Safeguarding Children, Young People & Vulnerable Adults Sub-Committee Annual Report

Betsi Cadwaladr University Health Board Committee 03.01.13 Item QS13/017.2.1 Subject: Summary or Issues of Significance Safeguarding Children, Young People & Vulnerable Adults Sub-Committee Annual Report 2011-2012 This Annual Report provides a concise update of: Key achievements during the period 2011-2012 Ongoing Safeguarding Children & Children Looked After (CLA) Vulnerable Adults, Domesic Abuse operational and strategic activities. Challenges and actions for the year ahead. Strategic Theme / Priority addressed by this paper To ensure compliance with section 25, section 27 and section 28 of the Children Act 2004, the Vulnerable Groups Act 2006, the key principles and core values arising from In Safe Hands. Ensuring Betsi Cadwaladr University Health Board reports and communicates progress and risks relating to Safeguarding to the Quality & Safety Committee and ultimately to the Board Legislation or Healthcare Standard: Evidence base or other relevant information to inform decision (e.g. risks) Children Act 1989 Children Act 2004 All Wales Child Protection Procedures (2008) Safeguarding Children Working Together under the Children Act 2004 (2006) All Wales Interim Adult Protection Policy and Procedures in Wales (2010) Doing Well, Doing Better 2010 (11&22), HCS 17, NSF, HIW, Vulnerable Groups Act 2006, NICE 16, Standard 13 (Vulnerable Groups) In Safe Hands, Deprivation of Liberty Standards (DOLS) (2007), Mental Capacity Act (MCA) (2005) The Children Act 1989 places specific duties to co-operate to safeguard and promote the welfare of children section 27 and section 25 Children Act 2004. The Children Act 2004 section 27, responsibilities for functions under section 25 in which requires key agencies to appoint senior officers with safeguarding responsibility. The Children Act 2004, section 27 requires NHS organisations to make arrangements for ensuring that their functions are discharged having regard to the need to safeguard and promote the welfare of children. In Safe Hands places statutory Vulnerable Adults guidance upon NHS organisations. All Wales Interim Adult Protection Policy and Procedures in Wales (2010)

Consultation with others: Safeguarding Children & Vulnerable Adults Sub-Committee members Equity Impact Assessment: Has EqIA screening been undertaken? Has a full EqIA been undertaken? All guidance activities and Policy & Procedures undertake an Equality Impact Assessment. Y / N Y / N Recommendations: The Quality & Safety Committee accept the report as reassurance that the organisation is fully actioning and developing the safeguarding provision in line with legislation and guidance to Safeguarding Children/Young People and Vulnerable Adults and Domestic Abuse/Violence for whom we provide a service. Author(s) Presented by Michelle Denwood, Assistant Director for Safeguarding Children & Vulnerable Adults on behalf of Jill Galvani Michelle Denwood, Assistant Director for Safeguarding Children & Vulnerable Adults Date of report 20.12.12 Date of meeting 03.01.13 BCUHB Coversheet v3.3 Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board

The Safeguarding Children, Young People & Safeguarding Adults Introduction Annual Report 2011-2012 This report serves to inform the Health Board of the ongoing safeguarding activities undertaken by the Board in relation to Safeguarding Children, Young People, Children Looked After and Safeguarding Vulnerable Adults and Domestic Abuse for the period 2011 2012 and the priorities identified for 2011 2012 as agreed by the Safeguarding Children and Vulnerable Adults Sub-Committee. It is imperative for Betsi Cadwaladr University Health Board to safeguard vulnerable persons in accordance with the legislation framework of the Children Act 1989, Children Act 2004, and key principles and core values arising from In Safe Hands, All Wales Interim Adult Protection Policies & Procedures (2010) and the Domestic Abuse Strategic Agenda. Domestic Abuse & Violence, Honour Based Violence & Human Trafficking and Female Genital Mutilation are key target areas for the Safeguarding agenda and influence both Adult Protection and Child Protection. The Safeguarding agenda has increased significantly and Adult Protection remains a key patient safety issue for the Health Board. 1 Title of Sub-Committee: Safeguarding and Protection of People at Risk Sub-Committee 2 Name and role of person submitting this report: Michelle Denwood, Assistant Director of Safeguarding 3 Dates covered by this report: 2011-2012 4 Number of times Sub-Committee met during the year: 4 meetings per annum 24.06.11 23.09.11 16.12.11 (cancelled due to adverse weather conditions) 17.02.12 30.03.12 5 Assurance/s this Sub-Committee is designed to provide: Introduction The Health Board has placed Safeguarding on a strong footing ensuring that robust systems and processes are in place to Safeguard Children & Vulnerable Adults who are at risk of harm, exploitation and where abuse has occurred to support the victim. Safeguarding Annual Report 2012 FINAL 1

Assurance The Terms of Reference were formally agreed by the Quality & Safety Committee and assures the Board of their responsibilities which are:- To ensure the organisation complies with section 28, 27(2) (a) (b) and section 25 And section 31 of the Children Act 2004; To ensure the organisation complies with the Protection of Vulnerable Adult Policy/and Strategic Guidance; To ensure the organisation complies with safe recruitment and monitoring arrangements following CRB & ISA guidance; To provide leadership, commitment and operational support to the Safeguarding Process; Ensure systems are put in place to review and monitor the ongoing development and implementation of the Safeguarding Strategy within Clinical Programme Groups including developing and Implementing a system for urgent escalation and resolution of issues; To facilitate LHB Board compliance with external standards; good practice guidance; and legislation; Manage an on-going process of self assessment and improvement against the Healthcare Standard 17 to enable the annual self-assessment submission; To ensure that recommendations made by internal and external reviews are considered and acted upon; Oversee the on-going development, review and implementation of relevant sections of the Healthcare Standards Improvement Plan; To ensure the effectiveness of all working groups with accountability to the Safeguarding Sub committee including the production of relevant minutes, plans, report and other documentation; To provide an Annual Report to the Quality & Safety Committee providing positive assurance that the Sub-Committee has met its terms of reference and Safeguarding duties. Safeguarding Annual Report 2012 FINAL 2

6 Overall *RAG status against Sub-Committee s annual objectives / plan: Action Plan 2010 2011 ACTION PLAN 1 Implementation of the agreed Safeguarding Children & Vulnerable Adults Structure. 2 Implement a Clinical Programme Group and Corporate action plan relating to Doing Well, Doing Better: Standards for Health Services in Wales 2010-2012. 3 Review and audit existing Serious Case Reviews action plans relating to recommendations. 4 Implement and disseminate the identified recommendations; identified lessons and good practice from Serious Case Reviews and Internal Reviews. 5 All CPG s and corporate departments to record and review training data/statistics and complete annual training needs analysis. 6 Implement the E-Learning Child Protection package across the organisation. 7 Secure funding to develop and implement the Protection of Vulnerable Adults E-Learning package. 8 Betsi Cadwaladr University Health Board to develop and implement the Training Strategy with greater engagement with Primary Care, GPs and Care Homes funded to provide NHS care. 9 Implement an identified action plan relating to the implementation of statutory guidance and procedures relating to Domestic Abuse. 10 Strengthen and develop internal procedures relating to Escalating Concerns with and closure of Care Homes (providing services WAG May 2009). 11 Ratify the final Safeguarding Children & Vulnerable Adult and Domestic Abuse Strategy. 12 Ratify the Safeguarding Children & Vulnerable Adult and Domestic Abuse Procedures. 13 Formally consider the appointment of a Named Doctor for the Protection of Vulnerable Adults. STATUS July 2011 May 2011 2 x annually Aug 2011 & Nov 2011 Review of progress and activity 6 x annually May 2011 Aug 2011 All Wales Initiative All Wales Initiative Oct 2011 June 2010 June 2011 June 2011 May 2011 The implementation will be monitored by the Assistant Director of Safeguarding with appropriate delegation to the Operational Forum and Task and Finish Groups Safeguarding Annual Report 2012 FINAL 3

7 Main tasks completed / evidence considered by the Sub-Committee during this reporting period: The corporate direction of the Safeguarding Agenda is clearly strengthened by combining the Safeguarding Children, Vulnerable Adult and Domestic Abuse Agenda. Safeguarding is highly emotive, political and the agenda is significantly increasing. The complexity of abuse cases and high level of risk is making the organisational agenda challenging with increased expectation of further multiagency activity. This multi-agency agenda includes activities under Multi-Agency Public Protection Arrangements (MAPPA) which places a statutory duty upon NHS organisations including specific reference to Mental Health Services, to fully engage with the preventative plan to reduce the risk of individuals who have served a custodial sentence and are assessed as High Risk or Very High Risk or known as the Home Office critical few of re offending. The Multi Agency Risk Assessment Conferences focus upon victims of Domestic Abuse and again are recognised as high risk of further and or continued violence. Safeguarding Children & Vulnerable Adults 7.1 Safeguarding Children Named Doctor The appointment of the Named Doctor for Betsi Cadwaladr University Health Board was noted as a risk to the organisation as it remains an outstanding appointment due to the formation of the new organisation. Work has been ongoing to secure the position and hopefully Dr Lindsay Groves will be appointed to this position and takes the strategic and professional medical lead on all aspects of the health service contribution to safeguard children across the organisation and other agencies. This appointment provides the consistent strategic direction for medics and the identified accountability and responsibility to support the Assistant Director of Safeguarding whose duties also include the responsibility and accountability of the Named Nurse function. 7.2 Safeguarding Team Structure The implementation of the structure due to financial arbitration agreements with Clinical Programme Groups and the required re-writing of the job descriptions and progress activities required by the Organisational Change Policy. The designated post of Domestic Abuse remains fundamental especially due to the increased scope, which includes Female Genital Mutilation, Human Trafficking and Honour Based Violence, which spans across the Safeguarding Children & Vulnerable Adult agenda. 7.3 Quality Assurance Framework The Quality Assurance Framework remains a benchmark for the Clinical Programme Groups (CPG s) and Corporate Teams and has provided guidance relating to statutory legislation and best practice guidance to enable some of the CPG s to implement a safeguarding forum within their internal reporting framework. This structured approach provides them with the ability to measure their compliance and improve patient care and safety through greater awareness. Safeguarding Annual Report 2012 FINAL 4

Safeguarding Children and young People 7.4 Safeguarding Children & Young People Supervision Strategy Statutory guidance and the All Wales Child Protection Procedures 2008 requests Health Visitors, School Nurses and Midwives to have clinical case supervision. The purpose of the strategy was to develop a consistent standardised approach and awareness across the new organisation and include the service provision for nursing staff who hold a case load but also include adhoc supervision and advice for all employees (medical and nursing) contractors and volunteers. Whilst supervision s overriding priority is to promote and protect the interests of the service users, effective and accessible supervision is also essential in order to ensure staff working with children and families, on a regular basis, are fully supported. It enables practitioners to enhance patient/client protection and safety of care in complex clinical situations. It is central to the process of learning and to the expansion of the scope of practice, and should be seen as a means of encouraging self-assessment and analytical and reflective skills. Betsi Cadwaladr University Health Board provides an opportunity for all Health Visitors and School Nurses to access Safeguarding Supervision every six months or more frequently if required. A standardised system was introduced in September 2011 ensuring this staff group were provided with equal opportunities for supervision across the organisation. Documentation used for supervision was also standardised in October 2011 across the organisation to ensure a consistent approach by supervisors. This standardised system has been successfully implemented and is perceived positively by both supervisors and supervisees. Supervision 2 x Annually Health Visitors/ School Nurses/Other 1 x Annually Health Visitors/ School Nurses/Other More than 2 x Annually Health Visitors/ School Nurses/Other No Supervision accessed Health Visitors/ School Nurses/Other Group Supervision Health Visitors/School Nurses/Other No. % No. % No. % No. % No. of Sessions within the 12 month period 15.6% 60% Gwynedd (Converted to 12 37.5% 5 6 6 mthly June ) 14 43.7% 1 (sick leave 3.1% 15 plus 58 by Liaison Nurse in the Acute Setting 6 Anglesey 2 7.6% 18 81.8% 0 0% 0 0% 6 Conwy 25 71% 7 20.5% 3 9% 0 0% 6 Denbighshire 20 50% 13 32.5% 6 15% 1 2.5% 6 Wrexham 6 12% 52 100% 0 0% 0 0% 3 Flintshire 21 41% 51 100% 4 8% 0 0% 4 2X NHS & 2 x F/Start Midwifery individual case specific supervision 20 excluding telephone & adhoc Safeguarding Annual Report 2012 FINAL 5

Children on Register Gwynedd As at 31.03.11 As at 31.03.12 No. % No. % 0.23% 36 + 8 0.24% temp 0.22% 13 0.26% 41 + 2 temp 11 Gwynedd North Anglesey 66 0.47% 93 0.66% Conwy 42 0.2% 53 0.2% Denbighshire 87 0.34% 84 0.33% Wrexham 156 0.05% 68 0.02% Flintshire 88 0.28% 95 0.3% Number of Case Conferences 1 st April 2011 31 st March 2012 Total: Gwynedd 127 Gwynedd North 58 Anglesey 108 Conwy 124 Denbighshire 356 Wrexham 427 Flintshire 193 Additional activity driving the supervision is the number of children on the Child Protection Register and the number of Case Conferences, which require supported preparation and expert advice and guidance by the Safeguarding Children Nursing Team. 7.5 Multi Agency Public Protection Arrangements (MAPPA) NHS organisations under statute have a significant role in the multi-agency arrangements. The MAPPA Guidance has statutory authority (duty to co-operate) Sec.67 & 68 of the Criminal Justice and Court Services Act (2000). It was noted by the strategic MAPPA Board that Mental Health Service Provision at MAPPA Level 3: Very High Risk of Harm was inconsistent. The Safeguarding Lead within Mental Health and Learning Disabilities CPG developed guidance and a memorandum of understanding within the service to ensure full participation and guidance with recorded and noted successful engagement. The Duty to Co-operate imposed duties on the Police and Probation Service to establish arrangements to work together with support and engagement with statutory agencies to manage risk posed by dangerous offenders in the community. MAPPA 2: High risk of harm monthly meetings in each Local Authority area MAPPA 3: Very high risk of harm on a basis of need in each Local Authority area Strategic MAPPA: 4 times per year, inclusive of 3 sub-groups Safeguarding Annual Report 2012 FINAL 6

The North Wales MAPPA Performance Management Report 2011/2012 indicates Betsi Cadwaladr University Health Board activity. It recorded the attendance at Strategic MAPPA Board meeting 100% and; Attendance at Level 2 meetings Attendance at Level 3 meetings 1 st Quarter 2 nd Quarter 3 rd Quarter 4 th Quarter TOTAL 100% 100% 100% 99% 100% 100% 100% 100% 93% 98% It was noted that the attendance of Health shows consistent improvement. 7.6 Multi Agency Risk Assessment Conference (MARAC) MAPPA guidance requires monthly meetings in each Local Authority areas to manage and co-ordinate multi-agency protective measures for victims of Domestic Abuse. Number of cases discussed which involved children held between 01.04.11 31.03.12 Local Authority Area 2010-2011 2011 - -2012 Flintshire 158 Wrexham 180 Conwy 125 Denbighshire 137 Gwynedd 134 Anglesey 91 1167 825 7.7 Domestic Abuse and Violence The Domestic Abuse agenda has had an impact upon activities and expectations of Betsi Cadwaladr University Health Board employees and independent contractors. The Agenda includes the awareness of Honour Based Violence (HBV) in relation to three aspects; Forced Marriage, Honour Crimes; and Female Genital Mutilation. Trafficking and Sexual Exploitation Training to identify and inform detection and risk, reporting and engagement with this agenda is paramount. Domestic Homicide Reviews are part of the Domestic Violence, Crime and Victims Act of 2004 and became law from 13 th April 2011. They do not replace but will be in addition to the inquest or any other form of inquiry. Currently one Homicide Review is ongoing. Safeguarding Annual Report 2012 FINAL 7

Referral Statistical Data received by Wales Domestic Abuse and Sexual Violence Helpline for the purpose of MARAC referrals: Cases heard at MARAC per Local Authority 01.04.11-31.03.12 Total Anglesey 13 Gwynedd 24 Conwy 37 Denbighshire 37 Flintshire 29 Wrexham 43 Total Number of Cases taken to MARAC 183 Total Number of Cases NOT taken to MARAC 65 (52 accounted for by Eastern PPU Division: 13 accounted for by Central & Western PPU Divisions in addition to Out of Hours 7.8 Training The Training Task & Finish Group was requested to develop a combined Safeguarding Children, Vulnerable Adult & Domestic Abuse Training Strategy, this remains in draft at the time of writing this report. The Annual Training Programme was reviewed but inconsistent support from the corporate Training Department has caused difficulties with the development of an Annual Training Programme; however, work is ongoing to resolve this. The provision of venues continues to cause an inconsistent approach and remains a recognised risk. E-Learning Level 2 Basic Awareness Total BCUHB 662: have completed with an average score of 89.64% Total BCUHB101: are in progress started but not finished pass mark 80% The development of this training package was funded by Charitable Funds Total BCUHB141: BCUHB staff attended Local Safeguarding Children Board Training Events and Specialist Events It has been agreed that: BCUHB Board Members will received Safeguarding Role & Responsibility Training from the Assistant Director of Safeguarding (April 2012). Domestic Abuse Domestic Abuse training is currently offered as mandatory training for all staff Safeguarding Annual Report 2012 FINAL 8

employed by and contracted to BCUHB at Level 2. This training includes raising awareness, enquiry into domestic abuse, risk assessing domestic abuse using the DASH model, referring to specialist support services & MARAC. Honour Based Violence HBV training is currently offered as part of the BCUHB Child Protection mandatory training strategy. This training includes raising awareness in relation to all three aspects of HBV. These aspects are: Forced Marriage; Honour Based Crimes; and Female Genital Mutilation. Trafficking & Sexual Exploitation The delivery of health services and support for victims has been enhanced through the Sexual Assault Referral Centre (SARC) in Colwyn Bay. The Service Manager for SARC is a member of the BCUHB Domestic Abuse Forum, which has further enhanced the interface between Domestic Abuse, Trafficking and Sexual Exploitation. BAWSO are currently leading on the Honour Based Violence Campaign across North Wales to educate communities and professionals in relation to Female Genital Mutilation, Forced Marriage and Human Trafficking. Whilst there is no dedicated training strategy in relation to Trafficking and Sexual Exploitation it does form part of the Child Protection Level 3 training and will continue to be incorporated into future training strategies of both Child & Adult Protection. 2011 2012 LEVEL TRAINING TOTAL Level 2 Domestic Abuse 792 monthly training across 3 divisions Level 3 Honour Based Violence 160 Safeguarding Annual Report 2012 FINAL 9

SAFEGUARDING CHILDREN TRAINING STATISTICS March 31 st 2011 to April 1 st 2012 Flintshire & Wrexham 2010/11 2011/12 LEVEL 2 TOTAL 458 334 LEVEL 3 TOTAL 212 249 FINAL TOTAL 670 583 Conwy & Denbighshire 2010/11 2011/12 LEVEL 2 TOTAL 634 645 LEVEL 3 TOTAL 114 40 FINAL TOTAL 748 685 Gwynedd & Anglesey 2010/11 2011/12 LEVEL 2 TOTAL 278 318 LEVEL 3 TOTAL 364 335 FINAL TOTAL 642 653 Safeguarding Annual Report 2012 FINAL 11

LEVEL 3 FACILITATED BY Named Doctor LEVEL 3 Medical Students 74 Paediatricians 49 A&E Staff 48 Crisis Workers SARC 9 Police 6 Joint Investigation Lecture 25 Various CPG audience 175 FINAL TOTAL 386 GP Training/Independent Contractors LEVEL LEVEL 2 BCUHB 76 LEVEL 2 PHW TRAINING 39( from BCUHB Database) 252 ( from SCS/ PHW database) LEVEL 3 PHW TRAINING 22 Training sessions for this period from SCS/PHW were available to BCUHB but due to internal organisational issues within BCUHB these were not utilised Midwifery Training LEVEL 2 TOTAL LEVEL 3 18 (student midwives) TOTAL 218 FINAL TOTAL 236 Level 1 Induction Programme Level 4 2010 2011: 60 2011 2012: 24 FINAL TOTAL 137 Safeguarding Annual Report 2012 FINAL 12

Children Looked After (formally known as LAC) 7.9 Health Assessments for Children and Young People Looked After BCUHB A child or young person becomes Looked After when they live with foster carers with or without a care order, or with their parents but under a care order to the local authority. It is a statutory requirement for all children and young people who are looked after to have regular assessments of their health and development to ensure that all their health needs are met and to empower and educate them about their own health issues. The requirement for these assessments is annually for children above five years of age and six monthly for children below five years of age. Across BCUHB these health assessments may be carried out by community paediatricians, health visitors, school nurses or specialist nurses for looked after children. Over the recent years and specifically after the tragic death of baby Peter Connolly in 2006 the numbers of children and young people entering the care system has steadily increased. There are three categories of children looked after within a local authority at any one time: 1. Child placed within the home local authority. (The child/young person is the responsibility of the home authority and looked after health assessments are undertaken within the county) 2. Child is placed in another local authority (The child is the responsibility of the home authority but the looked after health assessments are undertaken by clinicians out of county ie: in the county where the child lives) 3. Child from another local authority is placed within the home county ( out of county placements ). (The child/young person is the responsibility of the placing authority but the looked after health assessment is undertaken within the county where the child has been placed) The figures in Table 1 have been collated across BCUHB. This is the first time it has been done and it is possible that figures may relate to different activity eg: the figures from Anglesey include the examination of out of county placements, whereas the Conwy figures reflect only Conwy children (they do not capture the health assessments completed by BCUHB staff for children from other authorities). There will be an attempt to standardise collection, retrieval and presentation of data more accurately for the forthcoming reports. What is clear, however, is that April 2011 to March 2012 showed an increase in looked after health assessments in three of the local authorities. Conwy had lower numbers that the previous year. Flintshire provided figures for 2011/12 only. Statistics were not received from Gwynedd. Table 1. HEALTH ASSESSMENTS FOR LOOKED AFTER CHILDREN AND YOUNG PEOPLE 2010 2011 2011 2012 County Number of health assessments % completed within target time Number of health assessments % completed within target time Wrexham 164 not stated 187 not stated Flintshire - - 287 not stated Conwy 225 95% 205 88% Denbighshire 251 83% 251 80% Mon 151 not stated 182 98% Gwynedd - - - - Safeguarding Annual Report 2012 FINAL 13

Child Protection Medical Examinations BCUHB Examinations for non accidental injuries (NAIs) are undertaken at the request of Social Services or the Police. After hours or when children present with acute or life threatening injuries they are seen by the acute paediatricians in Glan Clwyd, Ysbyty Gwynedd and the Wrexham Maelor Hospitals. Within the counties of Flintshire, Wrexham, Conwy and Denbighshire the majority of non acute examinations for suspected physical abuse, sexual abuse, emotional abuse and neglect have traditionally been undertaken in the community by community paediatricians. The situation has been different in the West where the majority of these examinations were undertaken in Ysbyty Gwynedd by hospital paediatricians. From 2012 this situation has changed and in future more of the examinations in the Gwynedd & Anglesey will be undertaken in the community. A small number of forensically trained community paediatricians undertake forensic examination for suspected child sexual abuse both within office hours and out of hours. These examinations take place in the Sexual Assault Referral Centre (SARC) which is situated in Colwyn Bay. The number of examinations for suspected non accidental injuries has remained fairly constant over the past two years. The larger numbers for Wrexham and Flintshire shown below are because they include examinations by hospital paediatricians.the system for capturing the number of non accidental injury examinations conducted within the hospitals is currently not standardised. Table 2. CHILD PROTECTION EXAMINATIONS CONDUCTED BY PAEDIATRICIANS (WITHIN OFFICE HOURS) physical abuse, sexual abuse and neglect County 2010/11 2011/12 Wrexham 57 both community and WM hospital 56 both community and WM hospital Flintshire 52 both community and WM hospital 51 both community and WM hospital Conwy 21 community only 30 community only Denbighshire 24 community only 25 community only Mon 10 community 15 YG hospital 16 community 22 YG hospital Gwynedd - - SARC Activity Examinations for suspected sexual abuse (both acute and historic) take place in the SARC. These are carried out by community paediatricians all of whom have been forensically trained Six community paediatricians take part in a rota to cover the out of hours forensic examinations for alleged sexual abuse in children. Children are seen from the ages 0 to their17 th birthday. Young people with learning difficulties who attend special schools may also be seen up to their 19 th birthday The number of requests for sexual abuse examinations for children remain small. The reason for this is unclear and this has been discussed at the SARC Steering Group, at LSCBs, with the Police and within the Child Protection Teams of the Social Services Departments. Safeguarding Annual Report 2012 FINAL 14

Table 3. CHILD PROTECTION EXAMINATION FOR SEXUAL ABUSE CONDUCTED BY COMMUNITY PAEDIATRICIANS (OUT OF HOURS) ACROSS NORTH WALES Calls and contacts Medical examinations undertaken out of hours 2008 2009 2010 2011 53 43 37 35 37 28 25 23 TOTAL 90 71 62 58 7.10 Local Safeguarding Children Boards (LSCBs) There are currently three LSCB s, each operating Executive Boards, Development/Operational Groups, Sub-groups and Task & Finish Groups. Betsi Cadwaladr University Health Board participation is a statutory requirement under Sec 31 (1) Children Act 2004; this necessitates participation and financial contribution. LSCB ANNUAL COSTINGS 2009-2010 2010-2011 2011-2012 2012-2013 Invoice Total Invoice Total Invoice Total Invoice Total Gwynedd & Anglesey 26,560.00 26,560.00 26,560.00 26,560.00 Conwy & Denbighshire 17,838.00 21,982.00 21,982.00 21,600.00 Flintshire 4,166.00 13,347.00 Wrexham 5,000.00 13,577.73 27,476.72 27,476.72 TOTAL 53,564.00 75,466.73 76,018.72 75,636.72 7.11 Safeguarding & Protecting Children in NHS Wales: A Report by Professor Sir Mansel Aylward CB (Nov 2010) On the 29 th September 2011 Health Boards and NHS organisations were informed that the Welsh Government accepted all the recommendations set out in Professor Sir Mansel Aylward s Report on the outcome of a review of Safeguarding and Protecting Children in the NHS in Wales. Safeguarding Annual Report 2012 FINAL 15

One particular recommendation (65) noted was the request for the establishment of an All Wales NHS Clinical Network for Child Protection and Safeguarding to be established by the end of 2011. Dr Heather Payne, Deputy Director of Maternal Child Health, was to provide advice and guidance, Public Health Wales is to lead on this activity on behalf of the Welsh Government. The report and recommendations were shared with the Safeguarding sub-committee and require collaboration from Workforce and Organisational Development to ensure implementation or recommendations relating to training activities. Progress was reported to the Welsh Government in January 2012. 7.12 Safeguarding & Protection of People at Risk In October 2011, in a written statement to the Assembly, The Deputy Minister for Children and Social Services set out her approach to safeguarding and protecting people in Wales. The announcement has built on the Welsh Government s commitments set out in Sustainable Social Services and A Programme for Government and includes a commitment to carry forward a Social Services (Wales) Bill in 2012. The Bill will include a statutory framework for protecting people (adults and children). It will consolidate arrangements for children and encompass new duties to investigate, co-operate and share information in the field of adult protection. It will also include a statutory definition of an adult at risk. Evidence presented by CSSIW and other Inspectorate boards suggest that Local Safeguarding Children Boards are not working as effectively as hoped. There is a rationale for fewer Boards, as is the case for placing Adult Protection Boards on a equitable footing with those for children. The new Safeguarding and Protection Boards will match the proposed Public Service Delivery footprint of six. When ministers believe that these Boards are operating effectively, assessed and ameliorated and there is evidence to support integration, then steps will be taken for the Safeguarding Children Board and Adult Protection Boards to merge to reflect the holistic approach required to safeguarding and protect people in Wales. 7.13 Significant Events Serious Case Reviews Under Section 32 (2) of the Children Act 2004, a Local Safeguarding Children Board is to have functions under regulation of review and investigate cases where a child dies, commits suicide or sustains a life threatening injury or there are safeguarding concerns, or the child/young person has been killed by a parent with a mental illness. The LSCBs in North Wales agreed that two cases met the criteria for a review and a further four cases were completed with recommendations and action plans implemented and audited. In addition a further case was reviewed under A Case of Special Interest. Safeguarding Annual Report 2012 FINAL 16

Allegations of Abuse or Cause of Concern about a Person who works with Children. Six cases were investigated both internally and externally. To date one case remains a criminal investigation. Safeguarding procedures dictate that a Multi-agency meeting must be convened to ensure independence and professional challenge and information gathering. 7.14 Adult Protection Introduction Adult Protection is a key patient safety issue for the Board and remain high on the agenda for Safeguarding. The Board promote a culture of zero tolerance to any form of abuse. Staff training and raising awareness is desirable and essential to minimise the risk of harm to a Vulnerable Adult. The BCUHB Adult Protection policy provides a safeguarding framework for staff to react appropriately and effectively arising from a concern, disclosure or suspicion of abuse. The policy document is accessible to staff on the intranet and underpins the key principles arising from the National Guidance In Safe Hands 2000 and the All Wales Interim Adult Protection Policy and Procedures in Wales published in November 2010. 7.15 National Profile The status of the All Wales Interim Policy and Procedures introduced last year has had a positive impact across the Health Board ensuring consistency of practice across all agencies involved in Safeguarding. In light of the proposed legislation announced, it is inevitable that All Wales Policy may require further amendment to reflect any changes arising from the final legislation. The key themes arising from the Social Services Bill are:- - Providing a legal definition of adult at risk and harm. - Classification of people deemed to be at risk, thus widening the threshold of Safeguarding. - Creating a duty to report, cooperate, investigate and sharing of information. - Defining a range of duties for agencies, although Social Services will continue to be the lead agency in Adult Protection in Wales. - Introducing a power to intervene and protect. At Executive level a National Independent Safeguarding Board will be established which will be responsible for Adult and Child Protection. A shadow Board is likely to be in place later this year. At Regional level 6 Safeguarding Adult and Children s Board will be set up each running parallel of each other replacing the 22 LSCBs. Its duty and Terms of Reference will be set out in the regulation. There is no clear timetable as to when the Bill will become law. However, the early indication is that a draft Bill will be presented to the Welsh Government by October 2012. The proposed legislation will replace the National Guidance and a further review of the All Wales Policy document is inevitable to comply with the regulation. Safeguarding Annual Report 2012 FINAL 17

7.16 Regionally There is ongoing discussion across 4 local authorities in North Wales excluding Gwynedd and Ynys Mon who have already merged to form a joint Adult Protection Committee. The rationale is to have 3 APC across North Wales. The current discussion involve Wrexham and Flintshire, also Denbighshire and Conwy. The future status of the APC remain unclear in light of the proposed changes in particular the link between the APC, Strategic Safeguarding Adult Board and the National Independent Safeguarding Board. 7.17 Progress arising from last year key objectives a. Amendments to the BCUHB POVA Policy The BCUHB Adult Protection Policy was amended to reflect the changes arising from the implementation of the All Wales Interim Policy document in April 2011. Further changes were also made to the guidance issued to Hiring Managers arising from Review of the Safeguarding Group Act (2006) to the role of the Independent Safeguarding Authority (ISA) with responsibility for Vetting and Barring Scheme (VBS). Reporting of pressure ulcer grade 3&4 under Adult Protection to exclude neglect or negligent in compliance with HIW Inspection Report (March 2010) was also included in the Policy. The revised system and process was rolled out last October across the Health Board. The POVA network contact sheet was updated to provide frontline staff with the correct link and contact numbers during the POVA process. b. Safeguarding Training Strategy The Board has developed a draft Safeguarding Training Strategy underpinning Child/Adult Protection and Domestic Abuse. This is an overarching strategy underpinning common themes in training arising from the three Safeguarding Teams. To ensure consistency and identified accountability, there is to be a Safeguarding Training Strategy which will incorporate Adult Protection, Safeguarding Children and Domestic Abuse. c. Review of Adult Protection Training Following an audit of POVA training last year, the training content was revised to comply with the recommendations rising from National Inspection reports and All Wales policy document. d. Partnership Working The Health Board continue to engage with other partner agencies in Safeguarding to ensure that the principles and practice embedded in the local policy is consistently Safeguarding Annual Report 2012 FINAL 18

applies across the organisation. The Board has strong links with all key agencies working in partnership to improve practice at local level. 7.18 POVA Activities There is an increasing trend of POVA referrals raised by BCUHB staff over the last few years. Improved POVA training uptake has resulted in a reduction to the number of inappropriate referral. The implementation of the revised system and process to report pressure ulcers at grade 3 & 4 has significantly increased the workload of the POVA office. During the last 6 months, effective from October the 1 st 2011 when the revised system and process was introduced to report pressure ulcer under Adult Protection, 212 Trigger sheets were completed by BCUHB staff and sent to the POVA office 27 cases were escalated through the POVA process having meet the threshold. The breakdown of the activities per locality is as follows:- Locality POVA referrals (including pressure ulcer). Pressure Ulcer Trigger sheet (October to March) Central 177 24 3 East 110 145 23 West 74 43 1 Total 361 212 27 7.19 a Classification of Abuse No meeting the POVA threshold The classification of abuse is consistent with last years figures and the National profile in Wales. More than 1 category has been applied appropriately in line with the All Wales Policy. The breakdown is as follows:- - Physical = 130 - Neglect = 61 - Financial = 50 - Sexual = 16 - Emotional = 158 b Unsafe Discharges The HIW inspection report March 2010 recommended that unsafe discharge from hospital could have a negative impact on the Vulnerable Adult and thus poses a significant risk of harm to them. During the last 12 months 12 cases were referred through the POVA process, of which were 10 in the Central and 2 in the West. c Links with the Concerns Team A significant number of POVA referrals were also triggered off last year arising from an alert raised by the Concerns Team following a care concern raised by others. The POVA office has developed strong links between Safeguarding and the Concerns Team and remains a key recommendation arising from HIW Inspection report. Safeguarding Annual Report 2012 FINAL 19

The Safeguarding POVA trends Report 2011/2012 Place where alleged abuse occurred 0 Day care 0 2 (0.7%) 0 Public place 0 1 (0.4%) 77 (20.4%) Hospital - NHS 54 (13.5%) 29 (10.7%) 9 (2.4%) Supported tenancy 15 (3.8%) 16 (5.9%) 54 (14.3%) Care home - nursing place 43 (10.8%) 31 (11.4%) 56 (14.8%) Care home - residential place 58 (14.5%) 23 (8.5%) 175 (46.3%) Own home in community 220 (55.1%) 162 (59.8%) 0 50 100 150 200 250 300 35 2010 - (n=271) 2011 - (n=399) 2012 - (n=378) Safeguarding Annual Report 2012 FINAL 20

7.20. Significant Events Last year 18 cases were escalated and reported to the Safeguarding Sub Committee to include:- 4 Cases where significant harm or death of service user has occurred. 13 Allegations of poor practice by staff. 1 Allegation of assault made against staff. Issues of significance also involved the Independent Sector e.g. Nursing Homes and Hospitals where the Health Board has commissioned services on behalf of vulnerable groups of service users. The following care homes were subject to ongoing concerns arising from the statutory Guidance issued by WAG during May 2009. These were:- Subject of Type of Outcome Current status concern Home/Hospital Nursing EMH Anglesey Resolved needs monitoring Nursing EMH Gwynedd Resolved needs monitoring Nursing EMH Gwynedd Resolved needs monitoring Nursing EMH Flint Resolved needs monitoring Nursing EMH Wrexham Ongoing Nursing EMH Conwy Closed Nursing EMH Denbighshire Ongoing Independent AMH/ LD Wrexham Ongoing hospital Residential AMH / LD Gwynedd Ongoing Independent Hospitals (providing Mental Heath Service) 3 independent Hospitals Detention of patient with Mental Health without the proper legal authority arising from the Mental Health Act. HIW was very much involved as the Health Regulator Legal status reinstated 7.21 Serious Case Review The local APC has instigated a serious case review following the death of 3 service users in receipt of Mental Health Service. Safeguarding Annual Report 2012 FINAL 21

The death of 1 service user occurred in Denbighshire and was subject of a criminal proceeding last year. The other 2 were resident in Wrexham. The SCR is still ongoing. 7.22 HIW Inspection HIW undertook an inspection of services in the Central locality between February 27 th and March 2 nd 2012. Safeguarding (Adult) was a key factor and local system and process came under scrutiny by the reviewers. The Board await the outcome of the Report. 7.23 Training Adult Protection is mandatory at level 1 on induction and at the appropriate level 2 or 3 for Health Board staff coming in contact or working with Vulnerable Adults. Training is coordinated, planned and delivered at corporate and local level. An audit tool has been developed to test the effectiveness, robustness and fitness of purpose of POVA training delivered in house at level 2 and 3. Last year 160 training sessions were delivered across the Health Board of which 121 were at level 2 and 39 at 3. The breakdown per locality is as follows;- Locality Level 2 Level 3 East West Central 52 41 28 12 15 12 The overall BCUHB compliance is estimated at level 2 to be 60% and 70% at level 3. In addition 2 staff attended level 4 training specific to POVA investigation coordinated by the Local Authority. The CPGs have been contacted to provide details of staff training compliance at local level. Unfortunately, only one CPG has responded. It is anticipated for the CPG to provide the data which will form part of the Annual Training report for last year. 8 Key Objectives 2011-2012 Objective 1 To improve the overall Adult & Child Protection Training compliance, working in partnership with CPG and corporate Leads 2 Ratify the Safeguarding Training Strategy (Adult Protection, Child Protection & Domestic Abuse) 3 The system and process to report pressure ulcer under Adult Protection will be reviewed to test effectiveness 4 Develop the Dementia Action Plan in collaboration with all CPG stakeholders, Acute Care, Community, Mental Health Services and the independent sector 5 Implementation and review of the Action Plan arising from the older persons Commissioners Report underpinning Fundamentals of Care Timescale Sept 2012 Feb 2013 August 2012 July 2012 May 2012 June 2012 Feb 2013 Safeguarding Annual Report 2012 FINAL 22

6 Having considered the appointment of a named Doctor for Aug 2012 Adult Protection proceed with the activity 7 Full implementation of the Safeguarding Structure June 2012 8 Review the Safeguarding Reporting Framework Jan 2013 9 Implementation and dissemination of recommendations from Serious Case Reviews July 2012 Nov 2012 March 2013 10 Update and review the Safeguarding Quality Assurance Jan 2013 Framework 11 Identify and implement Reporting Framework relating to Children Looked After and the Nursing activities to the Safeguarding Sub-Committee Dec 2012 12 Implementation of Risk Assessments and Information Sharing Agreements relating to the Safeguarding agenda and Information Sharing agenda July 2012 Feb 2013 9 Significant Issues and all Safeguarding Sub-Committee minutes are recorded and forwarded onto the Quality & Safety Committee 10 New Risk Information Governance and Information Sharing (Data Protection/WASPI) Safeguarding Information sharing and accessibility are paramount within this agenda. Restrictions placed upon BCUHB delays communication, affects governance and may place those recognised as vulnerable and or at risk at greater risk. 11 The risk has been escalated by the Operational Forum to the Sub-Committee and discussed at the Quality & Safety Lead Officers Forum. Support has been given to enable implementation of the symphony System across BCUHB, collaborative work and agreed risk assessments have been developed with full support from Information Governance Team to develop strategies and pathways to share information safely and quickly to meet the statutory multi-agency agenda. 12 Further Comment The Safeguarding National, Local and Internal agenda has significantly increased recognising patient dignity, care and treatment within the arena of Fundamentals of Care meet the safeguarding agenda. The complexity of Child Abuse cases with reference to Substance Misuse, Mental Health and Domestic Abuse requires specialist intervention, knowledge and expertise. It is imperative that the Safeguarding Structure is fully implemented to support the organisation and fulfil its statutory duties to safeguarding the organisation, staff and more importantly service users. The introduction of legislation placing Adult Protection in statute will define the role and responsibilities of agencies creating a duty to report, protect, collaborate and share information within a multi-agency framework. The establishment of the National Independent Safeguarding Board at Executive level and the introduction of Safeguarding Boards for Adults and Children will have wider implications for all agencies involved in Safeguarding. Safeguarding Annual Report 2012 FINAL 23