Child Protection Policy

Child Protection Policy Reference Number: 221 Author & Title: Responsible Director: Beverley Boyd, Matron Paediatrics, Neonatology & Gynaecology Jennifer Daly, Named Nurse Safeguarding Children & YP Director of Nursing Review Date: December 2014 Ratified by: Helen Blanchard Director of Nursing Date Ratified: December 2014 Version: 3.3 Related Policies and Guidelines: Recruitment & Selection Policy, Pre & Post Employment Checks Policy Author: Beverley Boyd Page 1 of 22

Index: 1. Introduction 4 2. Purpose of this Policy 4 3. Definition of Terms Used 4 4. Duties and Responsibilities 4 4.1. Executive Lead 5 4.2. Designated and named role responsibilities 5 4.3. Allegations Officer 5 4.4. Human Resources 5 5. Safe Recruitment, pre and post-employment checks 5 6. Procedure 6 6.1. What to do if you have concerns a child is being abused or at risk of abuse 6 6.2. Allegations of abuse against a member of staff 7 6.3. Missed Appointments 8 6.4. Supervised Access 9 7. Training 9 8. Information sharing and confidentiality 10 9. Monitoring Compliance 10 10. Review 11 11. References (NHS LA Requirement) 11 Appendix 1: Hospital Protocol 12 Appendix 2: Named Nurse Notification 14 Appendix 3: Emergency Department Child Protection Form 15 Appendix 4: DNA Algorithm 17 Appendix 5: Safeguarding Children Training 18 Document Control Information 20 Ratification Assurance Statement 20 Consultation Schedule 21 Equality Impact: (A) Assessment Screening 22 Author: Beverley Boyd Page 2 of 22

Amendment History Issue Status Date Reason for Change Authorised 3 Approved December 2011 Planned Review Francesca Thompson Director of Nursing 3.1 Approved November 2013 Section 6.4 added. Contact name and bleep for the Named Nurse amended. Supervised Access added 3.2 Approved April 2014 Changes to Appendix 1 process for making referrals. Helen Blanchard Director of Nursing Helen Blanchard Director of Nursing Changes to Appendix 3 Emergency Department form changed. 3.3 December 2014 Changes to Appendix 1 Named Midwife name and contact number added. Changes to 4.4 Human Resources - Disclosure & barring checks. Changes to Section 5 pre and post-employment checks Changes to Appendix 5 levels of training. Changes to Section 7 training requirements. Helen Blanchard Director of Nursing Author: Beverley Boyd Page 3 of 22

1. Introduction The Trust recognises its responsibilities and is committed to ensuring that all children in their care are safe from risk of harm. The underlying principle of the Children Act 1989 is that by law the interests of children come first, thus all health care workers have a professional responsibility to protect children and young people. The purpose of this policy is to provide a co-ordinated approach to the management of safeguarding issues related to children and young people for all RUH staff to use. 2. Purpose of this Policy The aim of the policy is to: Protect Children and young people from abuse or exploitation. Provide guidance and support to all RUH Staff. Respond quickly and sensitively to issues relating to abuse. 3. Definition of Terms Used Substantial Access Staff working: alone with children; on regular basis therefore able to build up an influential relationship with a child; in any situation where it is possible that they could for however short a period be left alone with a child. 4. Duties and Responsibilities All staff have a responsibility for ensuring that the principles outlined within this document are universally applied. All staff should know who to contact in the organisation if they have concerns about a child s welfare. RUH staff who work directly with children, young people and families should be able to recognise indicators of possible abuse and neglect and know how to refer concerns to statutory agencies in line with this policy. Key organisational duties are identified as follows: The Trust will have a clearly identified Executive lead, Named Nurse and Doctor, and Allegations Officer. Author: Beverley Boyd Page 4 of 22

4.1. Executive Lead The Executive Lead for Safeguarding is the Director of Nursing who is responsible for overseeing the delivery of the safeguarding agenda. 4.2. Designated and named role responsibilities The Named Nurse and Doctor will have allocated time to undertake the role as set out in Working Together to Safeguard Children. (2010). The job description of the Named Nurse and Role Profile of the Named Doctor reflect responsibility for the following: Attending relevant meetings relating to child protection, both internal and external to the Trust. Maintenance and updating of relevant guidelines. Ensuring that the appropriate level of training is provided across the Trust. Providing support to staff involved in child protection cases. Ensuring that all standards relating to child protection are met and maintained. Auditing safeguarding procedures and staff knowledge. Updating policy and procedures relating to the safeguarding agenda. Responding to and undertaking serious case reviews, and ensuring any recommendations arising from these are implemented. Supporting the Allegations Officer in their role. Supporting the lead in their role. 4.3. Allegations Officer The Allegations Officer is responsible for responding to and following up allegations of abuse against members of staff. 4.4. Human Resources Maintain records of the Disclosure and Barring (DBS) process ensuring that: The required DBS checks are carried out. Specific staff working with children DBS are rechecked every 3 years A record of the DBS checking process is maintained. 5. Safe Recruitment, pre and post-employment checks The Disclosure and Barring Service (DBS) is an executive agency of the Home Office and provides access to information about criminal convictions and other police records to help employers make an informed decision when recruiting staff. Author: Beverley Boyd Page 5 of 22

The Trust Disclosure and Barring Service Policy and Procedure sets out the requirements of the Trust on checks of criminal records obtained through the Disclosure and Barring Service. The eligibility to undertake a DBS check will be determined at the recruitment stage based on the requirements of the post as outlined within the job description and mandated guidance available from the DBS and NHS Employers Employment Standards. All staff working with children will be required to have a DBS check, to confirm the type of DBS check required, managers and staff should refer to the DBS Policy. http://webserver/staff_resources/governance/policies/documents/non_clinical_policies/black_h r/hr_176_dbs.pdf Specific staff who work with children, will be required to have their DBS checked every 3 years in accordance with the Local Safeguarding Children Board requirements. The recruitment process will follow LSCB safer recruitment principles. All staff involved in recruitment and selection should be trained in fair and objective recruitment and selection techniques and understand the impact of the Equality Act on recruitment processes and practices. Panels will comprise no less than two members, one being the line manager for the job function. All Trust job descriptions will include the following statement: SAFEGUARDING ADULTS AND CHILDREN All Trust staff have a responsibility to safeguard adults and children which includes an understanding of the relevant Trust, and Local Safeguarding Adults and Children s Board Policies. 6. Procedure 6.1. What to do if you have concerns a child is being abused or at risk of abuse In the event that an employee has concerns that a child is being abused they are required to: Contact the named nurse or Doctor or a member of Paediatric team for advice or contact Social Services as outlined, see Appendix 1; Document all concerns within the patient s health records and sign and date the documentation; Maintain on-going concurrent records of actions to be taken in chronological order within the patient s health records; Follow Local Safeguarding Board (LSCB) procedure and guidelines, found at: Author: Beverley Boyd Page 6 of 22

Follow the South West Child Protection Policy and Procedures to be found at www.swcpp.org.uk and the Bath and North East Somerset handbook for children in need, found at www.bathnes.gov.uk and local protocol; Complete the named nurse notification form (Appendix 2) for all children/young people admitted with safeguarding concerns and send to the named nurse for children and young people, in-patients and outpatients; An Emergency Department Child Protection form (Appendix 3) must be completed for children who attend the Emergency Department; In accordance with the Bichard report, all young people below the age of 16 years who are referred to the RUH for a termination of pregnancy, should be offered the opportunity for a referral to Social Services and an initial assessment; Young people under the age of thirteen known to be sexually active must be referred to Social Services. 6.2. Allegations of abuse against a member of staff When an allegation of abuse has been made against a member of staff, whether involving contact with children in work, leisure time or their own children: The issue must be reported to the Divisional manager, or in their absence Senior Nurse. The above person will immediately inform the allegations officer. In the absence of the Allegations Officer, the Named Doctor or Nurse will be informed. The Allegations Officer will immediately inform Human Resources. The Allegations Officer will ensure that signed and dated written details of the allegations are received from the person reporting the allegation, and will collate and record the evidence. The Allegations Officer will inform the Local Authority Designated Officer (LADO) within one working day of receiving the allegation. The Allegations Officer will ensure that the person about whom the allegations has been made is informed, following taking advice from Human Resources and the LADO. The Allegations Officer should not: Take any action that may jeopardise future investigation or disciplinary procedures prior to contacting the LADO. Suspend or dismiss the accused member of staff without taking advice. If, following a detailed investigation, disciplinary action is to be taken, it will be conducted in accordance to the Trust Policy and Procedure. Author: Beverley Boyd Page 7 of 22

Following investigation it may be necessary to report misconduct of a member of staff to their professional body. Further information on the managing allegations can be found at www.swcpp.org.uk. 6.3. Missed Appointments In line with national requirements (Department of Health/Laming Reports), when any child does not attend a clinic appointment or the clinic appointment had been cancelled for no good reason the consultant or senior doctor in clinic will decide whether there may be a safeguarding/child protection concern in relation to the child. There are 3 categories of concern: Green - There are no known safeguarding concerns about the child and the medical condition is not thought to be serious enough to cause harm. Amber - would apply to a child where it is thought that the child s health might suffer if a consultation did not go ahead but the risks are not thought to be immediate. If a child was already known to be in care and the problem was not serious then it would also fall into the amber group. Red this is where there are known safeguarding concerns e.g. known to have a child protection plan; or if the child has a serious medical condition that has major consequences for health, if even one appointment was missed. A child might move from amber to red if repeated appointments were missed or cancelled e.g. diabetes. The recommended actions would be as follows: The clinician will tick the white did not attend (DNA) slip, which include boxes for green/amber/red and which will be attached to the front of the child s health records. The secretaries at the time of typing the letter will be in a position to check that the appropriate correspondence is generated. The DNA slip will also be attached to the notes when an appointment has been cancelled in the last week. Green (see algorithm appendix 4) a letter from the clinician to the GP with a copy to the parents (or vice versa), explaining that they were sorry the child was not seen in clinic stating that another appointment will be sent or it might be quite reasonable for the doctor to note that the child was not seen in the clinic and give the parents the option of contacting reception for a further appointment if either they or the GP thought this was necessary. A copy of the letter would be retained in the notes and used for audit purposes. A proforma letter can be used. Amber (see algorithm appendix 4) This applies to children in whom there is a definite need for them to be seen in outpatients, but in whom there are no obvious safeguarding issues - although repeated nonattendance may put that child into the red/serious safeguarding concern Author: Beverley Boyd Page 8 of 22

category. A letter from the clinician to the GP with a copy to the parents (or vice versa), explaining that they were sorry the child was not seen in clinic stating that another appointment will be sent. This will also be copied to the named safeguarding nurse but not Social Care unless already known to them. A proforma letter can be used. A copy of this letter will need to be kept in the notes to be used for audit purposes. Red (see algorithm appendix 4) - the following actions may be appropriate:- When there is an obvious safeguarding concern the social worker should be informed by telephone and this should be followed up in writing with a letter to Social Services, the GP, the parents and the named safeguarding nurse in the Trust of the child s residence. When there is a serious medical condition e.g. new referral for something regarded as very serious; this may involve a telephone call to the parents, GP or Health Visitor to attempt to arrange to see the child as soon as possible - but not Social Care although a repeated non-attendance may require contact with Social Care. The actions taken will also need to be recorded in a letter that goes to the child s GP, the child s parents and the Named Doctor. For children not brought for surgery or other procedures, the Clinician will need to make an appropriate judgement as to the action taken. 6.4. Supervised Access If social care request that contact between a child and their parent/s be supervised, social care must provide a suitably qualified member of staff to supervise the contact. 7. Training To ensure the Trust safeguards children, there is a requirement that all staff have safeguarding children training at a level commensurate with their role. The intercollegiate guidance Safeguarding Children and Young People: Roles and Competences for Health care staff (Royal Colleges 2014) describes these national requirements. The level of training required will be dependent on individual roles within the organisation, (Appendix 5). To confirm training required staff should check their individual training profile available on STAR, the Trust s mandatory training information system: https://reportserver-1/reportserver/pages/reportviewer.aspx?%2fedcentre%2fsearch MyTrainingRecord&rs:Command=Render Author: Beverley Boyd Page 9 of 22

If staff have any additional questions with regard the level of training required for their role, they should contact the Trusts Safeguarding Children Team on 01225 821538. All levels of safeguarding children training for all staff must be refreshed at a minimum of every three years. 8. Information sharing and confidentiality Personal information about children and families held by health professionals is subject to a duty of confidence and not normally disclosed without consent. In the case of safeguarding the welfare of children, the law allows disclosure of confidential information in ensuring the safety of the child. Staff can access further information at www.swcpp.org.uk. All professionals working with families MUST make it clear at the outset to those providing the information that confidentiality may not be maintained if withholding information will prejudice the welfare of the child. However, information disclosed will only be shared with key Child Protection Agencies. 9. Monitoring Compliance The Named Nurse / Named Doctor will maintain the evidence folder for compliance with the Care Quality Commission (CQC) essential standards of quality and safety, outcome 7. Compliance with the essential standards will be monitored through the Children s Safeguarding Committee. Where gaps in compliance are identified, any further work required will be incorporated into the work plan of the Children s Safeguarding Committee. The Named Nurse / Named Doctor will facilitate any audits required for assessing compliance with the CQC essential standards or where gaps in compliance have been identified. These audits will be incorporated into the Trust Annual Clinical Audit Programme. The Named Nurse / Named Doctor will provide an annual child protection report to the Trust Board, which details key actions that are taken to meet the requirements of safeguarding children. The Trust Children s Safeguarding Committee meets bi-monthly and will monitor and respond to compliance and implementation of national changes to the Safeguarding children agenda. Author: Beverley Boyd Page 10 of 22

10. Review This policy will be subject to a planned review every three years as part of the Trust s Policy Review Process. It is recognised however that there may be updates required in the interim arising from amendments or release of new regulations, Codes of Practice or statutory provisions or guidance from the Department of Health or professional bodies. These updates will be made as soon as practicable to reflect and inform the Trust s revised policy and practise. 11. References (NHS LA Requirement) Department of Health. (1989) Children Act. The Stationary office Department of Health (2000) The framework assessment. London: The Stationary office. Department of Health (2002) Safeguarding children in whom illness is induced or fabricated London. Stationary Office Department of Health (2003) Getting the right start The National Service Framework for children, young people and maternity services: Standard for Hospital services: London. The Stationary Office Department of Health (2003) What to do if you are worried a child is being abused: London. Department of Health Publications Department for children, schools and families (2010) Working together to safeguard children: A guide to interagency working to safeguard children. London: The Stationary office Laming (2003) The Victoria Climbie Inquiry: London. The Stationary office Royal College Paediatrics Child Health (2014) Safeguarding Children and Young People: Roles and Competencies for Health Care Staff. Author: Beverley Boyd Page 11 of 22

Appendix 1: Hospital Protocol ROYAL UNITED HOSPITAL CHILD PROTECTION PROTOCOL RUH staff member has concerns If any member of staff has a Safeguarding / Child Protection concern about an unborn baby or child they have a duty to share their concern with their line manager and Social Services. If you want to discuss your concern, you can: Contact the RUH Safeguarding Children Team on 01225 821538 and ask to speak to a named professional. Jenny Daly, Named Nurse can also be contacted by bleep 7005 or mobile phone 07557325586; or Contact on-call Paediatric Registrar - bleep 7205 (out of hours bleep 7202), who will liaise with on-call Paediatric Consultant. Paula Lockyer, Named Midwife can be contacted by bleep 7221 or mobile phone 07872696166 To make an urgent child protection referral, telephone the referral and access team in the area the unborn baby / child lives. Verbal referrals must be followed up in writing within 48 hours, by the professional who made the referral. For urgent child protection referrals for children who live in other parts of the UK that have accessed RUH services, contact BANES referral & access team to discuss case and seek advice on how to proceed. Author: Beverley Boyd Page 12 of 22

Referral & Access Teams Contact Information BANES Tel: 01225 396312/3 Out Of Hours Tel: 01454 615165 Fax: 01225 395416 Secure Email ChildCare.Duty@BATHNES.GCSX.GOV.UK Wiltshire Tel: 01380 826200 Out of Hours Tel :08456 070888 Fax: 01380 730022 Secure Email ReferralsandAssessment@wiltshire.gcsx.gov.uk Somerset Tel: 0845 345 9122 Out of Hours Tel: 01458 253241 Fax: 01823 321187 Secure Email SDInputters@somerset.gov.uk.cjsm.net South Gloucestershire Tel: 01454866000 Out of Hours Tel: 01454615165 Fax: 01454864380 Secure Email FirstPoint@southglos.gcsx.gov.uk Gloucestershire Tel: 01452 426565 Out of Hours Tel: 01452 614758 Fax: 01452 427342 Secure Email childrenshelpdeskgcsx@gloucestershire.gcsx.gov.uk Swindon Tel: 01793 466903 Out of Hours Tel: 01793 436699 Fax: 01793 463003 Secure Email FCP-GCSX@swindon.gcsx.gov.uk Bristol Tel: 0117 9036444 Out of Hours Tel: 01454 615 165 Fax: No Fax Secure Email first.response@bristol.gcsx.gov.uk Author: Beverley Boyd Page 13 of 22

Appendix 2: Named Nurse Notification NAMED NURSE CHILD PROTECTION NOTIFICATION FORM Please return form to Trust Child Protection Named Nurse when you have a patient undergoing child protection concerns / investigations Ward Name Address: DOB Hospital No Tel Number: Social Worker: Contact details Reason for admission/child protection issue/outcome if known Signature Date Please return form to Jenny Daly Named Nurse jenniferdaly@nhs.net Author: Beverley Boyd Page 14 of 22

Appendix 3: Emergency Department Child Protection Form Form to be completed RUH Emergency Department Child Protection Form To make a referral to Social Care for either a child or an adult when there are child protection concerns. To provide written notification when an urgent verbal referral has already been made. To share information regarding a Childs general welfare that has been raised during their attendance in the Emergency Department. (please indicate reason for completing form by ticking appropriate box above ) Attendance date at ED: Date form completed: Details of professionals completing form Name:. Job Title: Contact Tel No:... Concern related to a: Child Adult STICK PATIENT LABEL HERE Name:. Dob: Hosp Number:... Family contact telephone number Address:. (if known):.... Details of other children in family Full Name: (1)... DoB: (2) DoB: (3) DoB: Reason for attendance in ED:.......... Author: Beverley Boyd Page 15 of 22

What is the nature of the child protection concern: Substance Misuse Is this Child/YP or Parent/Carer Mental Health Is this Child/YP or Parent/Carer Homelessness Is this Child/YP or Parent/Carer Concern about parenting capacity Challenging/socially unacceptable behaviour Non Accidental Injury (NAI) Domestic Abuse Acrimonious relationship between Poor attachment/emotional wellbeing parents/carers Private fostering Sexually inappropriate behaviour Other.. Nature of concern and impact on children:.................. Patient outcome from ED: Home Admitted Other Have you informed the family that you are making this referral? YES / NO If no, please detail why:.. Note for Social Care Teams Should you need to contact the Emergency Department once this form is received please call one of the following. For urgent enquiries contact: Emergency Department Reception on 01225 824007 and ask to speak to the member of staff who completed the form or Nurse in Charge. For non-urgent enquiries contact: Emergency Department Child Protection Lead Nurses via email ruh-tr.edchildprotection@nhs.net who will respond to your enquiry. Author: Beverley Boyd Page 16 of 22

Appendix 4: DNA Algorithm Appointment offered GREEN No known safeguarding concerns / serious medical conditions identified Letter 1 sent to family Copy letter 1 to GP with request to check contact details No Are there any obvious safeguarding/ serious medical concerns? Maybe Yes AMBER Possible safeguarding concerns / health suffering Clinician will obtain further information to clarify risk e.g. contact GP, HV, social care depending on the nature of the concern. If a concern has been raised by referrer contact them directly and agree action Safeguarding concern Contact children s social care in accordance with South West Safeguarding Procedures http://www.swcpp.org. uk/index.htm RED Yes Medical concern Direct contact with family and maybe GP (or other Community Health Professional if known to be working with the child/family. Are there still safeguardin g Is there a significan t risk? Repeat appointment offered. Letter 2 and copy of new appointment to PCT Named Nurse Author: Beverley Boyd Page 17 of 22 No Maybe Yes Confirm concern to Children Social Care in writing attaching copy letter to parents. Copy letter 4 to GP and PCT Named Nurse No Send letter to family confirming situation Copy letter 3 to GP, HV and PCT Named Nurse

Appendix 5: Safeguarding Children Training Levels of Training and Staff Groups The intercollegiate guidance Safeguarding Children and Young People: Roles and Competences for Health care staff (Royal Colleges of Paediatrics & Child Health 2014) Level 1: All staff working in health care settings. Staff groups This includes, Board level Executives and non-executives, lay members, receptionists, administrative, caterers, domestics, transport, porters, community pharmacist counter staff and maintenance staff, including those non clinical staff working for independent contractors within the NHS such as GPs, optometrists, contact lens and dispensing opticians, dentists and pharmacists, as well as volunteers across health care settings and service provision. All staff working in healthcare settings (clinical and non-clinical) should be trained to this level. Level 2 All clinical staff who have any contact with children, young people and/or parents/carers. Staff groups This includes, administrators for looked after children and safeguarding teams, health care students, clinical laboratory staff, phlebotomists, pharmacists, ambulance staff, orthodontists, dentists, dental care professionals, audiologists, optometrists, contact lens and dispensing opticians, adult physicians, surgeons, anaesthetists, radiologists, nurses working in adult acute/community services (including practice nurses), allied health care practitioners and all other adult orientated secondary care health care professionals, including technicians. Competence comprises of: As outlined for Level 1. Uses professional and clinical knowledge, and understanding of what constitutes child maltreatment, to identify any signs of child abuse or neglect. Acts as an effective advocate for the child or young person. Recognises the potential impact of a parent s/carer s physical and mental health on the wellbeing of a child or young person. Clear about own and colleagues roles, responsibilities, and professional boundaries. Author: Beverley Boyd Page 18 of 22

Able to refer as appropriate to role, to social care if a safeguarding/child protection concern is identified. Documents safeguarding/child protection concerns in order to be able to inform the relevant staff and agencies as necessary, maintains appropriate record keeping, and differentiates between fact and opinion. Shares appropriate and relevant information with other teams. Acts in accordance with key statutory and non-statutory guidance and legislation including the UN Convention on the Rights of the Child and Human Rights Act. Level 3 RUH Level 3: All clinical staff working with children, young people and/or their parents/carers and who could potentially contribute to assessing, planning, intervening and evaluating the needs of a child or young person and parenting capacity where there are safeguarding/child protection concerns. Staff Groups This includes GP forensic physicians, forensic nurses, paramedics, urgent and unscheduled care staff, all mental health staff child psychologists, child psychotherapists, adult learning disability staff, learning disability nurses, specialist nurses for safeguarding, looked after children s nurses, health professionals working in substance misuse services, youth offending team staff, paediatric allied health professionals, sexual health staff, school nurses, health visitors, all children s nurses, midwives, obstetricians, all paediatricians, paediatric radiologists, paediatric surgeons, lead anaesthetists for safeguarding and child protection paediatric intensivists, paediatric orthodontists and dentists with a lead role in child protection. Author: Beverley Boyd Page 19 of 22

Document Control Information Ratification Assurance Statement Dear Helen Please review the following information to support the ratification of the below named document. Name of document: Child Protection (Ref 221) Beverley Boyd Name of author: Jennifer Daly Matron Paediatrics, Neonatology & Gynaecology Job Title: Named Nurse Safeguarding Children & YP We, the above named authors confirm that: The Policy presented for ratification meets all legislative, best practice and other guidance issued and known to us at the time of development of the Policy; We are not aware of any omissions to the Policy, and we will bring to the attention of the Executive Director any information which may affect the validity of the Policy presented as soon as this becomes known; The Policy meets the requirements as outlined in the document entitled Trust-wide Policy for the Development and Management of Policies (v4.0); The Policy meets the requirements of the NHSLA Risk Management Standards to achieve as a minimum level 2 compliance, where applicable; We have undertaken appropriate and thorough consultation on this Policy and we have documented the names of those individuals who responded as part of the consultation within the document. We have also fed back to responders to the consultation on the changes made to the Policy following consultation; We will send the Policy and signed ratification checklist to the Policy Coordinator for publication at the earliest opportunity following ratification; We will keep this Policy under review and ensure that it is reviewed prior to the review date. Signature of Author: Date: Name of Person Ratifying this policy: Job Title: Helen Blanchard Director of Nursing Signature: Date: To the person approving this policy: Please ensure this page has been completed correctly, then print, sign and post this page only to: The Policy Coordinator, IM&T Building. The whole policy must be sent electronically to: ruh-tr.policies@nhs.net Author: Beverley Boyd Page 20 of 22

Consultation Schedule Name and Title of Individual Date Consulted Peter Rudd, Named Consultant 12.01.11 Francesca Thompson, Director of Nursing, Executive 25.01.11 Lead Jim Grant, Deputy Divisional Manager 12.01.11 Julie Blackman, Clinical Skills 25.01.11 Rob Eliot, Lead for Quality Assurance 25.01.11 Sue Conway, Sister Emergency Department 25.01.11 Neil Boyland, Matron Critical Care and Adult 25.01.11 Safeguarding Lead Emma Langhorn, Sister Emergency Department 25.01.11 Jill Chart, Named Nurse BANES PCT 16.02.11 Fiona Finlay, Designated Doctor BANES PCT 16.02.11 Debbie Grant, Matron Neonatal unit 16.02.11 Alexandra Lucas, Head of Risk Management Rachel Slater, Divisional Manager, Speciality and 25.01.11 Allegations officer Tim Craft, Medical Director 16.02.11 Mr John Budd, Consultant Surgeon 09.03.11 Sue Smith, Human Resources 16.02.11 Heather Cooper, Theatres Manager 09.03.11 The following people have submitted responses to the consultation process: Name and Title of Individual Date Responded Name of Committee/s (if applicable) Date of Committee Children s Safeguarding Committee 17.02.11 Author: Beverley Boyd Page 21 of 22

Equality Impact: (A) Assessment Screening To be completed when submitted to the appropriate Executive Director for consideration and approval. Person responsible for the assessment: Name: Beverley Boyd Job Title: Clinical Manager, Paediatrics and Named Nurse Child Protection Does the document/guidance affect one group less or more favourably than another on the basis of: Yes/No Race Yes No Ethnic origins (including gypsies and travellers) Yes No Nationality Yes No Gender (including gender reassignment) Yes No Culture Yes No Religion or belief Yes No Sexual orientation Yes No Age Yes No Comments Disability (learning disabilities, physical disability, sensory impairment and mental health problems) Yes No Is there any evidence that some groups are affected differently? Yes No If you have identified potential discrimination, are there any valid exceptions, legal and/or justifiable? Yes No N/A Is the impact of the document/guidance likely to be negative? Yes No If so, can the impact be avoided? Yes No N/A What alternative is there to achieving the document/guidance without the impact? Yes No N/A Can we reduce the impact by taking different action? Yes No N/A If you answered NO to all the above questions, the assessment is now complete, and no further action is required. If you answered YES to any of the above please complete the Equality Impact: (B) Full Analysis Document name: Ref.: Issue date: Status: Author: Page 22 of 22