Safeguarding Children, Young People and Adults - PowerPoint Presentation

1. Safeguarding Children, Young People and Adults Annual Report 2017 – 2018 Alison Robertson Chief Nurse Assisted by Named Safeguarding Professionals & Head of Social WorkMay 2018 1

2. Key Achievements 2017/18 The Safeguarding Team reached a full complement of staff in March 2018, which has raised the profile of safeguarding across the organisation.Improved oversight of data relating to safeguarding activity across the Trust for the past 12 months and an enhanced data set is provided quarterly to QSAC. The Named and Deputy Named Doctors have provided cross –Trust supervision for cases of perplexing presentations in addition providing input to the complex gastro Multi Disciplinary Team. This was not previously possible due to team capacity.A review of the safeguarding children training requirement has taken place and future plans for 2018/2019 include increasing the number of staff who are required to complete an enhanced level 3 training to ensure a competent workforce.Progress has been made towards implementing the recommendation from an external safeguarding review to develop an integrated referral pathway for social work and safeguarding. A full update will be provided to the Quality Assurance Safeguarding Committee (QSAC) in July 2018. Safeguarding training has been extended with input from the social work team to include  such topics as risk assessment, difficult conversations and sexual abuse.In response to the identified numbers of adult patients, a specific Lead for Safeguarding Adults has been appointed who is working closely with the interim Mental Capacity Act Lead to ensure the needs of this group are met, as directed by statutory requirements. (6057 adults patients were seen in outpatients in 2017/2018 and 670 were admitted for a procedure, as a day case or overnight)The levels of safeguarding adult training requirements have been reviewed against the Intercollegiate Document for Safeguarding Adults 2016 and the Level 2 programme is now mandated for appropriate staff. Prevent e-learning and face to face training programmes have been included in the mandatory suite of training for the first time. Bi-annual safeguarding newsletters are sent to all staff to ensure they remain updated with key national and local developments. The Safeguarding Children and Young people Policy has been completely revised and was launched in January 2018.The Strategic and Operational Safeguarding Groups are now in place, enabling robust involvement from divisions and key disciplines across the Trust.There has been an increase in the areas of the Trust that have a Safeguarding Link and Safeguarding Link meetings are scheduled quarterly2

3. Introduction Great Ormond Street Hospital (GOSH) is an international centre of excellence striving to provide the very best care for children with rare and complex conditions to enable them to achieve their full potential. More than 296,252 admissions and appointments were made, across 63 different specialties, supported by a workforce of over 5,300 healthcare staff and volunteers. Most of the children we care for are referred from other hospitals throughout the UK and overseas. The Children Act 2004 (Section 11) places a duty upon all NHS Provider Services to ensure their functions are discharged with regard to the need to safeguard and promote the welfare of children. The Trust is expected to ensure that its provider arrangements are robust and that safeguarding and promoting the welfare of children is integral to clinical governance and audit arrangements. The Care Act 2014 sets out the statutory principles which apply to all health and care settings to safeguard vulnerable people over the age of 18 years. The Safeguarding Children, Young People and Adults Annual Report relates to the period from 01/04/2017 – 31/03/2018, and seeks to provide high level assurance to the Trust Board of the responsibilities and value delivered by the Trust Safeguarding Team and Social Work Service. The report updates on progress on work streams agreed within the work plan for 2017/ 2018. Reviews of the Safeguarding Service: Following an internal and external review of the safeguarding service, additional resources were identified for the Safeguarding Team.A full time Band 8A commenced in November 2017 in the role of Safeguarding Senior Nurse Specialist with a Lead for Safeguarding Adults, and 0.8 WTE Band 7 Safeguarding Nurse Specialist. In addition the team administrator role has increased from 0.7WTE to 1WTE.The additional resource allows for greater visibility across the Trust wards and departments to enhance early identification of any safeguarding concerns. The Safeguarding and Social Work teams are working with greater collaboration than ever beforeA joint away day was held in October 2017 to plan a more collaborative strategy and resulting in a Task and Finish Group established to implement the recommendations of the reviews. Both teams are:Co located for 2 hrs daily Monday – Friday. The time period will increase once suitable accommodation is secured. Co facilitating an increasing number of supervision sessions to staff.Providing a Multi agency delivery of training at level 3.Meeting fortnightly at senior level to address any challenges.Working with EPIC and Onbase teams to ensure appropriate access to safeguarding records. The Named Professionals and Head of Social Work meet regularly and are working together to implement the wider recommendations of both safeguarding reviews.3

4. Safeguarding is everyone’s responsibility. The Chief Nurse is the Executive Lead for Safeguarding and is supported by the Named Professionals and Head of Social Work. The Named Nurse provides strategic oversight and is assisted by the Senior Nurse Specialist with operational management of the safeguarding service to ensure both statutory and local requirements are achieved. The Executive Lead and Named Professionals attend Camden Safeguarding Children’s Board (CSCB) and its subgroups to ensure that the Trust is actively involved with local multi-agency developments and provision of assurance at all levels. The Strategic Safeguarding Committee (SSC) meets quarterly and Camden’s designated safeguarding professionals are invited. The Operational Safeguarding Group (OSG) meets twice between each SSC . The aims of both groups are to provide assurance that the Trust promotes the safeguarding of children young people and vulnerable adults at all times. A quarterly report is compiled for the Quality Assurance Safeguarding Committee (QSAC), and an annual report for Trust Board.Governance & Accountability Arrangements The Clinical Quality Review Group (CQRG) meets quarterly with commissioners from NHSE and receives safeguarding updates. The Trust provides quarterly metrics to its commissioners from North West Central London reporting on four key areas; - training - audit - safeguarding supervision - participation in Child Protection Conferences. The Care Quality Commission have safeguarding as a Key Line of Enquiry in their inspections. CQC inspected the Trust in January 2018. Safeguarding was judged to be good within the areas inspected with a challenge identified to improve Safeguarding Children compliance at Level 3. (see Training data) 4

5. Safeguarding Team Activity Case Activity The activity incorporates advice, support ,attendance at child protection meetings and multi-disciplinary team meetings as well as constructing chronologies and section 17/47 requests for information from Local Authorities. (Requests for information relating to Children in Need and Child Protection)Overall activity for this year has increased by 19% and there has been a year on year increase since activity data was formally reported in 2015.Case activity has increased for every quarter, compared to 2016/17 and there has been a year on year increase The co-location of the safeguarding and social work teams which enhance the single duty team approach continue daily but remain limited to part time, due to space restraints. Additional space is unlikely to be available in the interim. Child Protection Conference The Safeguarding Team coordinate and review reports provided by GOSH professionals to ensure appropriate contribution to the multi agency process. Non involvement by GOSH professionals is primarily due to late notification of conference or non engagement of professionals. The Trust takes its responsibilities for safeguarding children very seriously and the cases of non-engagement are escalated to Divisional Management to achieve compliance. Information is submitted but this may be post conference. Serious Case Reviews The Trust has been asked to contribute to 5 new SCRs in 2017/18 involving 9 children. 4 cases remain active with independent overview reports in progress. 4 cases have been published but 2 have been in a redacted format to protect the identity of the children.Learning is disseminated to staff and included in training and supervision.For the first time the majority of open SCRs with GOSH involvement have actual or suspected Fabricated or Induced Illness as their main factor, these require significant resources from the Safeguarding Team. 5

6. Safeguarding Adults The Operational Lead for Safeguarding Adults has been in post since November 2017. This role is incorporated into the Senior Nurse Specialist for Safeguarding Children and Adults position. Adult patients seen at GOSH in 2017: Safeguarding Adult Reviews (SARs)Safeguarding Adult Boards (SABs) have a statutory duty to arrange a SAR when an adult in its area who has care and support needs dies as a result of abuse or neglect, and there is concern that agencies could have worked more effectively to protect the adult. Over the past year the Trust has completed one Individual Management Review for Islington SAB regarding an adult who had historic contact with GOSH. We are waiting to hear whether this will progress to a SAR. Mental Capacity Act / Deprivation of Liberty Safeguards (DoLS) A scoping exercise looking at the role of the MCA Lead at GOSH has been undertaken by the Interim GOSH MCA Lead, supported by the Senior Nurse Specialist for Safeguarding Children and Adults. Gaps in compliance with the legislation have been identified. These include the need for a permanent MCA Lead, a MCA Policy and issues with capacity assessment and consent. Recommendations made to address these and to prepare for changes to the DoLS legislation are being acted on.Policy and proceduresThe existing Safeguarding Adults Policy will be comprehensively reviewed over the next few months to reflect current legislation and practice, and a new policy to provide guidance around the MCA (2005) is being developed. Supporting the local safeguarding systemGOSH is now represented on Camden SAB’s Learning and Communications Subcommittee and reports on safeguarding adults training compliance to Camden CCG.The Senior Nurse Specialist for Safeguarding Adults and Children also represents GOSH at the London Safeguarding Adults Provider Forum and the London MCA/DoLS Network.6TrainingLevel 2 Safeguarding Adults training will become mandatory for all qualified staff at GOSH from June 2018. Initially this will be an assessed 30 minute e-learning module. This is consistent with the draft intercollegiate document covering Safeguarding Adults training, which states that Level 2 is the minimum level of Safeguarding Adults training required for all qualified healthcare staff.Type of contact Numbers Admitted for 1 night or more (longest admission was 38 days)69Admitted for a procedure / as a day case.(Includes cardiac MRI)601Outpatients (2017/2018)6057TOTAL6727Top 5 admitting specialties:CardiologyUrologyDental & Maxillary FacialNeurologyPlastic Surgery 54922151310

7. Training Substantive Contract Holders A new model for Safeguarding Children Level 3 was introduced in February 2017. Staff are required to complete 2 hours of Safeguarding Children Level 3 training each year to maintain compliance. This is achieved through either attending a face to face course or completing an online module. Staff must attend a face to face session at least once over a 3 year period. One of the challenges of this model is that the learning management system (GOLD) cannot automate this process. Responsibility sits with the learner to ensure that they are doing the right course at the right time. The introduction of this new model has had a positive impact on compliance figures. In February 2017, compliance for Safeguarding Children Level 3 was 66%. In March 2018 it had climbed to 78%. The Safeguarding Team and the Learning and Development team completed a review of all Safeguarding Children training content in November 2017, updating content where appropriate.The external training resource was decommissioned in March 2017. All Safeguarding and Prevent training going forward will be delivered using internal resource.Prevent training moved from being a required competency to a mandatory requirement on 26th March 2018. Compliance for Prevent Level 3 stands at 79%. This is on track with NHS England’s directive to be 85% compliant in this topic by July 2018.A decision was made at the Education and Workforce board in March 2018 to make Safeguarding Adults Level 2 a competency for staff in the target audience (as defined by the Core Skills Training Framework and the Intercollegiate document) from April 2018. This will be moving to be a mandatory requirement from 1st June 2018.Honorary Contract holders In December 2017, medical Honorary contract holders were identified as the staff group with the lowest compliance across the Trust.In January 2018 an extensive piece of work was undertaken to ensure all Honorary Consultants contract holders were compliant with the required training by the end of March 2018, as follows:HR conducted an audit/data cleanse of honorary contract holders with HOCS and specialist teamsContract holders were contacted by email on 11th January requesting them to submit evidence of compliance in their statutory and mandatory training (from their substantive trust) by 25th January 2018In addition, HR also contacted the substantive Trusts and to request that they provide copies of the relevant training recordsAll evidence received by the Learning & Development Team has been uploaded/recorded in the GOLD Learning Management SystemContract holders who did not respond to the first email were contacted again on 19th February and 14th March stating if evidence was not provided (or it is not current/compliant), they must complete the relevant training by the end of March 2018 in order to retain their honorary contracts.If compliance was not demonstrated by the end of March, individual’s honorary contracts will be withdrawn along with system access etc.  To support this initiative, additional budget was agreed and the Learning & Development Team planned in 8 additional Safeguarding Level 3 Multi-Professional Study Days (from mid-February to end to March) to accommodate any consultant requiring to attend the face to face training.  Uptake of this training by Honorary Consultants was poor – only 6 honorary contract holders booked on and attended this training.7

8. Supervision Effective supervision has a significant function in maintaining the focus on the child (HM Government, 2015: 25) and is therefore integral to providing an effective person/child centred service. Supervision enables staff to see “the whole picture” by “thinking family” and to recognise the impact that parental and family behaviours have on children and young people and vulnerable adults. We recognise that clinical supervision is essential to professional development and helps the supervisee develop confidence in decision making.The Safeguarding Team can offer responsive supervision and guidance to any member of staff who asks for it. Clinical supervisors must have an advanced level of knowledge and understanding of safeguarding children and adults including (but not limited to) identification of concerns, vulnerability factors, remedies, and statutory responsibilities. In 2017/18 the number of staff that received planned and unplanned supervision was 1213, up from 1008 the previous year; an increase of 20.3%.The number of cases brought to supervision was 314 compared to 268 previously an increase of 17%. The number of sessions did not increase, 142 compared with 147. Although difficult to hypothesise supervision appears to be provided to a greater number of staff, with more cases being brought for discussion. With additional staff who are all fully trained supervisors it is envisaged that the next year will increase access further across the workforce. This will include the attendance at psycho social meetings in wards and departments to strengthen and standardise the model employed across the Trust. This will complement the presence of social work colleagues who currently provide a level of safeguarding oversight, and ensure that safeguarding concerns are identified and responded to in a timely and appropriate manner.Additional groups will be targeted, including medical staff and clinical nurse specialists.The Named Doctor will investigate developing a system of peer review for inflicted injury cases.Number of Staff to Receive Supervision by Divisional Portfolio 2017 -18 8

9. AuditInternal Audits: The Was Not Brought Audit (WNB) To determine compliance with the Trust Patient Access Policy and whether safeguarding issues were a factor, constituting neglect of health need.  Patients who did not attend (DNA) an appointment in a 12 month period were identified and cross referenced against the number of DNAs per patient, which was up to 15.  20 of these cases were randomly selected and reviewed against the Patient Access Policy.  This showed a low level of compliance with the principles and  highlighted that there is not currently an effective system for prompting or documenting any consideration of safeguarding concerns. Recommendations: Review of OPD systems for documenting action taken following a WNB – to include developing a system for EPR for capturing safeguarding concernReview of WNB Policy, protocols and pathwaysIncorporate into training and re-auditThink Family Audit A sample of 54 Family Forms were reviewed, to determine whether key social and demographic information is being collected when patients are admitted.  The results showed that there was a low level of completion of the key fields of information – between 0-17%.  There is an overlap over between the information collected on the Family Forms and that collected on PIMs and this is to be cross referenced before the report is finalised and recommendations are made.Action:The Safeguarding Team have contributed to the redevelopment of the Family FormRecommendations:Establish a consistent social information collection system which will include informing parents about Information Sharing practice within the Trust and re-audit the social information that is collected. This should be embedded in EPRIncorporate into training and re-auditSupervision Audit The audits were conducted with staff who had received supervision over two quarters. Safeguarding supervision is generally well received and felt to be beneficial ; staff valued a ‘safe space’ and felt more confident to raise safeguarding concerns. Group supervision was felt to be beneficial. Future audits will focus on specific staff groups to identify future training needs. External Audits:Section 11: The Trust were asked by Camden LSCB to complete an audit on Children with Disabilities. The panel did not require any further attendance at their ‘Challenge Panel’.Multi-agency themed audits Regular multi agency themed audits are completed, with information provided about cases as requested.Camden: Children with Disabilities – 4 GOSH casesIdentified the limitation of the GOSH IT system which automatically sends correspondence to a patient’s General Practitioner as the single point of contact within the primary care sector. Camden: Youth reoffending – 3 GOSH casesAlthough three patients were known to the Trust there was minimal involvement historically and no specific learning. Hackney: Potential sexual abuse – 1 GOSH caseHolistic consideration of need with involvement of wider psychosocial team including child psychology/child psychiatry and social work. There was good liaison between GOSH and LA in outlining ongoing concerns and potential risks despite the restriction from applied to disclosure to mother of the referral from the transferring hospital. 9

10. Safeguarding risks and requirementsReporting Female Genital Mutilation (FGM) There is continued national and international work being undertaken to eliminate new cases of FGM in the UK in a generation. The Serious Crimes Act 2015 placed a mandatory duty on all regulated professionals to report FGM to the police on 101 if they have a direct disclosure from a child under the age of 18 that is a victim of FGM. There is a requirement for staff to undertake this reporting if they are the recipient of a direct disclosure. All staff are made aware of this duty within all levels of safeguarding training. The Trust are required to report such cases to NHSE. There have been 3 concerns raised within the past year but no confirmed cases. Prevent The Trust has remained responsive to the counter terrorism strategy and we recognise that all members of staff have a duty under the Counter Terrorism and Security Act (2015) to have due regard to the need to prevent people being drawn into terrorism and to act positively to report concerns. There have been 2 concerns raised during the year one of which resulted in a referral to the local Prevent Channel Co-ordinator. Modern Slavery The Modern Slavery Act 2015 requires all employees to be committed to ensuring that there is no modern slavery or human trafficking in any part of our business activity, including externally contracted suppliers. There have been no identified victims of modern slavery or trafficking. Risks The Disclosure and Barring Service The Trust undertakes checks at recruitment of all staff, which was 100% as of 31.03.2018. Existing staff have rechecks which are currently at 95%.Persons Who Pose a Risk The Safeguarding Team works closely with the Risk , Social Work, Security and Divisional Nursing Teams to ensure a safeguarding perspective is included in the risk assessment where there are concerns about a person who may pose a risk.Risk RegisterWith the appointment of the substantive Named Doctor, this risk has now been closed. There is one risk remaining in relation to failure to safeguard children and young people from maltreatment and neglect, which recognises that safeguarding children always carry a risk. We will review this risk this year.Independent Inquiry into Child Sexual AbuseThere have been no cases identified to the Trust from the Inquiry to date. The Trust is compliant with the Action Plan which is updated annually. 10

11. Safeguarding across the Trust The Safeguarding Links are staff from across the Trust who are key to promoting good safeguarding practice across the Trust. In 2017 their role has been reviewed to ensure they have an overview of safeguarding within the team to ensure that staff are working towards best practice.The Links meet every quarter with the Senior Safeguarding Nurse Specialist to ensure they cascade information to update staff within their areas on policy, procedures and supporting staff on early identification of concerns and referring to the safeguarding and social work teams, or clinical site practitioners (out of hours). The Named Professionals attend the Divisional Clinical Governance Committees to ensure that local safeguarding information is fedback to relevant teams including any learning from Serious Case Reviews. Developing the support for Clinicians The Named Doctor supports medical and other colleagues both in supervision and case management. This has also involved the development of bespoke safeguarding level 3 training to some clinical teamsDiscussion of gastro and non- gastro complex cases which have a perplexing presentation continues and a Trust-wide system is being developedThe Named Doctor is continuing to work with colleagues to revise the procedural pathways attached to Safeguarding Children and Young People Policy.The Named Doctor attends Strategy Meetings whenever possible , particularly to support medical colleagues in sharing information to inform the Child Protection process11

12. GOSH Social Work Service12The service consists of a Head of Profession/Service post, 5 senior Social Work(SW) Practitioner (clinical / management posts), 12.5 Social Work WTEs, 3 Family Support Officers and 1 Psycho-Social Liaison worker. We have a partnership agreement with CLIC Sargent who provide a dedicated service to children with a cancer diagnosis.We have a full establishment of staff. Following a review of social work across the clinical attachments a decision has been made to convert one social work post into a family support worker post.The service is funded from the GOSH charity and NHS funding with a dedicated CLIC (Cancer and Leukaemia in Childhood) Sargent Service that works as part of the social work service but with a particular remit. Of the total composition of the social work service 4.5 WTE posts are funded by CLIC Sargent and this includes a dedicated senior practitioner. There is a service level agreement which requires this service to be overseen by the GOSH Head of Social Work.The social work service maintains links with the local authority to ensure that GOSH takes account of developments within the social work profession which is undergoing significant developments in terms of new accreditation requirements and the Children and Social Work Act 2017 The service is working with the GOSH EPIC team to look at developing an integrated record with the rest of the gosh multidisciplinary team. We have ensured that all staff within the service have updated their Camden Local Authority Child Protection(CP) training.The Social Work service at GOSH provides support to all wards and units within the hospital, operating a 9-5 duty service which ensures that there is always a social worker and a senior practitioner available. When any member of staff identifies child protection concerns, they make an electronic referral to the Social Work Service. The Social Work and Safeguarding Teams have worked closely together to ensure that there is an integrated response to referrals identifying safeguarding/child protection concerns with information being shared routinely across both teams. We are undertaking further work to strengthen information sharing working closely with the Named Doctor. We plan to undertake an annual social work survey. This does not relate specifically to safeguarding activity albeit a significant proportion of the social work service activity involves safeguarding in its broadest sense. 96% of families previously surveyed said that the social work service met or exceeded their expectations and 98% of families previously reported that they would be extremely likely or likely to recommend the Social Work Team to someone in a similar situation. Referrals have decreased slightly in 2017/18 compared with 2016/17.2014/152015/162016/172017/18118394515101392

13. GOSH Social Work Service13Work is being undertaken with EPIC to improve the efficiency and reliability of data collection across the department.

14. Practice Development 2017/18 Policy developmentSafeguarding is a rapidly changing and growing area of work. The Trust Policies and procedures are required to be reviewed and updated in line with national and local policy. The Trust responded to the consultation on the proposed changes to the statutory document Working Together to Safeguard Children which is due for publication imminently.The Pan London Procedures are the overarching policy that supports local safeguarding policies to which Trust policy should be complementary. Over the past 12 months the following policies have been reviewed Safeguarding Children & Young People Policy Prevent In progress: Safeguarding Supervision Safeguarding Adults Mental Capacity (stand alone) Safeguarding Children and Young People procedural appendices. Themed Safeguarding children training at Level 3 . In addition to the core training programme , themed face to face sessions are delivered to staff by subject matter experts including; Emotional Abuse and Neglect Perplexing Presentations and Fabricated / Induced IllnessTalking to children and parents Domestic Violence and Abuse Child Sexual Abuse Safeguarding and People with Learning DifficultiesWorking with families who are challenging Female Genital MutilationChild Abuse Pathology Meeting Engages with broader teams i.e. Radiology and Neuro-radiology, pathology, intensivists and acute transfer teams (CATS). Provides a forum for discussion but also engages with the wider multi agency network to consider safeguarding in its broadest context. Child Protection Information Sharing System (CP-IS). The Trust is on target to implement the national initiative for NHS Trusts and Local Authorities to ‘Go Live’ in April 2019. 14

15. 2018/19 PrioritiesReview of Trust safeguarding policies and procedures to ensure compliance with the changes in Working Together to Safeguard Children (2018).Ensure the Trust embeds the Camden Local Safeguarding Board priorities within training and practice . These are:Vulnerable adolescentsDomestic abuseNeglectPreventing radicalisation and extremismComplete the recommendations action plan from the safeguarding reviews. Continue to improve compliance with mandatory training and extend the current training programme to include specialist safeguarding training for key staff groups.Review of Trust Safeguarding Supervision Policy to ensure a robust system is in place for raising and reflecting on safeguarding concerns.Revision of the under-2 Non-accidental Head Injury pathway to be integrated into a general Unintentional Injury pathway.To establish a 24/7 medical rota for safeguarding support.Establish a consistent social information collection system which will include informing parents about Information Sharing practice within the Trust and re-audit the social information that is collected.To work with the interim MCA Lead to:define the role and scope of the MCA Leaddevelop a MCA and DoLS policy for the TrustDevelop training packages and Provide guidance and advice in relation to mental capacity assessments, best interest decisions and documentationFurther analyse issues relating to deprivation of liberty and prepare for future safeguards for 16-17yr olds.Develop the Looked After Children agenda at GOSH to meet the needs of this vulnerable group who can often enter the care system with a worse level of health than their peers, in part due to the combined effects of the impact of poverty, poor parenting, abuse and neglect.Continue to work with our partners in IT and NHS Digital to ensure a robust system is in place to meet the NHS contract deadline of April 2019. In addition working with the EPIC team to promote a smooth transition to the new recording system. Consolidating the work done on developing a system for complex case supervision and tracking to extend this to cover the whole Trust.Increase the number of staff who are required to complete enhanced Level 3 Safeguarding Children trainingReview policies, protocols and pathways relating to ‘Was Not Brought’15

16. Safeguarding Team Structure Chart16