Safeguarding Adults & Mental Capacity Act (2005) Annual Report 2016/17 Author: Candy Gallinagh Designated Nurse for Safeguarding Adults Supported by: Soline Jerram, Director of Clinical Quality & Patient Safety Completed: March 2017
Contents 1. Executive Summary... 3 2. Domestic Violence and Abuse... 3 3. PREVENT... 4 4. Training... 4 5. Supervision... 5 6. Primary Care Support... 5 7. Adult Safeguarding Alerts and Enquiries... 6 8. The Brighton & Hove Safeguarding Adult Board (SAB)... 6 9. Pan Sussex... 7 10. Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLS)... 7 11. Wider Safeguarding Adults Initiatives... 8 12. Safeguarding Adult Review (SAR)... 8 13. Domestic Homicide Review (DHR)... 8 14. Mental Health Homicide Investigation (MHHI)... 9 15. Assurance and Accountability... 9 16. Discussion... 9 17. B&H CCG Priorities 2017/18... 10 18. Conclusion... 10 2
Safeguarding Adults & Mental Capacity Act (2005) Annual Report 1. Executive Summary As a statutory member of the Safeguarding Adults Board (SAB), the B&H CCG Director of Quality and Patient Safety and the Designated Nurse for Safeguarding Adults have worked closely with partners throughout the year to develop the work of the Board. The role of the Designated Nurse has been developed within B&H CCG and they have become a key member on the SAB sub groups. B&H CCG have worked closely with health care providers to continue to embed the changes of the Care Act 2014 and increase the knowledge and understanding of health teams to safeguard adults at risk of abuse and/or neglect. The Director for Clinical Quality and Patient Safety and the Designated Nurse are also members of the Safe in the City Partnership Board, the Prevent Board and on the relevant subgroups for the Violence Against Women and Girls (VAWG) strategy. As a CCG, we continue to take our statutory responsibilities seriously and have executive leadership for Safeguarding and the Mental Capacity Act supported by the designated nurse. In April 2016, 18 health professionals from CCGs and providers across Sussex attended the Health Best Interest Assessors (BIA) course. The course was commissioned through NHS England, following a proposal from the B&H Director for Clinical Quality & Patient Safety, to increase the capacity to support compliance with Deprivation of Liberty Safeguards (DoLS) and to prepare for the changes announced by the Law Commissions review in March 2017. The training included a year-long support programme which is bespoke for health. B&H CCG has worked closely with the local authority on how this resource can be utilised moving forward. The South East Region of the NHS has a new Safeguarding Lead in post that sits on central safeguarding groups and represents Surrey, Sussex and Kent. She intends to reinstate the network meetings held between NHSE and the Designated Professionals. This report is a summary of B&H CCG activity and achievements in the field of safeguarding adults and MCA (2005) over 2016/17. 2. Domestic Violence and Abuse The Designated Nurse for Safeguarding Adults has continued to work closely with primary care, providing information and advice regarding domestic violence and representing primary care at the Multi Agency Risk Assessment Conferences (MARAC). During 2016, the work with MARAC has been extended to include the Designated Nurse for Safeguarding Children and the meeting attendance is shared. Training delivered to primary care staff continues to include recognising signs of domestic and sexual violence, referral pathways and the support available. Health IDVA The CCG continues to commission the Health Independent Domestic Violence Advocate (HIDVA) who is based at the Royal Sussex County Hospital. The HIDVA supports staff, provides training and offers assessment and referral for patients within various departments in the hospital, including A&E, maternity and sexual health. 3
Referral to the HIDVA service has increased during the last year due to staff training, greater awareness and having the support/presence within the hospital. There has also been an increased prevalence of DVA across the city. Between April September 2016, the HIDVA received 98 referrals. The majority of the referrals were from A&E (52%). 66% of the referrals were previously unknown to specialist DVA services, which may indicate this was their first disclosure or the first time they were offered specialist support following disclosure. 22% of the referrals were identified as high risk of homicide or serious harm and were referred to MARAC. There has also been an increase in referrals for victims who are 65 or over. The HIDVA and Safeguarding Adults Team now share an office space within the hospital which has improved collaborative working. 3. PREVENT The PREVENT duty was implemented in July 2015 and identifies responsibilities for health and other partners. The increased unrest across the world and incidents of radicalisation and terrorist attacks has highlighted the importance of the Prevent agenda. The Designated Nurse for Safeguarding Adults is the Prevent lead for the CCG and an accredited Workshop to Raise Awareness of Prevent (WRAP) trainer. Brighton & Hove CCG are supported by the NHSE Regional Prevent Co-ordinators for London and the South. The Prevent duty identifies that all staff require training to the appropriate level for their role. Prevent returns are sent by providers directly to NHSE. Providers compliance with the Prevent Duty is monitored by the Designated Nurse within the quarterly exception reporting and bi annual safeguarding assurance tool. The Designated Nurse has provided WRAP training to primary care safeguarding leads as part of the level 3 safeguarding adults training. The Designated Nurse is a member of the Prevent Board and has worked closely with the Prevent Lead for the Local Authority in ensuring a multi-agency response. The Designated Nurse has been part of the strategic group planning the Home Office Pilot (Dovetail), which is underway in Brighton & Hove. The Channel Duty came into effect in April 2015 and the Local Authority has responsibility around co-ordinating and chairing the Channel Panel meetings; the Designated Nurses for Safeguarding Children and Adults share attendance on behalf of health. The Prevent Lead monitors attendance from health providers at the Channel Meeting to ensure the relevant parties are involved in the safeguarding of individuals. 4. Training All CCG staff are required to attend level 1 safeguarding adults training in combination with level 1 safeguarding children training. The training includes MCA & DoLS awareness and Prevent Basic Awareness and is delivered by the Designated Nurses for Children and Adults. In April 2016 NHS England developed a draft Safeguarding Adults intercollegiate document/competency framework. This draft document has been used to develop a training programme for level 3 training for the Quality & Patient Safety Team and the Continuing Health Care team in the CCG and for GP safeguarding leads in primary care. Current data, from March 2017, indicates that 77% of CCG staff are up to date with level 1 safeguarding adult training. Of the staff requiring level 3 training, 88% are up to date. In primary care, 70% of safeguarding practice leads have attended one of the level 3 safeguarding adults training sessions and a further session is planned for May 2017. The level 3 training includes the Care Act 2014, case studies, Workshop to Raise Awareness of 4
Prevent (WRAP), the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). The Designated Nurse works closely with the Named GP for Safeguarding Children and joint adult & child safeguarding level 3 update sessions have been delivered throughout 2016. The update sessions include topics such as information sharing, learning from Safeguarding Adult Reviews (SARs), Serious Case Reviews( SCRs) and domestic violence. The Designated Nurse for Safeguarding Adults and the Safeguarding Lead Nurse for the Multi Agency Safeguarding Hub (MASH) Children s Services delivered training to a group of GP trainees around domestic violence and abuse in primary care. A further bespoke session has been arranged for a practice in the city that has a high number of patients that are referred to MARAC. In March 2017 a safeguarding awareness audit was undertaken in the CCG. 50% of staff completed the survey and 90% of those staff know how to access Brighton and Hove CCG safeguarding policies. 82% are confident about when to share information in relation to safeguarding. B&H CCG has led on a Pan Sussex initiative and commissioned a Best Interest Assessor programme for providers and CCG staff. The intention of this initiative is to build a robust cohort of health practitioners with the skills to support their organisations to improve compliance with the DoLS legislation and to ensure resources are in place to meet the requirements of the Law Commission Review, March 2017. The training was delivered by Brighton University in April 2016 and was attended by 18 health practitioners. Throughout the year, these practitioners have been shadowing experienced BIA assessors and have met on a regular basis to plan how the role will develop and be utilised effectively in the coming year. http://www.lawcom.gov.uk/?s=dols 5. Supervision During 2016/17 the Designated Nurse has provided safeguarding supervision to the lead nurses for safeguarding at the Royal Sussex County and Princess Royal hospitals. Group safeguarding supervision has also been developed with the CHC team to allow practitioners to discuss and reflect on cases. Ad hoc supervision is offered to the CHC Team and the Quality and Patient Safety Team. 6. Primary Care Support In 2016 NHS England allocated extra resources for CCGs to support the adult safeguarding agenda. In B&H CCG it was decided this resource would extend the role of the safeguarding lead nurse to become a full time Designated Nurse. The Designated Professional is a clinical expert and acts as a vital source of advice and support and strategic leadership across the health sector including primary care. This role provides the voice of the GP at various safeguarding reviews, meetings and the board and can ensure primary care is linked into multiagency work and that communication pathways are in place. 5
7. Adult Safeguarding Alerts and Enquiries B&H CCG has continued to work closely with Brighton and Hove City Council (BHCC) the statutory lead for safeguarding, supporting the safeguarding team with clinical expertise for health enquiries. Safeguarding Enquiries The Health Investigation Officer role changed with the implementation of the Care Act and from 1 st April 2015, investigations became enquiries. This is the action taken or instigated by the local authority in response to a concern of a sufficient level that warrants the local authority to implement their duty to enquire responsibility under Section 42 of the Act. In this circumstance, the local authority will request that an agency or service provider responds to the concerns identified under the Care Act. This enquiry would be the responsibility of the organisation providing care or treatment closest to the individual, unless there are exceptional circumstances for them not to undertake the enquiry. There may be occasions where it is appropriate for the CCG Clinical Quality team to undertake an enquiry. B&H CCG have been working closely with the local authority to ensure information is shared around providers safeguarding or quality concerns. The CCG Quality Managers also offer advice and scrutiny where significant safeguarding concerns are raised requiring clinical oversight, e.g. medicines related, pressure damage, nutrition, end of life care, etc. A member of the team may attend a meeting facilitated by the local authority in relation to an individual case or wider concerns regarding an organisation. The team may also visit the home/unit concerned and review the records and, where appropriate, the CHC team will review individuals who receive funding. During the year the Designated Nurse and the Quality Manager have worked with the Adult Social Care (ASC) team to develop a pathway for informing the CCG of safeguarding enquiries involving providers commissioned directly by the CCG and those which may involve a health professional. These pathways are shared within the ASC teams and are due to be embedded in the Pan Sussex Policies and Procedures which will be published in July 2017. The Quality Team have been involved in various cases during the year; the majority of these have been in Care Homes with Nursing. Organisations such as NHS Trusts have their own enquiry systems in place and the Quality Team do not carry out reviews within these settings but they may be involved in strategy meetings and case conferences in their role as commissioners of these services. The Quality Team keep a database of enquiries so themes and patterns can be identified and we can ensure cases are appropriately followed up. The team are occasionally contacted in cases where Safeguarding concerns have been raised in relation to GPs. These cases are passed to NHS England as they have responsibility for ensuring engagement of primary care in safeguarding enquiries. The CCG keeps a log of quality/safeguarding concerns regarding GP practices to maintain an oversight of any issues. 8. The Brighton & Hove Safeguarding Adult Board (SAB) The Care Act (2014) required every local authority to set up a Safeguarding Adult Board with core membership from the local authority, the police and CCG. The Director of Quality & Patient Safety and the Designated Nurse are Board members. The Board continues to have an independent chair, Graham Bartlett, who also chairs the Local Safeguarding Children s Board (LSCB). The CCG is a member for all the sub groups to the Board, including Quality Assurance, MCA DoLS (chaired by the CCG), Learning & Development, SAR sub group, Pan Sussex Policies and Procedures, and Participation & Evaluation (will be attended by the CCG Head of Engagement). 6
During the last year the Designated Nurse was part of a task and finish group, reviewing the deaths of 18 homeless people during 2015 in Brighton & Hove, and the planning process around how to take the learning forward. The Quality Assurance Sub Group is due to undertake an audit of current cases of homeless individuals with complex physical/mental health needs. The Designated Nurse has worked with mental health and homelessness commissioners and clinical leads to ensure this work is fed back and communicated across the various work streams. 9. Pan Sussex The CCG is represented on the Pan Sussex Domestic and Sexual Abuse Executive Team and will become a member of the Modern Slavery Executive Group, currently in development. The Designated Nurses across Sussex meet regularly and a collaborative piece of work was undertaken to update the safeguarding assurance and exception reporting tools. Meeting Held with Independent Health Providers During the last twelve months safeguarding leads from independent health providers have been invited to quarterly safeguarding meetings with the Designated Nurses and Doctor. BPAS, Pavilions, Spire, Here (formerly BICS), Nuffield and Elysium (formerly The Priory) have attended throughout the year; IC24 have not attended this meeting. The main aim of the meeting is to ensure there is a safeguarding communication pathway between the CCG, LSCB and SAB and independent providers. Following feedback from the safeguarding assurance tool it has been agreed that the session will incorporate safeguarding supervision to allow practitioners to discuss cases. 7 10. Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (DoLS) CCG Statutory Responsibilities The CCG retains responsibilities as commissioners of healthcare for providing assurances that the MCA (2005) and supplementary DoLS legislation is applied by the services it commissions and that staff are knowledgeable in its application. We have been working with BHCC MCA Team and providers to ensure the CCG has access to information (Hospitals, Hospice NHS and Private) in the locality around the number and outcome of applications for DoLS assessment and use of the IMCA service. BSUH provide the CCG with the number of DoLS applications each quarter. Further work regarding providers reporting continues to be developed. Over the last year, the Director for Quality and Patient Safety and the Designated Nurse have worked closely with the CHC team to develop knowledge and understanding of the application to the Court of Protection around DoLS in the community. This will continue to be developed with local authority MCA leads when the law commissions bill is finalised and the expectations going forward are established. CCG Actions to Monitor and Support Providers with the Application of the MCA (2005) and DoLS Legislation The MCA DoLS training commenced in 2014 and has continued over the last year with funding support from NHSE. Working with partners the Sussex wide training program is accessible to acute, community, primary care, local authority and independent providers. This
initiative is ending at the end of March 2017. A total of 720 people have attended this training over the last year. 11. Wider Safeguarding Adults Initiatives The designated nurse works closely with the strategic commissioner for the Violence Against Women and Girls agenda and attends the sub groups of the Safe in the City Partnership Board. This includes operational domestic and sexual violence groups and the harmful practices group which is co-chaired by the Designated Nurse. Other joint working initiatives this year have included Multi Agency Risk Assessment Conference audits and a sex workers task and finish group. 12. Safeguarding Adult Review (SAR) The Care Act 2014 places a statutory duty on Safeguarding Adults Boards to undertake Safeguarding Adult Reviews (SAR). https://www.gov.uk/government/publications/care-act-statutory-guidance/care-and-supportstatutory-guidance The purpose of having a Safeguarding Adult Review is not to reinvestigate or to apportion blame, it is: To establish whether there are any lessons to be learnt from the circumstances of the case and around the way in which local professionals and agencies work together to safeguard adults To review the effectiveness of procedures To inform and improve local inter-agency practice To improve practice by acting on learning To highlight good practice The SAB has carried out one SAR over the last year; the final report will be published in April 2017. The case reviewed involved a homeless person who had complex physical and mental health issues and self-neglect. They had a diagnosis of personality disorder and was difficult and reluctant to engage with services. One of the issues identified was also around them moving in and out of the city which meant looking at the communication between services across areas. The Designated Nurse supported the GP in the review and presented the relevant chronology and health records to the SAR sub group. 13. Domestic Homicide Review (DHR) The Safe in the City Partnership has a statutory duty to conduct domestic homicide reviews, where a death of a person has, or appears to have, resulted from abuse or neglect by a former or current intimate partner or a member of the same household. An Authority may also decide to use a DHR to review near misses where there may be relevant learning. The Statutory Guidance requires that the membership of the DHR panel includes identified statutory agencies which include the CCG. Brighton and Hove CCG Director for Clinical Quality is the named representative with the support of the Designated Nurse. A DHR has recently just begun and the Designated Nurse has completed the Individual Management Review (IMR) on behalf of the GP for the alleged perpetrator. Information from the review will be presented in the 2017/18 Annual Report. 8
14. Mental Health Homicide Investigation (MHHI) The publication of guidance on the single operating model for investigating mental health homicides by NHS England was incorporated into the Serious Incident and Learning Framework revised and published March 2015; NHSE lead on all MHHI and there is currently one MHHI being undertaken within Brighton & Hove. http://www.england.nhs.uk/wp-content/uploads/2015/04/serious-incidnt-framwrk-upd.pdf 15. Assurance and Accountability During 2016, the Safeguarding Assurance Tool was reviewed and updated by the Designated Nurses and was included in all provider contracts. Following the completion of the tool by providers in 2015, site visits were carried out by the Designated Nurses and the Quality and Patient Safety Team to follow up on actions from the assurance tool. Site visits have taken place with the Nuffield, Spire, BPAS, Pavilions and HERE; a visit to Elysium is planned for May 2017. Feedback on the visits was given to the providers with requests for any outstanding information. Overall, the majority of providers gave a good level of assurance. However, following a site visit to Pavilions substance misuse service, the Designated Nurses met with the Lead Commissioner for Substance Misuse (Public Health) to feedback some of the concerns regarding safeguarding processes and further assurance has been requested. The assurance tool will be sent out for completion by providers in September 2017. BHCCG has a bi monthly Safeguarding Committee which is chaired by the Lead Nurse, Director of Clinical Quality & Patient Safety. This is a multi-agency and multi professionals meeting that reports into the BHCCG Quality Assurance Committee (QAC). Primary Care In 2015 we invited all practices to complete a specially adapted self-assessment tool to support them with providing evidence around statutory requirements. We had a low response rate to the tool so, over the past year, we have continued to work with the Quality Manager for primary care and the CCG practice manager leads to look at how we can increase understanding and assurance in the future. From April 2017, the CCG will be cocommissioning primary care and will be working with practices to develop assurance tools and site visits to allow safeguarding assurance to be gained. Communication between GPs and the Designated Nurse has continued to develop over the past year and shared knowledge and understanding of working with vulnerable adults appears to be increasing. 16. Discussion The continued implementation of the Care Act (2014) has further increased the demand and statutory requirements for Safeguarding Adults. The B&H CCG has worked closely with the local authority to ensure processes of monitoring and offering support and advice to providers has met with the changes in role within the Care Act (2014). The quality team continues to work closely with colleagues across CCGs, local authorities and NHSE. The population of frail and vulnerable people, and those with dementia and cognitive impairment, continue to increase both in hospital and in the community. Domestic Violence incidents, the refugee population and risk of radicalisation and exploitation have continued to increase over the past year; this brings increased safeguarding risks and issues. 9
The CQC placed BSUH in special measures during 2016 although safeguarding was not deemed to be an area of concern. This will continue to be monitored closely and a further CQC inspection is due to take place in April 2017. CQC inspections are monitored by the Quality and Patient Safety Team and the local authority. Over the past year GP practices across Brighton & Hove have undergone CQC inspections. The themes identified that needed addressing around safeguarding were recruitment checks/dbs, training of staff and out of date policies. The Designated Nurses have been working in partnership with the Quality Team to address these safeguarding concerns; the follow-up CQC inspection ratings have shown improvement. Compliance with MCA/DoLS and the new Law Commission ruling have been a large focus over the past year and will continue to be a high priority for 2017/18. 17. B&H CCG Priorities 2017/18 A great deal has been achieved and B&H CCG has continued to develop its expertise and processes to support its responsibilities in the area of patient safety and safeguarding. Priorities for 2017/18 include: Continuing to work closely with providers in gaining assurance in regard to safeguarding and the statutory requirements. Completion by providers of the safeguarding assurance tool in September 2017. Work with primary care to develop compliance with Safeguarding Adults training and practices. To develop assurance tools and site visits to improve assurance as B&H CCG moves into co-commissioning and to develop our role as commissioners of primary care. To establish the role of a clinical lead in the CCG for safeguarding adults to the support the work with Primary Care. To continue to develop the role of the health BIA, to support the local authority in DoLS assessments. For the CCG to understand the role of the NHS in DoLS application following the Law Commissions ruling and establish training and pathways as appropriate. Further improve data captured and shared of NHS commissioned services in the application of DoLS. To continue to work with partners on implementing the Care Act into practice and integrating the updates. To continue to implement the Prevent Duty and work with providers on compliance with training and referral. To further develop health involvement with the Channel Panel. Continue to work closely with the local authority in regard to safeguarding enquiries and ensure pathways are communicated effectively 18. Conclusion This is a summary of the activity B&H CCG has been involved in or led within the area of safeguarding adults over 2016/17. There has been a large amount of work undertaken and the team continues to develop its skill mix to meet the demands. The safeguarding team works in collaboration with a large number of statutory and voluntary providers to ensure services are safe and proactive to the most vulnerable populations. 10