Quality Assessment Framework 2 (QAF2) Core Service Objectives

Quality Assessment Framework 2 (QAF2) Core Service Objectives NIHE Supporting People

Contents C1.1 Assessment and Support Planning...3 C1.2 Security, Health and Safety..11 C1.3 Safeguarding and Protection from Abuse..15 C1.4 Fair Access, Diversity and Inclusion...23 C1.5 Client Involvement and Empowerment..30 Service providers are strongly urged to read the guidance Using the Quality Assessment Framework when assessing services against these standards. PLEASE NOTE: Evidence examples for Level B and A services are included to give an indication of what we would expect of services delivered to such standards. The indicative evidence for levels A and B are not intended to act as a checklist or to prescribe the services that organisations would be providing if they were judged by reviewing officers to have an excellent or a good service. When assessing compliance with level A and B standards therefore, it is acceptable to cite alternatives to the evidence examples where these genuinely demonstrate that the standards are being met by other means. While meeting individual standards cannot guarantee the achievement of specific outcomes with clients, in general they will support the service to better meet outcomes in the domains indicated. Page 2 of 63

C1.1 Assessment and Support Planning All clients receive an assessment of their support needs and any associated risks. All clients have an up-to-date support and risk management plan. Assessment and support planning procedures place clients views at the centre, are managed by skilled staff and involve other professional and/or carers as appropriate. Standard Performance Level Essential requirements (C) or Indicative evidence (A / B) Evidence This standard supports the service to meet outcomes in the following outcome domains: Achieve economic well-being, Enjoy & achieve, Be healthy, Stay safe and Make a positive contribution. Basic minimum requirements for an adequate service (Performance Level C) The needs and risk assessment policy and procedure is written down and reviewed in response to changing legislative or contractual requirements and at least every three years. There is a needs and risk assessment policy, which is reviewed annually. (2, 3, 4, 61) C1.1.1 The needs of applicants / clients and any inherent risks are assessed on a consistent and comprehensive basis prior to a service being offered, or very shortly afterwards as appropriate to the needs of the client group. Level C The procedures state how clients will be involved. Policies (1, 2, 3, 4, 54, 76) and Residents Handbook (10 (pages 9-11), 19) refer to clients involvement. Applicants and residents are involved in and consulted as part of the process of risk and needs assessments. Their individual requirements, preferences and choices are incorporated. A series of assessments have been developed which address the needs and risks of the particular client group. (5, 7, 14, 89, 90) Staff understand and follow the procedures. Staff have received training in needs and risk assessment. (6) They understand and follow procedures. The procedures are monitored through supervision, appraisal, monthly monitoring and annual quality assurance and service improvement Page 3 of 63

planning. (15, 19, 22, 24, 75) There is a needs and risk assessment tool appropriate to the client group. The needs and risk assessment procedures are covered in staff induction and training programmes. Risk assessment procedures address: Risk to self Risk to others (including staff and the wider community) Risks from others (including staff and the wider community). Needs and risk assessments take into account the views of other services as appropriate. Copies of all assessments are securely stored and accessible to relevant staff and clients. A comprehensive needs and risk assessment tool has been developed. (5, 7, 8, 14, 89, 90) A variety of in-house induction and training cover needs and risk assessment procedures. (6, 28) Risk assessment procedures cover risks to self, risks to others and risks from others and address management of risks, action required and by whom and benefits of risk taking. (3, 5, 8, 14, 89) A wide range of views is incorporated in the application and admission pack. Views are sought from the referral agent, other services, professionals and carers as appropriate. (8) CCC views risk proactively working in partnership with applicants and professionals. Applicants / representatives input in application form is solicited on the form. (9) Where individuals avail of other services the views and assessments of those are incorporated into needs and risk assessments. (23) The Admissions Officer ensures that all assessments are securely stored and accessible and that records are transferred to personal files as appropriate. (20, 56, 69) Page 4 of 63

Evidence examples for Level B and A services are included below to give an indication of what we would expect of services delivered to such standards Level B The service works constructively with risk and does not use risk assessment to exclude applicants inappropriately. Staff harness individual clients insight into the assessment of needs and risks. Specialist expertise is sought, where required, when conducting needs / risk assessments. CCC is committed to managing risk constructively, through weighing up the potential benefits and harms of exercising one choice of action over another, identifying the potential risks involved, and developing plans and actions that reflect the positive potential and stated priorities of the client. Positive risk taking is encouraged and the individual client s insight into the assessment of needs and risks is harnessed. (14, 91, 92) Risk identification, assessment and management is a dynamic process and through this CCC is committed to promoting the independence, choice and inclusion of the individual and is recognised to widen and enrich life experience, develop skills and learning and lessen vulnerability. Risk assessment is integrated into all care and support plans. (14, 7, 5, 90) CCC facilitates a collaborative approach to risk assessment and management planning, involving the individual, their family and HSC Trust representative and seeking specialist expertise as appropriate. Risk is reviewed at a minimum annually and according to change in circumstance and after any incident or near miss. (5, 92) Human rights will always be considered in risk management. Where the risks have an increased potential for harmful outcomes occasionally more restrictive measures will be considered. (91) Any restrictive practice is based on a multi-disciplinary assessment Page 5 of 63

process which addresses the principles of necessity, proportionality and least restriction to ensure the safety and welfare of the client. (90) CCC is committed to ensuring that the use of restrictive intervention is continuously monitored and minimised. Level A The needs and risk assessment policy and procedures encourage appropriate risk taking and discourage risk avoidance as the key feature of support delivery. Needs and risk assessments balance promotion of independence with effective risk management. The service can demonstrate that changes have been made to improve service delivery as a result of policy and procedure review. Policy and procedure review can show the impact of client and stakeholder involvement. Page 6 of 63

Standard Performance Level Essential requirements (C) or Indicative evidence (A / B) Evidence This standard supports the service to meet outcomes in the following outcome domains: Achieve economic well-being, Enjoy & achieve, Be healthy, Stay safe and Make a positive contribution. Basic minimum requirements for an adequate service (Performance Level C) C1.1.2 All clients have individual outcomes-focussed support and risk management plans that address the needs and risks identified by the assessment process. Level C Support and risk management plans identify control measures to eliminate, minimise or respond to identified risks. Clear links can be seen between assessments of clients needs and associated risks, and their support / risk management plans. Support plans incorporate individual outcomes which have been negotiated with clients and, if appropriate, carers, relatives or other advocates. Support and risk management plans are comprehensive, identify risk factors, indicators, control measures and barriers and include appropriate support activities, benefits of risk taking and outcomes. (3, 4, 7, 5, 14, 89, 92) Clear links are evident between assessments of clients needs and associated risks, and their support / risk management plans. (3, 4, 7, 5, 14, 89, 92) Residents, carers and relatives participate in support planning via the Person-Centred Planning meeting (14) and via informal feedback. (4, 57) The annual PCP meeting (14) addresses progress made in achieving personal goals and objectives and identifies further goals in the individual s personal plan. In short-term accommodation based services, move on and resettlement needs are addressed from the start of service delivery. N/A. Support plans incorporate SMART There is a continual process of encouraging and supporting residents to attain their Page 7 of 63

objectives that are clearly understood by clients, as milestones towards achieving outcomes. goals and achieve outcomes e.g. through applying SMART objectives, offering personal support and accessing appropriate resources. The annual PCP meeting (14) addresses progress made in achieving personal goals and objectives and identifies SMART objectives in the individual s Support Plan. This process includes addressing communication needs e.g. using Makaton and pictorial methods. (14, 23, 88) Copies of all support / risk management plans are securely stored and accessible to relevant staff and clients. The service is aware of, and seeks to take into account, other care and support services provided. Copies are filed securely and are accessible to relevant staff and clients. (10 (page 12), 20, 56) As a holistic service is provided (including domiciliary and day care) support, care and risk management plans are inclusive and comprehensive. Account is also taken of additional services accessed in the locality and/or bought in according to individual choices and needs i.e. individual tutorials, special interest membership groups, RDA, SW College and external day care. (14, 23) Other individuals and services are involved in supporting clients and specialist expertise is sought and incorporated. Learning disability specialist and mainstream services are involved e.g. Psychiatry, Physiotherapy, Speech and Language, OT/Sensory OT, Dietetics. (4, 14, 23) Evidence examples for Level B and A services are included below to give an indication of what we would expect of services delivered to such standards Page 8 of 63

Level B Level A Support planning takes account of the wider needs of the client (beyond those being met directly in the service) which impact upon their need for support. The service proactively seeks to engage other agencies in supporting clients. Specialist expertise is sought, where required, when drawing up support / risk management plans. Support and risk management plans complement any statutory care plan or support plans provided by other agencies. Support and risk management plans indicate that clients are encouraged to take reasonable risks in developing their independence. Mechanisms are in place between the service and external agencies to facilitate and enable joint working. Client outcomes are used to inform service development and strategic planning. CCC proactively seeks to engage other agencies, professionals and volunteers in supporting clients to maximise their potential, widen and enrich life experience and develop social networks. (23, 14,96) Support and risk management plans indicate that clients are encouraged to take reasonable risks in developing their independence. (5, 14, 92) Mechanisms are in place between the service and external agencies to facilitate and enable joint working. (14, 23, 93) Specialist assessments i.e. psychology/psychiatric reports inform support and risk management plans. (94, 95) Page 9 of 63

Standard Performance Level Essential requirements (C) or Indicative evidence (A / B) Evidence This standard supports the service to meet outcomes in the following outcome domains: Stay safe and Make a positive contribution. Basic minimum requirements for an adequate service (Performance Level C) The frequency of individual reviews reflects the needs and risks identified by the assessment process. Staff are proactive in identifying and reviewing changing need and risk. This is highlighted in Supervision, Team Meetings, Home and Work Life and Home Group Meetings. (11, 21, 22) C1.1.3 Needs / risk assessments and support / risk management plans are reviewed regularly on a consistent and systematic basis. Level C Clients files show that all clients needs have been reviewed with appropriate frequency and at least annually (and more frequently following an incident or significant change in circumstances). Individual support and risk management plans are revised in response to reviews to reflect changing outcomes and objectives. Needs/risk assessments and support/risk management plans are reviewed at a minimum annually and according to change in circumstance and after any incident or near miss. (5, 92) Other professionals are involved on a multidisciplinary and multi-agency basis as appropriate. (4, 5, 7, 14, 89) According to the identified needs and risks individuals are reviewed weekly (11) and/or monthly (11, 21, 22, 23), action plans documented and implemented and risk management and support plans revised. (4, 5, 7, 14, 89) Support and risk management plans record intended review dates. Action plans, PCP notes, support and risk management plans record intended review dates. (5, 11, 14, 21, 22) Page 10 of 63

Needs / risk assessments and support / risk management plans are quality monitored internally. Monthly monitoring provides quality monitoring through interviews with service users, relatives/representatives, staff and HSC Trust professionals and a review of documentation. This is then communicated to the Management Council and action points are implemented. (75, 54, 58) A comprehensive Quality Assurance and Service Improvement Plan is compiled annually. (54, 16, 17, 19, 97, 98, 36) Reviews take a wide ranging approach involving all relevant parties and are incorporated in service development and strategic planning. (13, 16, 17, 36) Evidence examples for Level B and A services are included below to give an indication of what we would expect of services delivered to such standards Level B Level A Procedures state that reviews can be initiated at any time by a client and clients confirm this is the case. This right is explained within the service description, clients handbook, etc. Staff are proactive in identifying and reviewing changing need and risk. Reviews are co-ordinated to complement the reviews of any statutory care plan or support plans provided by other agencies. Policies and procedures, the Residents Handbook and Statement of Purpose, state and explain that reviews can be initiated at any time by a client or their representative. (10 (page 12), 4, 26) Staff are proactive in identifying and reviewing changing need and risk. This is highlighted in Supervision, Team Meetings, Home and Work Life and Home Group Meetings. (11, 21, 22) CCC takes the lead role in coordinating and facilitating annual PCP meetings, inviting all relevant statutory and voluntary agencies and professionals. The individual is involved in the planning of the meeting, inviting persons of their choice i.e. relatives, friends and staff. (14) Page 11 of 63

Standard Performance Level The service takes a case conference approach that includes engaging other services in reviews. Reviews of needs and risks (client outcomes) are used to inform service development and strategic planning. Essential requirements (C) or Indicative evidence (A / B) Evidence This standard supports the service to meet outcomes in the following outcome domains: Achieve economic well-being, Enjoy & achieve, Be healthy, Stay safe and Make a positive contribution. C1.1.4 Needs and risk assessment, support planning and reviews involve clients and take full account of their views, preferences and aspirations. Basic minimum requirements for an adequate service (Performance Level C) Level C There is evidence of clients views being incorporated. Where clients disagree with assessments or reviews their views and reasoning are recorded. Residents views are sought and incorporated in assessment, planning and review by means of personal questionnaires (16), house meetings (12), and PCP meetings (14) as well as informal conversation and feedback. Relatives confirm that clients views and wishes are incorporated. (17) The assessment and planning process aims to harness the insight of the individual client and achieve mutual understanding and consensus but where clients disagree their views are respected and a record is kept. (5, 7, 14, 89) Clients have access to their file and are provided with a copy of assessments and reviews if they wish. The service complies with the Data Protection Act. Residents have access to their file on request and may ask for a copy. (10 (page 12, 20), 69) In line with good practice the service subscribes to the eight principles of the Data Protection Act 1998. (20) Page 12 of 63

Clients confirm that their views have been listened to and taken into account. A high priority is given to ascertaining and taking into account residents views (12, 16) and they can confirm this in conversation. Relatives confirm same. (17) Clients confirm that information is made available to them to meet their cultural, religious and/or lifestyle needs. Clients confirm that they are supported to meet their cultural needs and are able to observe their religious and cultural customs. A holistic, balanced and person-centred approach underpins the service which promotes equality and diversity. (1, 57, 59) Residents cultural and life style needs are widely addressed. (10 pages 17-18) Through making information available to them, exploring with them their cultural, religious and/or lifestyle needs and supporting them to participate in and observe their own individual customs. (12, 14, 16, 23) Evidence examples for Level B and A services are included below to give an indication of what we would expect of services delivered to such standards Level B Needs and risk assessments, support plans and reviews seek to involve other professionals, carers, family and/or friends as the client wishes. The support plan is person centred. In 2013 a new support plan format was developed and implemented for all service users. Due to the holistic nature of the service the support plan incorporates supported living, personal care and day care. The support plan is person-centred, and written in the I form using user friendly language. (14). There is a coordinated, joined up approach to needs and risk assessing and support planning and reviewing. This involves staff supporting the individual in the various facets of life within CCC and externally as well as family and/or friends and other professionals as relevant. (5, 7, 14, 89, 94, 91, 85, 90) Page 13 of 63

Clients wishes are respected with regard to involvement of other professionals, family and/or friends, and this is recorded as relevant. (14) The reviewing and planning process aims to harness the insight of the individual client and achieve mutual understanding and consensus but where clients disagree their views are respected and a record is kept. (5, 7, 14, 89) Clients are supported to access a range of day opportunity services provided by CCC, and explore and engage in a variety of activities i.e. farming, gardening, cooking and baking, woodwork, hand crafts and weaving which are tailored to meet their individual needs. (14, 23) An expression of interest and preference including the wish for change is encouraged. (16, 23, 14, 11) Clients are provided with suitable information on the range of activities and services available in the local community and how to access them and are given the support to do so. Examples include SW College, RDA, leisure and fitness facilities, external day care and special interest groups. (14, 23, 99) Level A Needs and risk assessment and support planning procedures balance respect for clients views, preferences and aspirations with effective risk management. Staff are able to describe how they deal with disagreements and how they balance respect for clients wishes with effective risk management. Clients confirm how they have been supported to access a range of services to Page 14 of 63

meet their diverse needs both those provided by the organisation and those available through other providers. Standard Performance Level Essential requirements (C) or Indicative evidence (A / B) Evidence This standard supports the service to meet outcomes in the following outcome domains: Achieve economic well-being, Enjoy & achieve, Be healthy, Stay safe and Make a positive contribution. Basic minimum requirements for an adequate service (Performance Level C) Clients confirm that staff are sensitive to their particular needs and respect their right to choice and control. Staff and clients are fully aware of the service values of choice, control and person-centred support. Clients participate in needs and risk assessing and support and care planning and confirm that they are satisfied with the outcomes. (4, 16, 17, 57) C1.1.5 Staff carrying out needs and risk assessments and negotiating support and risk management plans are competent to do so. Level C Staff are able to describe outcomes the service can help clients to achieve, and how they would support them to do so. Staff directly supporting clients have been trained in needs and risk assessment and support planning. Team Meetings (21) and Supervision (22) provide a forum to discuss and review clients goals and aspirations and implementation of action plans. Staff have received training (6) and team meetings (21), supervision (22) and appraisal (24) reinforce these values and principles. Over the past years a wide range of training has been undertaken. (6) Staff are able to describe the assessment and support planning processes and the rationale behind the key elements. Staff are experienced in working with those needs most commonly encountered amongst clients. A pro-active, multi-professional approach to needs assessment, care/support planning and risk management and networking is a key value and striving of the service and a wide variety of awareness raising and training opportunities is pursued. (6) Page 15 of 63

Staff are knowledgeable about the range of services and support provided by their own organisation that may meet the needs of clients. Staff are appropriately inducted and supervised. Staff understand and are sensitive to the diverse needs of clients. As we familiarise new staff with the totality of our holistic service we provide them with a range of materials e.g. Statement of Purpose for Domiciliary Care in Supported Living (26) and Day Care (100), PR information. (27) Induction and supervision of staff take place as required. (22, 28) Staff awareness and understanding of the diverse needs of residents is promoted and is fundamental to the organisation s value base. (59) Evidence examples for Level B and A services are included below to give an indication of what we would expect of services delivered to such standards Level B Level A Staff are aware of relevant individuals in key agencies and can give examples of regular information sharing. Staff are knowledgeable about and can facilitate access to support and services provided by other organisations that may meet the needs of clients. There is a variety of staff training targeted to meet the needs of the clients being supported. Staff are able to explain the concept of appropriate risk taking and how this impacts on their work. Staff are committed to continuing professional development and a variety of training, networking and practice development opportunities is available to and engaged in by staff. Recent examples include: Makaton, Learning Disability and Dementia, RNIB Visual Awareness, Dr Volbehr Conference, Person Centred Planning, Active Support and Mental Health Seminar. (6, 22, 24) Staff liaise with other organisations and agencies to facilitate access to services and contact with family/friends and local community in meeting the needs of clients. (23) Page 16 of 63

Staff are committed to continuing professional development. C1.2 Security, Health and Safety The security, health and safety of all individual clients, staff and the wider community are protected. Standard Performance Level Essential requirements (C) or Indicative evidence (A / B) Evidence This standard supports the service to meet outcomes in the following outcome domains: Be healthy, Stay safe and Make a positive contribution. C1.2.1 There is a health and safety policy which has been reviewed in the last three years and is in accordance with current legislation. (Note: where they are not the same body, some of the legislative requirements may be the responsibility of the landlord rather than the support provider.) Basic minimum requirements for an adequate service (Performance Level C) Level C The health and safety procedures are covered in staff induction. Staff are able to describe the health and safety procedures and the impact on their work. Staff confirm they are consulted on the health and safety policy and procedures. Within the first week staff are made aware of key health and safety issues and relevant procedures to follow. (28, 31, 70) A handbook is issued which extensively addresses health and safety issues. (49, 50) Further in-depth training is given on fire safety, infection control, COSHH and manual handling. (6) Staff are encouraged to be proactive and assume responsibility for health and safety and feed concerns back to senior coworkers. (12, 22) As part of the review of policy and procedures staff are routinely consulted on health and safety. Following any adverse incident or near miss staff input is sought and incorporated in policy and procedure review and development. (21, 6, 22, 29) Page 17 of 63

Clients confirm they are aware of the health and safety procedures. The Residents Handbook addresses health and safety issues. (10 pages 19, 24,) Over the past years an intensive effort has been made to involve residents in health and safety procedures e.g. agenda item in house (12) and forum meeting (13), tenants involvement in weekly health and safety checks. (30) Evidence examples for Level B and A services are included below to give an indication of what we would expect of services delivered to such standards Level B Clients confirm they have been consulted about health and safety policies and procedures and that their views are taken into account. There is a range of information provided to clients about health and safety within the service. Annual general health and safety training, food hygiene and manual handling training are offered to all clients and clients are encouraged to participate. The training is tailored to the individuals environment and their needs, delivered in a way commensurate to their level of understanding, using easy read, pictorial images and appropriate examples in the hand-outs. (71, 63) Personal Questionnaires seek clients views on health and safety within the service. (16) Clients representatives are also encouraged to comment on aspects of health and safety as part of completing the Relatives Questionnaire. (17) Health and safety is also addressed in the house and forum meetings and a range of easy pictorial information to highlight this has been developed. (12, 13, 77) Visual aids are used as prompts to remind individuals of hand and personal hygiene requirements and procedures as appropriate. (77) Page 18 of 63

Level A The service can demonstrate that changes have been made as a result of policy and procedure review. Policy and procedure review can show the impact of client involvement. In very short-term housing it may be more desirable or practical to involve an alternative person or organisation in lieu of clients (e.g. a principal referral agency). The intention is to bring a perspective that is external to that of staff involved in day-today service delivery. Page 19 of 63

Standard Performance Level Essential requirements (C) or Indicative evidence (A / B) Evidence This standard supports the service to meet outcomes in the following outcome domains: Be healthy, Stay safe and Make a positive contribution (at levels A and B only) Basic minimum requirements for an adequate service (Performance Level C) A formal procedure exists for conducting risk assessments. Health and safety is a regular agenda item in all meetings e.g. House Meetings (12), Forum (13), Homegroup (11), Team Meetings. (21) Formats exist for risk assessing the houses and fire risks which are updated annually in consultation with home coordinators and staff. (31, 32) C1.2.2 The service has a coordinated approach to assessing and managing security, health and safety risks that potentially affect all clients, staff and the wider community. Level C The procedure is documented and covers all potential risks (other than risks to individual clients) and appropriate information sharing mechanisms. The general Health and Safety Policy (29) highlights procedures and the importance of appropriate information sharing. The service places a high priority on security, health and safety and proactively addresses potential risks and implements a risk management strategy. Information sharing mechanisms include informal conversations e.g. at meals, regular meetings (12, 13, 21) and timetable. (40) Staff are able to describe the approach to risk assessment. On 25/06/2014 staff underwent Risk Assessment and Management Training. (6) Staff are encouraged to identify and report risks and be responsible in day-to-day risk management. (12, 21, 22) Page 20 of 63

Risk assessments of the service and any premises within which the service is delivered, are conducted at service inception and with appropriate frequency thereafter, following an incident, and at least annually. Appropriate risk assessments are updated annually and following any incident, accident or near miss. (31, 32, 34) The Monthly Monitoring Report (75) and Annual Quality Report (19) highlight accidents and incidents and are brought to the attention of staff and the Management Council (58) and action plans are developed if necessary. There are regular health and safety inspections to monitor risk. There are records of the inspections, participants, key findings and action taken. Where staff work alone, risk assessments specifically address the risks faced by lone workers and clients. Qualified consultants visit regularly to inspect systems, installations and appliances. (41) Staff are responsible for monitoring risks in houses and implementing regular checks. (38, 30) Monthly monitoring visits assess the suitability of the physical environment and identify potential risks and action plans. (75) There are records of health and safety inspections (41), participants, their findings and action taken. Regular estates, buildings and services checks are undertaken by qualified agencies e.g. PAT tests, gas, fire safety systems, environmental health. (41) Qualified consultants visit regularly to inspect systems, installations and appliances. (41) Staff are responsible for monitoring risks in houses and implementing regular checks. (38, 30) Individual Risk Management Plans (79) specifically address the risks to lone workers and residents and detail appropriate measures e.g. mobile phone Page 21 of 63

There is a lone working policy that sets out procedures to minimise the risks to people working alone and to clients. usage, contact numbers, rotas. (35) Policies on Lone Workers (33) and Emergency Staff Cover (35) detail the procedures which are in place to minimise and manage risks to staff working alone and clients. Evidence examples for Level B and A services are included below to give an indication of what we would expect of services delivered to such standards Level B Clients are involved in risk assessments (other than individual client risk assessments), which record their participation. There is a dynamic approach to risk management and the service proactively looks to reduce risk, but is not risk averse. Consistent efforts are being made to ensure client involvement in reviewing and updating risk assessments and their participation is recorded. (31) Clients are actively involved in weekly health and safety checks the findings of which inform the domestic risk assessment. (30, 31) Maintenance request forms are completed by individual clients where appropriate. (78) There is a dynamic approach to risk management and the service proactively looks to reduce risk, but is not risk averse. Level A Page 22 of 63

Standard Performance Level Essential requirements (C) or Indicative evidence (A / B) Evidence This standard supports the service to meet outcomes in the following outcome domains: Be healthy, Stay safe and Make a positive contribution (at levels A and B only) C1.2.3 There are appropriate arrangements to enable clients to access help in crisis or emergency. Basic minimum requirements for an adequate service (Performance Level C) Level C Emergency call-out and out-of-hours support arrangements are documented and publicised to clients in ways appropriate to their needs. Clients and staff understand both the emergency call-out procedures and any out-of-hours support procedures. The Residents Handbook (10 page 19) documents arrangements in place to enable residents to access help in crisis and emergency. There is 24-hour cover in all houses and residents are fully aware as to how to access support and help. (12) Staff live permanently on site which ensures intensive 24-hour availability. Planned absences are covered by rotas e.g. weekend, holiday periods. (39) The policy Emergency Staff Cover (35) documents relevant procedures. Rotas (39) are operated in houses and across the Community and relevant information is shared with residents and staff on a day-to-day basis, via the timetable (40), in house meetings (12), team meetings (21) and supervision. (22) Clients and staff can correctly describe the arrangements. Residents confirm that they feel safe and know who to turn to in an emergency. (16, 12) Staff are familiar with emergency arrangements in place. Page 23 of 63

Evidence examples for Level B and A services are included below to give an indication of what we would expect of services delivered to such standards Level B Level A The service equips clients and staff to deal with a crisis or emergency. There is a plan for dealing with any disruption to the service. Emergency numbers and other appropriate contact details are well publicised to clients in handbooks, leaflets, posters, etc. There is a periodic (at least annual) review of the effectiveness of emergency call-out or out-of-hours support procedures. Client feedback is actively sought about the effectiveness of current arrangements. (This may not apply to very short-term housing) The service can demonstrate that changes have been made to improve service delivery as a result of review or testing of current emergency call-out or out-of-hours support procedures. Review of these arrangements can show the impact of client involvement. Clients are involved in testing the effectiveness of current arrangements. (This may not apply to very short-term housing). CCC is a life sharing intentional community where competent and experienced staff permanently reside on site and are able to coordinate emergency call out and out of hours support as required. Policies and procedures including the emergency action plan inform staff and volunteers on how to deal with a crisis or emergency and/or any disruption to the service. (101, 29, 33, 35) Emergency numbers and other appropriate contact details are well publicised to clients in, leaflets, posters, etc. ( 77) Page 24 of 63

C1.3 Safeguarding and Protection from Abuse There is a commitment to safeguarding the welfare of adults and children using or visiting the service and to working in partnership to protect vulnerable groups from abuse. There is a difference between safeguarding vulnerable adults/children and adult/child protection. Safeguarding is everybody s responsibility, and includes measures to prevent or minimise the potential for abuse occurring. Protection is a statutory responsibility in response to individual cases where risk of harm has been identified. When it comes to a service s safeguarding responsibilities towards children, it may be helpful to think of services as one of four types: Services where children are known to live Services where children may live Services where children may visit Services where children neither live or visit, but clients may have access to children While we recognise the variable degree of contact different services will have with children, all the following standards are relevant to all services. How you implement them, and how detailed your policies are, may depend on the nature of this contact. Standard Performance Level Essential requirements (C) or Indicative evidence (A / B) Evidence This standard supports the service to meet outcomes in the following outcome domains: Be healthy, Stay safe and Make a positive contribution (at level A only). C1.3.1 There are robust policies and procedures for safeguarding and protecting adults and Basic minimum requirements for an adequate service (Performance Level C) Level C The procedures address both adults and children and comply with good practice. (See guidance) Policies and procedures are in place to safeguard and protect vulnerable adults (42) and children. (43) The Vulnerable Adults Policy highlights good practice and Page 25 of 63

children, that are less than three years old and in accordance with current legislation. measures to be followed. It also contains a flowchart outlining steps to be taken when abuse is alleged or suspected. Child protection also applies to this service as children live on site and visit. There are recruitment checks, including professional references and Access NI checks, for staff and volunteers. There is a whistle blowing procedure in accordance with the Public Interest Disclosure (NI) Order 1998. Individual client risk assessments address the potential for abuse from others. Lone working risk assessments address the increased risk to clients. Recruitment checks for staff and volunteers include: confirming ID, certificate and health status. (44, 45, 46) A Whistle Blowing Procedure (47) is in place and brought to the attention of staff. Individual Risk Management Plans (5) address individual residents vulnerability and highlight safeguarding measures. Staff comply with the policy on Lone Working. (33) Lone working risk assessments (79) address situation and person specific risk associated with lone working. Individual Risk Management Plans (5) address the increased risk to clients in lone working situations. Access NI checks are updated in accordance with contractual requirements. Access (NI) checks are undertaken and managed in accordance with contractual requirements. (45) Evidence examples for Level B and A services are included below to give an indication of what we would expect of services delivered to such standards Level B There is a periodic (at least annual) review of the effectiveness of safeguarding and protection from abuse policies and procedures and their implementation. The Annual Quality Assurance and Service Improvement Plan (19) overviews safeguarding practices and incidents and reviews the effectiveness of safeguarding Page 26 of 63

and protection from abuse policies and procedures (42) and their implementation. There is a planned approach to working with other agencies such as the referring HSC Trust, the HSCT VA Designated Officer, the Gateway Team, RQIA and ISA. The VA Designated Officer determines the level of response required according to regional policy and procedure. Intervention from specialist services such as psychiatry and psychosexual services is sought as needed. The policy and procedure review seeks to identify and address disincentives to reporting concerns. Access NI checks are updated every three years. CCC fosters a culture of openness and transparency and policies and procedures encourage and advise staff to raise any concerns or suspicions of abuse. Staff training, team meetings, supervision and appraisal promote a proactive approach to safeguarding and protection of vulnerable adults and highlight potential safeguarding concerns. Any vulnerable adult incident routinely triggers a review of the incident by the team and the manager, offers opportunity for peer review and reflection. Example (81) highlights the process in response to an allegation of abuse and demonstrates the practice review and the organisational learning and training development that followed. Access (NI) checks are according to current requirements and legislation. Level A There is a planned approach to working with other agencies. The service can demonstrate that key Page 27 of 63

safeguarding partners are involved in policy and procedure review. The service can demonstrate that changes have been made to improve service delivery as a result of review or following an incident. Policy and procedure review can show the impact of client and stakeholder involvement. Standard Performance Level Essential requirements (C) or Indicative evidence (A / B) Evidence This standard supports the service to meet outcomes in the following outcome domains: Be healthy, Stay safe and Make a positive contribution (at level A only). Basic minimum requirements for an adequate service (Performance Level C) Prompt action is taken in response to individual concerns from staff, clients or others and appropriate support is provided to them. The service promotes a high degree of awareness of this issue and ensures that prompt action is taken when concerns are raised. (42, 21, 22) C1.3.2 Staff are aware of policies and procedures and their practice both safeguards clients and children and promotes understanding of abuse. Level C Support is provided to victims of abuse. Appropriate support is provided to victims of abuse and any resident affected by challenging behaviour of other residents through internal mechanisms e.g. supportive counselling, increased support, staff rotas. Where appropriate welfare checks are being conducted by the referring HSC Trust professional and access to other services is facilitated e.g. therapeutic interventions, victim support. (81, 23) The service works appropriately with alleged perpetrators. In case (81) the alleged perpetrator was a volunteer co-worker. Following an initial Page 28 of 63

A log records details of cases and outcomes and shows that appropriate action is taken, including reporting to appropriate authorities (including Supporting People Contract Manager). Safeguarding and protection from abuse policies and procedures are covered in staff induction and training programmes, and integrated into staff management interview to collate information it was ensured that he had no further access to vulnerable adults or children and he was kept fully informed of statutory reporting requirements that CCC had to follow and of the investigative process that ensued. He was supported in making arrangements to terminate his volunteering and return to his home country. The volunteering agency who placed him within CCC was kept fully informed of the process and outcome of the investigation. In cases where the alleged perpetrator was another vulnerable adult, behaviour management support was given and follow up conversations took place. Where appropriate the individual was supported to apologise to the victim. Specialist services involvement was instigated to initiate psychiatric review and/or hospital admission and multi-disciplinary case discussions were convened. (82, 83) The log of safeguarding incidents (84) records details of incidents and outcomes raised by residents and carers. An Annual Quality Report and Service Improvement Action Plan (19) evaluates the issues raised and highlights improvements in practice and service delivery required. Monthly Monitoring (75) reviews the management of the incident and that the appropriate documentation is in place. Safeguarding and protection from abuse policies and procedures are covered in staff induction (28, 70), supervision (22), team meeting (21) and annual training Page 29 of 63

practices. programmes. (6) Staff are able to describe the policies and procedures, the reasons behind them and the implications for their work. Staff are able to describe how their practice promotes safeguarding. Staff and volunteers can describe how they would report any actual or suspected abuse or neglect, and who incidents should be reported to. Staff and volunteers are well informed about the importance of safeguarding and protecting vulnerable adults and how their practice, observation and pro-active attitudes are crucial in ensuring that the service keeps people safe. Reporting procedures in relation to any actual or suspected abuse or neglect and key people are well known. (42, 43, 47, 48, 49, 50) Evidence examples for Level B and A services are included below to give an indication of what we would expect of services delivered to such standards Level B Staff are appropriately supported through supervision in dealing with abuse cases. Staff are aware of the potential impact on themselves and clients of being involved in abuse cases. Staff receive specialist training appropriate to the needs of the client group. Supervision sessions offer staff opportunity for post incident debriefing, reflection and learning. (22) Behaviour support and risk management plans are reviewed and revised. (5, 85) Preventative strategies are explored in order to minimise the impact on clients and staff and self-protection methods are discussed. Where appropriate staff training needs are identified. (22, 82) Where possible individuals awareness is raised of self-protection and alternative coping strategies. Training on personal safety is provided to clients tailored to their individual needs. (71) Staff receive a range of training appropriate to the needs of the client group including training on Learning Disability and Dementia, on Communication as well as a four day workshop on Current Perspectives on Learning Disability and Soul Disturbance. Staff participate in regular Makaton training sessions. (6) Page 30 of 63

The service is proactive in promoting and sharing good practice beyond the service on safeguarding vulnerable adults and children. Level A The service can demonstrate that changes have been made to improve service delivery as a result of policy and procedure review. Policy and procedure review can show the impact of client involvement. Standard Performance Level Essential requirements (C) or Indicative evidence (A / B) Evidence This standard supports the service to meet outcomes in the following outcome domains: Be healthy, Stay safe and Make a positive contribution (at level A only). Basic minimum requirements for an adequate service (Performance Level C) C1.3.3 Staff are made aware of and understand their professional boundaries and their practice reflects this. Level C There is a documented risk assessment addressing the potential for personal benefit through abuse and this has been reviewed in the last three years. There are procedures to prevent staff from personal benefit when working with vulnerable people. The policies Conducting Appropriate and Professional Relationships (51) and Managing Residents Finances (52) address the potential for personal benefit through abuse of vulnerable people and are revised and updated annually and as and when required. The issue is continually raised in staff induction (28), in-house training (6), supervision (22) and team meetings. (21) The nature and limits of relationships between staff and clients, children of clients or children visiting the service are covered in staff induction and training programmes, Staff and volunteers are well aware of the particular character of the service where children live and visit and of the importance of a high degree of heightened awareness Page 31 of 63

and integrated into staff management practices. Staff and volunteers are able to describe the policies concerning relationships with clients, children of clients or children visiting the service. Staff and volunteers are able to explain how their practice maintains effective boundaries. A Code of Conduct (or similar document) makes clear appropriate boundaries for staff and volunteers. and monitoring to ensure safeguarding of children as well as maintaining of professional boundaries. (21, 43, 51,) Handbooks (49) are distributed to staff and volunteers (50) containing information about professional boundaries. These issues are periodically raised in team meetings. (21) NISCC Handbooks have been issued to all staff and volunteers. (28) Information to clients makes clear what are appropriate boundaries for staff and volunteers. The Residents Handbook (10 pages 19, 25-29) raises awareness about appropriate boundaries between staff and residents and indicates what to do if a person has concerns. This information is also displayed in the houses. Evidence examples for Level B and A services are included below to give an indication of what we would expect of services delivered to such standards Level B Staff receive appropriate training. There is a periodic (at least annual) review of the effectiveness of the policies and their implementation. The service has mechanisms in place that reinforce professional boundaries. Training on maintaining professional boundaries is integrated into Safeguarding Vulnerable Adults training and Finance training. (6) The Annual Quality Assurance and Service Improvement Plan (19) overviews the practices and reviews the effectiveness of policies regarding professional boundaries. Mechanisms have been introduced to ensure professional boundaries and clear documentation is kept, such as gift Page 32 of 63