Lambeth Safeguarding Adults Bard Safeguarding Adults and Pressure Ulcers: Decisin Making Guidance April 2016 Versin 2.0 1
1.0 Intrductin 1.1 This is guidance t supprt decisins abut whether the respnse t cncerns abut pressure ulcer care need t be referred fr cnsideratin fr a safeguarding enquiry, hw safeguarding enquiries regarding pressure ulcer care can best be undertaken hw such enquiries can be aligned with clinical gvernance and ther prcesses, and hw partner agencies can best wrk tgether t ensure the wellbeing f peple at risk f pressure wunds is prmted. 1.2 Skin damage has a number f causes, sme relating t the individual persn, such as pr medical cnditin, nn-cmpliance with recmmendatins r self-neglect and thers relating t external factrs such as pr care, ineffective multi-disciplinary team wrking, and lack f apprpriate resurces, including equipment and staffing. It is recgnised that nt all skin damage can be prevented and therefre the risk factrs in each case shuld be reviewed n an individual basis t help decide whether a safeguarding adults cncern shuld be referred t the lcal authrity. 2.0 Scpe 2.1 This guidance shuld be applied t pressure ulcers reprted by anyne including carers, relatives and patients, as any pressure ulcer where the harm has ccurred as a result f neglect r acts f missin shuld be investigated n matter wh reprts it. 2.2 Thse wrking with peple with pressure ulcers shuld als refer t: their wn rganisatin s plicies and prcedures n pressure ulcers their wn rganisatin s plicies and prcedures n safeguarding adults ther relevant lcal and natinal guidelines, prtcls and plicies such as NICE Guidance and incident reprting plicies 3.0 Backgrund 3.1 The framewrk in law fr safeguarding adults wrk is the Care Act 2014 and the Care and Supprt statutry guidance which accmpanies it. 3.2 The plicy cntext is the Lndn safeguarding adults plicy and prcedure, and the varius plicies and prcedures f lcal safeguarding adults bards and partner agencies, which are all bradly in line with the Care Act 2014 and the Lndn plicy and prcedure n safeguarding adults. 3.3 Fr the purpses f Lambeth Safeguarding Adults Bard, this guidance replaces the Safeguarding Adults and Skin Damage Prtcl issued by Lambeth and Suthwark Safeguarding Adults Bards in 2010. 2
4.0 Making safeguarding persnal and pressure ulcers Making Safeguarding Persnal is a sectr-led initiative in adult scial care which aims t imprve safeguarding adults wrk s it is mre persn-centred and utcmesfcused. Bth Suthwark and Lambeth Cuncils are participants. The principles f Making Safeguarding Persnal are applied in practice by: Establishing early n what utcmes the persn wants Keeping them invlved thrughut the prcess, checking if the utcmes they want remain the same, and that they are n track t be met Checking at the end whether their utcmes were met r nt 4.1 Challenges may cme frm invlving smene when they are unwell r in pain. This might be addressed by: Delaying sme element f their invlvement until they are better able t manage it Ensuring that if the persn can t be directly invlved there can be sme representatin f them in the prcess such as by friends, family r advcacy 5.0 Deciding whether t refer a safeguarding cncern regarding pressure ulcers 5.1 The test fr whether there shuld be a safeguarding enquiry is set ut in sectin 42 f the Care Act 2014. This says that the lcal authrity must ensure there is a safeguarding enquiry where it has reasnable cause t suspect that an adult in its area (whether r nt rdinarily resident there) has needs fr care and supprt (whether r nt the authrity is meeting any f thse needs) is experiencing, r is at risk f, abuse r neglect, and as a result f thse needs is unable t prtect himself r herself against the abuse r neglect r the risk f it. 5.2 The Care Act 2014 says that, if these tests are met, then the lcal authrity must make, r cause t be made, whatever enquiries are necessary t enable it t decide what actin, if any, needs t be taken and if s, wh by. Other partner agencies must refer matters that may meet the tests in sectin 42 f the Care Act t the lcal authrity. 5.3 The Care and Supprt statutry guidance makes clear there are sme factrs which are nt relevant t the decisin whether t refer a safeguarding cncern t the lcal authrity It des nt matter whether r nt the persn at risk f abuse has the capacity t make relevant decisins (paragraph 14.6 f the statutry guidance) It des nt matter whether r nt the abuse r neglect is thught t be have been intentinal (paragraph 14.32 f the statutry guidance) 3
It is nt fr frnt line staff t secnd-guess the utcme f an enquiry in deciding whether r nt t share their cncerns (paragraph 14.169 f the statutry guidance) 5.4 In many circumstances the decisin whether r nt t refer a safeguarding adults cncern t the lcal authrity will be a straightfrward ne. Where it is nt, cnsideratin shuld be given t using the assessment and decisin making guidance tl in Appendix 1 r a similar tl. What tl is used will be rganisatin specific but the utcme must be patient centred and persnalised. The Mini RCA used fr this purpse by Guys and St Thmas can be fund in Appendix 2. 5.5 Lcal arrangements will need t be put in place in each rganisatin t set ut the practical arrangements such as when peple are expected t use the tl, wh will d s, and hw this will be recrded. Lcal arrangements shuld als address things like the expectatins arund training and supprt f thse cmpleting the tl, and quality assurance arrangements. 5.6 If further advice r supprt is needed with regards t making the decisin t refer t the lcal authrity, the safeguarding adults lead r Head f Safeguarding within the rganisatin shuld be cntacted. If the matter is still unclear, cntact the lcal authrity fr advice. 6.0 Timeliness in using the tl 6.1 The assessment and decisin making guidance tl shuld be cmpleted as sn as is practicable, and shuld nt cause undue delay in reaching a decisin abut whether t refer a safeguarding adults cncern t the lcal authrity, nr shuld it delay the making f such a referral. There are expectatins abut timeliness in the Lndn Safeguarding Adults plicy and prcedure, and there may be lcal expectatins such as within particular rganisatins. What is imprtant is that the patient invlved in the incident is safe and receiving apprpriate care and treatment and that there is n freseeable risk t the patient and thers. 7 Obtaining relevant infrmatin 7.1 When answering the questins n the assessment and decisin guidance tl, yu shuld cnsider whether yu have available all the relevant infrmatin and, if nt, what needs t be dne t btain it. These example scenaris illustrate sme f the ptins available If the pressure wund develped while a persn was living in a care hme r was a patient in a hspital, and the cncerns abut abuse and neglect relate t their time in that place, then it is likely that service will have available all the relevant infrmatin If a persn is living in a care hme and has develped a pressure wund while there, and the cncerns abut abuse and neglect relate t their time there, but anther service may have sme infrmatin that wuld be f use in cmpleting the assessment and decisin making guidance tl, then the persn cmpleting that tl might decide t ask that ther service fr the relevant infrmatin 4
If a persn has arrived at hspital with pressure wunds need t align wunds t ulcers and keep dcument with the same wrdage and there were cncerns that these may be related t abuse r neglect by health r scial care services invlved in their care previusly then there may be A need t cntact that ther service t btain infrmatin that will infrm the immediate care and treatment fr that persn A need t put the cncerns in t the multi-agency safeguarding adults framewrk by making a referral t the lcal authrity, which can enable the pulling tgether f infrmatin acrss agencies 8 Pressure Ulcer incidents and Safeguarding Enquiries 8.1 When a safeguarding cncern meets the tests in sectin 42 f the Care Act, the lcal authrity has a duty t Make, r cause t be made, the necessary enquiries Decide what actins, if any, are required and wh by 8.2 The set f enquiries required t respnd t a particular situatin are referred t, cllectively, as the Safeguarding Enquiry. The bjectives f a Safeguarding Enquiry are t: establish facts; ascertain the adult s views and wishes; assess the needs f the adult fr prtectin, supprt and redress and hw they might be met; prtect frm the abuse and neglect, in accrdance with the wishes f the adult; make decisins as t what fllw-up actin shuld be taken with regard t the persn r rganisatin respnsible fr the abuse r neglect; and enable the adult t achieve reslutin and recvery. 8.3 Where a safeguarding cncern relates t a pressure ulcer, the lcal authrity is likely t be dependent n partners in health care services wh have the relevant expertise. Typically the elements f a safeguarding enquiry in such a situatin might include The lcal authrity undertaking an assessment f the persn s need fr care and supprt under s9 f the Care Act 2014 A clinical gvernance prcess such as a Serius Incident investigatin, where the cncerns relate t the prvisin f health care. This might include a rt cause analysis undertaken by smene such an experienced RGN and supprted by a senir nurse. Where there are cncerns abut the actins f an emplyee f a health prvider, scial care service r ther rganisatin, the emplyer f that persn may use relevant prcesses t examine the actins f that persn and reach a judgement n thse, and cntribute relevant infrmatin arising t the Safeguarding Enquiry 5
Thse respnsible fr the prvisin f health services, scial care services r any ther relevant service t the matter in hand may undertake sme management investigatin r use sme ther prcess such as a quality assurance prcess Cmmissiners r thse with a cntract management rle may have a cntributin t make Where there may have been a crime there may be a rle fr the Plice r sme ther bdy with a relevant pwer such as the Health and Safety Executive r lcal Trading Standards Where the persn wh has experienced r been at risk f abuse and neglect raises cncerns, r smene des s n their behalf, there may be a rle fr a cmplaints prcess 8.4 This is nt an exhaustive list, and the lcal authrity may invlve thers as apprpriate in its decisin making abut what will cmprise the Safeguarding Enquiry in any particular instance. 8.5 When arranging fr ther prcesses t cntribute t a safeguarding enquiry, cnsideratin needs t be given t The lcal authrity ensuring there are clear expectatins abut the breadth and depth f each element cntributing t the Safeguarding Enquiry, s that the varius elements cver the range f what is needed and there are n gaps The lcal authrity ensuring there are clear expectatins abut the timing and sequencing f the actins needed Ensuring there is a rle fr the lcal authrity in quality assurance and sign-ff f each f the elements that are cntributing t the safeguarding enquiry There is a prcess in place fr aggregating the infrmatin frm the varius elements f the enquiry and analysing it s that gaps, discrepancies and such like can be addressed Having clarity abut hw the decisin making abut what actins, if any, are required and wh by will be carried ut and cmmunicated 9 Making fr a useful Safeguarding Enquiry 9.1 Hw useful the actins arising frm a Safeguarding Adults Enquiry are is greatly determined by hw effective that Enquiry has been. In turn, this is greatly determined by hw well the planning f the Enquiry has been dne. Planning A multi-agency plan needs t invlve cnsultatin with the relevant agencies. A cnversatin between the IO and the SAM is nt usually ging t be enugh. 6
The persn with the need fr care and supprt shuld be invlved. They shuld knw what is ging n, and the planning shuld be infrmed by a clear understanding f what utcmes they want frm the prcess. The presenting situatin shuld be lked at critically, rather than accepting any presenting narrative withut scrutiny. Ask what are the range f explanatins fr what has been seen, and what infrmatin will be needed t chse between thse explanatins. There shuld be clarity abut wh is ding what. The RASCI mdel can be useful fr this Enquiring Make sure the parts f the enquiry are being dne by smene wh has the knwledge and expertise t make sense f what they are lking at and t be able t answer the questins Was what happened OK? If nt, what shuld have been dne? Why did it nt happen that way? Keep the mmentum ging and dn t let things drift. A delayed enquiry will take mre effrt and has a much prer chance f prducing a useful utcme Develping the safeguarding plan If the rt causes have been identified well, then the actins needed shuld be easier t identify But critically appraise the safeguarding plan. Ask des it really address the causes f the situatin?, and dn t just cme up with a list f the usual suspects as an actin plan. Fr example, if the absence f a plicy, r the cntent f ne, were nt the cause f a prblem, then writing r revising ne wn t address the issue. If smething has gne wrng it can be imprtant t distinguish between whether the cause sits with an rganisatin r with the actins r inactins f individuals. There are gd mdels which can help determine these, s make use f them if needed. Reviewing the safeguarding plan A safeguarding plan wn t have an impact if it is nt put in t actin. Having a gd review prcess can be essential t ensuring this particularly if there is n ther existing prcess that will review the actins that have been identified, r if they spread acrss a number f rganisatins r areas f respnsibility 10 Preventin Sptting patterns 7
There are a number f issues that can help with sptting patterns Tissue Viability Nurses have an imprtant rle Within hspitals, they will be aware f all serius pressure ulcers In cmmunity health services in Lambeth and Suthwark, they will knw f all pressure ulcers knwn t cmmunity health services, whether in peple s wn hmes r fr peple living in care hmes, r arising in care hmes with nursing There shuld be effective systems in place that allw fr aggregatin f the infrmatin abut instances f pressure wunds, and this infrmatin shuld be rutinely used by Cmmunity and acute health service prviders Cmmissiners f cmmunity and acute health services Cmmissiners f care hmes The rle f scial care services Hme care and care hme wrkers will ften be well-psitined t spt and respnd t pressure ulcers. Prvider services need t ensure their staff knw what t lk ut fr and what d if a pressure wund has r is at risk f develping Scial wrkers and scial care assessrs need t knw hw t take accunt f the risks f pressure ulcers when assessing peple and planning their care with them The rle f the Safeguarding Adults Bard and the Health and Wellbeing Bard The HWWB Bards need t receive assurance that apprpriate measures are in place t reduce the likelihd f pressure ulcersccurring. The Safeguarding Adults Bards will need assurance that cncerns that pressure wunds have resulted frm abuse and neglect are sptted and are respnded t apprpriately. Health and scial care services and their cmmissiners will need t prvide the Bards with the apprpriate assurances, and there will be lcal arrangements fr this. 8
Appendix A: NHS England decisin making guidance tl, and ntes n its use Details f individual with pressure ulcer(s) First name D.O.B Address Last name NHS Number Lcal authrity f usual residence Persns cmpleting decisin guide fr safeguarding cncern Department/ Base /Address Organisatin Name Telephne Number Name f assessing nurse (PRINT) Jb Title Signature Name f secnd assessr (PRINT) Jb Title Date and Time assessrs witnessed pressure ulceratin Signature Date / time f cmpleting dcumentatin/referral Synpsis f cncern regarding pressure ulceratin and safeguarding State site and categry/ grade f all pressure ulcer(s) Decisin guide Scre Summary f cncerns abut abuse r neglect r the risk f these Ratinale fr decisin whether a safeguarding adults referral is t be made 9
Safeguarding adults referral required Yes N Adult Safeguarding Decisin Guide fr patients with pressure ulcers Patient Name Patient Number Date tl cmpleted Persn cmpleting the tl Rle and cntact details Risk Categry Level f Cncern Scre Evidence 1 Has there been an unexpected Prgressive nset / 5 deteriratin in the patient s skin deteriratin f skin integrity integrity frm the last pprtunity Sudden nset / deteriratin 0 t assess? f skin integrity 2 Has there been a recent change in their /clinical cnditin that culd have cntributed t skin Change in cnditin cntributing t skin damage 0 damage? e.g. infectin, pyrexia, N change in cnditin that 5 anaemia, end f life care (Skin Changes at Life End ), critical culd cntribute t skin damage illness 3 Was there a pressure ulcer risk Current risk assessment and assessment r reassessment withcare plan carried ut by a apprpriate pressure ulcer care health care prfessinal and plan in place and dcumented? Indcumented apprpriate t line with each rganisatins plic patients needs and guidance 4 Is there a cncern that the Pressure Ulcer develped as a result f the infrmal carer wilfull ignring r preventing access t care r services 5 Is the level f damage t skin incnsistent with the patient s risk status fr pressure ulcer develpment? e.g. lw risk Categry/ grade 3 r 4 pressure ulcer Risk assessment carried ut and care plan in place dcumented but nt reviewed as persn s needs have changed N r incmplete risk assessment and/r care plan carried ut N / Nt applicable 0 Yes 15 Skin damage less severe than patient s risk assessment suggests is prprtinal Skin damage mre severe than patient s risk assessment suggests is prprtinal Answer (a) if yur patient has capacity t cnsent t every element f the care plan 0 State date f assessment Risk tl used Scre / Risk level 5 What elements f care plan are in place 15 What elements wuld have been expected t be in place but were n 0 10 10
Answer (b) if yur patient has been assessed as nt having capacity t cnsent t any f the care plan r sme capacity t cnsent t sme but nt all f the care plan 6A Was the patient cmpliant with Patient nt cmpliant with the care plan having received care plan 0 infrmatin regarding the risks f nn-cmpliance? Patient cmpliant with sme aspects f care plan but nt 3 all Patient cmpliant with care plan r nt given infrmatin t enable them t make an infrmed chice. 5 6B Was apprpriate care undertaken in the patient s best interests, fllwing the best interests checklist in the Mental Capacity Act Cde f Practice? (supprted by dcumentatin, e.g. capacity and best interest statements and recrd f care delivered) Dcumentatin f care being undertaken in patient s best interests N dcumentatin f care being undertaken in patient s best interests Tta If the scre is 15 r ver, a safeguarding adults referral is indicated. Use this frm as yur safeguarding referral t the relevant pint f cntact. When the decisin guidance tl has been cmpleted, even when there is n indicatin that a safeguarding refferal needs t be made, the tl shuld be stred in the patient s ntes. 0 10 11
Appendix 2 Patient s name Datix n Cmpleted by: Hsp / NHS n Ward / Cmmunity team Mini RCA Pressure ulcers Age STEIS ref: Date f cmpletin DOB Assessment and findings 1. Date pressure ulcer detected/date deteriratin f ulcer detected 2. Where was the persn resident when the pressure ulcer was acquired 3. Current waterlw / braden scre Scre Date 4. Previus waterlw / braden scre Scre Date 5. Lcatin and size f pressure ulcer(s) 6. Grade / stage f pressure ulcer(s) 7. Reasn fr admissin / transfer? 8. Outline any relevant past medical histry 9. Has a mvement and handling assessment been carried ut? (delete as apprpriate) Yes N 10. Were there delays in: using apprpriate preventative equipment Yes N prviding nursing care Yes N If yes please state reasn 11. Cmments / additinal infrmatin: 12. Has there been a rapid nset / deteriratin f skin integrity? (delete as apprpriate) Yes N 13. Has there been a change in medical cnditin? (delete as apprpriate) Yes N If yes, explain briefly: 14. Were reasnable steps taken t prevent skin damage? Yes N Apprpriate pressure relieving mattress (delete as apprpriate) Yes N Regular turning (delete as apprpriate) Yes N Heel prtectrs (delete as apprpriate) Yes N Pressure relieving cushin (delete as apprpriate) Yes N Regular skin checks (delete as apprpriate) Yes N Other (please specify) 15. Were the pressure areas and any skin breaks mnitred regularly Yes N 16. Were treatments and care plans altered as necessary and recrded Yes N 17. Was there cncrdance with the care plan? Yes N 18. If n please explain what the issues were: 19. Did the patient have capacity t make infrmed decisins? Yes N Was the capacity assessment recrded Yes N 12
Are / were there cncerns regarding family / carers? Yes N Is a safeguarding referral needed? Yes N 20. Were agreed prtcls fllwed? (delete as apprpriate) Yes N 21. Summary f findings 22. Rt causes what caused the pressure ulcer t develp / deterirate? 23. Is there any cncern abut nursing care? (delete as apprpriate) Yes N If yes please prvide detail 24. What are the lessns learned (if any)? 25. Actins t be taken t address any lessns learned By when In GSTT actin plan T be added (Y/N) 26. If any actins are nt being added t the GSTT actin plan please specify mnitring arrangements 27. Being pen (duty f candur) fr PUs grade 3 / 4 please detail discussin/s with the patient (family / carers if the patient cnsents / des nt have capacity) abut the pressure ulcers Date: 28. Cpy f the mini RCA prvided t the patient / family / carers Date Name Designatin Date: Name Designatin Date: Frmal apprval by pressure ulcer assurance grup Signed Date Tissue viability lead Signed Date Safeguarding lead Signed Date Patient safety lead Avidable / Unavidable (delete as apprpriate) Cmments / actins (if any) 13
Mini-RCA Crib Sheet Please read this sheet befre cmpleting a mini-rca. All mini RCAs shuld be cmpleted within 5 days f reprting n Datix (IR1) fr all GSTT acquired stage 2 pressure ulcers and abve. The frm must be fully cmpleted - incmplete mini RCAs will nt be accepted by the pressure ulcer assurance grup and returned fr revisin. This will delay the ratificatin prcess. Pints t remember: Only utline the events and timeline related t the pressure ulcer develping nt the whle patient s histry Please d nt ver-write an existing dcument; it is essential that dates and patient infrmatin are accurate Ensure that yu have dated when assessments were cmpleted and pressure relieving equipment prvided Please dcument the date the pressure ulcer was first nted If a patient declined care and was judged t lack capacity, please cnfirm a best interest prcess was fllwed and dcumented If a patient declined care / equipment, and had capacity, please make sure it is made clear in the mini RCA what infrmatin the patient was given abut the cnsequences f this t enable them t make an infrmed decisin Please ensure all sectins are cmpleted as fully as pssible including rt causes, lessns learned and what actins are being taken in the clinical area t prevent this ccurring again Fr pressure ulcers grade 3 & 4 the Duty f Candur applies. It is imprtant t dcument discussins with the patient r where apprpriate relatives and carers bth in the patient recrds and recrd n the mini RCA frm. The frm must be electrnically signed by tw peple Once fully cmpleted a typed wrd versin (nt scanned cpy) shuld be emailed t: :Risk Management :Tissue Viability Nurse Specialists :Safeguarding Adults 14
Appendix C: Flwchart shwing typical prcess Pressure ulcers and safeguarding adults cncerns: general purpse flwchart Cncern arises: Pressure wund identified, wrsened r nt imprved as expected Cncern abut abuse, neglect r the risk f these? Immediate Dn t knw Yes Manage immediate risks; plan fr freseeable risks Make a safeguarding adults referral t the lcal authrity Yes N T timescale in Lndn plicy and prcedure fr deciding whether t refer cncern t the lcal authrity Cmmence assessment and decisin guidance tl Will it take lnger than relevant timescale? N Cmplete the ASDG tl Safeguarding adults referral indicated? Yes T timescale in Lndn plicy and prcedure fr safeguarding enquiries N Safeguarding adults enquiry crdinates ther actins Implement actins arising frm safeguarding enquiry Return t business as usual N Respnd in the usual way (e.g. SI prcess, Incident management, Assess and review Have cncerns abut abuse, neglect emerged? 15
Appendix D: NHS England (Lndn Regin) gd practice principles Pressure Ulcers The brad principals f gd practice in relatin t Maintaining skin integrity Preventing pressure ulcers shuld be a key pririty fr all agencies and may r may nt be an indicatr f abuse. They d hwever have a significantly adverse effect upn a persn s quality f life and shuld be prevented. If they d ccur, irrespective f which investigatin is being used, rganisatinal learning has t ccur. All care, supprt and explanatin fr patients wh are at risk f develping pressure ulcers r wh have pressure ulcers has t be dne within: The principals f the MCA and the principals f duty f care and autnmy fr thse wh have capacity. The engagement f, carers, paid and unpaid and legal representatives such as thse hlding LPOA fr Health and welfare and relatives shuld be evident fr thse wh lack capacity. Patients shuld receive an initial and n-ging risk assessment within 6 hurs f the first episde f care. Thse assessed as at risk shuld be cared fr as guidance suggests dependent upn the degree f risk. This shuld include a care plan that recrds the frequency f pressure area care required/skin care regime and the type f pressure relieving equipment required. An ptimum envirnment shuld be created t maintain skin integrity r where cmprmised the ideal wund healing interventins. This will include satisfactry maintenance/referral/management f nutritin and Hydratin; hygiene; cntinence care and maintaining mbility. Gd cmmunicatin is essential, which wuld include accurately recrded assessments; care/treatment plan; transfer/discharge frms and includes pen/transparent and apprpriate infrmatin sharing between agencies. Safeguarding cnsideratins All NHS rganisatins have a duty f candur and transparency in their utcmes. Any pressure ulcer may be an indicatr f neglect/abuse; therefre all shuld be apprpriately assessed t identify any pssible safeguarding cncerns. Nt all grade 3 /4 pressure ulcers are indicative f abuse/neglect. Patients must be invlved and empwered t engage with all stages f the safeguarding prcess and, their preferred utcme must be recrded. Once a safeguarding cncern is identified, a safeguarding alert must be raised within the guidelines f the Lcal Plicy and prcedure timescales t safeguard adults frm abuse. Keep up t date with best practice/evidence thrugh learning the lessns frm the investigatin prcess. A duty f candur and penness is applicable and imprtant fr all cncerned. 16
Appendix E: Rles and respnsibilities Lcal authrity Lcal authrities have adult scial care respnsibilities fr Assessing the needs f peple wh may be in need f care and supprt, and leading multiagency planning abut hw thse needs are best met. This might invlve the lcal authrity arranging fr care and supprt r prviding the persn with a Direct Payment s that they can arrange their wn care Leading n the respnse t safeguarding adults cncerns. In particular they have duties t Make, r cause t be made, a Safeguarding Adults Enquiry when there is a cncern that a persn with care and supprt needs has experienced r is at risk f abuse r neglect and, because f their care and supprt needs, they cannt prtect themselves frm the abuse r neglect On cmpletin f a Safeguarding Adults Enquiry, t determine what, if any, actin needs t be taken and wh by. Lcal authrities may have arrangements in place t delegate sme r all f their adult scial care functins t ther bdies. A cmmn example f this is where scial care respnsibilities fr peple with mental health needs are undertaken by multi-disciplinary teams within health services. In this dcument, references t the lcal authrity shuld als be taken t relate t such arrangements. General Practitiners General Practitiners (GPs) are lead clinicians fr day-t-day cntact with patients. Fr peple with r at risk f pressure ulcers they have a key rle in recgnising, assessing, respnding, mnitring and referring. Thrugh Clinical Cmmissining Grups, GPs als have a rle in ensuring that the right types f service are available fr peple with r at risk f pressure ulcers. Cmmunity Health Services Cmmunity Health Services had a rle in targeted health services. Cmmunity nurses have rles in regard t recgnising, assessing, respnding, mnitring and referring t pressure wunds and the risks f these Tissue Viability Nurses have particular expertise and play a rle in giving specialist advice t health and scial care partners as well as in managing cmplex cases Acute Health prviders; Primary preventin thrugh risk assessment f all in-patients and taking apprpriate actins t minimise that risk 17
Early recgnitin f skin breakdwn, assessment, respnding t any skin break dwn and cntinuusly mnitring healing prgress Prviding patient infrmatin Clinical Cmmissining Grups Clinical Cmmissining Grups (CCGs) cmmissin the bulk f lcal health services, ther than GPs, s they have a rle in ensuring that the right type and amunt f services are available t meet the healthcare needs f the ppulatin, and fr checking the quality f these services. They cntract with care hmes and hme care prviders fr Cntinuing Care Patients. Where things have gne wrng and a health prvider needs t undertake a Serius Incident (SI) investigatin, CCGs review the quality and timeliness f the investigatin and implementatin f any learning. NHS England NHS England cmmissin GP services, and they versee the wrk f CCGs. They set expectatins abut hw CCGs and health prviders undertake SI investigatins. Hme care prviders These are services that prvide care t peple in their wn hmes. These are mstly independent r vluntary sectr rganisatins, and are regulated by CQC. Lcal authrities and CCGs will have cntractual arrangements with these prviders t deliver care n their behalf, and many peple will cntract directly with these services t meet their care needs. Care Hmes and Care Hmes with Nursing Care hmes are used by peple whse health and scial care needs are such that living in their wn hmes is nt pssible. Peple might pay fr their care hme placement themselves, r sme r all f it might be paid fr by a lcal authrity r a CCG. Care hmes are staffed by care wrkers; care hmes with nursing have nursing staff in additin. Care hmes are respnsible fr ensuring they are able t meet the needs f peple living there, and that they respnd apprpriately t changes in health and care needs. Scial Care Cmmissiners Scial care cmmissiners cntract with hme care and care hme prviders. They are respnsible fr mnitring services they cntract with t ensure services are f gd quality. 18
Appendix F: Applying the RASCI mdel t safeguarding cncerns relating t pressure ulcers The RASCI mdel can help clarify rles in a prject such as a safeguarding enquiry. Fr each task invlved, identify wh is respnsible, accuntable, r supprtive f the wrk and wh is t be cnsulted, and t be infrmed Respnsible: The persn r stakehlder that leads the ding f the wrk. They must cmplete the task r bjective r make the decisin. There must be ne and nly ne R. R has an integratin rle and is directly accuntable fr quality f decisins. This persn ensures that the task is cmpleted effectively and handed ver fr sign ff fr apprval by A t mve n t the next step. Accuntable: Persn r stakehlder wh is the "wner" f the task. He r she must sign ff r apprve when the task, bjective r decisin is cmplete. This persn must make sure that respnsibilities are assigned in the matrix fr all related activities. There can be mre than ne A, but the aim is always t have as few as pssible, since all A s must apprve every actin that takes place. This persn caches, prvides feedback, adds value, prvides directin, sets verall terms f reference and is ultimately accuntable fr verseeing the implementatin. Supprtive: The persn r team f individuals wh are needed t d the real wrk. Cnsulted: Peple r stakehlders wh need t give input befre the wrk can be dne and signed-ff n. These peple are "in the lp" and active participants, and the cmmunicatin with them is tw-way. C s input shuld be btained befre a decisin is made, thugh it may nt necessarily be used. Infrmed: Peple r stakehlders wh need t be kept "in the picture." They need updates n prgress r decisins, but they d nt need t be frmally cnsulted, nr d they cntribute directly t the task r decisin. They shuld be advised after decisins have been made t avid being sucked int the decisin making. 19
Fr example: A safeguarding cncern arises when a persn wh lives in a care hme arrives at hspital by ambulance. The persn is in a smewhat unkempt state, and the ambulance crew say this was the cnditin they were in when they arrived at the care hme. They als mentin that there were delays bth with the respnse frm the ambulance service t the call frm the care hme, and nce they arrived at the hspital with A&E being able t receive the persn frm the ambulance. A cuple f hurs after they have arrived at hspital, staff and A&E ntice that the persn has pressure ulcers. The hspital staff make a safeguarding referral t the lcal authrity, nting there is the ptential that the pressure wunds culd be assciated with pssible neglect at the care hme, by the ambulance service, r the hspital. A RASCI matrix fr the likely steps invlved in respnding t such a situatin might lk like this Persn at risk Lcal Authrity: SAM rle Lcal Authrity: IO rle Hspital Ambulance Service Care Hme Healthcare Cmmissiner Scial Care Cmmissiner CQC Immediate risk management C A R S S S I I I Deciding what the safeguarding enquiry will invlve S A R C C C C C I Undertaking the safeguarding enquiry Develping the safeguarding plan Implementing the safeguarding plan C A R S S S S S I S A R C C C C C I S A R S S S S S I 20
Reviewing the safeguarding plan S A R S S S S S S 21