Safeguarding Children, Adults and Looked After Children Annual Report 2016-2017 1
Sarah Vaux: Chief Nurse Medway CCG Executive Summary I am pleased to present the first substantive safeguarding adult, children and LAC report following the disaggregation of Medway and North Kent CCG partnerships earlier this year. This report sets out our accomplishment and the strategic priorities for the coming year and we look forward to embedding our long-term ambitions in the upcoming safeguarding strategic plans. This will set out how we will continue to deliver on the NHS Accountability and Assurance Framework. We continue to see significant progress with services for Looked After Children rated as good by CQC review. More importantly Looked After Children in Medway strongly agreed that the services they received were good and involved their views and wishes. We are continuing to transform Safeguarding services bringing in acknowledgement of the think family agenda, fostering cohesive working with adult and children safeguarding agenda to improve the lives of families in Medway. However we recognise that there is still much to do with demand for services continuing to grow against shifting sets of priorities. This year has been one of change, achievements and determination. However we will continue to work collaboratively with Governing Bodies, partner agencies and patient groups to achieve our ambitious safeguarding work plan. The strategic priorities outlined out in this document are underpinned by our values and principles. We remain committed to these challenges in the coming year. 2
Contents 1 Introduction... 5 1.1 Purpose of the Report... 5 1.2 Promoting Equality... 5 1.3 Statutory Responsibilities for Safeguarding... 6 1.4 Links to Governance Arrangements... 6 2 Governance Arrangements and Assurances... 7 2.1 Governance... 7 2.2 Compliance... 8 2.3 Quality Assurance... 8 2.4 Services Commissioned... 9 3 Safeguarding in Medway... 9 3.1 National and Local Context... 10 4 Emergent Themes in Safeguarding Children... 13 4.1 Serious Case Reviews... 14 4.2 Safeguarding Adult Review (SAR)... 14 4.2.1 Female Genital Mutilation (FGM)... 15 4.2.2 Child Sexual Exploitation (CSE)... 15 4.2.3 Domestic Violence and Other Hidden Harms... 15 4.3 Special Educational Needs and Disabilities (SEND)... 15 5 Looked After Children... 16 5.1 Expected Outcomes For Looked After Children... 17 5.1.1 Achievements Against Expected Outcomes... 18 5.1.2 The Voices Of Looked After Children... 18 6 Child Protection Information Systems (CP-IS)... 18 7 Safeguarding Adult Emergent Themes... 19 7.1 Prevent and Medway Chanel Panel... 21 8 Multi-Agency Safeguarding Hubs... 21 9 Training and development... 22 9.1 Safeguarding Training Compliance Figures... 23 10 Strategic Priorities and Forward Planning... 23 11 List of Abbreviations... 24 3
Document revision history Date Version Revision Comment Author/Editor 8.5.2017 1 Draft complete Jen Sarsby 30.5.2017 2 Review with comments Kate Bushell 31.5.2017 3 Review Satvinder Lall and Folake Durowoju 01.06.17 4 Review by Chief Nurse 4
1 Introduction This annual report provides the Governing Body with an overview of how Medway Clinical Commissioning Group (CCG) has fulfilled its statutory obligations in collaboration with the strategic partnerships to safeguard the welfare of children (including Looked After Children) (LAC) and adults across the health economy in Medway. Medway CCG prioritises safeguarding governance within all services commissioned and subcontracted. This is achieved through working collaboratively with strategic partners and health providers to ensure constructive challenge, robust monitoring and proactive safeguarding actions are taken to mitigate identified risk, maintain sustainable improvements and work innovatively to protect vulnerable adults and children in Medway. Guidance from NHS Safeguarding Vulnerable People in the NHS Accountability and Assurance (2015) suggests that statutory organisations must work together to mitigate risks and develop workable local solutions based on local need. 1.1 Purpose of the Report This report reviews the progress from 1st April 2016 until 31st March 2017, and provides assurance that the CCG has effectively discharged their statutory duties to safeguard the welfare of children and vulnerable adults across the health services that they commission. It outlines the safeguarding challenges and provides assurance that the CCG has worked collaboratively with partner agencies to secure improvements in the quality of services and outcomes for patients and service users. The report evaluates key achievements and areas for improvements alongside the strategic priorities and forward planning for the organisation. A separate report on child death will be produced. 1.2 Promoting Equality In line with the Equality Duty Act 2010, CCGs are required to demonstrate that they protect against discrimination and promote equality by ensuring fair access and equity for all service users regardless of dis/ability, genders, sexuality, race and ethnicities. In relation to this Act, Medway CCG is committed to working in a way that promotes equality and fulfils NHS Constitution values, rights and pledges, particularly: 5
Value - The NHS provides a comprehensive service, available to all irrespective of gender, race, disability, age, sexual orientation, religion, belief, gender reassignment, pregnancy and maternity or marital or civil partnership status; Right - You have the right not to be unlawfully discriminated against in the provision of NHS services including on grounds of gender, race, disability, age, sexual orientation, religion, belief, gender reassignment, pregnancy and maternity or marital or civil partnership status. Details of our commitments can be found in the Medway CCG Equality and Diversity Annual Report (2016/17). 1.3 Statutory Responsibilities for Safeguarding Medway CCG alongside NHS England has a statutory duty to ensure that arrangements are in place to safeguard and promote the welfare of children, young people and adults. NHS Medway CCG is a group of 50 GP member practices from across the Medway towns, responsible for planning and buying local NHS services. The Chief Nurse and the reporting role of the Deputy Chief Nurse have oversight and accountability of the Quality and Safety agenda. The local safeguarding arrangements ensure that there is expertise available to the CCG and wider health economy from the Designated Doctor for safeguarding Children and LAC, the Named GP and Designated Nurses for both Children and Adults. The team recently successfully appointed a new full time Designated Nurse for safeguarding children and LAC. Please see appendix 1 for structure. Medway CCG consists of 50 practices. All practices are CQC registered and have declared that they have a named safeguarding lead. The CCG has oversight of the named safeguarding leads. However each practice is responsible for safeguarding training of their staff. Work is continuing with a planned merger of single-handed practices with the stated aim to improve patient experience for the population of Medway. In response to the Children and Family Act (2014) (s3), there is currently 1 outstanding vacancy for the Designated Clinical Officer for Special Educational Needs and Disability (SEND). This is a recently created post and latest recruitment to this position was unsuccessful. However an interim professional has been employed as part of the business continuity plan for this vacancy. 1.4 Links to Governance Arrangements The Children Act 1989/2004. The Care Act 2014 Working Together to Safeguard Children (2015). 6
Safeguarding Vulnerable People in the NHS-Accountability and Assurance Framework: (NHS England 2015). Information Sharing Advice for Practitioner Providing Safeguarding Services to Children, Young People Parents and Carers: (HM Government, 2015). The Serious Crime Act 2015. Mental capacity Act (2015) Modern Slavery Act 2015 The Counter Terrorism and Security Act 2015 Promoting the wellbeing of Looked After Children: statutory Guidance for Local Authorities, Clinical Commissioning Groups and NHS England (HM Government 2015). Safeguarding Adults: Role and Competencies for Health Care Staff-Intercollegiate Document Royal College of Nursing, 2015). Information Sharing To Protect Vulnerable Children And Families: A report from the centre of Excellence (DFE, 2016). Next Steps on the NHS five Year Forward View 2017. Medway CCG safeguarding structure and governance arrangements adopts the think family agenda. The existing safeguarding policy and strategic aims are currently under review and completion is anticipated in July 2017. 2 Governance Arrangements and Assurances 2.1 Governance Governance is achieved internally for the CCG via the Quality, Finance and Performance Committee which reports to the Governing Body and is established in accordance with Medway Clinical Commissioning Group s Constitutions, Standing Orders and Scheme of Delegation. Healthcare commissioners must have: Designated Professional (DP) for safeguarding children and a safeguarding adults lead and lead for Mental Capacity Act (MCA)- or arrangements to access advice from DP to support commissioning activity Executive lead for safeguarding, effective policies and procedures, safer recruitment, training, supervision and reporting arrangements for safeguarding adults and children that link to local procedures for the Local Safeguarding Children Board (LSCB) /Safeguarding Adult Board (SAB) Arrangements to ensure services they commission are safe for children and adults at risk of abuse or neglect arrangements to ensure the health commissioning system as a whole is working effectively - disseminating policy and escalating key issues and risks. 7
Medway CCG is compliant with this and has key post-holders to support safeguarding and these are a Designated Nurse for Safeguarding Adults, Designated Nurse for Safeguarding Children and a Named GP for safeguarding children as well as Designated Doctors for safeguarding children and LAC. All safeguarding risks are identified and monitored on the risk register and form an integral part of the Quality and Safety Risk Register. Safeguarding risks are monitored in the Quality Finance and Performance Committee of the CCG. Contracts for provider services commissioned by the CCG include clear service standards, safeguarding metrics and agreed reporting mechanisms. Arrangements are in place are in place to scrutinise provider arrangements and safeguarding is included in the clinical quality review meetings (CQRGs). 2.2 Compliance Providers compliance is assured through; Contract monitoring process. Clinical Quality and Performance Review Group meetings. Attendance by the Designated Nurses at providers internal safeguarding committees. Regular meetings with providers Named professionals. Local Safeguarding Boards activities and sub groups, Section 11 submissions, monitoring of outcomes from CQC reviews/inspections and undertaking safeguarding and quality focused site visits. Where ongoing issues are identified, these are managed via formal contract performance notifications. 2.3 Quality Assurance Medway CCG has submitted a safeguarding adult s assurance framework to Kent and Medway Safeguarding Adult Boards (SAB) and a Section 11 Safeguarding Children Report in compliance with the Children s Act 2004, to Medway Safeguarding Children s Board (MSCB) during 2016/17. These documents demonstrate and assure that the CCG is discharging its statutory duties for safeguarding vulnerable adults and children effectively. All declarations are either met or identified actions are currently progressing with a robust action plan in place. 8
2.4 Services Commissioned Medway NHS Foundation Trust - provides Accident & emergency services Paediatric acute and community, LAC Health team, midwifery, school nursing and general medical and surgical services Medway Community Healthcare (MCH) is a Community Interest Company (CIC) and provides a wide range of community health services for Medway residents; from health visitors and community nurses to speech and language therapists and out of hour s urgent care. Child and adolescence emotional health and wellbeing services are commissioned by Sussex Partnership NHS Foundation Trust. Medway CCG is also an associate to Kent and Medway Partnership Trust (KMPT), Sussex Partnership, Southeast Coast Ambulance service and holds a range of smaller contracts. NHS England Medway CCG. responsible for ensuring that general practices commission safe system that safeguards children and adults at risk of abuse and neglect Medway CCG prioritise safeguarding within all services commissioned to ensure that statutory and governance arrangements are in place to safeguard the welfare of children, young people and adults. SAB &MSCB monitor and evaluate the effectiveness of adult and children safeguarding MFT/MCH/KPMG/CAMHS and SECAmb actute servics including LAC, community health services, emotional health and wellbeing services Figure 1 Partnerships and Governance 3 Safeguarding in Medway 9
Medway census report shows a population of 263,925 in 2011 with an average growth of 5.5% since 2001. Compared to England, the population of Medway has a smaller proportion of residence over the age of 65 years (Medway 15.4% and England 17.7%). 3.1 National and Local Context The proportion of population groups between 0 and 14 years is much higher than the national average in England (19.1% and 17.9% respectively) and between the ages of 15 and 24 years (10.4% and 9.7% respectively). Evidence from the Office of National Statistics, Public Health England and the Department of Health (DH) demonstrate how disproportionately younger population provides opportunities for ecological growth, be a predictor for higher infant mortality, higher teenage pregnancy rates, lower breastfeeding rates and greater health inequalities. At the same time the net proportion of immigration to Medway is at a much higher rate of migration, with a significant proportion of new arrivals supported as Looked After Children. The aforementioned evidence remain consistent with Medway Public Health report 2015, citing the all-age group mortality rates as significantly higher that England and the South East. For instance life expectancy varied between wards in Medway but consistently increased for male and females respectively over the last 5 decade. Similarly the under 16 and under 18year old conception rates are higher in Medway, than the South East and the national average. However there has been a consistent decrease over the last 5 years. Furthermore the proportion of conceptions to young people age13-15 years which leads to abortion (57.7%) is much lower than the national average. Table one below shows the latest statistics for Safeguarding and Looked After Children for Quarter 3 2016-2017 from Medway Safeguarding Children Board. Safeguarding Children in Medway Quarter 3: 2016-17 Cases open to Children s Services at end of period 1920 Rate of open cases at period end (per 10,000 of 0-18 305 population Number of Child Protection plans in place at period end 319 Rate of Child Protection plans in place at period end (per 50 10,000 0-18) Proportion of Child Protection plans lasting more than 2 years 1.90% at period end Proportion of CYP becoming subject to a Child Protection plan 26% for a subsequent time in 2 years Number of Looked After Children at period end 395 Rate of Looked After Children at period end (per 10,000) 62 Figure 2 Safeguarding Children in Medway 10
In 2015/16 there were 744 reported domestic abuse incidents where there were children and young people in the household resulting in a domestic abuse notification. This compares to 700 in 2014/15. This is significant because domestic abuse is the predominant contributory factor in in 89% of child protection cases and it is one of the main predictors for safeguarding co-morbidities such as child sexual exploitation and child emotional and mental health wellbeing. Indices of deprivation measurements show that some neighbourhoods in Medway were relatively worse off in the 2015 than compared to the 2010. For example, Medway is ranked 118th most deprived Local Authority of 326 in England in the latest index. This is a relatively worse position than in the previous index in 2010, when Medway was ranked 136th most deprived of 325. Medway has many areas with higher levels of poor income and employment deprivation: However the two major themes in the multiple index crime stands out as a particular weakness, with Medway ranking 53rd most deprived Local Authority in England for crime. After that, education, skills and training has a ranking of just 86th most deprived. In the 2015 index Medway has thirty two neighbourhoods ranked in the 20% most deprived nationally and 12 ranked in the 10% most deprived. Medway s most deprived neighbourhood, in River ward, is now ranked in the most deprived 1% of areas nationally. In the 2010 index, this area was ranked in the 3% most deprived nationally. Just over twothirds of the neighbourhood areas in Medway have a relatively worse ranking than in the 2010 index. Gillingham South appears to have shown the most significant relative decline since the 2010 index while this ward does not contain the most severely deprived neighbourhoods of Medway, a number (4/10) of neighbourhoods in Gillingham South have shown a significant relative decline. Adult Safeguarding is a part of safeguarding in general and is the promotion of the welfare of individuals. This refers to the activity that is undertaken to protect specific adults who are at risk of harm or abuse as described in the Care Act 2014, which came into effect in April 2015 and which may affect an individual at different times during their lives. An adult is a person who is aged 18 or over. 11
Safeguarding must aim to stop abuse or neglect wherever possible; prevent harm and reduce risk of it happening and enable adults at risk to have choice and control in how they live their lives. It must also: Promote an approach that concentrates on improving life for the adults concerned raise public awareness enable communities to help prevent, identify and respond to abuse and neglect provide accessible information about types of abuse, staying safe, raising concerns and addressing cause enable access to community resources; safe town centres and groups to reduce isolation ensure roles & responsibilities are clear Between 2014 and 2024, the number of people aged 65 and above is estimated to increase by 25% to 52,100. Over the same period, the number of people over 85 years is projected to increase by 48% to 6,800. From 2012 to 2020 the number of people over 65 years with a limiting long-term illness is expected to increase by 21%. Average life expectancy is 77.3 years for men and 81.6 years for women. This remains below the national average (MSCB, (2016; Medway Public Health Report, 2016). Medway has seen a 10% increases in the numbers of Safeguarding Enquiries in the past year. This is believed to reflect greater awareness and more robust reporting following the implementation of the requirements of the Care Act 2014. Physical abuse remains the most prevalent, but there has been a notable increase in Enquiries for neglect. Figures collated by the Kent & Medway Safeguarding Adults Board show a continued four year decline in financial and material abuse which is deemed to be a testament to the combined prevention efforts across Medway. Kent & Medway Safeguarding Adults Board figures identify that in the period 2015 to 2016, the majority of all enquiries, 41.4%, related to the 18-64 age group. The second most prevalent group is the 85+ age group, representing 26.4%. There has been no significant variation in the proportions of enquiries across the age groups over the past four years. The highest proportion of victims continues to be female (50.3%) but this margin is decreasing, and the highest percentage of reported victims are from a white background (89.6%) with 10.4% reported as being from a BME background, this indicates a 4% higher rate of reporting in victims from a BME background than the rest of Kent. In 2015 to 2016 the main location for incidences of alleged abuse was within care homes, with 42% of incidents occurring in such settings. This represents a 3.4% increase from 2014-15. 34.7% of incidences were reported to be in the alleged victims own home, this represents a 3.3 percentage point increase from 2014-15. 12
Due to the Care Act changes and changes within statutory reporting, from 2015-16 the location of alleged abuse is reported on by own home, community service, care home, hospital and other. The location of other has reflected an increase, but this location will include cases where the alleged abuse took place in public or where the location of abuse was not known. 4 Emergent Themes in Safeguarding Children The Care Quality Commission (CQC) carried out a review of safeguarding children by the NHS in Medway. The review explored the effectiveness of the health services for looked after children and the effectiveness of safeguarding arrangements within health for all children. CQC (2016). The review rated services for looked after children as Good. This is reflected in the voices of Medway children section 5.1.2 of this report. The final report was published in February 2016 found that MFT. The review made 16 recommendations for service improvements at Medway NHS Foundation Trust (MFT) and Medway CCG 4 respectively. Against these recommendations, Medway CCG has: Supported the development of General Practice (GP) information sharing systems for vulnerable children. Developed a reporting format for child protection conferences. collaborated effectively with MFT to monitor and support the CQC action plan and carried out an audit of the cases referred to Child Advice Duty (CAD) services, provided a robust monitoring process effectively. Carried out an audit of the cases referred to CAD services to provide robust monitoring process. There has been significant improvements following the recommendations and a robust action plan is now in place to ensure the protection of children in Medway. The latest CQC inspection rating published in March 2017 following the inspection of Medway Foundation Trust. This is illustrated in figure 3 of this document. Safe Effective Requires improvements good 13
Safe Caring Responsive Well led Figure 3 CQC Final Review Requires improvements good Requires improvement good Work is progressing to ensure that recommendations are proposed by the CQC are embedded and making a difference to the wellbeing of patients. 4.1 Serious Case Reviews The MSCB has three Serious Case Reviews (SCRs) which are in progress. Medway CCG is continuing to work with the Local Safeguarding Children Board to ensure that the processes set in the Working Together to Safeguarding Children 2015 document. Medway CCG will ensure that if gaps are identified, steps will be taken to ensure that lessons can be learnt from these cases about the way in which local professionals and organisations work together to safeguard children. 4.2 Safeguarding Adult Review (SAR) The domestic violence crime and victims act 2004 was updated in 2014 and places a duty on community partnerships to make arrangements for domestic homicide reviews; health agencies including Medway CCGs are required to participate in these. Kent and Medway Safeguarding Adult Board has a duty to carry out a Safeguarding Adult Review (SAR) when an adult at risk in Kent or Medway dies as a result of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked more effectively to protect the adult. KMSAB must also arrange a SAR if the same circumstances apply where an adult is still alive but has experienced serious neglect or abuse. KMSAB can also arrange for a SAR in other situations where it believes that there will be value in doing so. This may be where a case can provide useful insights into the way organisations are working together to prevent and reduce abuse and neglect of adults, and can include exploring examples of good practice. There have been no Serious Adults Review or Domestic Homicide Review (DHR) implicating Medway residents in past year. However three further SAR applications were received between April 2015 and March 2016 from other areas across Kent. Of these, two progressed to a Safeguarding Adult Review and concluded in 2016. The overview reports and recommendations were presented to KMSAB and all relevant agencies developed action plans to address the recommendations. These plans were reviewed after six months and a progress report was presented to the Board, provided assurances on progress of the 14
actions. In addition multi-agency workshops were held to present findings and disseminate the lessons learned. 4.2.1 Female Genital Mutilation (FGM) Services within MFT and MCH have now implemented the statutory requirements from the Serious Crime Act 2015 to mandatory report FGM and implement robust safeguarding practices for women and children affected by the practice. Dataset relating to FGM is still in its infancy and reporting will prioritised within the CCG forward planning. 4.2.2 Child Sexual Exploitation (CSE) Sexual exploitation is an emerging safeguarding issue for children, young people and adults with care and support needs in Medway. 2016-2017. Medway System for Task and Operation Resource Management received 66 CSE calls. Between 10.1.17-22.2.17 28 intelligence/ information documents submitted into the Child Sexual Exploitation Team. Medway CSE multi-agency Strategic Action Group have now prioritised intelligence gathering, revising the CSE toolkit, tacking sexually harmful behaviour, issuing child abduction warning notices, preventative and raising awareness raising as key priorities. Medway has a specialist CSE nurse who is jointly employed with Kent CCGs. Medway CCG alongside other strategic partners acknowledges CSE as a significant safeguarding concern and has prioritised the issue within its strategic planning. The strategic partnerships are committed to raising awareness about the scale of the problem, ensuring clear pathways for referral and access to services and building the resilience of these affected. 4.2.3 Domestic Violence and Other Hidden Harms Domestic Violence and Other Hidden Harms (such as modern slavery, forced marriage) outlined Section 3.1 of this document outlined the local context in which domestic violence and other hidden harms damage the lives of these affected and prevent them from reaching their full potentials. The implementation of the new safeguarding model of RISK assessments via the planned MASH will enable greater information sharing and more robust risk assessment and risk planning for children, young people and adults who are affected by domestic violence. 4.3 Special Educational Needs and Disabilities (SEND) The Special Education and Disability Act (2001) provided statutory guidance for organisations who work with children to take action to reduce inequalities and improve the life changes amongst these groups of children. These actions are aimed at improving inequality and inclusivity as part of the health equality agenda. However In 2006 Ofsted 15
published reports which identified children Special Educational Needs and Disability (SEND), 0-19 years where amongst some of the most overlooked and disadvantaged amongst their cohort. Work is underway at Medway CCG to implement the SEND agenda. 5 Looked After Children Looked After Children share many of the same health risk and problems as their peers but often to a greater degree because of the added vulnerabilities. For instance children entering care are far more likely to be exposed to a number of enduring traumatic events such as sexual exploitation, domestic violence, bereavements, parental drug and alcohol addiction as well as parental mental illnesses. Furthermore they often enter care with a worse level of health due to the impact of deprivation, abuse and neglect and other physical and educational development concerns. These concerns are further compounded by the local context outlined in section 4 of this document. The Looked after children service is currently provided by Medway NHS Foundation Trust through their block contract (511K of 2.8M and 100% CCG funded. It is included within the remit of the commissioning of children s health services. A key element of service delivery for looked after children is the statutory obligation to ensure that LAC children that are placed Initial health assessment (IHA) within 28 days of entering care Review Health Assessment (RHA) - age 0-5 receive 6 monthly assessments RHA - age 5-18 annual health assessments. The 2015 Ofsted inspection rated the services for looked after children as requiring improvement to be good. Notably the inspection rated the experiences and services for care leavers and Good. The inspection was carried out against the backdrop which showed that 433 children were being looked after by the local authority, an increase from 425 (68 per 10,000 children). This is consistent with the national average for England where the national population of over 60,000 in England at any given time. Looked After children in Medway Ofsted 2015/6 17 lived outside the local authority area. 33 live in residential children s homes, of whom 88% live out of the authority area. One lives in a residential special school, which is outside of the authority area 352 live with foster families, of whom 41% National Context DfES 2007 Poor mental health and emotional wellbeing, including self-harm. Poor physical health. Teenage parenthood. 16
live out of the authority area. Five live with parents, of whom one lives out of the authority area Three are unaccompanied asylum-seeking children in the last 12 months. 12 children and young people ceased to be looked after and are now living in houses of multiple occupations. There have been 29 adoptions. 20 children became the subject of special guardianship orders. A total of 184 children ceased to be looked after, of whom 3% subsequently returned to be looked after. 11 children ceased to be looked after as a result of child arrangement orders. 5 children and young people ceased to be looked after and moved on to independent living. Figure 4 Local and National Context Engaging in risk behaviors (drugs alcohol and young parenthood). Poor sexual health. Missed immunisations. Missed appointments. Missed developmental reviews. Undiagnosed/ undetected health problems. Speech and language delays. No preventative healthcare. No dental checks or treatments and poor oral health. 5.1 Expected Outcomes For Looked After Children Medway council has published its strategic vision priorities outlining details plans to progress and monitor services 2015-18. An up-to-date version can be found at: Alongside this, Medway CCG also published details of the service specification to optimise the standards of care delivered to LAC children. 1. To ensure that 85% of initial assessments are undertaken within the statutory 28 days of the child or young person becoming Looked After. 2. To ensure that 95% of initial health assessments are undertaken within 28 days of the request being made. 3. To ensure that 100% of health care plans that need to be reviewed are within 3 months after completion after completion of the assessments. 4. To ensure that 90% of review health assessments are continually in date. 5. To ensure that 95% of health histories are completed by the by the young person s 18 th birthday for 207/8. 6. That there are systematic and detailed processes and practices in place to ensure that there are identification of unmet or unrecognised health needs amongst LAC. 7. That holistic, young-person focused, health assessments take place in a timely and efficient manner. 8. That there are comprehensive health summaries and recommendations to inform future care planning for each looked after child. 17
9. That there is an increase in quality outcomes that effectively demonstrates the value for money is being secured. 5.1.1 Achievements Against Expected Outcomes Services commissioned for looked after children achieved 75% of initial health assessments within the statutory timeframe and 88% of review health assessments. The service also completed 100% of initial adoption assessments by doctors and 92% completed by LAC nurses respectively. In March 2017 there were LAC in Medway; of these 82% had a review care plan within 3 months. Similarly 1 of 3 health history was completed on time. 5.1.2 The Voices Of Looked After Children Responses The Voices Of Looked After Children Survey 2017 and 2017 Time and place of The nurse Friendly and appointment listened to approachable convenient my views staff Strongly agreed 51% 68% 75% 65% Agreed 31% 31% 24% 31% Disagreed 6.6 % 0% 0% 3.4 Don t know 8% 0% 0% 0% Health action plan was agreed Overall the responses from LAC children reported that they were either satisfied with the quality of care given and their level of involvement with their health plans. The following extracts were taken from written feedback from LAC children and their carer: This is my first and hopefully last, no offence but it was a good experience. Very comfortable, and three LAC medical done very well with a lot of care and attention to details. Good experience except parking. Francis was excellent and spends time and agreed with what I was saying. 6 Child Protection Information Systems (CP-IS) Information sharing is identified as defining factor in the majority of serious case reviews that takes place following the death or injury of a child. CP-IS ensures that child protection information is shared securely between local authorities and NHS Trust across England. 18
CP-IS connects local authority children's social care systems with those used by NHS unscheduled care settings, such as Accident and Emergency, walk-in centres and maternity units. It ensures that health and care professionals are notified when a child or unborn baby with a child protection plan (CPP) or looked after child status (LAC) is treated at an unscheduled care setting. CP-IS is a secure system with clear rules governing access. Only authorised staff involved with the care of a child can access the information. Medical staff are alerted if a child they're treating is subject to a CPP or LAC and given contact details for the social care team responsible for them. The system automatically notifies the Local Authority of the attendance. Social care teams are alerted when a child in their care attends an unscheduled care setting Providing instant access to this information means vulnerable children can be identified wherever they are cared for in England. The Clinical Commissioning Croup acknowledges the capacity of CP-IS to significantly improve safeguarding and have been working throughout the past year to facilitate CP-IS within Medway. Medway Foundation Trust are planning to go live with the system on the 22nd May and are being assisted by NHS Digital with this project. It is hoped that this will significantly improve the quality of safeguarding interventions for children and young people across the health economy. 7 Safeguarding Adult Emergent Themes Deprivation of Liberty Safeguards (DoLS) came into force in England and Wales in April 2009, under an amendment to the Mental Capacity Act 2005. These safeguards are intended to protect individuals, who lack the capacity to consent to care or treatment, from being deprived of their liberty unless there is no other, less restrictive alternative, and a Deprivation of Liberty is assessed to be in their best interests to protect them from harm, or to provide treatment. The national context of a significant increase in the numbers of Deprivation of Liberty Safeguard applications since the Supreme Court ruling of 2014 is reflected in both Kent and Medway. Given the high number of referrals, both local authorities have robust triage processes in place, as recommended by ADASS, to prioritise applications. The current DoLS process puts significant pressure on the health and social care system. Since the Supreme Court Judgement in 2014, there has been a 17 fold increase in the number of applications locally. 19
In March 2016 the Law Commission delivered its final recommendations to Government on replacing the Deprivation of Liberty Safeguards (DoLS), after concluding that the current system was in crisis. The government asked the commission to review the DoLS amid concerns councils were failing to cope with a tenfold rise in deprivation of liberty cases triggered by the Supreme Court s landmark Cheshire West ruling in March 2014. On 13th March 2016 the Law Commission published its final report and draft legislation for a new system to authorise care placements involving deprivation of liberty for people lacking capacity. The commission believes its proposed Liberty Protection Safeguards (LPS) scheme will be less onerous than the DoLS while still offering human rights protections. The LPS covers a broader group of people than the DoLS, which is restricted to placements in care homes and hospitals. The commission also recommended wider reforms to improve decision-making across the Mental Capacity Act, not just in cases involving deprivation of liberty. The MCA proposals place a requirement on decision-makers to place greater weight on the person s wishes and feelings when making decision under the act and confirm in writing that they had complied with the act. It is now up to the government to decide whether to take the commission s recommendations forward. The next step will be for the Department of Health to respond to the Law Commission's recommendations, which should happen within 12 months. Depending on whether the Department of Health accepts, rejects or suggests modifications to the proposed system, the draft bill produced by the Law Commission alongside its report would then be scrutinised by both Houses of Parliament, as part of the usual legislative process. It is therefore likely that nothing will be changing in the short term and until these recommendations become law, commissioners and providers must continue to abide by the DoLS regime in its current form. Activity from both the Kent and Medway DoLS Offices are reported on a quarterly basis to the Safeguarding Adults Board and the CCG requests that all provider health organisations report the numbers of DoLS applications they submit and the numbers agreed by the DoLS Office on a quarterly basis as part of the contract monitoring process. The Medway Safeguarding Adults Executive Group (MSAEG) has been established to bring together senior representatives from the key agencies responsible for the effective delivery of Adult Safeguarding in Medway. The MSAEG will work collaboratively to deliver the strategic priorities of the Kent and Medway Safeguarding Adults Board, strengthening delivery, oversight and governance. The Chief Nurse and the Designated Nurse for Safeguarding Adults both attend this group. 20
7.1 Prevent and Medway Chanel Panel In September 2015, a Multi-Agency Prevent Duty Delivery Board was established to oversee the delivery of the Prevent Duty across Kent and Medway. The Board receives feedback from Channel, shares information regarding Prevent awareness raising and training activity within individual agencies and has agreed to the development of a Kent-wide action plan. This board is attended by the Chief Nurse for Canterbury & Ashford CCG on behalf of Health. Over the past year a separate Medway Prevent Strategy Board has been implemented with the aim of bringing together senior representatives from the key agencies within Medway responsible for the effective delivery of the PREVENT agenda in Medway. The Chief Nurse for Medway CCG is a member of the Medway Prevent board. Currently Medway remains a low risk area at tier 3. There are separate Channel Panels for Kent and Medway and the Designated Nurses for both Children and Adults attend the Channel panels. The Designated Nurses in conjunction with the Prevent Lead from the Community Safety Partnership arranged and hosted a workshop on Prevent/Channel, Modern Slavery & Gangs which was open to all Safeguarding Leads both Children and Adults across Kent to attend. The workshop took place on 14th December 2016 and was well attended by 30 delegates. Some provider organisations have also used these trainers to deliver sessions in-house. Medway has a Channel Panel separate to Kent s. This Panel meets every month and referrals are made using the Kent-wide referral form. Medway Council also has its own internal Prevent Board as well as a multi-agency Prevent Board to meet the guidance laid down in the Counter Terrorism and Security Act 2015. The Designated Nurses for Children and Adults both attend the Medway Channel panel meetings. 8 Multi-Agency Safeguarding Hubs Work is progressing in Medway to establish the Multi-Agency Safeguarding Hub (MASH). It is anticipated that this will be fully implemented by September 2017. It is expected that this model of safeguarding arrangement will help to mitigate risk through robust information sharing; multiagency risk assessments and safeguarding planning will explicate the think family safeguarding agenda. Evidence from established working MASH has shown that this model of safeguarding approach significantly improves health and safeguarding outcomes for adults and children Home Office (2014), underscoring the value of multiagency approach to tackling safeguarding risk. 21
9 Training and development The Designated Nurses have implemented a comprehensive training programme for all CCG staff in partnership with CCG Human Resource Leads and in line with Safeguarding children and young people: roles and competences for health care staff Intercollegiate Document 2014 and Safeguarding Vulnerable People in the NHS Accountability and Assurance Framework (2015). Level 1 Training All staff working within health and care organisations, both clinical and non-clinical, including paid and voluntary staff are required to undertake: Prevent awareness training- e-learning module Level 1 Safeguarding Children training- e-learning module Level 1 Adults Safeguarding- e-learning module Level 2 Training Level 2 Children s Safeguarding training should be undertaken by all staff who are working with adults. Clinical staff should complete this module in addition to the level 1 module. This training is in the form of an e-learning module. Level 2 Adults Safeguarding training should be undertaken by all staff with professional and organisational responsibility for safeguarding adults, able to act on concerns and to work within an inter- or multi-agency context. Clinical staff should complete this module in addition to the level 1 module. Level 3 Level 3 Children s Safeguarding training must be undertaken by professionals working with children delivering care and this must be delivered face to face. Level 4 Children s safeguarding training Level 4 Children s Safeguarding training and above must be undertaken by Children s Safeguarding Leads in the CCG. There can be different methods of updating knowledge for these Levels including attending safeguarding meetings, reading publications, being involved in Serious Case Reviews and Domestic Homicide Reviews, undertaking supervision with other safeguarding leads and linking to the meetings for NHS England for safeguarding. The training needs for Adult Safeguarding has been reviewed by NHS England and the new Intercollegiate Guidance is in draft form. The final guidance is expected to be published in the very near future and will mean that clinical staff with key involvement in the multi- 22
agency safeguarding process will need to undertake Level 3 training in addition to Levels 1 & 2 training. The cohort of staff needing to undertake this training in the CCG is likely to be those staff in the Specialist Assessments & Placement team. 9.1 Safeguarding Training Compliance Figures A Safeguarding Training Database of all CCG staff have been developed and will be maintained by Human Resources (HR). Staff are requested to return certificates of completion for the training they have undertaken to HR in order that the database can be updated for compliance. Compliance rate Looked After Children Adult safeguarding Children safeguarding Level 1 85.5% 83.1% Level2 79.3% 76.2% Level3 TBA TBA Level4 TBA TBA Table 1 Safeguarding Training Compliance 10 Strategic Priorities and Forward Planning Voice of the Child: Ensuring that the wishes of children and young people remain an integral part of all services commissioned and is explicit in outcome measures for children Child Death Reporting: A child death reporting pathway is now compete and work is in progress to monitor its implementation. Audit Cycle: Cycle One of the audit strategy is now complete and dissemination of learning delivered December 2016: Cycle two of the CAD audit date will begin in July 2017. This audit is linked to the CQC action plan: An additional audit to evaluate GP s compliance and participation with safeguarding conference will commence in July. A learning event for the findings form this audit will be delivered in September 2017. Safeguarding Training: work is progressing to ensure compliance with safeguarding training. A further 6 training dates for level 3 safeguarding training will be delivered to GP protected learning time and the CCG learning events. Safeguarding Learning: A Level 4 multi-agency safeguarding conference is planned for October 2017. This is a collaborative effort involving the Medway Safeguarding partnerships. Medway CCG Safeguarding Newsletter: Medway CCG quarterly safeguarding newsletter will begin publication in July 2017. 23
Improving Outcomes for Children: Medway CCG is leading a task and finish collaborative group to develop a whole systems approach to develop support for children and families affected by foetal alcohol syndrome. Hidden Harms: in relation to the legislative changes outline in the Serious Crime Act 2015;(Article, 78) Medway CCG will prioritise addressing hidden safeguarding harms such as female genital mutilation, sexual exploitation, modern slavery, and honour-based violence as part of the drive to improve access and equity for all residence in Medway. The Special Education and Disability: work in partnership to reduce inequalities and improve the life changes amongst these groups of children. Supporting GP s in Discharging Their Statutory Safeguarding Duty: A 0.5 whole time equivalent Safeguarding Adults Nurse Advisor who s remit was to develop support and links with Primary Care commenced in post in September 2016 for a fixed term until April 2017 utilising additional safeguarding funding provided by NHSE. This post was shared across Dartford, Gravesham & Swanley, Swale and Medway CCG s. The Safeguarding Adults Nurse Advisor attended the GP Protected Learning Time session to present an overview of her role and to outline the support she will be able to provide GP Practices at an individual level. This included linking with individual practices via their Safeguarding Lead to bench mark current safeguarding performance and identifying what support they require to ensure they are discharging their statutory safeguarding duty. This work will provide the basis for further strengthening of safeguarding arrangements from June 2017. Safeguarding policy for General Practice: this generic policy which clearly outlines roles and responsibilities for safeguarding within general practice can be adopted by all GP s pan-kent. The policy has been agreed by NHS England. The policy will be presented to governing bodies across Kent and Medway in July 2017 for approval. Review of Safeguarding training requirements: Safeguarding training requirements for providers have been reviewed in line with the NHS England Safeguarding Adults: Roles and competences for health care staff Intercollegiate Document. (draft); provider contractual safeguarding metrics have been revised to reflect these. Safeguarding adults training matrix has been developed by the Designated Nurses that will be circulated to Primary Care once the final draft Intercollegiate Document has been published. Community Safety partnership working; to continue to participate in the sharing of assessments and plans, so as to foster improved strategic alignment amongst the Health and Wellbeing Board, Medway Safeguarding Children s Board, the Kent and Medway Safeguarding Adults Board and the Community Safety Partnership. 11 List of Abbreviations CCG: Clinical Commissioning Group 24
CAD CSE CQC CP-IS DP DoLS FGM IHA RHA LAC LPS Children Advice and Duty Service Child Sexual Exploitation Care Quality Commissioning Child Protection Information System Designated Professional Deprivation of Liberty Safeguards Female Genital Mutilation Initial Health Assessment Review Health Assessment Looked After Children Liberty Protection Safeguards SEND Special Educational Needs and Disability. MSCB Medway Safeguarding Board MFT MAC SAB Medway Foundation Trust Mental Capacity Act Safeguarding Adult Board MASH Multi-Agency Safeguarding Hubs 25
26