Agenda Item No: 17 Date of Meeting: 21 st July 2016 Governing Body in Public Paper Title: Annual Report Safeguarding Children and Looked After Children 2015/16 Decision Discussion Information Follow up from last meeting Report author: Report signed off by: Mary Emson, Designated Nurse Safeguarding Children, Looked After Children & Care Leavers Sheilagh Reavey, Director of Nursing Purpose of the paper: To provide assurance to the board on Safeguarding Children/Looked After Children Health Services for the year 2015/2016. Please review the Register of Interests of the Governing Body and highlight to them any potential conflicts, which they need to manage: http://www.enhertsccg.nhs.uk/ declarations interest Conflicts of Interest involved: None Identified Recommendations to the Governing Body: To approve
Annual Report Safeguarding Children and Looked After Children. 2015-2016 2 P age
Abbreviations CP-IS - Child Protection Information System CCG - Clinical Commissioning Group HSCB - Hertfordshire Safeguarding Children Board HUC - Hertfordshire Urgent Care MAR - Multi Agency Review MARAC - Multi Agency Risk Assessment Conference CSE - Child Sexual Abuse HV - Health Visitor SSAG - Strategic Safeguarding Adolescent Group CQC - Care Quality Commission HPFT - Hertfordshire Partnership Foundation Trust SDQ - Strength and Difficulty Questionnaire CPP - Child Protection Plan CDOP - Child Death Overview Panel JSNA - Joint Strategic Needs Assessment JHWS Joint Health and Well Being Strategy WHHT - West Hertfordshire Hospital Trust RHA-Review Health Assessment. CASH - Contraceptive and Sexual Health LAC - Looked After Children DNA - Did Not Attend IHA-Initial Health Assessment ENHT - East & North Hertfordshire NHS Trust FGM - Female Genital Mutilation MASH - Multi Agency Safeguarding Hub MHS - Mental Health Service HCT - Hertfordshire Community Trust 3 P age
Contents Page 1. Introduction 5 2. National Context 6 3. Local Context 6 4. East & North Herts CCG s Governance Arrangements 8 5. NHS England 8 6. Hertfordshire Safeguarding Children Board 9 7. Developing Multi-Agency Working 13 8. Safeguarding Monitoring of Commissioned Services 14 9. Non-NHS Providers 19 10. Looked After Children and Care Leavers 19 11. National Context 19 12. Local Context 20 13. CCG s Governance Arrangements 20 14. Performance indicators 21 15. Challenges within the Safeguarding Children and LAC Team 2015/16 23 16. Safeguarding Children and LAC Key priorities for 2016/17 23 17. Conclusion 22 4 P age
1. Introduction The purpose of this report is to provide an overview of Safeguarding Children and Looked After Children for the period April 2015 March 2016. The report is to assure East and North Hertfordshire CCG s governing body that Safeguarding Children and Looked After Children arrangements are robust and statutory obligations are met. Key Achievements during 2015/2016 Maintenance of positive and productive relationships with partner agencies; health, police, children social care, safeguarding children board. The Ofsted review in 2015considered the HSCB to be good and commented positively on partnership arrangements. Establishment of a MASH with partner agencies due to agreement and funding arrangements from the CCG. Recruitment of the Designated Nurse Safeguarding Children Nurse, Looked After Children and Care Leavers Increase in Looked After Children Health Assessment compliance. Fully functioning Looked After Children GP model. Family Safeguarding Project. 2015-2016 priorities and progress Last year s safeguarding children and looked after children priorities focused on the continuous improvement of practice to demonstrate an improved outcome for children. Due to continued sick leave and changes in personnel within the Designated Office objectives were prioritised. Review the 3 year safeguarding strategy partially achieved To further strengthen provider quality monitoring systems and processes as part of the patient safety agenda - Achieved To ensure that there is the same level of performance monitoring for General Practice Out of Hours Services (HUC) - Achieved To evidence the impact of learning from serious case reviews across the health economy partially achieved To review current Female Genital Mutilation activities and identify gaps developing a time limited action plan as appropriate partially achieved To review current CSE activities and identify gaps developing a time limited action plan as appropriate partially achieved Ensure all CQC actions are completed Achieved 5 P age
To ensure a step change in performance against timeliness for the completion of both initial and review health assessments - Achieved To work with Hertfordshire Children Services and health providers to ensure full data for attendance at dental appointments and immunisations are captured accurately Achieved To work with Hertfordshire Children Services and health providers to ensure that Hertfordshire LAC have their emotional and mental health needs adequately assessed and timely support given through the SDQ process - work underway To monitor the You are Welcome status of LAC providers and the results of audits and feedback from LAC and carers regarding service(s) received to ensure that their experiences are routinely sought and used to improve services - work underway 2. National context The Children Act 1989/2004 provides the legal framework for safeguarding children. Section 11 of the Act places specific duties on a range of organisations, including the NHS to ensure their functions and any services they contract out to others, are discharged having regard to the need to safeguarding and promote the welfare of children. Working Together 2015 provides key statutory guidance on how agencies should work together to safeguard children. The guidance clearly identifies CCGs responsibility as major commissioners of local health services for safeguarding quality assurance through contractual arrangements with all their provider organisations. Safeguarding Vulnerable People in the NHS Accountability and Assurance Framework (2015) defined the safeguarding responsibility and duty of CCGs, as having statutory responsibility for ensuring that the organisations they commission from have safe systems that safeguard children at risk of abuse and neglect. CCGs should ensure that robust processes are in place to learn lessons from cases were children die of abuse or are seriously harmed and abuse or neglect is suspected. Since October 2015, all regulated health and social care professionals and teachers are required to report cases of FGM in girls less than 18 years of age which they identify in the course of their professional work to the police. A number of reports published this year noted the key role health professionals play in identification and response to young people/children who are victims, or are at risk of child sexual exploitation. Hertfordshire Provider organisations include CSE in safeguarding training; with plans to develop tools to aid staff recognise subtle signs/symptoms. 3. Local context East and North Herts CCG commission health services for almost 282,100 children and young people. The CCG shares co-terminus boundaries with the Local Authority which supports a mutual focus on the welfare of children. The number of children subject to a Child Protection Plan (CPP) in Hertfordshire is illustrated in the tables below. Table 1 shows the number of children on a child protection plan 6 P age
according to category, table 2 shows the number of children on a child protection plan by age. Table 1 - Number of children subject to Child Protection Plan by category Neglect Emotional Abuse Sexual Abuse Physical Abuse Multiple Q1 15/16 503 177 22 14 0 Q2 15/16 482 175 22 17 0 Q3 15/16 411 208 17 23 1 Q4 15/16 443 236 31 22 1 Neglect accounted for the highest category of children requiring child protection plans, with lower numbers requiring plans for physical abuse, which echoes 2014/15 data. The need to address the high numbers of neglect cases in Hertfordshire was recognised by the HSCB and partners. This resulted in the development of a neglect strategy. Neglect is also a key priority in the 2016/17 HSCB business plan. Table 2 Number of Children on a CP plan from 2013-2016 1000 900 800 700 600 500 400 300 200 100 0 2012/13 2013/14 2014/15 2015/16 No of Children CP plan There has been a decline in the total number of children subject to a child protection plan from14/15. The number of children aged between 1 to 15 years on a children protection plan remains unchanged. There has been a decline in the number of unborn children on the child protection plan from 222 for 2014/15 to 147 for 2015/16 period. This decline is likely to result from the Family Safeguarding project and the extensive early intervention work currently underway in Hertfordshire. 7 P age
Table 3 Number of children by age on a CP plan 2015-2016 Q1 15/16 Q2 15/16 Q3 15/16 Q4 15/16 Unborn Under 1 1 to 4 5 to 9 10 to 15 16+ Snap Shot at end of each quarter 36 112 192 215 147 9 711 25 111 184 207 161 8 696 38 97 185 179 153 8 660 48 96 207 217 156 9 733 Family Safeguarding is a partnership initiative, developed by Hertfordshire County Council, Public Health and CCGs, Police, Probation and Rehabilitation Services and the Police and Crime Commissioner. The project established co-located teams of skilled professionals in children s and adult social work, domestic abuse, substance misuse and mental health who will work together in teams to tackle the root causes of harm in families. The teams are supported by a clinical psychologist. Evaluation is in progress by Bedfordshire University with results due in 2017. 4. East and North Herts CCG s Governance Arrangements East and North Herts CCG are statutorily responsible for ensuring that the organisations from which they commission services provide a safe system that safeguards children at risk of abuse or neglect. This includes specific responsibilities for Looked After Children and supporting the Child Death Overview process to include sudden unexpected death in childhood. During parts of the reporting period the Designated Nurse was on long term sick leave and Senior Management Interim arrangements were put in place to support the Deputy Designated Nurse. All statutory clinical posts are filled and service level agreements for the Designated Doctors are in place. Section 11 of the Children Act 2004 places a duty upon all NHS bodies along with partner agencies to ensure that their functions are discharged with regard to the need to safeguard and promote the welfare of children. The CCG needs to ensure that the staff it employs are trained, knowledgeable and competent in safeguarding children. 5. NHS England NHS England is the policy lead for safeguarding and has safeguarding responsibilities for some directly commissioned services, it provides oversight and assurance of the CCG s safeguarding arrangements and supports the CCG in meeting its responsibilities. 8 P age
The revised Safeguarding Vulnerable People in the NHS- Accountability and Assurance Framework 2015 has discharged the responsibility for Named GPs to the CCGs as part of co-commissioning and it sets out clearly the safeguarding roles, duties and responsibilities of all organisations within the NHS. The CCG Designated Professionals work closely with the Named GPs for Safeguarding Children. In Hertfordshire, co-commissioning will come into effect from April 2016. East and North Herts CCG policies and procedures have been reviewed in line with the following NHS England updated policies: Managing Allegations Policy Alerts Policy The overarching NHS England safeguarding Policy 6. Hertfordshire Safeguarding Children Board (HSCB) The key function of the HSCB under the section 11 of the Children Act 2004 is to measure effectiveness of organisations independently and collaboratively improving outcomes for children. The CCG and the NHS health providers work in close partnership with the HSCB through attendance at and chairing sub groups of the board. Partners are encouraged to challenge performance metrics, action plans, and audit results to improve outcomes for children. 6.1 Ofsted Inspection Ofsted inspected Children s Services in Hertfordshire from 14 th September to the 8 th October 2015 with a report published in November. The inspection covered arrangements for children in need of help and protection; children looked after and care leavers. As well as inspecting Children s Services, Ofsted also reviewed how the HSCB functioned and its engagement with partner agencies. The Designated Professionals and the Director of Nursing and Quality were involved in the interviews, and some of the NHS health providers contributed. Both Children s Services and the HSCB were rated as good. 6.2 Health s Participation in HSCB and Local Partnership Arrangement s East and North Herts CCG is a committed partner to the HSCB, this is demonstrated by the regular attendance and involvement by the Director of Nursing and Quality, Designated Professionals at Board meetings, executive meetings, sub-groups and development sessions. This engagement is a key section 11 responsibility for the CCG. The CCG works closely with the HSCB to implement the business plan with the Director of Nursing having responsibility for Learning and Development. The main NHS health providers have Director level representation on the HSCB board and are all represented on the sub-groups. The Designated Professionals sit on the HSCB s subgroup meetings, aimed at monitoring and evaluating the effectiveness of the Board partners. Attending these meetings provides the Designated Professionals with oversight of the health provider s contribution to safeguarding children. 9 P age
The CCG makes a financial contribution of 52,150 per annum to the HSCB, and also through the work undertaken by the Designated Professionals such as chairing the learning and development subgroup and providing health perspective into serious case reviews and learning reviews. 6.3 Reviews Reviews include serious case reviews, multi-agency reviews and other reviews required to identify lessons and disseminate learning across single and multi-agency organisations. The HSCB is required by Working Together 2015 to have a local learning and improvement framework which is shared across local organisations who work with children and families. The local framework covers the full range of reviews and audits which are aimed at driving improvements to safeguard and promote the welfare of children. 6.3.1 Serious Case Reviews During the course of the reporting period there were 2 new cases referred to the serious case review panel, one case did not meet the criteria and 1 was accepted. Learning from this review will be reported to the CCG once the review has been completed. ENHCCG had 4 open Serious Case Reviews from previous years, three of which are at various stages of completion; one case was downgraded by the chair of the LSCB to a less intensive review. A SCR was published on the 11 th May 2016, with no specific health recommendations identified. Individual health providers identified recommendations within their own Individual Management Reviews which were implemented and are being monitored by the Designated office and by the providers via their safeguarding committees. 6.3.2. Multi Agency Review (MAR) In March 2015 the local authority referred a case involving an infant with a head injury to the SCR group, however the case did not the SCR criteria. Chapter Four of Working Together (March 2015) clearly states that local Learning and Improvement Frameworks should support the work of the LSCB and its partners so that: Reviews are conducted regularly not only on cases which meet statutory criteria but also on other cases which can provide useful insights into the way organisations are working together to safeguard and protect the welfare of children and that this learning is actively shared with relevant agencies In light of the above the Hertfordshire Safeguarding Children Board made the decision to test a MAR process that would support Serious Case Reviews and Partner ships Reviews as an additional methodology for multi-agency learning and development. The Chair of the SCR Group, Deputy Designated Nurse and an independent consultant worked through a review process for the case. The MAR was well received by everyone involved, and it is anticipated that MARs will be undertaken for those cases that have not reached the statutory requirement for a Serious Case Review (SCR) but demand a level of scrutiny and analysis given the significant issues contained within the case. 10 P age
6.4 Child Death Overview Panel (CDOP) In line with Working Together 2015, it is a statutory requirement for agencies to notify their local LSCB of all child deaths up to the age of 18 years. The HSCB is responsible for ensuring that a review of each death of a child normally resident in the Hertfordshire areas is undertaken by the CDOP. The panel is chaired by the Deputy Director of Public Health, and has a fixed core membership drawn from agencies represented on the HSCB. CDOP reviews the deaths of children and young people who fall broadly into the following categories: Neonatal Deaths these deaths occur within the first 28 days of birth and are often attributed to perinatal events Unexpected Deaths - defined as being the death of an infant or child (less than 18 years old) which was not anticipated as a significant possibility) Expected Deaths - where a child s death is expected, such as where an End of Life Care Pathway has been in place. During the reporting period, the CDOP reviewed 56 cases there were 5 neonatal deaths with modifiable factors and 22 without modifiable factors. The provisional main causes of death during the year mirrored those of the previous year. A more detailed report will be published by the CDOP. 6.6 Rapid Response to an Unexpected Child Death Service The Rapid Response service is a nurse-led, multi-agency response to enquire into and evaluate each unexpected child death following the criteria laid out in Working Together 2015. The focus of the Rapid Response service is to work with other agencies to ascertain why the child died and to provide support to bereaved families. The team comprises of Hertfordshire Community Trust (HCT) Safeguarding Children Team and three experienced health visitors who are trained as case clinicians for this process. The service is provided from 8am to 8pm every day of the year. The information gathered as part of this process is then shared with the CDOP process; HCT s Named and Deputy Nurse are members of CDOP. The table below, (generated from HCT Rapid Response data), shows the number of unexpected child deaths for 2011/12; 2012/13; 2013/14 and 2014/15, which were referred to the Rapid Response Nurses and those that were managed as a Rapid Response following assessment. Table 4. Child deaths from 2011-2016 11/12 12/13 13/14 14/15 15/16 Total number of unexpected child deaths reported to team 35 22 25 23 17 11 P age
Number of unexpected child deaths managed as a Rapid Response 24 6 21 16 14 Deaths under 1- year of age 10 5 6 8 8 Table 5. Themes of Child Deaths 25.0 20.0 15.0 10.0 5.0 0.0 6.7 Child Sexual Exploitation (CSE) CSE continues to be a priority area in Hertfordshire and response to CSE is led by the HALO team, which is the police, led service. A key purpose strategy is in place to respond proactively to the risks associated with CSE. The Designated Professionals continue to sit on the Strategic Safeguarding Adolescents Group (SSAG). Children and young people at risk of CSE will come into contact with health services; awareness needs to be heightened to all health providers. All Health providers are being monitored by the Designated office for training compliance around CSE and the use of a CSE assessment tool, this is an area that needs further strengthening by the Designated Professionals. 6.8 Domestic Abuse and the Impact Upon Children The CCG s Safeguarding Team receives domestic abuse notifications from the police for all cases where a child is under the age of 5. There has been a slight decline in the number of referrals from 4935 for 2014/15 to 4817 for 2015/16 period. Domestic abuse remains high on the CCG s agenda and the Deputy Designated Nurse attends the MARAC steering group 12 P age
meetings to identity any health related performance concerns that arise from the MARAC meetings. Table 6. Domestic Abuse referrals to Hertfordshire Constabulary 7. Developing Multi-Agency Working Over the last two years, the CCG has been involved in the setting up of two multiagency communication projects. These projects improve how information is shared across agencies allowing for adequate risk assessments to be undertaken in a timely way. 7.1 Multi Agency Safeguarding Hub (MASH) MASH is partnerships between a range of local authority departments, health, police, education and probation. The agencies are co-located in order to provide a holistic response to referrals that are made to children s services, assessing risk and directing services more efficiently. Hertfordshire s MASH has been fully operational since July 2015, with two health practitioners employed within the MASH. Hertfordshire Community Trust (HCT) directly employ the two health practitioners, who co-ordinate collection of information from other health organisations which contributes to a relevant assessment. ENHCCG contribute funding to this along with HVCCG and Public Health. 13 P age
7.2 Child Protection Information System (CP-IS) CP-IS is an NHS England sponsored project which involves information sharing solutions that will improve a higher level of protection to children who visit unscheduled care settings. The system allows health practitioners to access key social care information for children and unborn babies on child protection plans and children looked after information. Hertfordshire was one of the first counties to implement CP-IS in all its unscheduled care settings, and this has been operational since April 2014. East and North Hertfordshire NHS Trust signed up to the CP-IS project, which contributes to practitioners assessment of a child s risk of abuse or neglect. The Designated Nurse will continue to work with NHS health providers to ensure there is compliance in the use of CP-IS. Due to problems in compliance with systems, Hertfordshire Urgent Care Centre (HUC) has not yet implemented CP-IS. This is being monitored closely by the Designated Nurse. 8. Safeguarding Monitoring of Commissioned services The CCG is responsible for ensuring that all organisations they commission health services from, adhere to the standards of section 11 of the Children Act 1989. All health providers are required to have effective arrangements in place to safeguard children. The CCG is required to provide assurance that safeguarding children activities within all commissioned services meets national safeguarding standards and demonstrates a model of continuous improvement. This is achieved by including a safeguarding assurance framework in all CCG contracts with NHS Providers. The Designated Professionals have a key responsibility in assuring the CCG that the service it commissions have measures in place to safeguard and protect children at risk of harm through the following: Ensure all contracts for the providers outline the expectations of processes and policies to safeguarding children. The Designated/Deputy Nurse are members of the Provider safeguarding children committees, where they provide constructive challenge and scrutiny of safeguarding children activities Monitor the Providers dashboard on a quarterly basis; this is part of the quality schedule. Key areas in 2015/16 that have been subject to challenge relate to providers training compliance Annual section 11 visits to the providers, these visits provide an opportunity for information sharing and challenge regarding all aspects of safeguarding children ensuring providers are compliant with the requirements of section 11 Dip sample audits following the annual section 11 visit Designated Nurse carries out supervision with Named professionals Whole systems meeting-designated team meet quarterly with named and specialist professionals across the Health economy 14 P age
During the reporting period the Deputy Designated Nurse worked closely with the Named Nurses to refine and establish effective systems and processes to ensure the CCG gained assurance relating to safeguarding children. The Designated Professionals offered and provided expert advice, support and developmental guidance in relation to safeguarding to provider organisations. 8.1 Single agency training The Designated/Deputy Nurse monitors all the providers training compliance on a quarterly basis and training compliance is also monitored at the trusts safeguarding committees. Variations in compliance are challenged by the Designated professionals. All the Named Nurses within all the providers were up-to-date with safeguarding children training 2015/16. Each provider trust has specifically tailored safeguarding children training, and they also access the HSCB s training courses. All the provider trusts have contributed to the HSCB learning and development subgroup work. There have been significant improvements within all the providers training compliance; the CCG has set an aspirational compliance of 95 for all the providers. Table 7-Safeguarding Children Training Compliance HPFT HCT ENHT HUC Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Level 95 96 94 94 78 86 87 95 91 92 91 89 100 100 100 100 1 Level 95 96 94 94 88 91 97 94 91 92 92 90 100 100 100 100 2 Level 95 91 89 83 96 94 99 100 79 85 88 82 100 100 100 100 3 GPs 86 86 86 89 8.2 Section 11 (S11) Annual Visit for NHS providers and Dip Sample audits Section 11 visits are carried out annually by the CCG as a way of seeking assurance from all commissioned health provider services. The purpose of s11 visit is to ensure the commissioned health providers have safe systems that safeguard children in line with Section 11 of the Children s Act 2004 in place, by having clear accessible policy and procedures, safer recruitment arrangements, training and governance systems in place. The emerging theme from the S11s visit was the need for the health providers to strengthen their supervision practice. Action plans have been developed and the Designated Office will monitor these to ensure full implementation. The section 11 visits will be followed up by dip sample audits. 8.3 Hertfordshire Community Trust (HCT) HCT had their annual section 11 visit on the 6 th of November, the Trust is compliant with the section 11 requirements, and 10 recommendations were made for the Trust to ensure children are full safeguarded. 15 P age
1. To further strengthen the quality of supervision by undertaking dip sample audits on the quality of supervision to review the content 2. Identify tools to assess impact of training across the Trust 3. Strengthen internal audit process 4. The Director of Nursing to chair the Safeguarding committee bi annually 5. Introduce Domestic Abuse and Child Sexual Exploitation champions across the Organisation 6. To incorporate and ensure implementation of the CSE toolkit for LAC Review Health Assessment 7. To provide CSE training for all LAC staff 8. Quality assure the outcomes for LAC through dip sample audits of Initial Health Assessments completed 9. Undertake another wider service audit on Was Not Brought In (formerly DNA) across the Trust Strengthen the quality of safeguarding audits 8.4 Hertfordshire Partnership Foundation Trust (HPFT) The section 11 visit to the Trust was carried out on the 6 th April 2016. The recommendations are as outlined below. 1. The trust agreed to implement a robust audit schedule for 2016/17. 2. To provide data in relation to numbers of referrals made to Children s Social care. 3. To capture data of referrals to cross reference if Think Family is being embedded in practice via 6 monthly audits of contacts by staff 4. Scope setting up parent/carer group for CAMHs carers. 5. Incorporate training on Looked After Children and Care Leavers into safeguarding level 2/3. 6. Promote staff attendance at Initial Case Conferences. 7. Review safeguarding children related court request process within the organisation to ensure a seamless system is in place 8. Grey out the safeguarding concerns form on PARIS to indicate the form is no longer in use. 9. Supervision to be recorded in patient records with agreed standards for doing so across the organisation It was noted that HPFT had made considerable progress throughout the year. 8.5 East and North Hertfordshire NHS Trust (ENHT) The Trust had their Section 11 visit on the 15 th of January 2016, and was complaint with the section 11 requirements. Five recommendations were made for the Trust to further strengthen safeguarding children across the organisation. 1. To achieve 90 training target compliance for all levels 2. The safeguarding team to review all referrals to children services the next working day to ensure that any issues with the referrals are dealt within a reasonable time 3. Finalise the CSE tool for use in children s emergency department and for LAC reviews where indicated 4. Include a section on safeguarding children in the on call handbook for Directors/Senior Managers 5. Yearly audit plan to include referrals to children s social care and staff views on effectiveness of supervision 16 P age
8.6 Hertfordshire Urgent Care The section 11 visit was undertaken on the 11 th May 2016 with many improvements made to safeguarding children practise. A number of recommendations were made to further improve practise. 1. The Job Descriptions for Medical Director and Head of Nursing and Quality require additional clarity with regard to safeguarding responsibilities, i.e. supervision, participation with HSCB, etc. 2. DNA procedure requires review to make it clear for users with regard to those who frequently DNA and safeguarding risk assessment completed when a child is not brought for an appointment. 3. Safeguarding children supervision policy required by end of June 2016 4. How information is shared with health visitors needs to be considered. 5. Designated Doctor, Nurse and Head of Nursing & Quality to develop curriculum of training. 6. Designated doctor to meet with Dr.Choudhary. 7. Chaperone policy for GP s seeing children. 8. Report writing course for those who provide SI reports. 9. Continued reduction in non-safeguarding referrals to Children s Services. 10. Staff to have access to a practitioner who is trained up to level 3. Statutory Inspections During the reporting period, Hertfordshire s main health providers care was inspected by Care Quality Commission (CQC). Findings were published between August and September 2015. CQC Inspection reports are based on a combination of what the inspectors found on their inspection visit, information from their Intelligent Monitoring system and information given to the CQC by people who use the services, the public and other organisations including their CCG(s). Providers are rated in five key areas; are services: Safe, Effective, Caring, Responsive Well led Set out below are the CQC judgements on whether services are safe alongside (a wider judgement than just safeguarding) areas of good practice and specific areas of safeguarding improvement required. 8.7 HCT The Trust was inspected from the 17 th -20 th February and the overall judgment score was requires improvement. The Trust got a formal safeguarding compliance action, Regulation 11 2008 (Regulated Activities) Regulations 2010 safeguarding service users from abuse. There were areas for improvement directly related to children s safeguarding that the Trust must do: 17 P age
Ensure that there is a Trust policy for safeguarding children Ensure that the safeguarding leads report all safeguarding concerns to the local authority Ensure all the staff are aware of the importance of reporting safeguarding concerns to the local authority Ensure that all safeguarding concerns are reported via the Trust s electronic system promptly Ensure that health visitor caseloads reflect national best practice There were also areas for the Trust to improve on relating to safeguarding children practice: Ensure robust action is taken to manage the risks surrounding recruitment and vacancies Ensure that all staff complete their mandatory training to reach the Trust s target 8.8 HPFT Inspected 27 th April 1 st May although there were no formal safeguarding compliance actions for the Trust, there were areas for improvement directly related to safeguarding children: The Trust must: Recruit to fill vacancies, decrease the number of agency staff and increase permanent staff across each of their core services Ensure that all environmental safety concerns are fully addressed in Child and Adolescent in-patient services Ensure that the resuscitation equipment is working effectively and checked daily within their child and adolescent mental health in-patient services Ensure that unlicensed medications are discussed with the young person or their parents and recorded appropriately in patient records within their child and adolescent in-patient services The Trust should: Ensure that the electronic system has up to date risk assessments in place within their community child and adolescent mental health services Ensure that training in relation to the MHS and MCA and the interface of the Children Act is in a format that meets the needs of staff within community child and adolescent mental health services Ensure that staff within their community child and adolescent mental health services attend mandatory training and clinical supervision 8.9 ENHT The Inspection was carried out by CQC from 20 th to 23 rd October 2015. The Trust received an overall judgement of requires improvement. CQC said safeguarding systems were in place to ensure children were protected from abuse. There were no recommendations made in relation to safeguarding children. A number of services were identified as good such as Children s Community Services. The Trust had a number of findings that required improvement and a further inspection planned. 18 P age
9. Non-NHS Providers The Deputy Designated Nurse has continued to provide advice to the Public Health Commissioning team in relation to Sexual Health Services (CASH) and School Health Services across Hertfordshire around their service specifications to ensure safeguarding children remains an integral part of the services they provide. A joint CASH section 11 visit will be undertaken by the Designated Professionals and the Public Health team. 10. Looked After Children and Care Leavers (LAC) Most children become looked after as a result of abuse and neglect. Although they have many of the same health issues as their peers, the extent of these is often greater because of their past experiences. For example, almost half of children in care have a diagnosable mental health disorder and two-thirds have special educational needs. Delays in identifying and meeting their emotional well-being and mental health needs can have far reaching effects on all aspects of their lives, including their chances of reaching their potential and leading happy and healthy lives as adults. (1. Promoting the health and well-being of looked after Children DfE, DH 2015) During the reporting period there was instability with the LAC Nurse Specialist post, the original post holder resigned and was replaced by another nurse who within 3 months of being in post also resigned. This was compounded by the Designated Nurse Safeguarding Children who also is the Designated Nurse for LAC being on long term sick leave. Despite this instability the core CCG LAC business had minimal disruptions with compliance being monitored by the Deputy Designated Nurse Safeguarding Children with the support of the Associate Director of Patient Experience and the Designated Doctor. 10.1 Responsible Commissioner East and North Herts CCG is the responsible commissioner of health services (of services commissioned by CCGs) for children looked after who are taken into the care by Hertfordshire County Council. When Children Looked After are placed out of County, the responsible CCG should communicate with the CCG where the child has been placed to notify them of this placement. East and North Herts discharges its responsible commissioner responsibility by ensuring relevant CCGs are contacted when a child from Hertfordshire is placed outside of the county and clarifies the arrangements for health assessments and secondary care utilisation cost recovery. 11. National Context Under the Children Act 1989 & 2004, CCGs have a duty to comply with requests from the local authority to help them provide support and services to children in need which includes LAC. The statutory duties of CCGs and professional requirements in meeting the health needs of children looked after were been clarified through the revision of two national documents Promoting the health and well-being of looked-after children: statutory guidance for local authorities, clinical commissioning groups and NHS England (March 2015). 19 P age
The new document outlines the revised statutory guidance for local authorities, CCGs groups and NHS England, it replaces the Statutory Guidance on Promoting the Health and Wellbeing of Looked After Children, (DCSF 2009) and has been updated to reflect reforms to the National Health Service following the Health and Social Care Act 2012. The guidance also outlines the number and range of requirements to be met by the CCG in partnership with the local authority, in particular that: CCGs and NHS England have a duty to cooperate with requests from local authorities to undertake health assessments and help them ensure support and services to children looked after are provided without undue delay. Local authorities, CCGs, NHS England and Public Health England must cooperate to commission health services for all children in their area. The health needs of looked after children should be taken into account in developing the local Joint Strategic Needs Assessment (JSNA) and the Joint Health and Wellbeing Strategy (JHWS). Every local authority should have agreed local mechanisms with CCGs to ensure that they comply with NHS England s guidance on establishing the responsible commissioner in relation to secondary health care when making placement decisions for children looked after, and to resolve any funding issues that arise CCGs should ensure that any changes in healthcare providers do not disrupt the objective of providing high quality, timely care for the child. 12. Local Context The Hertfordshire Looked After Child population has remained stable from 2012 to date, with small variations. ENHCCG as a responsible commissioner is responsible for ensuring all children and young people who are Looked After by Hertfordshire Local authority irrespective of placement type and location, reach their optimum health and wellbeing. Table 8 Number of Children Looked After Year Under 1 1-4 5-9 10-15 16 Plus Total LAC 2012 55 175 180 370 275 1055 2013 60 169 184 359 265 1037 2014 50 159 183 352 297 1041 2015 54 141 200 346 283 1024 CLA Source: SSDA903 13. CCG s Governance Arrangements East and North Herts CCG has a statutory responsibility to ensure that they secure the expertise of both a Designated Doctor and Nurse for Looked After Children and that the health needs of LAC are met. The delivery of the health care elements is met through provider service arrangements which are monitored by the Designated Professionals via a range of mechanisms. 20 P age
The Health of LAC Leadership Group continues to have strategic oversight of all activity regarding Hertfordshire LAC. Quarterly Deep dive audits are undertaken on Initial Health Assessments (IHA s) and Review Health Assessments (RHA s) for both in and out of county by the Designated Doctor LAC and LAC Nurse Commissioning to drive quality of health action Plans. Health assessments not compliant are sent back with appropriate feedback. The CCG has strengthened the reporting requirements for all health assessments within the Monthly Quality Reporting Schedule to ensure that tracking of progress against requirements is more effective. The LAC Specialist Nurse worked alongside the Designated Doctor at a strategic nonoperational level, to lead and support all activities necessary to ensure that organisations within the health community, meet their responsibilities for LAC in line with statutory guidance for local authorities, CCGs and NHS England. 14. Performance Indicators The LAC Data and Quality Indicator Dashboard has been reviewed and strengthened to provide a robust view of the health needs of LAC in Hertfordshire and also support and influence commissioning appropriate services for Hertfordshire s LAC population. All partners are now working on their reporting streams and building on their information systems to improve the collection of data. 14.1 Table 9. Looked After Children and Care Leavers Health Service Clearance Rates No of HA's Requiring Completion 2015/16 No Returned within Timescales Completed Within Time Scales PROVIDERS Paediatrician - East & North 47 32 68 Paediatrician - West 14 9 64 Paediatrician - Out of County 4 1 25 General Practitioner - East & North 0 0 0 General Practitioner - West 1 0 0 General Practitioner Out of County 50 14 28 Adoption - East & North 111 103 93 Adoption - West 66 58 88 Adoption - Out of County 7 1 14 CUS LAC Nurse 399 366 84 21 P age
Herts LAC Nursing Team 114 96 84 LAC Nurses - Out of County 126 26 21 Total 939 676 71 14.2 Health Assessments Statutory Guidance requires that the Initial Health Assessment (IHA) should result in a health plan, which is available in time for the first statutory review by the Independent Reviewing Officer. That care review must happen within 20 working days from when the child started to be looked after. Review Health Reviews are required every 6 months for children under 5 years and annually for children over 5 years. The data displayed is specific to health as the verified data from Department for Health is not available until July 14.3 Looked After Children and Care Leavers Health Service Clearance rates 2015-16 PROVIDERS No of HA's Requiring Completion 2015/2016 No Returned within Timescales Completed Within Time Scales Paediatrician - East & North 110 82 75 Paediatrician - West 109 99 90 Paediatrician - Out of County 24 1 4 General Practitioner - East & North 18 0 0 General Practitioner - West 28 1 4 General Practitioner Out of County 51 0 0 Adoption - East & North 1 1 0 Adoption - West 4 4 100 Adoption - Out of County 0 0 0 LAC Nurses - Out of County 41 6 15 Total 493 275 56 14.4 IHA Provider Performance There continues to be significant improvements in the compliance for Initial Health Assessments (IHAs). The new implemented LAC GP model is already starting to make an impact on increasing the percentage rate for initial health reviews. The overall percentage continues to be affected by the out of county initial health reviews as we do not have control over their timeliness. This is being reviewed by HCT to establish a more robust approach to 22 P age
address this. HCT employed 2 more GP s to undertake assessments for 16/17, which should support increase in compliance. 15. Challenges within the Safeguarding Children and LAC Team 2015/16 Children Looked After Health Team HCT s specialist children looked after team has experienced challenges with recruitment during the reporting period. The Designated Doctor and the LAC Specialist Nurse have provided support and advice during this time. 16. Safeguarding Children and LAC Key priorities for 2016/17 To ensure the priorities for 2014/15 are achieved To review in partnership with other agencies the effectiveness of MASH Incorporate the HSCB s business plans as part of the safeguarding priorities To work across the partnership to identify an effective response to reduce the risk of children who experience CSE In partnership with the HSCB, strengthen individual and organisational learning in practice from SCR s Strengthen the monitoring of safeguarding children activities in General Practice In partnership with the HSCB and provider trusts implement the neglect strategy For the Designated professionals to continue to monitor provider trust s safeguarding arrangements and compliance To work closely with the Head of Safeguarding Adults to manage the expanding agenda in safeguarding relating to Prevent To ensure there is continuity in the compliance rate for LAC, both for IHAs and RHAs To support the secondment arrangements of Named GP s 17. Conclusion Safeguarding children is complex with arrangements frequently being reviewed and changed. The Designated Professionals have undertaken comprehensive work to demonstrate compliance of the statutory duties changes placed on the CCG. The year has been an intense year for the CCG as the Designated Nurse was on extensive long term sick leave this brought some instability to the team. A new Designated Nurse for both LAC and safeguarding children is now in post which will mitigate risks previously in place and ensure there is continued focus on safeguarding improvements. 23 P age