Corporate CCG CO16 Safeguarding Vulnerable Adults Policy Version Number Date Issued Review Date V1: 28/02/2013 28/02/2013 28/02/2014 Prepared By: Consultation Process: Formally Approved: 29/05/2013 Policy & Corporate Governance Lead, NHS County Durham & Darlington Governance Lead, NHS South of Tyne and Wear Information Governance Advisor, NHS Tees Senior Manager, Corporate Affairs, NHS North of Tyne Safeguarding Vulnerable Adults Leads Policy Adopted From: Approval Given By: NHS Tees Governance and Risk Committee Document History Version Date Significant Changes 1 28/02/2013 Equality Impact Assessment Date Issues 6 February 2013 See Section 9 of this document POLICY VALIDITY STATEMENT This policy is due for review on the latest date shown above. After this date, policy and process documents may become invalid. Policy users should ensure that they are consulting the currently valid version of the documentation. Policy for Safeguarding Vulnerable Adults South Tees CCG CO016 Safeguarding Vulnerable Adults Policy Page 1 of 13
Contents Section Title Page 1 Introduction 3 2 Definitions 4 3 Policy for Safeguarding Vulnerable Adults 5 4 Duties and Responsibilities 6 5 Implementation 9 6 Training Implications 9 7 Documentation 9 8 Monitoring, Review And Archiving 10 9 Equality Analysis 10 Appendices 1 Training Matrix 12 South Tees CCG CO016 Safeguarding Vulnerable Adults Policy Page 2 of 13
1. Introduction Policy for Safeguarding Vulnerable Adults No Secrets (DH, 2000) guidance was issued under section 7 of the Local Authority Social Services Act 1970 to create a framework for action within which all responsible agencies work together to ensure a coherent policy for the safeguarding of vulnerable adults at risk of abuse. Underpinning the guidance is the notion that Safeguarding adults is everybody s business. All staff have a responsibility to help prevent abuse and to act quickly and proportionately to protect people where abuse is suspected. This policy sets out how, as a commissioning organisation, South Tees Clinical Commissioning Group (CCG) will fulfil its statutory duties and responsibilities effectively both within its own organisation and across its local health economy via its commissioning arrangements. The CCG will ensure that it has in place robust structures, systems, standards and an assurance framework which enable compliance with legal and local governance arrangements. The CCG will ensure that the six fundamental actions identified by the Department of Health: Safeguarding Adults; the role of NHS Commissioner are implemented. This will involve: The use of safeguarding principles to shape strategic and operational safeguarding arrangements Set safeguarding adults as a strategic objective in commissioning health care Use integrated governance systems and processes for assurance to act on safeguarding concerns in services Work with local Adult Safeguarding Boards, patients and community partners to create safeguards for patients Provide leadership to safeguard adults across the health economy Ensure accountability and use of learning within the service and partnership to bring about improvement. The CCG, as a member of the local Safeguarding Vulnerable Adult Board and Local Adult Safeguarding Committees have formally adopted the principles of the local Adult Safeguarding Policy and Procedures. 1.1 Status This policy is a corporate policy. 1.2 Purpose and Scope South Tees CCG CO016 Safeguarding Vulnerable Adults Policy Page 3 of 13
This policy relates to all vulnerable adults who are resident in, or access services commissioned by the CCG. This policy describes how the CCG will discharge its responsibility for ensuring their own organisation, and how the health services they commission fulfil their duty to safeguard vulnerable adults. This policy applies to all staff employed by the CCG including agency, selfemployed or temporary staff. All CCG staff have an individual responsibility for raising concerns that a vulnerable adult is being abused or neglected. 2. Definitions 2.1 A vulnerable adult is defined as a person aged 18 years or over, who is or may be in need of community care services by reason of mental or other disability, age or illness and who is or maybe unable to take care of him/herself or unable to protect him/herself from significant harm or serious exploitation. (No Secrets, DH 2000) 2.2 Abuse is a violation of an individual s human and civil rights by any other persons. (No Secrets, DH 2000) 2.3 Abuse can be unintentional or deliberate and can result from either actions or omissions. 2.4 Abuse can take many different forms and is often considered under the following headings: Physical Sexual Emotional Financial or material Neglect Discriminatory Institutional 2.5 Executive Lead for Safeguarding Adults NHS South Tees CCG 3. Safeguarding Adults Policy Executive Nurse 3.1 Procedures to follow when there is a concern about a vulnerable adult Any member of staff, who believes that a vulnerable adult has suffered abuse or is likely to do so, has a duty to respond. South Tees CCG CO016 Safeguarding Vulnerable Adults Policy Page 4 of 13
It is important that advice is sought at an early stage. Please see appendix 1, Single Point of Contact (SPOC) Where concerns are raised an alert/referral to the appropriate Local Authority must be made. The contact details in relation to the Local Authorities can be found at appendix 1. All alerts/referrals should be appropriately recorded. The Adult Safeguarding Lead will provide advice and guidance if necessary in relation to recording of information. The Local Authority will respond to the alert within 48 hours of the alert being raised. The Local Authority will identify whether or not the alert meets the criteria. It is the responsibility of those who have made the alert/referral to the Local Authority to ensure that the alert has been received and is being dealt with, should a formal response not be received within 3 working days. 3.2 Commissioned Services - Governance and Accountability The CCG s governing body is responsible for ensuring that NHS services commissioned on behalf of the CCG have in place arrangements to meet their statutory duties in relation to safeguarding vulnerable adults. Standards have been developed and incorporated into contracts with providers that will ensure the following arrangements in relation to adult safeguarding are adhered to: Leadership a named Lead(s) is identified who is responsible and accountable for safeguarding adults. Policies/Procedures/Strategies Policies are produced that are accessible and ensure clarity in relation to raising and reporting concerns relating to a vulnerable adult. These policies comply with the local Vulnerable Adult Safeguarding Policies and Procedures. Training and Continuous Professional Development staff will receive relevant mandatory adult safeguarding training appropriate to their roles and responsibilities. Safe Recruitment and Vetting Procedures Criminal Records Bureau checks are completed for staff working with vulnerable adults and the Independent Safeguarding Authority (ISA) requirements are complied with. Whistleblowing Providers will ensure policies are in place and staff are aware of how to raise concerns. South Tees CCG CO016 Safeguarding Vulnerable Adults Policy Page 5 of 13
Serious Case Reviews Providers contribute to Serious Case Reviews in accordance and ensuring compliance with the local Vulnerable Adult Safeguarding Policies and Procedures. Incidents/Serious Incidents Policies are in place and confirm how incidents/serious incidents relating to adult safeguarding are dealt with. Supervision Supervision policies are in place for the provision of adult safeguarding supervision. 4. Duties and Responsibilities Council of Members Accountable Officer The council of members has delegated responsibility to the governing body (GB) for setting the strategic context in which organisational process documents are developed, and for establishing a scheme of governance for the formal review and approval of such documents The accountable officer has overall responsibility for ensuring that the CCG has appropriate strategies, structures, policies and procedures in place to ensure that vulnerable adults are safeguarded from harm and abuse and that the organisation complies with all relevant national legislation and discharges its duties effectively. South Tees CCG CO016 Safeguarding Vulnerable Adults Policy Page 6 of 13
Lead Nurse The Lead Nurse will ensure that the CCG has in place assurance processes to ensure compliance with adult safeguarding legislation, guidance, policy, procedures, quality standards, and contract monitoring of providers. The Lead Nurse is responsible for ensuring that the Accountable Officer and governing body members are made aware of any concerns relating to a commissioned service which may be presenting a safeguarding risk to a vulnerable person or persons. The Lead Nurse will ensure appropriate representation of the CCG at the Local Adult Safeguarding Board/Committees. Adult Safeguarding Lead The Lead Nurse will work closely with and performance manage the CCG Adult Safeguarding Lead. The Adult Safeguarding Lead is the strategic and professional lead on all aspects of adult safeguarding, which includes all commissioned providers. They will: Work with the Associate Director/Board Nurse to ensure robust safeguarding adults assurance arrangements are in place within the CCG and provider services. Provide advice and expertise to the Local Safeguarding Board/Committees and to professionals across both the NHS and partner agencies. Provide professional leadership, advice and support to lead adult safeguarding professionals in each provider organisation. Represent the CCG on relevant committees, networks and multiagency groups charged with the management of safeguarding vulnerable adults. Lead on investigation and provision of appropriate information to inform and support reviews including serious case and management reviews. Lead and support the development of adult safeguarding policy, and procedures in the CCG in accordance with national, regional, local requirements. Provide advice and guidance in relation to safeguarding adults training including standards. Ensure quality standards for safeguarding adults are developed and included in all provider contracts and compliance is evidenced. South Tees CCG CO016 Safeguarding Vulnerable Adults Policy Page 7 of 13
Senior Managers Continuing Health Care (CHC) Managers (Strategic/Operational) Senior Managers are responsible for ensuring the adult safeguarding policy is implemented within their area of responsibility. Senior Managers will ensure that all staff undertake mandatory training at the appropriate level for their role and that a record of this training is maintained. The Continuing Health Care Manager will be responsible for ensuring that adult safeguarding concerns identified by CHC staff are raised with the Adult safeguarding Lead. The Continuing Health Care Manager will be responsible for ensuring CHC representation at adult safeguarding strategy and progress meetings. The Continuing Health Care Managers will be responsible for undertaking multiagency adult safeguarding investigations. The Continuing Health Care Managers will be responsible for ensuring the provision of relevant and timely information to multiagency adult safeguarding meetings. The Continuing Health Care Managers will be responsible for ensuring all CHC staff are familiar with and implement the adult safeguarding policy and procedures. The Continuing Health Care Managers will be responsible for ensuring all CHC staff undertake mandatory adult safeguarding training in accordance with their role. The Continuing Health Care Managers are responsible for ensuring the professional registration of CHC clinical staff who have direct contact with patients comply with their respective codes of conduct/practice. Continuing Health Care (Nurse Assessors) Continuing Health Care (Nurse Assessors) are responsible for ensuring they attend multiagency adult safeguarding meetings as determined by the CHC Manager. Continuing Health Care (Nurse Assessors) are responsible for ensuring they provide relevant and timely information to multiagency adult safeguarding meetings as determined by the CHC Manager. Continuing Health Care (Nurse Assessors) are responsible for maintaining their own professional registration and comply with their respective professional bodies code of conduct. South Tees CCG CO016 Safeguarding Vulnerable Adults Policy Page 8 of 13
All line managers All Staff Continuing Health Care (Nurse Assessors) are responsible for ensuring any safeguarding concerns in relation to NHS funded services are raised with the CHC Manager. All Line Managers are responsible for ensuring that staff have completed mandatory adult safeguarding training. They will ensure that staff are aware of this policy and the local Vulnerable Adult Safeguarding Policies and Procedures and understand how to raise a concern relating to a vulnerable adult. CCG employees are responsible for actively co-operating with managers in the application of this policy to enable the CCG to discharge its legal obligations and in particular; 5. Implementation All staff must be aware of the potential for abuse of vulnerable adults and the actions required of them should they have any concerns. They should be familiar with the agreed multi-agency policy and procedure and attend training commensurate with their role. Staff must adhere to this policy. 5.1 This policy will be available to all Staff for use in the circumstances described on the title page. 5.2 All managers are responsible for ensuring that relevant staff within the CCG have read and understood this document and are competent to carry out their duties in accordance with the procedures described. 6. Training Implications 6.1 All CCG staff are required to complete mandatory Safeguarding Vulnerable Adults training commensurate with their role and responsibilities. Refer to appendix 2, Mandatory Training Matrix. 7. Documentation 7.1 Other related policy documents 7.2 Legislation and statutory requirements Care Quality Commission, 2009 Essential Standards for Quality http://www.cqc.org.uk/sites/default/files/media/documents/gac_- _dec_2011_update.pdf 7.3 Best practice recommendations South Tees CCG CO016 Safeguarding Vulnerable Adults Policy Page 9 of 13
8. Monitoring, Review and Archiving 8.1 Monitoring The governing body will agree a method for monitoring the dissemination and implementation of this policy. Monitoring information will be recorded in the policy database. 8.2 Review 8.2.1 The governing body will ensure that this policy document is reviewed in accordance with the timescale specified at the time of approval. No policy or procedure will remain operational for a period exceeding three years without a review taking place. 8.2.2 Staff who become aware of any change which may affect a policy should advise their line manager as soon as possible. The governing body will then consider the need to review the policy or procedure outside of the agreed timescale for revision. 8.2.3 For ease of reference for reviewers or approval bodies, changes should be noted in the document history table on the front page of this document. NB: If the review consists of a change to an appendix or procedure document, approval may be given by the sponsor director and a revised document may be issued. Review to the main body of the policy must always follow the original approval process. 8.3 Archiving The governing body will ensure that archived copies of superseded policy documents are retained in accordance with Records Management: NHS Code of Practice 2009. 9 Equality Analysis Equality Analysis Screening Template (Abridged) Title of Policy: Short description of Policy (e.g. aims and objectives): CCG CO016 Safeguarding Vulnerable Adults Policy This policy sets out how as a commissioning organisation the CCG will fulfil its statutory duties and responsibilities effectively both within their own organisations and across their local health economies via their commissioning arrangements. The CCG will ensure that it has in place robust structures, systems, standards and an South Tees CCG CO016 Safeguarding Vulnerable Adults Policy 13 Page 10 of
assurance framework which enable compliance with legal and local governance arrangements. Directorate Lead: Is this a new or existing policy? New Equality Group Age Disability Gender Reassignment Marriage And Civil Partnership Pregnancy And Maternity Race Religion Or Belief Sex Sexual Orientation Carers Does this policy have a positive, neutral or negative impact on any of the equality groups? Please state which for each group. Screening Completed By Job Title and Directorate Organisation Date completed Jeff Pearson Policy and Corporate Governance Lead NHS County Durham and Darlington 6 February 2013 Director s Name Director s Signature Organisation Date South Tees CCG CO016 Safeguarding Vulnerable Adults Policy 13 Page 11 of
Appendix 1 Adult Safeguarding Mandatory Training Title NHS Staff Status Method of Training Period Level 1 Foundation Safeguarding Adults Awareness Raising All NHS staff Mandatory e-learning or face to face provided by local authority Every 3 years Level 2 (SAM 1) Intermediate Safeguarding Adults Awareness Raising CHC team Medicines management team Adult Safeguarding Lead Clinical Quality assessor Patient Safety Quality Advisor(s) Mandatory 2 day course Once Only Advanced safeguarding training risk assessment, chairing, investigations, Adult Safeguarding Lead In accordance with commissioned training providers availability Once only South Tees CCG CO016 Safeguarding Vulnerable Adults Policy 13 Page 12 of
South Tees CCG CO016 Safeguarding Vulnerable Adults Policy Page 13 of 13