report... 12 Appendix 1 NHS Bolton CCG Safegaurding Team contribution to local safeguarding arrangemnts. 1

1. Introduction This is the third Safeguarding Annual Report of NHS Bolton Clinical Commissioning Group (NHS Bolton CCG). It includes both adult and children s safeguarding and covers the period from April 2015 to the end of March 2016. It provides both the national and local context to safeguarding developments during the reporting period; outlines how NHS Bolton CCG is meeting its statutory responsibilities for safeguarding; and highlights how challenges relating to safeguarding are being managed locally. 2. Safeguarding governance and accountability arrangements 2.1 Safeguarding Vulnerable People in the NHS NHS England published the revised Accountability and Assurance Framework for Safeguarding 1 in July 2015. The purpose of the document is not to generate new policy but to articulate the safeguarding roles, duties and responsibilities of all NHS organisations commissioning NHS health and social care. It also provides guidance on the minimum standards for local safeguarding practice. Although it is the responsibility of NHS England to provide assurance and system leadership for safeguarding the document clearly sets out that CCGs, as commissioners of local health services, must assure themselves that the organisations from which they commission services have effective safeguarding arrangements in place. CCGs are also responsible for securing the expertise of designated professionals on behalf of the local health system. 2.2 NHS Bolton CCG Governance arrangements To ensure that NHS Bolton CCG is fulfilling its statutory responsibilities for safeguarding a bi-monthly report is tabled at NHS Bolton CCG Quality and Safety Committee. In addition to this the Chief Nurse Chairs the Bolton Integrated Safeguarding Committee (BISC), a bi-monthly meeting for safeguarding leads across the health economy of Bolton. BISC not only seeks assurance that NHS providers have appropriate safeguarding arrangements in place, but also the forum provides the opportunity to share good practice and to disseminate key safeguarding developments, both local and national. 2.3 Safeguarding arrangements within NHS Bolton CCG The Chief Officer is ultimately responsible for ensuring that the statutory duties for safeguarding children and adults across the health economy are effectively discharged. Executive Board level responsibility for safeguarding sits with the Chief Nurse. 1 Safeguarding Vulnerable People in the NHS Accountability and Assurance Framework, NHS England, 2015 2

NHS Bolton CCG is supported in fulfilling its safeguarding responsibilities by the CCG safeguarding team, led by the Associate Director of Safeguarding. This post incorporates the roles and responsibilities of the statutory post of Designated Nurse for Safeguarding Children and support within this aspect of the role is given via the Specialist Safeguarding Practitioner (children). The adult agenda is led by the Specialist Safeguarding Practitioner (adults), whose role also incorporates those responsibilities of both an MCA and Prevent lead. Administrative support is also provided, and this is fundamental in ensuring the efficient and effective functioning of the team. NHS Bolton CCG employs a Named GP for Safeguarding Children. Although only commissioned for one session per week this role is instrumental in keeping member practices informed of changes to safeguarding practice, guidance and legislation. This role is also supported via the Specialist Safeguarding Practitioner (children) in terms of driving improvements in the quality of safeguarding response within primary care. A number of other statutory posts are commissioned from a provider organisation; including those of Designated Doctor, Designated Doctor for Looked after Children and Designated Nurse for Looked after Children. The specialist skills and knowledge of team members ensures that safeguarding expert professional advice is available to NHS Bolton CCG, partner agencies and health organisations across the health economy as well as providing the health expertise to the local safeguarding children and adult boards. A priority for 2016/17 is to strengthen the safeguarding service, building increased resilience through the review of structure, job descriptions and supporting improved integration of those designated posts currently commissioned externally. 2.4 Safeguarding assurance in relation to commissioned services NHS Bolton CCG Safeguarding team have been working collaboratively with colleagues across Greater Manchester to ensure a consistent approach is taken to obtaining safeguarding assurance. To this end, there is an agreed set of Safeguarding Standards for commissioned services which are incorporated into contract arrangements. Compliance against the standards is measured via the completion of an annual audit which is subject to scrutiny by Bolton CCG safeguarding team. During 2015/16 NHS Bolton CCG sought assurance from the main providers in line with the Greater Manchester Safeguarding standards. Following analysis of the information submitted NHS Bolton CCG safeguarding team has been working with providers to strengthen safeguarding arrangements. For 2016/17 wider assurance will be sought from all commissioned services including Primary Care. 3

2.5 External audit of Bolton CCG Safeguarding arrangement Mersey Internal Audit Agency undertook a review of NHS Bolton CCG s safeguarding arrangements during the reporting period. The overall objective of the review was to assess the systems and processes in place across NHS Bolton CCG to ensure compliance with safeguarding statutory requirements and guidance. The main recommendations included a requirement to improve the recording system for employment DBS checks for CCG employees, a recommendation to improve provider assurance processes and to ensure CCG staff complete mandatory safeguarding training appropriate to their role. Based on the recommendations of the report an action plan was developed and is being monitored by the CCG safeguarding team reporting to the Quality and Safety Committee. The Mersey Internal Audit Agency will return during 2016/2017 to review progress on the recommendations. 2.6 Greater Manchester Collaborative arrangements for safeguarding NHS Bolton CCG forms part of the Greater Manchester Safeguarding Collaborative. Working in this manner means that CCGs across Greater Manchester continue to work together collectively in the development of initiatives and policy, to promote resilience, allow for the sharing of best practice and learning and facilitate consistency in service developments across Greater Manchester. However, future development will be significantly influenced by the devolution from national government to Greater Manchester of public funding for health and social care. 2.7 Safeguarding and General Practice NHS Bolton CCG Safeguarding Team, including the Named GP for safeguarding children, work to support member practices to meet their responsibilities for safeguarding children and adults at risk and to help drive up the quality of safeguarding provision to their registered populations. Much work has been undertaken to improve practice in both the recognition and response to safeguarding issues. This has included supporting the development of new or revisions to existing processes, and promoting communication and interface with other health colleagues and agencies. To support the implementation of these developments specific standards for safeguarding have been included within the Bolton Quality Contract. The Safeguarding Team continue to support the identification and referral of domestic abuse and violence within Primary Care (IRIS). This is a training and advocacy programme currently commissioned via Bolton s Community Safety Partnership. Since the launch in December 2014 all practices have been approached and 38 practices have engaged with the programme, of which 23 are fully trained and 15 partially training. This correlates to a total of 665 members of practice staff being trained and 177 referrals made to the Advocate Educators from 29 different practices. 4

Priorities for 2016/17 include: the development of a Safeguarding Lead GP forum to offer support, shared learning and information and to contribute towards their Level 3 safeguarding training requirements supporting audit in practice; including of communication with other community health services and quality and quantity of reports to Child Protection Conferences, rolling out and supporting completion of the NHS Bolton CCG Safeguarding Quality Assurance Audit template; this will enable practices to collate all the evidence to meet the requirements of the Care Quality Commission, NHS England and NHS Bolton CCG as delegated commissioner further development of the Primary Care Resource Pack; this was developed in Bolton and disseminated via NHS England to all CCGs across Greater Manchester. This is to be updated and developed locally as a virtual toolkit bringing together all the required information regarding policies, guidance, and training into one place for primary care. Review of the safeguarding standards within the Bolton Quality Contract to facilitate more robust monitoring of compliance. 3. Safeguarding Children This section outlines key developments throughout the reporting period in respect to safeguarding children developments at both a national and local level. 3.1 The Child Protection Information sharing project (CP-IS) CP-IS is a national system through which key local authority information pertaining to children and unborn babies subject to Child Protection Plans and those with Looked After Child status is shared with unscheduled care providers in health. This system enables practitioners in these health settings to quickly identify whether a child being seen is currently within either of those categories and therefore already identified as requiring statutory support. This system is currently being implemented across Bolton with the NHS Bolton CCG safeguarding team working with local urgent care providers and the local Authority to ensure the system goes live in October 2016. 3.2 Child Sexual Exploitation The Government response to the chronic failure to protect children from child sexual exploitation in Rotherham was published in March 2015 2. In recognition that those failures were not unique to Rotherham and affects all communities, the Government took a step change approach in their response to child sexual exploitation making a number of recommendations for all partner agencies working with children and young people. These recommendations include the need to strengthen accountability; to change the culture of denial; to improve joint working and information sharing; to 2 Government Response to the 9th Report of the Communities and Local Government Select Committee 2014/15 Child Sexual Exploitation in Rotherham: Ofsted and Further Government Issues, Her Majesty s Stationery Office, August 2015 5

protect vulnerable children by improving the local response to child sexual exploitation; to better protecting children who go missing or who are placed in care; stopping offenders and supporting victims and survivors. At a local level Bolton Safeguarding Children Board have developed multi-agency arrangements for CSE and missing arrangements (locally known as SEAM) to improve co-ordination and risk management of children who are missing and at increased risk. The evaluation of these arrangements is that they have been a positive step in further improving the safety and welfare of children in Bolton. Bolton also has a specialist multi-agency child sexual exploitation team known locally as Phoenix Exit. The team has seen a 58% increase in referrals for 2015/2016. It is thought that increased publicity and training is likely to be a contributing factor to this overall increase in referrals. The effectiveness of the team was subject to a peer review in December 2015; the review found that overall practice in the team was of a high standard and made a positive contribution to managing the risks associated with CSE. NHS Bolton CCG does not specifically commission any service for child sexual exploitation team; health contribution to Phoenix Exit is via 5-19 service commissioned by Public Health. Locally, priorities for 2016/17 include developing effective approaches for tackling child sexual exploitation among boys and young men and those young people with physical and learning disabilities. 3.3 Female Genital Mutilation (FGM) In October 2015, a new professional mandatory reporting duty was introduced which requires regulated health and social care professionals and teachers in England and Wales to report known cases of FGM in under 18s which they identify in the course of their professional work to the police. In addition to this mandatory reporting for under 18s, NHS Acute Trusts, GPs and mental health trusts are now mandated under the Health and Social Care Act 2012 to record FGM patient data under the FGM Enhanced Dataset. To raise awareness on FGM locally, Bolton Safeguarding Children Board are supporting a local voluntary group to develop training and deliver awareness raising and interventions where FGM is suspected to be a risk to children. During 2015 the safeguarding team delivered awareness rising regarding the legal process of FGM reporting to GP Clinical Leads and the safeguarding annual training event. During 2015-2016 the CCG Safeguarding Team will continue to raise awareness of the safeguarding element of FGM across Primary care. 3.4 Post Savile The Lampard Inquiry and subsequent Report 3 identified themes and lessons learnt from the NHS investigations into matters relating to Jimmy Savile and were published 3 Themes and lessons learnt from NHS investigations into matters relating to Jimmy Savile 6

in February 2015. The report identified that the findings of a number of separate NHS investigations about the cultures, behaviours and governance arrangements that allowed Savile to gain access to various NHS hospitals, and gave him the opportunity to carry out abuses on their premises over many years were strikingly consistent. Six common themes were identified, which included raising complaints by staff and patients, observance of due process and good governance and safeguarding. Nine of the 13 accepted recommendations applied to NHS Trusts and NHS England, Monitor and the Trust Development Authority subsequently requested formal responses on the implementation of these recommendations from Trusts. The Greater Manchester CCGs were requested by the NHS England Greater Manchester Area Team Quality Surveillance Group to monitor responses and provide assurance that relevant Trusts had fully implemented the recommendations. This included oversight by Designated Nurses. Compliance with the recommendations will continue to be scrutinised by NHS Bolton CCG as this is now integral to Bolton s Safeguarding Contractual Standards for 2016/17. 3.4 Bolton s Multi-Agency Safeguarding and Screening Service (MASSS) In November 2015, Bolton Children s Services Referral and Assessment Social Work teams and Greater Manchester Police Public Protection and Investigation Unit came together to form phase 1 of Bolton s Multi-Agency Safeguarding and Screening Service (MASSS). This was developed to promote better consistency at the front door and ensure a responsive and more effective service to child protection concerns. Phase 2 of the MASSS is hoped to bring together partner agencies within Education, Health, Probation and other professionals who have contact with children, young people and their families to make the best possible use of combined knowledge and resources to keep children safe from harm. NHS Bolton Clinical Commissioning Group Safeguarding Team will support and influence this process going forward through collaboration with colleagues from Public Health and the providers of the 0-5 and 5-19 services to consider what the health provision into the MASSS may look like. 4. Bolton Safeguarding Children Board Bolton Safeguarding Children Board (BSCB) as a statutory body has oversight of how partners cooperate to safeguard and promote the welfare of children. It ensures arrangements for working collaboratively are robust enough to bring improved outcomes for children and young people. As a core member of BSCB, NHS Bolton CCG is represented on the Board by the Chief Nurse whilst the designated doctor and nurse for safeguarding provide professional advice to the Board. In addition to this NHS Bolton CCG contributes to Independent report for the Secretary of State for Health, Kate Lampard Ed Marsden, February 2015 7

the work of the Board both financially and by participation in the sub groups of the board. Please see Appendix 1 NHS Bolton CCG Safeguarding Team contribution to Local and Statutory Boards. 6. Looked after Children As of 31 st March 2016, 563 children were in the care of Bolton Local Authority; this equates to a rate of 85 looked after children per 100,000 population. This is a decrease of 1.5% when compared with March 2015 data. Of these children 24% were placed out of area which compares favourably to the national average of 38% and is a reflection of Bolton s commitment to placing children close to home. Bolton CCG retains responsibility for commissioning and monitoring services for these children. A significant proportion of children in Bolton are of pre-school age when they are admitted into the care system, 48% compared to the national average of 38%. The past 12 months have also seen an increase in the percentage of children admitted during secondary school years, 23% compared to the 17% the previous year although this remains below the national average. This generally younger population on admission is an indication of Bolton s policy of early intervention and this data is useful in terms of workforce planning to meet the needs of this specific population As of 31 st March 2016, 202 children were placed in Bolton by other local authorities. Whilst NHS provider organisations have a duty to provide care for these children commissioning responsibilities lies with the originating CCG. 6.1 CCG responsibilities for looked after children CCGs have specific responsibilities for promoting the health and wellbeing of looked after children as detailed in statutory guidance 4. Of particular note for CCGs is the implementation of Payment by Results in relation to the commissioning of statutory health assessments. Interpretation as to how this is implemented is creating challenges across the health system both locally and regionally. Key priority areas for development for 2016/17 will be in reviewing NHS Bolton CCG compliance against statutory guidance, including the implementation of payments by results, identifying any gaps and taking the necessary action to ensure full compliance. This presents many challenges to health and also to social care, due in part to the fragmentation of the commissioning arrangements as a result of the health service reforms in 2013. 4 Promoting the Health and Wellbeing of Looked-After Children : statutory guidance on the planning, commissioning and delivery of health services for looked-after children, DfE/DoH, 2015 8

7. Safeguarding Adults The key legislative framework that governs how local authorities and partner agencies, including health, work to safeguard and protect adults at risk of abuse and neglect is the Care Act 2014. This includes: Leading a multi-agency local adult safeguarding system Establishing Safeguarding Adults Board The requirement for the local authority to make enquires, or to request others to make enquires where they think an adult with care and support needs may be at risk of abuse and neglect Working in partnership to undertake a safeguarding adult s review The Act includes a statutory requirement for local authorities to collaborate, cooperate and integrate with other public authorities, including health, and also requires seamless transitions for young people moving to adult social care services. Of particular relevance is the strengthening of the assessment and decision making process within the parameters of the NHS Continuing Healthcare assessment and the local authority limits test. NHS Bolton CCG has been working with local health providers to ensure they are aware of local arrangements and how to make a safeguarding alert. This work is also driven by the Bolton Integrated Safeguarding Committee (BISC) where health providers safeguarding leads are represented to progress this agenda. 7.1 Making Safeguarding Personal Making Safeguarding Personal is a shift in culture and practice, reinforced within the Care Act, which sees safeguarding practice moving from a process driven system to one that is person-led and outcome focused. It engages the person in a conversation about how best to respond to their safeguarding situation in a way that enhances involvement, choice and control as well as improving quality of life, wellbeing and safety. This agenda is in its infancy and one of the objectives for Bolton Council is to roll this out in 2016 / 2017. 7.2 Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) The Mental Capacity Act 2005 provides a statutory framework to ensure that individuals who may lack capacity are supported and empowered to make decisions about their care and treatment. In 2009 the Act was amended to incorporate the Deprivation of Liberty Safeguards (DoLs). The Act is supported by a Code of Practice. However, on-going changes to case law do affect the manner in which the safeguards are implemented. March 2014 saw the implementation of the Supreme Court Judgement known as Cheshire West. The impact of this judgement has been significant from a local and 9

national perspective due to the threshold of a DoLS now being significantly lowered and a new Acid Test 5 criteria introduced. It also raised the significance of deprivation of liberty for children s and transition services as the minimum age at which the Court of Protection can authorise a deprivation of liberty is 16 years. NHS Bolton CCG has been working with the Local Authority and healthcare providers to ensure the judgement is fully understood and embedded. NHS Bolton CCG have responsibility for ensuring the DoL also considers a person aged 16 or 17 year olds who is placed in care and support facilities they commission and who lack capacity. These include (but are not limited to) the family home, foster homes, adoptive homes, children s homes (secure, non-secure, and certain special schools), care homes, residential special schools, boarding schools, further education colleges with residential accommodation, and hospitals. NHS Bolton CCG is reviewing the existing DoLS policy to ensure that appropriate safeguards are in place. This policy will be implemented from 2016 / 2017. For NHS Bolton CCG, the functions of the MCA lead are incorporated into the role of the Specialist Safeguarding Practitioner (adults). In order to ensure local arrangements are embedded across the health economy NHS Bolton CCG MCA Lead has been attending the MCA sub group of the adult safeguarding board and working to support the development of policies in this area. To ensure that frontline practitioners across Bolton health economy understand the principles of the Act, the MCA Lead has worked in collaboration with key partners to deliver a number of training and awareness raising sessions. 8. Bolton Safeguarding Adult Board Bolton Safeguarding Adult Board (SAB) has been established in line with the Care Act 2014 to coordinate the delivery of Adult Safeguarding across multi-agencies; a independent chair was appointed early 2015. The main objective of the Board is to be assured that local safeguarding arrangements and partners act to help protect adults in Bolton. The Board is a partnership of statutory and non-statutory organisations. NHS Bolton CCG is represented on the board by the Chief Nurse whilst the specialist safeguarding adult practitioner sits on the board as a professional advisor. NHS Bolton CCG contributes to the work of the board both financially and by participation in the four sub groups of the board. An Adult Board development day has been planned for August 2016 to look at the new priorities for 2016-20 to help develop the Board s vision for the next five years. 5 The definition of the Acid Test is when a person is under continuous supervision and control for a not negligible period of time, not free to leave and lacks capacity to consent to these arrangements. 10

9. Prevent Prevent is part of the government s Contest strategy to reduce the threat to the United Kingdom from terrorism by stopping people becoming terrorists or supporting terrorism. It focuses on working with vulnerable individuals who may be at risk of being exploited by radicalisers and subsequently drawn into terrorist-related activity. From a health perspective, although only becoming a legal duty in February 2015, the NHS Standard Contract has included the requirement to identify a Prevent lead and to embed Prevent duties into the delivery of services, policies and training since 2013. This requirement is also reinforced within the NHS Bolton CCG safeguarding standards incorporated into all contractual arrangements and monitored annually. At an NHS Bolton CCG level the functions of the Prevent lead are incorporated into the role of the Specialist Safeguarding Practitioner (adults). Prevent leads across the health economy are supported by the regional Prevent coordinator, a post commissioned by NHS England. NHS Bolton CCG Prevent Lead is a member of the national and regional Prevent Sub-group and has been delivering awareness training to GP Practices and to internal staff employed by NHS Bolton CCG. NHS Bolton CCG Prevent lead has also been working closely with health providers in ensuring this statutory function is embedded in safeguarding policies and that staff are aware of their duty to report any concerns. 10. Conclusion This annual report has provided an insight into local issues, developments and initiatives pertaining to safeguarding that have taken place during the last twelve months. In doing so it aims to provide a level of assurance that the organisation is fulfilling its statutory duties and responsibilities for safeguarding children and adults at risk of harm. The agenda continues to evolve and its workload continues to escalate in line with national policy, legislation, findings from critical incidents and serious case reviews. In addition to this local safeguarding arrangements will be influenced by developments taking place as part of devolution Manchester. The underpinning message however remains the same in that safeguarding is everyone s business irrespective of role or position. 11

11. Contributors to this Report Pam Jones Associate Director of Safeguarding/Designated Nurse for Safeguarding Children Jean Rollinson Interim Designated Nurse for Safeguarding Helen Bolton Specialist Safeguarding Practitioner (children) Kaleel Khan Specialist Safeguarding Practitioner (adults) Charlotte Mackinnon Named GP Val Coupes Designated Doctor for Looked After Children Thanks also go to Mary Moore Chief Nurse Gabi Lipshen Designated Doctor Charlotte Thaker and Nilofer Razzak administrative support to the safeguarding team 12

Appendix 1 NHS Bolton CCG Safeguarding Team contribution to Local Safeguarding Arrangements