1 MAST staff to be actively involved in improving the awareness of schools about self harm and the importance of early intervention. Social Inclusion Review of the MAST training that is currently provided to educational providers, including school governors, to ensure that self-harm and suicide prevention is appropriately included in training programmes. District Senior EP DSEP convened Psychology Service Special Interest Group to plan materials and training for schools. Guidance completed. Training and information in place. 31.10.12. An increased awareness of the needs of these vulnerable students within school. 2 Development of youth services contributions to targeted work with self harmers and those at risk of suicide 3 Preparation of Policy and Procedures guidance for Social Care and MAST staff in relation to their respective responsibilities for overlapping Social Inclusion Social Inclusion Referral pathways to be developed. Training needs analysis of youth service staff to be undertaken to gauge their current and future capacity to undertake this work. Training plan to be devised and implemented. Develop a specific policy and procedure for relevant staff. Launch the policy and procedure at Social Inclusion and Youth Service Social Inclusion and CIN/CP Referral pathway and Training agreed between DSEP, Head Social Inclusion and Youth Service. Materials developed into C&FSS Policy Guidance. 31.12.12 31.12.2012 Service agreement on an integrated approach involving Youth Worker and other Children & Family Support staff as an outcome of the Youth Service re-organisation when Youth Workers will be deployed to area teams. Youth Service staff given access to materials used to brief Children & Families staff. Presentation on self-harm delivered to Children, Young People and Families staff as part of staff briefings. Action Plan Updated 25 October 2013 1
areas of work. 4 MAST staff to ensure that all child in need, and CAF plans should have clear detail and instructions about cover arrangements when the key worker/lead professional is absent. 5 Specialist Core assessments must provide a balanced analysis of the child s story. Social Inclusion Children s Social Care Joint Children s Services event. All MAST staff to be informed of this expectation through management supervision and team meetings. Regular audits of plans to monitor this expectation. Commission training to be delivered by the organisation - Child and Family Training in Evidence informed approaches to assessment. Deputy Head of SI Workforce Development and Children in Need and Child Protection Cover arrangements agreed and incorporated into Policy and Procedural guidance. Child & Family Training was commissioned in vember 2011 and is w embedded using in-house trainers and provides the underpinning methodology for social work assessments in the city. Assessing Parenting and the Family Life of Children is part of our induction programme for new social 31.12.2012 vember 2011 Policy established and in place. A systematic and evidencebased approach to specialist assessments. This will result in practitioners providing improved analysis and more helpful plans being created with children and their families. It will help embed a good practice culture of analysis and critical thinking in the department. Action Plan Updated 25 October 2013 2
6 Core Assessment pro forma on Care First should be redesigned to ensure it encourages the gathering of information from all available sources and the completion of comprehensive chronologies 7 Recruitment of permanent staff should be achieved with minimum delay to avoid having too high a ratio of agency staff in the department. Children s Social Care Children s Social Care Business Change Manager will be employed to consult with practitioners to review Wolverhampton Children s Social care forms. All agency filled posts will be recruited to. Care First User Group (CFUG) chaired by Looked After Children Children in Need and Child Protection workers. Development of New forms began in summer 2012 and were introduced in June 2013 and are being used by all social workers When vacancies arise in social work posts they are recruited to without delay. The recruitment process is supported by robust HR processes. June 2013. July 2012 A pro forma which is easy to read and helps tell the child s story. The needs of Children and their families will be better understood and help offered will target those needs. A stable and highly motivated workforce 8 Induction processes in the department should be updated and reviewed, identifying key policies and procedures in regular use and which require staff to demonstrate that they have read and understood them. Children s Social Care An induction pack will be written and issued for new staff and their supervising managers to follow. The departments Child Protection policies and procedures will be reviewed and updated paying close regard to those available from the Children in Need and Child Protection And Policies and Procedures Officer The induction policy, including the employee checklist, has been updated annually. August 2012 Confident staff with: not only a clear understanding of their own department s roles and responsibilities but also a clear understanding of other key partners roles and responsibilities. Action Plan Updated 25 October 2013 3
9 Copies of assessments and plans must be evidenced as having been received by service users and other agencies. Children s Social Care WSCB TriX online manual. Departmental policy guidance will be updated, to require that where forms are designed to be copied to service users and which ask for signatures that practitioners do so or record why they have failed to do so. Monthly auditing will include monitoring of this expectation. Children in Need and Child Protection And Policies and Procedures Officer Department s policies and procedures have been updated and staff forums utilised to embed responsibilities/ expectations. Social Workers record that service users have received assessments and plans on the Electronic Social care record. Monthly audits/thematic audits address information sharing. December 2012. Children and their families will be able to check out their understanding and relationships will be enhanced. 10 Key partners to always be informed when case responsibility is to transfer or close. Children s Social Care Departmental policy guidance will be updated to require that key partners and most specifically children and their families and referrers are written to when Children in Need and Child Protection And Policies and Procedures Department s policies and procedures have been updated and remain under regular review. Most recent update October 14.10.13 Well informed Children, Families and key partners. Action Plan Updated 25 October 2013 4
case responsibility is to transfer and close. Team meeting minutes and individual supervision records will record that practitioners have discussed and understood the importance of this communication standard. Officer. Children in Need and Child Protection 2013 Since December 2011 Information sharing with partners is addressed within minutes... Monthly auditing will monitor compliance of this expectation. Children in Need and Child Protection Since March 2012 Monthly audits/thematic audits address feedback to partners regarding significant change/transfer. 11 Children s Social Care to ensure that there is an improved understanding by all staff of good practice in working with children and young people who self harm or threaten suicide. Children s Social Care The CiN and CP in Children and Family Support will write a memo to all of the departments staff supporting the WSCB guidance in section 5 sub section 19, Children who self - CIN & CP Memo sent out to all staff outlining good practice 08.12.12 Department staff to be given the opportunity to reflect on issues of self harm in supervision and as a team, particularly when they are in the role of lead professional. Action Plan Updated 25 October 2013 5
12 Quality of case recording must be improved. 13 Provision of on-site counselling for students presenting with complex mental health issues. Children s Social Care School 1 harm. Practitioners supervision notes will record that the memo has been discussed. A set of good practice exemplars for case note recording will be created and circulated to staff. Auditing will monitor the effectiveness of this approach. Seek governor approval for an increase in staffing. Ascertain level of need in order to determine amount of time required. Consider location for counselling service once established. Set protocols for student access to the counselling service. Children in Need and Child Protection Headteacher / Deputy Headteacher New Carefirst forms contain links to good practice exemplars. Quality of recording monitored via monthly audit and supervision. Report completed and as a result, Counsellor employed by school 1 morning a week since October 2011 and 2 mornings a week from January 2012 In addition Counselling Psychologist attached to the school for 1 day a 08.08.13 30.03.12 Consistent clear case note recording standards across the department. An additional resource is available for students and staff in school. Students and staff are able to access appropriate support to address specific needs. Action Plan Updated 25 October 2013 6
week ( from MAST 5) from September 2012 July 2013. This service is well used by students. Referrals are made via Pastoral Leaders and students 16 years and over self- refer. 14 Provision of training for pastoral staff in dealing with students with complex mental health issues. 15 Provision of parent support classes. School 1 School 1 Identify appropriate trainer. Book training. Plan parent support classes to provide parents with greater insight into social networking sites in order to understand how cyber bullying happens, their Deputy Headteacher Headteacher / Deputy Headteacher Pastoral Leaders Training Day off site took place 16 th January 2012. Included all Pastoral staff, 2 Learning mentors and School counsellor. E-safety bulletins have been a feature of the termly school newsletter since September 2012. School has put in 16.01.12 September 2013. Staff feel more confident and better equipped to support and address the needs of students with complex mental health issues. Parents feel better informed and better equipped to deal with these issues. Action Plan Updated 25 October 2013 7
16 HQ Public Protection should instruct officers engaged in missing persons co-ordination duties to record all actions undertaken after a missing episode within retrievable police systems (the systems are already in place and it is not onerous for officers to complete this task. Periodic dip sampling of systems will enable supervisory checks. West Midlands Police responsibility to protect their children from it and how they can do so. Plan parent support classes on how to deal with issues of adolescent mental health, supporting parents to know how to address these issues. Missing persons coordinator practices to be revised to direct officers to appropriately record actions undertaken in a format which is readily available Force Lead Officer place Parental sessions for 2013/14 academic year including e- safety and cyber bullying (and adolescent mental health. In addition school has run drop ins for parents to discuss any pastoral issues with a member of the SLT. A new Force Policy on the Management, Recording and Investigation of Missing Persons was introduced in June 2013. It includes electronic recording on the COMPACT system of tasks and updates to be completed in the same tour of June 2013 An improvement in the ability of officers to retrieve relevant information in a timely way. A more effective missing persons policy will be available to officers. Action Plan Updated 25 October 2013 8
Bold italic is additional entry from review of IMR Action Plan details duty. Missing enquiries are supervised by an Inspector and have an identified Officer in the Case. Debriefs following/ misper absent episodes are recorded on COMPACT. All entries are searchable and retrievable. Recommendation / Issues Lead 17 To review the systems and practice of information shared between the acute and community health care services on presentation of children and young people with self-harming behaviour in the A & E department Community Services CLHVS, A& E staff,, SN service 1. Response from CLHVS 2. Review notification procedure -form and timeliness 3. Standard operating procedure CLHV Pathways developed in partnership with Alcohol Liaison Nurse, Aquarius /Birmingham and Solihull Mental Health Trust (new providers since April 2013) and are working well. July 2013 Improved Identification of need for young people presenting at A&E departments as a result of self-harming behaviour. Improved service delivery to these young people. Named Action Plan Updated 25 October 2013 9
Emergency Department[ED] Sister attends the alcohol steering group which monitors pathways. Verbal notification to services made by Paediatric Liaison Nurse. Independent Domestic Violence Advisor[IDVA] based in ED from October 2012 Specific training delivered to ED staff by Lead Nurse for Safeguarding Children with resultant improved training compliance. 18 To review the system and Community 1. Review SN attached System reviewed. Form and function of Action Plan Updated 25 October 2013 10
practice of collaborative working between School 1 and the SN service in the context of physical and emotional concerns for the welfare of individual children Services School 1 & SN service communication channels 2. Agree future systems of communication for urgent and nonurgent issues to School 1 School nurse (SN) now attends weekly for drop ins for students. Students needing access to SN identified by Pastoral Leaders and referred to SN by Deputy Head. SN also delivers health sessions in PSHCE at KS3 this has been ongoing for the last 4-5 years continues to be so. The Drop-in sessions provided by school nursing service is audited 6 monthly with positive findings 31.01.12 Drop-In sessions are understood by pupils and school staff Regular informationexchange takes place between health and education staff with regard to the health and well-being of pupils. Posters available in schools advertising school nurse drop ins School nurses advertise service during assemblies. Annual working together agreement completed with school nurses and individual schools. Safeguarding procedures followed and escalated appropriately. Action Plan Updated 25 October 2013 11
19 Where there are concerns about a child and the child is referred to another agency, there should be systems in place to ensure that the child attends the appointment and that the referrer is kept informed about the attendance GP Review the records systems operated by GP practices which enable acknowledgement of all correspondence as received. Ensure systems are robust. Review the systems operated by GP practices which flag the need for referral follow-up. Ensure systems are robust. SC Commissioni ng Lead WCPCT Named GP for SC Letter sent to all GP s and practice managers to ensure that each practice reviews its systems and procedures. Feedback to ensure that this occurred was received. 30.9.13 Records systems are robust which ensure all correspondence is available to inform ongoing care provision. Staff are alerted to the need to follow-up on referrals via established record-keeping systems. Named GP reports activities into the JHSCC Training events have been held across the city to highlight this issue and the named GP has circulated information to support the process. 20 Where a health professional visits a patient this should be fully recorded as should the actions taken even if the care is passed onto another eg ambulance crew GP Details to be forwarded to all GP Practices which inform on the expectation of record-keeping practices with regard to individual episodes of care provision. Expected record-keeping standards to be included in content of SC Training events for GP Practice staff. SC Commissioni ng Lead WCPCT Named GP GMC guidance sent to all practice managers and GP s as well as a series of safeguarding training sessions detailing this issue and embedding this within practice 30.06.12 Awareness-raising exercise is completed regarding record-keeping requirements. SC training programmes include information on record-keeping standards Named GP to report activities into the JHSCC Action Plan Updated 25 October 2013 12
21 There should be specific recording of when and in what way the children s wishes and feelings were ascertained and taken account of when making decisions about the provision of services. Refer to Rec. 6 GP Details to be forwarded to all GP Practices which inform on the expectation of record-keeping practices with regard to individual episodes of care provision Expected record-keeping standards to be included in content of SC Training events for GP Practice staff SC Commissioni ng Lead WCPCT Named GP All GP s and practice managers sent the GMC guidance and a series of Safeguarding training sessions undertaken to fully embed this within their practice. 30.06.12 Awareness-raising exercise is completed regarding record-keeping requirements. SC training programmes include information on record-keeping standards have been undertaken and area core part of the ongoing safeguarding training programme for the GP s. GMC guidance has been circulated and highlighted to all GP s and practices Named GP reports activities into the JHSCC 1 Primary Care Services are to be reminded of their responsibilities to identify vulnerable children without reliance on carers to pursue actions in response to their dependents health needs. For GP / Primary Care Services Details to be forwarded to all GP Practices which inform on responsibilities for identifying and attending to the needs of individual children Practice expectations are SC Commissioni ng Lead WCPCT Named GP Letter sent to all practices regarding this action and asking for assurance from practice managers. 30.09.13 Awareness-raising exercise is completed regarding practice requirements. SC training programmes include information on Action Plan Updated 25 October 2013 13
to be included in content of SC Training events for GP Practice staff practice requirements. Named GP reports activities into the JHSC 6 All direct consultations with a child should include an appropriate level of discussion with regard to: their perspective on their needs, their opinions on care planning and needs management and their impression regarding the impact on their well-being as a result of service intervention, all of which should be accurately reflected within the records as maintained. For GP / Primary Care Services Details to be forwarded to all GP Practices which inform on responsibilities for identifying and attending to the needs of individual children Practice expectations to be included in content of SC Training events for GP Practice staff SC Commissioni ng Lead WCPCT Named GP Letter sent to all practices regarding this action and asking for assurance from practice managers. Series of Safeguarding training sessions held across the city for Gp s and their practice staff to ensure that this is addressed within all consultations with children and young people September 2013 Awareness-raising exercise is completed regarding practice requirements. SC training programmes include information on practice requirements Named GP to report activities into the JHSCC Action Plan Updated 25 October 2013 14
22 When children are in-patients the hospital staff should ensure that their referrals to safeguarding services have been responded to before the child is discharged. 23 Where there are child protection concerns regarding Acute Trust Acute Trust This will be included in child protection audit. Re-distribute the Management of Concerns Flow chart 6-monthly reports on referral activity to continue which includes detail on referral tracking and outcome. Ref Overview Report: The hospital is to complete an exercise to verify that details of local liaison links are correct and introduce an expectation that all professional agencies which are known to be involved with a childpatient are informed of his/her admission and discharge. To discuss at peer review child protection Named Doctor for Safeguarding in hospital. Des Dr SC DSNSC DNSNC NNSC SC Strategic Lead RWHT Designated Doctor Following a multiagency task and finish group an updated Self Harm policy has been written and ratified by the providers. The policy will be audited in Feb 2014 to ensure that it is working well for all providers. Finding will be reported through Joint Safeguarding Children Committee [JSCC] and to Commissioners. Flow chart redistributed to all 31.07.12 Safeguarding procedures followed and escalated appropriately. Training for ED staff to covers specific requirements of patients. Ward staff have a full understanding of Action Plan Updated 25 October 2013 15
children on the ward consideration should be given to involving a consultant community paediatrician with expertise in this area at the outset. departmental meetings Re-distribute the Management of Concerns Flow chart Ensure that practice expectations are included in content of SC Training events for hospital staff Safeguarding Des DR SC DSNSC Des Dr SC DSNSC NNSC staff. Discussed at CP peer review meetings and embedded within the safeguarding training for paediatricians and paediatric nursing staff in all session 2013. 31.03.12 safeguarding children flow chart and of need to involve community paediatricians as required 24 When the team considers that there is a suicide risk, senior hospital staff should ensure that parents have been given advice about keeping the young person safe and that their concerns have been addressed before discharge from the ward. Acute Trust To include in Discharge planning meeting Refer to Rec 2 Clinical Director Discussed at CP peer review meetings and embedded within the safeguarding training for paediatricians and paediatric nursing staff in all session 2013. - 30.04.12 Discharge planning meetings involving parents / carers is routine practice pre-discharge 25 In complex cases Acute Trust Refer to Rec 2 Clinical Discharge Discharge planning Action Plan Updated 25 October 2013 16
consideration should be given to holding a multi-disciplinary discharge planning meeting. 26 All entries into the hospital records should be legible, signed with name and designation or registration number clearly stated. and dated with the time for inpatients. Acute Trust Staff to be issued with name and designation stamps with GMC/NMC nos. Director Directorate manager planning meetings involving parents / carers is now routine practice pre-discharge and if this does not occur then clear rationale for the absence of a meeting is documented in the notes. This is embedded within training and the self harm policy. All medical staff have received their name stamps June 2012 meetings involving parents / carers is routine practice pre-discharge Standardised documentation / record keeping policy followed in in-patient, out-patient and Emergency department areas. Practice expectations with regard to standards of record-keeping are to be re-issued Medical Director / Chief Nursing Officer Standards reissued. 30.06.12 Quarterly audit process in place which shows improvement in compliance. Trust audits 10 sets of case notes per month against NHSLA 2 The Deliberate Self Harm Assessment is to be strengthened to ensure that For Hospital Review and revise the existing procedure* Clinical Director RWHT Record keeping has been explicitly covered 30.06.12 Discharge planning meetings held for patients who required Action Plan Updated 25 October 2013 17
6 working practices between the hospital services and the are robust, that there is consistency of recordkeeping practices and that the explicit requirements for discharge planning are clearly defined. All direct consultations with a child should include an appropriate level of discussion with regard to: their perspective on their needs, their opinions on care planning and needs management and their impression regarding the impact on their well-being as a result of service intervention, all of which should be accurately reflected within the Services For Hospital Services Formulate a monitoring activity / audit of practice tool Complete 6 monthly audit and report into the JHSCC *ref Overview Report In all cases of self-harm of children there must be robust multi-disciplinary liaison and in relevant instances a predischarge planning meeting must be convened Details to be forwarded to all relevant hospital sites which inform on responsibilities for identifying and attending to the needs of individual children Practice expectations to be included in content of SC Training events for hospital staff Deputy Chief Nurse RWHT Clinical Director RWHT Deputy Chief Nurse RWHT within the safeguarding children training. A joint self harm policy has been written and ratified for use by BCPFT and RWT and is explicit in the expectation of record keeping and pre discharge planning meetings. Safeguarding training delivered specifically for ED medical and nursing staff and Children s Directorate staff on in-service study days high 90% compliance Work continues to refine person centred care plans and user satisfaction 30.06.12 enhanced care packages Records of patients reflect improvement in recording of care planning Action Plan Updated 25 October 2013 18
records as maintained. strategy design for autumn 2013. Monitored through JSCC annual schedule of work. 27 All staff to attend Record keeping Training A more robust system be developed to ensure all contacts are inputted into case files in a safe and timely manner ie. electronic system. Learning and Development (L&D) Review existing training arrangements and adjust according to need. Report submitted to management on numbers of staff attending training Random Case file Audits Discussions to take place in team meeting around how to ensure safe transferral of notes until a more robust system in place. Service Manager team managers L & D Discussions taken place by NNSC with Service Manager who has disseminated to staff areas of concern. Random file audits are taking place. Specialised training has now been delivered for all relevant staff. Issues around appropriate input of contacts and safe transferral of notes have been discussed and made priority by staff. 30.04.12 Good Practice in line with NMC / Trust Record Keeping Policy tes that are written on the ward are now Action Plan Updated 25 October 2013 19
scanned, with a copy filed into the Child and Family notes, ensuring mirror copies maintained within both. 28 A professionals meeting is called for all high risk cases where Children s Services are not involved Refer to Rec. 5 Raise staff awareness of Common Assessment Framework (CAF) Monitoring of number of meetings that occur. Minutes documented accordingly in case file team managers Staff have now completed or are booked on CAF training (some still those awaiting due to sessions being fully booked) The Deliberate Self Harm Policy has been amended to ensure multiagency discussion takes place prior to young person being discharged from hospital. Policy has been agreed by RWT/BCPFT. 30.06.13 CAF is utilised by Health professionals where Children s services are not involved thus ensuring co-ordinated service delivery. NNSC continues Action Plan Updated 25 October 2013 20
29 All High Risk Cases to be brought to Peer Meetings. Key members of staff involved in the case should receive the minutes. All staff involved in a child s case should meet to discuss views on levels of risk, especially when there are inconsistencies around levels, or risk changes from high/low in a short period of time. Minutes of Meetings documented in both case file and Peer meeting file. Random case audits to identify high risk cases and monitor their discussion. Service Director to be informed via virtual fax of each self-harm admission to hospital. All high risk cases discussed at weekly meeting which NNSC attends. Safeguarding issues are explored whether or not family known to CSC. Staff have received training regarding CAF process, NNSC/CAF coordinator offer refresher sessions. Staff are aware of internal escalation process and BCPFT Escalation Policythis is monitored by the safeguarding links and NNSC at the Dec 2011 Improved risk assessments and monitoring of activity to ensure children & Young People s needs are being addressed. Action Plan Updated 25 October 2013 21
Crisis Team Meetings. 30 Protocol to be developed for when a child has been identified as high risk but wishes to disengage. This should stipulate that these children and their families are offered 2 weekly contact, even by phone call, and reviewed after following 3 months. In the case of a medicated child specific arrangements need to be made to carefully monitor adverse reactions in line with NICE guidelines. All correspondence to the GP needs to clearly state how and why decisions are made around the prescribing of medication. Refer to Rec. 8 31 When a child is identified as a high suicide risk the member of Protocol to be developed and distributed to all staff. Audit to be completed of identified high risk cases and their care plans Audit of case notes Guidelines to be incorporated into Service Director Service Director Process in line with NICE guidelines has been informally developed and disseminated to staff via email, Process now ratified into service policy. High risk cases reviewed at weekly Crisis meetings and medication monitored in line with NICE guidelines. Included in Self Harm Policy. GP letter shares any information in relation to medication regime changes. These guidelines have now been February 2012 October 2012 A Protocol is in place and embedded to inform staff of their responsibilities when Children disengage from intervention. There is clarity regarding actions to be taken Action Plan Updated 25 October 2013 22
staff undertaking the initial assessment (Deliberate Self Harm Protocol) should be involved in subsequent assessments and case discussions. Should there be a variance in perceived risk between the initial assessment and the subsequent 2 nd opinion, the clinicians involved should discuss together the concluding plan of care. Refer to Rec. 2 32 Process to be developed which will give staff guidance and enable them to end a session should they feel intimidated or the session exceeds the time allocated Deliberate Self Harm Protocol. Audit of case files to ensure consistency of care Assessors invited to Peer meetings in high risk cases this can be monitored through attendance list of Minutes. Staff conducting high risk assessments to ensure they are familiar with previous/on-going assessments by reading case notes and/or direct contact with each other. The purpose and content, including time allocated, to be clearly explained to child and family before session begins. A contract agreeing to these terms to be signed by all involved. Awareness sessions to Service Director Team Mangers incorporated into the Self Harm Policy ( agreed by RWT/BCPFT) Initial assessors are invited to attend weekly meetings and contribute to case discussions. The escalation process has been disseminated to ensure staff are aware of where to take concerns should they feel perceived variance in risk needs addressing further. The F2F letter that is sent out clearly stipulates the time allocated and purpose of the meeting. Staff re-iterate this at the beginning of each session to ensure 30.06.12 regarding children who are identified as being at high risk of suicide. The effectiveness of increased clarity around times of sessions regularly monitored with any exceptions discussed within supervision. Action Plan Updated 25 October 2013 23
33 Safeguarding Supervision to be embedded into practice Safeguarding ensure staff are confident in assertion techniques. Review the existing Clinical Supervision arrangements and guidance for staff Arrangements and expectations of practise to be made explicit Service Director NNSC YP/and or parents understand the purpose and content of consultation It has been agreed that Clinical Safeguarding Children Supervision be integrated into existing Supervision Policy. June 2012 SGC supervision takes place during internal clinical supervision and this covers the support they require. NNSC to offer additional support and advice when required, on both a 1-1 level, or by group discussion through our safeguarding link forums. 34 Staff to undertake mandatory Safeguarding Children training Learning and Development NNSC Review the existing inservice mandatory training and adjust according to need. Accommodate needs, ensuring expectations of required levels are clear. Team Managers L & D NNSC Mandatory training passports have been developed through L & D to advise staff on required levels, act as on going September 2013 A more robust system underway to ensure external supervision available on request Mandatory Safeguarding Training is embedded and available to all relevant staff. Action Plan Updated 25 October 2013 24
35 Staff Support should be offered appropriately and timely following the death of a child. 2 The Deliberate Self Harm Assessment is to be strengthened to ensure that working practices between the hospital services and the are robust, that there is consistency of recordkeeping practices and that the explicit requirements for discharge planning are clearly defined. Refer to Rec. 5 For the Staff questionnaire/reflective exercise to understand individual needs and requirements and accommodate accordingly. To review existing processes and explore ways to enhance, including external support. Review and revise the existing procedure* Formulate a monitoring activity / audit of practice tool Complete 6 monthly audit and report into the JHSCC *ref Overview Report In all cases of self-harm of children there must be Service Director Team Managers NNSC Dir C & YP BCPFT records and contain action plans for those whose training is outstanding. Support is offered by NNSC and Managers to staff. This is available on an Individual and group reflection basis. The Deliberate Self Harm Assessment has been strengthened and completed through Task and Finish Group. Deliberate Self Harm Policy has been agreed by BCPFT/RWT. 31.03.12 30.06.12 Timely support is available to staff and the outline of this is embedded in policy and procedure. Deliberate Self Harm Assessment is effective and it s effectiveness is measured via regular audit. Action Plan Updated 25 October 2013 25
3 4 All electronic written details (in the form of e-mail informationexchange on case management relating to individual children s needs) are to be inserted into individual records which inform on and evidence on-going case management within and across agency sites and reflected as such within agreed standards of record-keeping and practice. The opportunity should be taken to make reference to information-exchange via SMS. Relevant enquiries regarding existing service involvement are to be made by the with key agency sites (eg Community Children s Nursing Service / Children s Services, Local Authority) following acceptance of a referral for service assessment of a child s mental well-being, the details For the For the robust multi-disciplinary liaison and in relevant instances a predischarge planning meeting must be convened Refer to Rec. 1 Management of e-mail information exchange with regard to recordkeeping practices is to be made explicit and incorporated into existing policies and procedures Existing policy and procedural documents are to be reviewed and revised to accommodate the need for enquiry with key sites. Local audit tool to be developed by which to monitor activity Dir C&YP BCPFT Dir C &YP BCPFT The BCPFT Information Governance Lead has reviewed current Record Keeping Policy to include these forms of communication. NNSC meets with staff (link/crisis team meetings) to ensure that appropriate liaison with relevant agencies is made. This has been included within updated 30.06.12 30.06.13 Records are fully informed on case management details which involve e- mail exchange. Expectations of recordkeeping practices are explicit with regard to the use of e-mail informationexchange Relevant record-keeping audit activities to be reported into the JHSCC Liaison and networking practices are enhanced. Practice expectations are explicit. Audit activity is to be reported into the JHSCC. Action Plan Updated 25 October 2013 26
5 6 of which are to be fully documented. When involved in care provision, the is to directly engage in multi-agency integrated service activities (Common Assessment Framework / Child in Need / Child in Need of Protection planning), ensuring that documentation is maintained which fully informs the progression and effectiveness of care delivery. All direct consultations with a child should include an appropriate level of discussion with regard to: their perspective on their needs, their opinions on care planning and needs management and their impression regarding the impact on their well-being as a result of service intervention, For the For the Refer to Rec. 2 Existing policy and procedural documents are to be reviewed and revised to accommodate the need for practice expectations with regard to engagement in integrated multi-agency activities Local audit tool to be developed by which to monitor activity Details to be forwarded to all relevant sites which inform on responsibilities for identifying and attending to the needs of individual children Practice expectations to be included in content of SC Training events for staff Dir C &YP BCPFT Dir C&YP BCPFT Deliberate Self Harm Policy. NNSC has highlighted need fro to engage in multiagency fora via link meetings etc. Staff are booked onto, or attended, Case Conference training. CAF training is embedded in service NNSC reports number of CAF s raised/conferenc e invites/attendance into JHSCC Responsibilities have been forwarded to relevant staff and are reiterated via training programme. Impact to be Evidenced within records/supervisio 30.06.12 30.06.12 Practice expectations are explicit. Engagement in integrated activities is enhanced. Record-keeping practices are robust Audit activity is to be reported into the JHSCC. Awareness-raising exercise is completed regarding practice requirements. SC training programmes include information on practice requirements Activities to be reported into the JHSCC Action Plan Updated 25 October 2013 27
all of which should be accurately reflected within the records as maintained. n notes. Quarterly audits to be presented to Care Governance Meeting. Relevant corporate record-keeping audit activities to be reported into the JHSCC. 8 Existing systems and practices with regard to the prescribing of medication by the and the associated care packages supplied by the service are to be audited with reference to compliance with NICE guidelines. For the Comprehensive audit to be undertaken with regard to level of compliance with NICE guidelines Dir C&YP BCPFT All high risk cases and care plans are reviewed weekly and medication monitored in line with NICE guidance. 30.06.12 Status of local practices as compliant with national guidelines is explicit. Findings inform local action plan for on-going service development Audit activities to be reported into the JHSCC. Supplementary Recommendation 7 Guidance is to be produced by which to support the completion of Independent Management Reviews with regard to Primary Care Service provision and which takes account of the management of Serious Case Review requests for health information as Production of guidance to support process with regard to IMR of GP / Primary Care Services Awareness-raising of IMR process within GP SC Training events Dir. Primary Care Services WCPCT Des Dr SC DSNSC IMR process now included within the training of GP s for safeguarding children training Dec 2012, Jan 2013, Feb 2013 30.09.13 Explicit guidance available to support the IMR process Effective and efficient engagement in the SCR process by GP Practices Activity is to be reported Action Plan Updated 25 October 2013 28
relating to adults. SCR subgroup has developed IMR training for all agencies therefore no longer need full guidance specifically for Health professionals. into the JHSCC and the SCR Sub-committee WSCB. for completion Overview Report Recommendations OR 1 Wolverhampton Safeguarding Children Board should seek from Wolverhampton Children's Trust Board details of the local provision for minimising among children and young people, self harm and suicide and a Overview report A formal request to be made by the Chair of the WSCB to the chair of the WCTB for information. Report from the WCTB to be Safeguarding Chair of the Sub group Public Health has been requested to provide an update on source provision for YP + Self-Harm October 2013 The WSCB to be informed of local provision of services to this vulnerable group. A policy and procedure will be available to all Action Plan Updated 25 October 2013 29
for completion OR 2 reassurance as to the relative effectiveness of that provision. Wolverhampton Safeguarding Children Board will write to each member agency and ask them to issue a written reminder to all staff (and ensure their training programmes address) a): the need in law and best practice to include non-resident parents (especially though not just those with parental responsibility and actively involved) in all assessments of need, planning and delivery of service; and b): the obligation of all professions without regard to discipline or rank within it, to Overview report considered by the Quality and Procedures Best Practice sub-group of the WSCB, who will then formulate a multi-agency policy and procedure for all staff who may work with children and young people who self harm or threaten suicide. Letter to be written, and to include the request that evidence of the impact of this request will be monitored through regular auditing and management oversight of case records. WSCB Quality and Performance subgroup to request regular updates on audits of practice in this area. CIN and CP. Safeguarding Chair of the Quality and Performance sub-group. Health and Wellbeing Board now responsible rather than CTB Letter re-sent to H&W Board in view of changes in Health economy. Self-harm Policy remains outstanding. Embedded in all relevant WSCB training and requested for inclusion in all partner agency training. Information only report to WSCB in vember 2013. Information added to QA windscreen - 30 March 2013 agencies which will be based on local provision and will ensure best practice in this area. All staff to be reminded of expectations of good practice in assessment and planning. Managers to monitor this issue and address practice issues. Action Plan Updated 25 October 2013 30
for completion OR 3 offer respectful challenge to colleagues Wolverhampton Safeguarding Children Board will write to Wolverhampton PCT and ask that it remind all local community pharmacies of the professional expectation to make direct contact and query any proposed prescription which appears to the pharmacist in question not to be in the patient s best interests Overview Report Letter to be written. Safeguarding SC Commissioni ng Lead WCPCT October 2013 Letter re-sent to CCG since the demise of PCT in April 2013. October 2013 Awareness-raising exercise is completed regarding practice requirements. SC training programmes include information on practice requirements Evidence of completed action is reported into the Quality & Assurance Committee, WCPCT Action Plan Updated 25 October 2013 31