1

MERTON CLINIVAL COMMISSIONING GROUP

GOVERNING BODY Date of Meeting: 30th November 2017 Agenda No: 11.15 Attachment: 17a

Title of Document: Safeguarding Children Annual Report 2016/17

Purpose of Report: Review

Report Author: Liz Royle Head of Safeguarding Designated Nurse Safeguarding Children Merton & Wandsworth CCG

Lead Director: Julie Hesketh Director of Quality and Governance

Executive Summary: The Annual Report 2016/17 seeks to demonstrate how the Governing Body of Merton Clinical Commissioning Group (MCCG), in discharging its functions as a commissioner of healthcare services has been assured that the arrangements to safeguard children and young people have been effective, compassionate and most importantly listened to and engaged children and young people. In addition, the annual report provides assurance that the MCCG has in 2016/17 achieved compliance with the duties and responsibilities as outlined by existing legislation, guidance and frameworks.

Key sections for particular note (paragraph/page), areas of concern etc: The Merton Annual Safeguarding Children Report covers the following: Section 2 :Merton CCG Compliance with Guidance and Statutory Duties Section 3:Safeguarding Children Assurance Data from Commissioned Services Section 4:Children Looked After (CLA)

Recommendation(s): Section 6 of the Annual Report – conclusions: New shared safeguarding arrangements require a work plan to align the governance, polices and reporting processes across the two CCGs The new shared safeguarding arrangements require monitoring in 2017/18 to fully understand impact and capacity issues. PREVENT (WRAP) compliance is an NHSE priority with a target of 85% compliance in March 2018 and so the CCG must track providers progress – namely St Georges Hospital and SWL and St Georges MH Trust. All providers will be required to submit and present a Section 11 Audit to the MSCB in 2017.

Committees which have previously discussed/agreed the report: Merton and Wandsworth CCG Safeguarding Committee 30/10/17

Financial Implications: None identified

Implications for CCG Governing Body: To note both the areas of progress, risks and actions in 2016/17 and the priorities for 2017/18

How has the Patient voice been considered in development of this paper: 2.11 MCQC has received papers on the SCR Child B and Learning Review Child C 2.18 LGBT Learning Event / CLA Event

2

Other Implications: (including patient and public involvement/Legal/Governance/Risk/Diversity/ Staffing) Risk Register Number 1012: If CCG fails to establish appropriate systems and processes for safeguarding children and children looked after, vulnerable children may be at risk of harm 3x3=9 Risk Register Number 1037 : If the CCG fails to establish appropriate systems and processes for assuring compliance of commissioned services with safeguarding children statutory duties, children and young people will be at risk of harm 3x4=12 New risk has been submitted – new shared safeguarding arrangements.

Equality Assessment: Not required for this paper

Information Privacy Issues: None identified

Communication Plan: (including any implications under the Freedom of Information Act or NHS Constitution) Will form part of Governing Body papers and be available on the Merton CCG website.

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Merton Clinical Commissioning Group Safeguarding Children Annual Report

2016/17

Author: Liz Royle Designated Nurse Safeguarding Children Merton CCG and Wandsworth CCG Date: September 2017

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Contents:

1. Introduction

2. Merton CCG Compliance with Guidance and Statutory Duties

3. Safeguarding Children Assurance Data from Commissioned Services

4. Children Looked After ( CLA)

5. Actions for 2017/18

6. Conclusions

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Foreword This is the fifth and final Merton Clinical Commissioning Group (CCG) Annual Safeguarding Children Report. It is to be noted that following a consultation with staff and stakeholders in December 2016 the Merton CCG and Wandsworth CCG safeguarding teams were merged into a new shared structure with safeguarding roles having responsibility across both Boroughs. Merton CCG and Wandsworth CCG will receive a Merton and Wandsworth Annual Safeguarding Report in 2017/18. The content of this report is based on the quarterly safeguarding children reports submitted by the Designated Nurse Safeguarding Children and approved by Merton CCG Governing Body relating to 2016/17. This report is to be read in conjunction with the annual Children Looked After Report 2016/17, CDOP Report 2016/17 and MSCB Report 2016/17. At the time of writing this annual report Merton LA had been inspected by OFSTED (June 2017) with the report published August 2017. The LA was rated a ‘good’ with an outstanding rating for adoption performance and leadership, management and governance. https://news.merton.gov.uk/2017/08/25/merton-childrens-services-receives-one-of-the-highest-ofsted-ratings-in-the-country/ Liz Royle Head of Safeguarding / Designated Nurse Safeguarding Children Merton CCG and Wandsworth CCG

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1. INTRODUCTION

1.1 This annual report 2016/17 seeks to demonstrate how the Governing Body of Merton Clinical

Commissioning Group (MCCG), in discharging its functions as a commissioner of healthcare services has been assured that the arrangements to safeguard children and young people have been effective, compassionate and most importantly listened to and engaged children and young people. In addition, the annual report provides assurance that the MCCG has in 2016/17 achieved compliance with the duties and responsibilities as outlined by existing legislation, guidance and frameworks;

Children Act (1989) and (2004).

Working Together to Safeguard Children (2015)*

Promoting the Health and Well-being of Looked after Children (2015)

Safeguarding Vulnerable People In the NHS – Accountability and Assurance Framework (2015)

Safeguarding children and young people: roles and competences for Health care staff, intercollegiate document (2014). (* guidance being currently being revised following Children and Social Work Act 2017)

1.2 Safeguarding is embedded within the wider duties of all organisations across the health

system with providers organisations charged with the duties and responsibilities of delivering safe and high quality care and commissioners being charged with the responsibilities and duty to be assured of the safety and quality of the services commissioned. The annual report 2016/17 will give an overview of the performance of each provider highlighting achievements, risks and actions for 2017/18.

1.3 Safeguarding duties for commissioners of health service as a minimum requirement are (NHSE 2015);

A Designated Doctor and Designate Nurse for Safeguarding Children to support and provide expert advice on the commissioning of services,

An 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 LSCB/SAB.

Arrangements in place to ensure services they commission are safe for children and young people who may be at risk of abuse or neglect,

Arrangements in place to ensure the health commissioning system as a whole is working effectively in disseminating policy and escalating key issues and risks.

These are the duties against which the performance of Merton CCG is measured.

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2. MERTON CCG COMPLIANCE WITH STATUTORY GUIDANCE / DUTIES 2016/17 2.1 The Merton Safeguarding Annual report 2015/16 set the following objectives for 2016/17:

MCCG host 3 GP safeguard training events 2016/17 In 2016/17 two safeguarding training events were held.

Named GP function arrangements to established The named GP function was incorporated into a clinical lead post.

Supervision arrangements to be put in place for safeguarding leads All CCG safeguarding leads access supervision.

Development of complaints leaflet which is child / young people friendly The leaflet in still in draft awaiting feedback from children and young people.

Completion of serious case review and learning reviews and dissemination of learning and recommendations to health providers The serious case review Child B and the Learning and Improvement Review Child C have been completed. The SCR was published February 2017. The MCQC has received reports on the learning from both reviews. LSCB briefing dates have been circulated to staff and the Designated Nurse has delivered training to Practice staff (clinical and non-clinical).

2.2 Merton CCG in 2016/17 achieved compliance with statutory guidance and safeguarding requirements and this was endorsed by the NHSE Deep Dive Audit (Nov 2015) and external auditing in 2016/17. Actions in regard to policy updates have been completed.

2.3 Merton CCG external facing safeguarding statement was reviewed by the Designated Nurse

and following approval by the Safeguarding Executive Group (SEG) is online with next review date in 2017. This is annual statement provides current information and assurance to the public as to Merton CCG’s compliance with safeguarding legislation, statutory and commissioning guidance.

2.4 In 2016/17 CCG staff compliance of 80% was achieved for safeguarding children training across all staff groups requiring level 1 and 2 safeguarding training. All staff in specialist safeguarding roles are compliant with safeguarding training; 100%.

2.5 The CCG has hosted two safeguarding events aimed at primary care staff; level 3 safeguarding children and level 2 safeguarding adults. Both events were well attended and evaluated.

2.6 GPs have been directed to the MSCB training offer and received safeguarding updates via

the Merton CCG Primary Care Update (online newsletter).

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2.7 Merton CCG in 2016/17 has submitted a Section 11 Audit to MSCB and has an action plan

in place to ensure continuous improvement of safeguarding arrangements. The Section 11 Challenge Panel will be held in Q3 2017/18.

2.8. Merton CCG is represented on the MSCB Board by the Director of Quality and Governance

Designated Nurse and Doctor. Attendance at MSCB Board by Merton CCG is 100%. 2.9 The Merton CCG Designated Nurse chairs the Merton Safeguarding Children Board (MSCB)

Policy Subgroup and in 2016/17 has overseen the development and approval of the following MSCB documents;

MSCB Escalation Procedure

MSCB Bruising in Pre-Mobile Infants.

MSCB Neglect Strategy (update)

MSCB FGM Strategy (update) 2.10 The Serious Case Review Child B has been published; February 2017.

https://webcache.googleusercontent.com/search?q=cache:V8mYr3lUZ3MJ:https://www2.merton.gov.uk/health-social-care/children-family-health-social-care/safeguardingchildren/lscb/serious_case_reviews.htm+&cd=1&hl=en&ct=clnk&gl=uk

The Learning and Improvement Review Child C is complete however, there is no directive to

publish. 2.11 The Merton Clinical Quality Committee has received reports on both the Child B and Child C

reviews. LSCB briefings on the learning and findings from the both reviews have been circulated to Primary Care. The CCG has completed the MSCB assurance frameworks in regard to both reviews.

2.12 The Child Death Overview Panel (CDOP) is hosted by Merton CCG and chaired by Public

Health. The CDOP up to January 2017 was a shared arrangement reviewing child deaths in Sutton and Merton. In January 2017 at the request of Sutton LSCB and Public Health the arrangement ended and a Merton CDOP was set up chaired by as Pubic Health consultant for Merton Local Authority.

2.13 The CDOP annual report 2016/17 captures the performance, activity and makes

recommendations for 2017/18. 2.14 The Designated Nurse represents Merton CCG on the following multi-agency panels and

meetings:

Multi-Agency Safeguarding Hub (MASH) strategic group

Violence Against Women and Girls (VAWG) strategic group

Multi-Agency Child Sexual Exploitation Panel (MASE)

Multi-Agency Risk Assessment Conference (MARAC) – high risk domestic abuse cases

Family Nurse Partnership Advisory Board (FAB)

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2.15 Merton CCG in 2016/17 has demonstrated commitment to working in partnership with both

statutory and non-statutory partners on both a strategic and operational level to identify and address key areas of risk for Merton children and young people.

2.16 In September 2016 the Designated Nurse was nominated and elected to Chair of the London

Children Looked After (CLA) Nurses Forum. In this role the Designated Nurse has co-ordinated the delivery of accredited public health training for London CLA Nurses; Health Champions. Thirty London CLA nurses attended and completed the course. The course evaluations were positive.

2.17 As chair of the London CLA Forum the Designated Nurse has won funding for the delivery of

two learning events for London CLA Nurses set at level 5 competency (RCPCH 2015). This activity was referred to in the NHSE Annual Report.

2.18 The Designated Nurse has successfully won monies from NHSE to deliver the following

projects in 2017/18:

CPIS – support to enable uploading of data to the NHS Spine by the LA

Signs of Safety Training for Primary Care and Health Providers in Merton

LGBTQ Learning event for health providers in Merton.

CLA Nurse Learning Events for London CLA Nurses.

NHS England

London Region Safeguarding Update Report 2016-17 FINAL.pdf

2.19 The new shared Merton and Wandsworth CCG safeguarding arrangements were implemented in February 2017 following a staff consultation in November 2016. Permanent staff have been recruitment to the posts of Designated Nurse Looked After Children and Safeguarding Adult Lead. The impact of this shared arrangement will require close monitoring in regard to capacity and the development of an action plan to align the governance, policies and reporting processes across the two Boroughs.

3. SAFEGUARDING CHILDREN ASSURANCE DATA FROM COMMISSIONED SERVICES

2016/17: 3.1 Merton CCG requires provider organisations to submit information in regard to their

safeguarding children arrangements and activity. The purpose of this reporting is to assure Merton CCG that the services commissioned are safe, effective in achieving good outcomes for children and young people and comply with national guidance and statutory duties.

3.2 The five healthcare providers submitting safeguarding children data to Merton CCG are:

South West London and St Georges Mental Health NHS Trust

Central London Community Healthcare CLCH

St Georges University Hospital NHS Foundation Trust

Epsom and St Helier University Hospital NHS Trust

Wilson Walk In Centre

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3.3 From 31st March 2017 the Wilson Centre will no longer be providing a service in Merton. 3.4 South West London and St Georges Mental Health NHS Trust The 2015/16 annual report identified the following as areas of improvement for the Trust: • Improvement in safeguarding children training compliance • Report on safeguarding children supervision compliance Data relating to the Trust’s compliance with safeguarding children training 2016/17 is captured

in the table below. The Trust has achieved the target of 80% for level 2 training. The target of 90% for level 3 has not been achieved – however compliance does exceed 80% for Q3 and Q4 2016/17.

Table 1: South West London and St Georges Mental Health NHS Trust Safeguarding children

training compliance 2016/17

Safeguarding Children training level %

Q1 2016/17 Q2 Q3 Q4 Target 80% level 2

Target 90% level3

Level 1 All staff trained at L2

80%

Level 2 90% 91.5% 91.5% 94% 80%

Level 3 78% 75.8% 81.2% 83% 90%

3.5 The Trust following a CQC inspection in 2016 now reports on supervision compliance, however

this performance metric includes all forms of supervision – managerial, clinical and safeguarding. Safeguarding supervision compliance is not reported on by the Trust as a specific metric. The Trust have now achieved a CQC rating of ‘good’.

http://www.cqc.org.uk/provider/RQY 3.6 The following area remains as requiring for improvement in 2017/18:

Report on practitioner supervision compliance 3.7 Central London Community Health care (CLCH) 3.8 CLCH from 1st April 2016 become the children community services provider in Merton. The

following as areas of improvement for the Trust are:

CLCH to report on safeguard children training compliance

CLCH to report on safeguarding children supervision arrangements – model and policy

CLCH to report on safeguarding children supervision compliance 3.9 CLCH has demonstrated improvement in safeguarding training and supervision compliance

throughout 2016/17.

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Table 2 CLCH Safeguarding Children Compliance 2016/17

Safeguarding Children training level %

Q1 2016/17 Q2 Q3 Q4 Target 90%

Level 1 79% 83% 90% 100%

Level 2 80% 81% 88% 95%

Level 3 47% 59% 83% 80.6%

Level 4 100% 100% 100% 66 % CLCH started reporting on safeguarding supervision compliance from Q2 2016/17. CLCH has

demonstrated a high level of supervision compliance which is evidence in table 3. CLCH has a safeguarding children supervision policy in place. Practitioners access safeguarding supervision from the Merton CLCH safeguarding team which is comprised of a Named Nurse for Child Protection and Child Protection Advisors.

Table 3: CLCH Safeguarding Supervision compliance 2016/17

Safeguarding Children Supervision %

Q1 Q2 Q3 Q4

Proposed target 100%

Health Visitors

No data 97% 97% 96%

School nursing Schools (special needs)

100% 100% 100%

89% 84%

FNP * 100% 100% 100%

Therapists 79% 82% 80%

MASH* 100% 100% 100%

CLA * 50% 100% 100%

Safeguarding Team

100% 100% 100%

3.10 CLCH is rated a ‘good’ by the CQC with the last inspection in 2015 which makes an inspection

likely in 2017/18 http://www.cqc.org.uk/provider/RYX The following area is to remain requiring for improvement in 2017/18:

• To report on and improve safeguard children training level 3 compliance

3.11 St Georges University Hospital NHS Foundation Trust:

3.12 The 2015/16 annual report identified the following as areas of improvement for the Trust:

• Improvement in safeguarding children training compliance

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• Report on safeguarding children supervision compliance 3.13 Data relating to St Georges University Hospital NHS Foundation Trust compliance with

safeguarding children training 2016/17 is captured in the table below Table 4. The Trust has achieve training compliance that exceeds 80% in 2016/17.

Table 4: St Georges University Hospital NHS FT Safeguarding children training Compliance 2016/17.

Safeguarding Children training compliance %

Q1 2016/17 Q2 Q3 Q4 Target 90%

Level 1 83% 84% 85% 88% 90%

Level 2 79% 76% 78% 80% 90%

Level 3 93% 88% 90% 88% 90%

Level 4 100% 100% 100% 100%

3.13 Safeguarding supervision compliance throughout 2016/17 has been reported by the Trust as

100% for both the safeguarding team and practitioners. 3.14 CQC inspection in 2016 rated the Trust a ‘requires improvement’. The report highlighted

specific areas of concern safeguarding training. http://www.cqc.org.uk/location/RJ701 3.15 The Trust provides safeguarding data from A/E, paediatrics and Maternity which is captured

in Table 5. This data is shared with the MSCB and enables both the CCG and MSCB to have an overview of the presenting issues of the children, young people and families. The data highlights the number of young people presenting with self-harm and following bullying. This is linked to the number of CAMHS referrals.

3.16 The data set identifies cases where the parent/ carer is identified as a safeguarding risk to

the child with domestic abuse and mental health as key areas of concern.

Table 5: St Georges Hospital University Trust NHS FT Safeguarding data A/E, Paediatrics and Maternity 2016/17

St Georges Hospital University Trust NHS FT

Q1 Q2 Q3 Q4

Number of children admitted with safeguarding concerns

16 3 4 5

Number of Looked After Children attending A&E where Merton Children's Social Care were informed

6 6 5 5

Number of Children subject of a Child Protection Plan attending A&E where

0 0 2 3

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Merton Children's Social Care were informed

Safeguarding Concerns: Number of children attending A&E due to self-harming

14 8 15 10

Safeguarding Concerns: Number of children attending A&E due to bullying/assault

15 4 14 7

Safeguarding Concerns: Number of children attending A&E due to alcohol/drug misuse

1 0 2 2

Safeguarding Concerns: Number of children attending A&E attempting suicide

1 0 0 0

Safeguarding Concerns: Number of children attending A&E where risk linked to adult identified - domestic violence

8 14 19 13

Safeguarding Concerns: Number of children attending A&E where risk linked to adult identified - mental health

4 18 15 18

Safeguarding Concerns: Number of children attending A&E where risk linked to adult identified - drug and alcohol misuse

4 4 5 5

Paediatrics In-Patients: Number of referrals to Merton's Children's Social Care

41 54 41 37

Paediatrics In-Patients: Number of children subject to a Child Protection Plan admitted Number of children looked after admitted

0 0

0 0

1 0

1 0

Paediatrics In-Patients: Number of children referred to CAMHS

13 8 10 10

Maternity: Number of Unborn babies referred to Merton Children's Social Care

8 0 6 3

Maternity: Number of births subject to a Child Protection Plan

0 0 3 0

Maternity: Number of concerns raised about

1 3 0 5

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Female Genital Mutilation (FGM)

Maternity: Number of concerns raised about Domestic Abuse

4

Data now included in overall reporting above.

3.17 The following area is to remain requiring for improvement in 2017/18

To report on and improve safeguard children training compliance 3.18 Epsom and St Helier University Hospital NHS Trust (ESTH): 3.19 No specific actions identified in the 2015/16 annual report as Trust was demonstrating

compliance with reporting data set. The safeguarding children training compliance for ESTH is captured in table 6. Notably, the Trust target is 95% compliance which is higher than all other Trusts.

Table 6 Epsom and St Helier University Hospital NHS Trust Safeguarding training compliance 2016 /17

Safeguarding Training Compliance

Q1 2016/17 Q2 Q3 Q4 TARGET

Level 1 81% No longer training staff at level 1

95%

Level 2 81% 76% 80% 86% 95%

Level 3 85% 78% 78% 87% 95%

Level 4 100% 100% 100% 100% 95%

3.20 The Trust supervision compliance has exceeded 80% for practitioners throughout 2016/17.

Compliance for the safeguarding team has been 100%. Following the CQC inspection 2016 investment in the safeguarding team and specially the number of trained child protection supervisors has ensured a high level of compliance. The CQC rating for the Trust remains ‘requires improvement’.

http://www.cqc.org.uk/provider/RVR 3.21 The CQC Inspection highlighted the issue of a lack of capacity in the community paediatrics

the impact of which is referred in section 4 of this report. In addition, child protection notifications and attendance at case conferences was identified as an area requiring improvement.

3.22 ESTH has submitted data on safeguarding activity relating to A/E and community midwifery

services (table 7). There is a distinction made between young people presenting with mental health concerns and those having self-harmed. In both the case of self-harm and mental health concerns there has been a decrease in children presenting at A/E.

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3.24 Maternity cases that are ‘enhanced’ require additional support but do not meet the threshold

of child protection. Midwifery cases that are identified as ‘targeted’ are those where there is a child protection plan in place for the unborn child.

Table 7 – Epsom & St Helier University Hospital NHS Trust Safeguarding activity 2016/17

Epsom & St Helier University Hospital NHS Trust Safeguarding activity 2015/16

Q1 Q2 Q3 Q4

The rate of hospital inpatient admissions caused by unintentional and deliberate injuries to children and young people aged 0-17

6 0 8 8

The rate of Accident and Emergency attendance caused by unintentional and deliberate injuries to children and young people aged 0-17

71 78 127 130

Number of hospital admissions: due to alcohol specific conditions

2 1 1 1

Number of hospital admissions: due to substance misuse (15-24 years)

2 5 5 0

Number of hospital admissions: due to mental health conditions

10 5 6 5

Number of hospital admissions: due to self-harm (10-24 years)

0 7 0 3

Community Midwifery: number of enhanced cases in period

26 17 26 31

Community Midwifery: number of targeted cases in period

0 14 0 1

3.26 The areas for improvement in 2017/18 for ESTH are identified in section 4. 3.27 Wilson Walk in Centre (WIC): 3.28 The Wilson Walking Centre has submitted a data set throughout 2016/17. A notable feature

is the number of adults presenting with mental ill health. Table 8 – WIC safeguarding activity data 2016/17

Wilson WIC Q1 Q2 Q3 Q4

Children attending self -harm 0 0 0 0

Children attending CPP 0 0 0 0

Children referred to MASH 1 1 0 0

Children attending – bullying /assault 1 0 0 0

Children attending alcohol / self- harm 0 0 0 0

Adults - mental ill health 3 5 11 21

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Adults – drug / alcohol 5 5 4 6

Allegation against staff 0 0 0 0

Referral to LADO 0 0 0 0

Concerns FGM 0 0 0 0

3.29 The WIC closed March 2017 and no further data will be received. 4. CHILDREN LOOKED AFTER – CLCH AND EPSOM AND ST HELIER UNIVERSITY

HOSPITAL NHS TRUST (ESTH) 4.1 The 2015/16 annual report identified the following as areas of improvement for the Trust:

Improve Compliance with statutory timeframes for IHA and RHAs 4.2 ‘Promoting the health and well-being of looked-after children statutory guidance for local

authorities, clinical commissioning groups and NHS England’ (2015) is the statutory guidance issued to local authorities, CCGs and NHS England under sections 10 and 11 of the Children Act 2004.

This guidance states the following in regard to Initial Health Assessments (IHA) and Review Health Assessments (RHA):

The initial health assessment must be done by a registered medical practitioner. Review health assessments may be carried out by a registered nurse or registered midwife.

The initial health assessment should result in a health plan, which is available in time for the first statutory review by the Independent Reviewing Officer (IRO) of the child’s care plan. That case review must happen within 20 working days from when the child started to be looked after.

The review of the child’s health plan (RHA) must happen at least once every six months before a child’s fifth birthday and at least once every 12 months after the child’s fifth birthday.

http://www.rcpch.ac.uk/system/files/protected/page/DH_Promoting_the_health_and_well-being_of_looked-after_children.pdf

4.3 The Children Looked After (CLA) service is provided by CLCH and Epsom and St Helier

University Hospital NHS Trust. The acute trust (ESTH) undertakes the Initial Health Assessments (IHA) for children looked after while the community services (CLCH) delivers the majority of Review Health Assessments (RHA).

4.4 ESTH compliance with IHA within statutory timeframes is illustrated in Table 9. The reasons

given for the children not seen within timeframe include; capacity issues so appointment not offered in timeframe, client choice not to attend appointment offered and / or client did not attend appointment (DNA). The CQC Inspection (2016) identified capacity issues in the community paediatric service that was impacting on the performance of the service.

Table 9 – 2016/17 ESTH Compliance with IHA statutory timeframes

*children leave ‘care’ prior to a heath assessment being arranged.

ESTH 2016/17 CLA IHA Compliance with statutory timeframes

Q1 Q2 Q3 Q4 – new data set

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Number of Merton children taken in to care (CLA)

27 17 30

Number of referrals from LA 25 15 31 10

*Number not requiring IHA 5 2 6

% offered appointment within statutory timeframe

84% (21)

60% (9)

58.3% (12)

% seen within statutory timeframe 52% (13)

60% (9)

50% (12)

30% (3)

% seen with 28 days of ESTH receiving a ‘ complete referral

50% (5)

Number DNA / refusals 4 3 3

*children leave ‘care’ prior to a heath assessment being arranged.

4.5 In Q4 2016/17 the Trust changed their data set to include a performance metric; number

and percentage of children seen with 28 days of the Trust receiving a complete referral. In Q4 the Trust report being notified of 10 children coming into care; 30% (3) had a health assessment within the statutory timeframe (within 28 days of entering care) and 50% (5) of children were seen in 28 days of the referral being received by the hospital. It is disappointing that statutory timeframes are not being met given the small numbers of children coming into care.

4.6 CLCH is the provider responsible for the majority of CLA Review Health Assessments

(RHA). RHAs are a health assessment which can be undertaken by a nurse however, in some situations the RHA may be undertaken by a GP or paediatrician – these would complex cases and pre adoption cases. Throughout 2016/17 compliance with the health assessment being undertaken within the statuary timeframes have exceeded 75%.

4.7 CLCH have made progress in ensuring young people leaving care have a Health Summary;

in Q4 2016/17 70% (7) received a health summary. The 30% (3) that did not receive a health summary for the following reasons:

One young person refused the health summary.

One young person currently in secure estate.

One young person could not be located. 4.8 The issue of poor compliance with statutory timeframe for health assessments (IHAs) children

entering care has been escalated within Merton CCG and to the lead commissioner Sutton CCG.

4.9 The areas for improvement in 2017/18 for ESTH and CLCH are:

Improved compliance with statuary timeframes for IHAs

Improved compliance with young people leaving care receiving a Health Summary.

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5. ACTIONS FOR 2017/18 5.1 Merton CCG:

Progress work to align safeguarding governance, policies and procedures across the two CCGs

Develop training offer to primary care

With additional investment develop a programme of support for GPs – CQC preparedness

5.2 South West London and St Georges Mental Health NHS Trust

Improve training and supervision compliance – PREVENT / Level 3

Attend MSCB Challenge Panel Section 11

5.3 Central London Community Healthcare CLCH Community Services

Improve training and supervision compliance - level 4

Attend MSCB Challenge Panel Section 11

5.4 St Georges University Hospital NHS Foundation Trust

Improve training and supervision compliance - PREVENT

Attend MSCB Challenge Panel Section 11

Progress CPIS

5.5 Epsom and St Helier University Hospital NHS Trust

Improve training and supervision compliance - Level 2 / 3

Attend MSCB Challenge Panel Section 11

Progress CPIS

5.6 CLCH and ESTH

Improve compliance with statutory timeframes for health assessments.

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6 CONCLUSION: 6.1 Merton and Wandsworth CCG from February 2017 have in place a team of safeguarding

professionals that cover both Boroughs, however systems and reporting processes require alignment – this is to be incorporated into the safeguarding work plans of each professional. The annual safeguarding report for 2017/18 will be a Merton and Wandsworth Report with the exception of the Looked After Children report which remain borough specific given this report is received by the Corporate Parenting Panel.

6.2 The CCG safeguarding governance arrangements are to be shared with implementation of

a Merton and Wandsworth Safeguarding Committee replacing the Wandsworth Committee and Merton SEG. The first meeting will be on 30th October 2017.

6.3 The implementation of the shared safeguarding arrangements will require monitoring in

regard to capacity of the safeguarding professionals given the workload of two boroughs and specifically the additional complexity of Wandsworth. The acute provider in Wandsworth, St Georges Hospital, is in ‘special measures’ and the LA was rated by OFSTED as ‘inadequate’ (2015). An indicator of the increased level of need in Wandsworth is the number of children subject to a child protection plan: Wandsworth has 400 children subject to a child protection plan while Merton has 140 (June 2017). In regard to Looked After Children Wandsworth has 288 while Merton has 160 (June 2017).

6.4 There will be increased scrutiny from NHSE on compliance with PREVENT WRAP training

with a target of 85% set for March 2018. St Georges Hospital and SWL and St Georges Mental Health Trust are currently not on track to meet this target. The Designated Nurse and Designated Safeguarding Adults Professional are working with each the Trusts to increase compliance.

6.5 The MSCB will require all providers including the CCG to submit a Section 11 Audit and to

present this at a Section 11 Challenge Panel. The Designated Nurse will attend the Health Partners Section 11 Challenge Panels.

1

MERTON CLINICAL COMMISSIONONG GROUP GOVERNING BODY

Date of Meeting: 30th November 2017 Agenda No: 11.5 Attachment: 17b

Title of Document: Safeguarding Adults Annual Report 2016/17

Purpose of Report: Review

Report Author: Marino Latour- Designated Safeguarding Adults Lead Merton & Wandsworth CCG

Lead Director: Julie Hesketh Director of Quality and Governance

Executive Summary: The Annual Report 2016/17 seeks to demonstrate how the Governing Body of Merton Clinical Commissioning Group (MCCG), in discharging its functions as a commissioner of healthcare services has been assured that the arrangements to safeguard adults at risks have been effective, compassionate and most importantly listened to and engaged with the adults in Making Safeguarding Adults Personal. In addition, the annual report provides assurance that the MCCG has in 2016/17 achieved compliance with the duties and responsibilities as outlined by existing legislation, guidance and frameworks.

Key sections for particular note (paragraph/page), areas of concern etc: The Merton Annual Safeguarding Adults Report covers the following: Section 1 :Merton CCG Compliance with Guidance and Statutory Duties Section 6:Partnership working with Merton Local Authority and Merton Safeguarding Adults Board Section 8: activities of all commissioned services within Merton CCG

Recommendation(s): Section 13 of the Annual Report – conclusions: New shared safeguarding arrangements require a work plan to align the governance, polices and reporting processes across the two CCGs The new shared safeguarding arrangements require monitoring in 2017/18 to fully understand impact and capacity issues. PREVENT (WRAP) compliance is an NHSE priority with a target of 85% compliance in March 2018 and so the CCG must track providers progress – namely St Georges Hospital and SWL and St Georges MH Trust. CCG Safeguarding Adults Lead continues to ensure that adults at risks receive high quality services that contribute to their safety and wellbeing through a robust assurance monitoring framework across South West London Alliance.

Committees which have previously discussed/agreed the report: Merton and Wandsworth CCG Safeguarding Committee 30/10/17

Financial Implications: None identified

Implications for CCG Governing Body: To note both the areas of progress, risks and actions in 2016/17 and the priorities for 2017/18

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How has the Patient voice been considered in development of this paper: Through the work of Making Safeguarding Personal (MSP) both from the Local Authority perspective and the work that SWL & St George’s are doing in MSP

Other Implications: (including patient and public involvement/Legal/Governance/Risk/Diversity/ Staffing) Risk 47 of the BAF:- failure to recognise poor quality care may not be recognise or addressed in a timely way. Therefore Trusts may fail to achieve required improvements to quality and hence put at risk. Risk 72: Failure to provide assurance that those most vulnerable in care home and in the community are free from harm. If the CCG is unable to provide appropriate oversight, scrutiny and assurance within the care home setting, this increases the risk of potential harm to vulnerable service users.

Equality Assessment: Not required for this paper

Information Privacy Issues: None identified

Communication Plan: (including any implications under the Freedom of Information Act or NHS Constitution) Will form part of Governing Body papers and be available on the Merton CCG website.

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Merton Clinical Commission Group Safeguarding Adults at Risk

Annual Report April 2016 – March 2017

Marino Latour- Designated Safeguarding Adults

Professional

August 2017

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CONTENTS pg. EXECUTIVE SUMMARY 3 PURPOSE 5 PROFILE OF MERTON 5 SAFEGUARDING ADULTS 6 CLINICAL COMMISSIONING GROUPS 7 MERTON SAFEGUARDING ADULTS BOARD 8 MSAB ACHIEVEMENTS 2016/17AND PRIORITIES FOR 2017/18 8 PREVENT IN MERTON 12 MERTON PROVIDER SERVICES 12 South West London & St Georges Mental Health Trust 12 Priorities for 2017/18 14 CENTRAL LONDON COMMUNITY HEALTHCARE NHS TRUST 14 Priorities for 2017/18 16 MERTON CCG PRIORITIES FOR 2017/18 17 CONCLUSION 17 REFERENCES 19 APPENDICES 19

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1 EXECUTIVE SUMMARY 1.1 This report provides an overview of the safeguarding adults’ activity across Merton

during 2016/17 1.2 CCGs are statutory NHS bodies with a range of statutory duties, including

safeguarding adults and children. They are membership organisations that bring together General Practices to commission services for their registered populations and for the unregistered patients who live in their area. CCGs as commissioners of local health services need to assure themselves that the organisations from which they commission have effective safeguarding arrangements in place. CCGs are responsible for securing the expertise of Designated Professionals on behalf of the local health system. These roles undertake a whole health economy role. It is crucial that Designated Safeguarding Professionals play an integral role in all parts of the commissioning cycle, from procurement to quality assurance if appropriate services are to be commissioned that support adults and children at risk of abuse or neglect, as well as effectively safeguard their well-being.

1.3 The South West London Alliance has agreed to work together to deliver the

safeguarding functions as part of the portfolio of the Director of Quality and Governance. The Designated Safeguarding Adults Professional work together with the Designated Safeguarding Children Nurse across both Wandsworth and Merton under the management of the Director of Quality and Governance.

1.4 CCGs are also required to demonstrate that they have appropriate systems in place

for discharging their statutory duties in terms of safeguarding this includes the need to have in place the following:

Clear line of accountability

The executive leadership role for safeguarding is delegated by the Managing Director to the Director for Quality and Governance.

Policies for safeguarding, safe recruitment and for dealing with allegations against people who work with adults. The CCG complies with the National Statutory requirements and Pan London procedures for safeguarding adults.

Staff are appropriately trained to carry out their responsibilities for Safeguarding. The Safeguarding Team are up to date with their training and have access to appropriate supervision either on a once to one basis or via a London peer network at NHS England. Safeguarding training is part of the mandatory training programme for all staff employed by the CCG.

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Effective interagency working with Local Authorities including within the operation of Safeguarding Adults Board (SAB) and Health and Wellbeing Boards (HWBBs) The CCG is effectively engaged with the work of Merton Local Authority with clear membership of the SAB via the Director of Quality and Governance. The Managing Director takes responsibility for membership of the HWBBs.

Ensuring effective arrangements for information sharing Merton CCG has arrangements in place for sharing information across the health economy and with partner agencies. The CCG has safeguarding quality assurance systems in place through contractual arrangements with all provider organisations.

1.5 The CCGs comply with the national statutory requirements and Pan London procedures for safeguarding children and adults. The Safeguarding Adult Policy is in operation within the CCG.

1.6 Staff are appropriately trained to carry out their responsibilities for safeguarding. 1.7 The safeguarding team are up to date with their training and have access to

appropriate supervision either on a one to one basis or via a London peer network at NHS England. Safeguarding children and adults training is part of the mandatory training programme for all staff employed by the CCGS. This will also include Prevent WRAP training and Mental Capacity Act and Deprivation of Liberty Safeguards.

Effective inter-agency working with Local Authorities including within the operation of Local Safeguarding Adult Boards (SABs) and Health and Wellbeing Boards (HWBBs).

1.8 The CCGs are effectively engaged with the work of the Local Authorities with clear

membership of the SABs via the Director for Quality and Governance, ensuring effective arrangements for information sharing.

1.9 The CCGs have arrangements in place for sharing information across the health

economy and with partner agencies for adults. The CCG has safeguarding quality assurance systems in place through contractual arrangements with all provider organisations

1.10 Wandsworth and Merton’s Designated Safeguarding Adults Professional took up

the post end of June 2017. 1.11 The process for gaining assurance from the main providers’ trusts has focused on

checking their respective Trust Board minutes to ensure that there is corporate responsibility for safeguarding. In addition, the safeguarding work of the CCG has been reviewed in relation to key achievements and challenges as well as engagement with the Local Safeguarding Adults Board. There was also a deep dive audit undertaken by NHS England in November 2015 of which assurances were gained that Merton CCG had effective arrangements in place to safeguarding Adults at risks.

1.12 This annual report identifies the extent to which Merton CCG can be assured that

they and their commissioned services are effectively discharging their safeguarding

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functions. It also highlights areas where improvements are required for the CCG to ensure that there are effective systems in place to safeguarding adults at risk in the future.

2. PURPOSE

2.1 CCGs have a duty to make arrangements to ensure that their functions are

discharged with regard to the need to safeguard adults of risks of abuse and neglect. CCG’s are responsible for ensuring that commissioned services, including NHS funded services provided by non NHS organisations, take account of the national legislation statutory guidance, Care Act 2014 and other overarching NHS standards. These duties transferred to CCGs and the NHS England on 1st April 2013.

2.2 This report provides the Governing Body of Merton CCG with an overview of

safeguarding across health services in the borough during 2016-17. The report reviews the work across the year, giving assurance that the CCGs have discharged their statutory responsibility to safeguard adults at risks across the health services the MCCG commissions. It also identifies the areas for the work plan for 2017/18.

2.3 The lead responsibility for each of the providers is allocated to one of the South West London CCG’s. Merton CCG is responsible for South West London and St George’s Mental Health NHS Trust and Central London Community Healthcare (CLCH). For the purpose of this annual report, the Designated Safeguarding Adults Professional has concentrated on the safeguarding practices in these two Trusts.

3 PROFILE OF MERTON

3.1 NHS Merton Clinical Commissioning Group (MCCG) is the GP led organisation responsible for planning and buying health services for people living in Merton. It operates from offices at the Broadway, Wimbledon. The London Borough of Merton is a borough in South West London. The borough was formed in 1965 by merging together the Municipal Boroughs of Mitcham and Wimbledon, and the Merton and Morden Urban District, all formerly within Surrey. The borough takes its name from the historic parish of Merton, which covered the area now known as South Wimbledon.

3.2 The CCG was established on 1st April 2013 with its mission to improve the effectiveness of clinical care and the patient experience and it is now made up of 23 General Practices (GP). In Merton the GPs are working in the localities areas of the borough to provide a more localised are, closer to home.

3.4 According to the Joint Strategic Needs Assessment (JSNA, 2014), Merton has a diverse and growing population. Merton’s population is projected to increase by 3,000 people between 2017 and 2010. The age profile is predicted to shift- with a notable growth in the proportions under the age of 16 years and those over 50 years old.

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3.5 Merton’s 2014 population was 203,200 people living in nearly 80,400 occupied households. Population density is higher in the east wards of the borough compared to the west wards. Just over half the borough is female (50.6%) and the borough has a similar age profile to London as a whole. Greater London Authority (GLA) population data (2014) shows Merton’s current BAME population is 76,188. Black, Asian and Minority Ethnic (BAME) groups make up 35.1% of the population, lower than London (40.2%).

3.6 The Indices of Multiple Deprivation (IMD) set out the relative position of local areas in terms of deprivation. Updated indices of deprivation were released in September 2015. The IMD reflects the multidimensional nature of deprivation, with an overall score that is weighted most heavily on the domains of income (22.5%) an employment (22.5%), but also includes other domains (not just financial). East Merton and West Merton are less deprived than the average for both London and England. However, three wards are more deprived than the average London: Cricket Green, Figge’s Marsh and Pollards Hill. One ward, Ravensbury, is less deprived than the average for London, but more deprived than the average for England.

3.7 Health outcomes in Merton are generally better than those in London, and in line with or above the rest of England. However, there is a difference between the most and least deprived areas within the borough of about 7.9 years for men and about 5.2 years for women. Between 2009-11 and 2011-13 this gap increased by about one year for women. Premature mortality (deaths under 75 years) is strongly associated with deprivation; all wards in East Merton are more deprived and have higher rates of premature mortality.

4 SAFEGUARDING ADULTS

4.1 Legal Framework for Safeguarding Adults

Responsibilities for safeguarding are enshrined in legislation. Adults have a legal right to make their own decisions, even if they are unwise, as long as they have capacity to make that decision (which must be free from coercion or undue influence). However, if an “adult repeatedly makes unwise decision that put them at significant risk of harm or exploitation, or makes a particular unwise decision that is obviously irrational or out of character”. There might be need for further investigation. Moreover, the wishes of victims of crime can be overridden in the public interest which includes responding to suspected offences against them or the suspected abuse or neglect of others.

4.2 The Care Act (2014) places a statutory responsibility on CCGs in adults safeguarding. In particular there is the requirement to create a culture that supports safeguarding principles and to participate in multi-agency working.

4.3 Local Authorities (Las) retain the lead responsibility for adults safeguarding that they were given over a decade ago in “No Secrets” (DH, 2000), the Care Act makes adults safeguarding statutory but it is still non-prescriptive about the way services should be organised to achieve this.

4.4 Section 42 of the act relate to the role and responsibilities of Safeguarding Adults Boards.

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4.5 The purpose of this safeguarding adults report for 2016/17 is to provide assurance to Merton Clinical Commissioning Group (MCCG) and Governing Body that safeguarding adults arrangements are robust and that statutory obligations are being met.

4.6 This report aims to provide assurance to the Governing Body, additional assurance and updates are provided to the Safeguarding Executive Group (SEG) committee on a quarterly report.

5 CLINICAL COMMISSIONING GROUPS

5.1 CCGs are statutory NHS bodies with a range of statutory duties, including safeguarding adults and children. They are membership organisations that bring together general practices to commission services for their registered populations and for unregistered patients who live in their area. CCGs are responsible for commissioning most hospital and community healthcare services. Initially in the reformed NHS CCGs were not directly responsible for commissioning primary medical care, but they have a duty to support improvements in the quality of primary medical care. Further to this, since 1st April 2016, Merton CCG has taken on fully delegated Primary Care Commissioning.

5.2 CCGs as commissioners of local health services need to assure themselves that the organisations from which they commission services have effective safeguarding arrangements in place. CCGs are responsible for securing the expertise of Designated Professionals on behalf of the local health system. It should be recognised that the Designated Professionals undertake a whole health economy role. It is crucial that Designated Safeguarding Professionals play an integral role in all parts of the commissioning cycle, from procurement to quality assurance if appropriate services are to be commissioned that support adults at risk of abuse or neglect.

5.3 Safeguarding forms part of the NHS Standard contract (service condition 32) and commissioners will need to agree with their providers, through local negotiation, what contract monitoring processes are used to demonstrate compliance with safeguarding duties.

5.4 CCGs must gain assurance from all commissioned services, both NHS and independent healthcare providers, throughout the year to ensure continuous improvement. Assurance may consist of assurance visits and attendance at provider safeguarding committees. CCGs are also required to demonstrate that they have appropriate systems in place for discharging their statutory duties in terms of safeguarding.

5.5 NHS Merton CCG has a clear line of accountability for safeguarding, properly reflected in the CCG Governance arrangements. Merton CCG and NHS England are statutorily responsible for ensuring that the organisations from which they commission services provide a safe system that safeguards adults at risk from abuse and neglect. NHS England is the policy lead for safeguarding and has safeguarding responsibilities for directly commissioned services. NHS England has a statutory duty to be a member of the safeguarding adults and provides oversight

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and assurance of the CCG’s safeguarding adults’ arrangements and supports the CCG in meeting the responsibilities.

6 MERTON SAFEGUARDING ADULTS BOARD

6.1 The Safeguarding Adults Board (SAB) has helped partners to review working relationships to make sure that effective interventions are being delivered. All adults safeguarding activity has been recorded in the Council’s core recording adults social care system which made it easier for practitioners and the board to monitor activity.

6.2 The governance of the Safeguarding Adults Board is to ensuring that tasks agreed by the board and its sub groups were followed up. Chairing the multi-agency groups is shared across the partnership. The sub groups will be further developed in due course.

6.3 Merton Safeguarding Adults Board (MSAB) has published their annual report in

regards to the progress made during the year April 2016- March 2017 including how

local and national developments have influenced this in line with the statutory

footing since the Care Act 2014 was introduced.

The Board meets quarterly, four times a year and has three core duties in line with the Care Act 2014 guidance.

it must publish a strategic plan for each financial year that sets how it will meet its main objective and what the members will do to achieve this. The plan must be developed with local community involvement, and the SAB must consult the local Health watch organisation. The plan should be evidence based and make use of all available evidence and intelligence from partners to form and develop its plan

it must publish an annual report detailing what the SAB has done during the year to achieve its main objective and implement its strategic plan, and what each member has done to implement the strategy as well as detailing the findings of any safeguarding adults reviews and subsequent action

it must conduct any safeguarding adults review in accordance with Section 44 of the Act.

6.3 Merton Safeguarding Adults Board’s achievement in 2016/17 and Priorities for next year 2017/18

The board have successfully achieved the following actions during this year:

Leadership and Governance

Set up an Operational Subgroup of the SAB to meet bi-monthly to ensure that the Delivery Plan is delivered (Chair - Member of the MSAB; Core Membership - safeguarding leads from 3 statutory partners). The operational subgroup to ensure that: delivery plan is actioned, monitored and reviewed.

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The first sub group will begin in June 2017, membership is established.

Task and Finish groups to be set up by the MSAB or Operational Subgroup to achieve the objectives of the delivery plan.

This action is in place and the board held a Hoarding task and finish group to update the Hoarding protocol into 2017.

Appoint an Independent Chair for MSAB and agree a MSAB Budget for the Chair and MSAB support.

MSAB has appointed a new independent chair in May 2017. Budget considerations have begun and will continue to be discussed and explored into the following year 2017/2018.

Review the membership of MSAB, including identifying advocacy and service user voices on the MSAB.

MSAB is yet to have an advocacy representative on the board but we continue to explore how we can ensure service user voice and welcome hearing about the South West London and St George’s Trust Making Safeguarding Personal Group.

6.4 Performance Management and Quality Assurance

Agree and establish a performance framework (both performance information and analysis) including reporting on: the ‘conversion rates’ from safeguarding concerns to enquiries, by referral source and category; trends in types of abuse; outcomes identified by service users and achieved through s.42 enquiries; impact of safeguarding activity; safeguarding activity reporting from all MSAB partners; provider quality and safeguarding concerns (from the multi-agency quality monitoring meetings); repeat adult safeguarding referrals and activity.

A task and finish group has been set up to look at this action in more detail and will be carried forward into the next year.

Develop and deliver quality assurance tools e.g. quality audits of case files.

This work will be carried out by the operational sub group and will be included in their annual work plan once fully operational.

Review 2016/17 Merton data in order to benchmark performance, both regionally and nationally, to inform future priorities

This work has begun and includes involvement in the work by the London Safeguarding Board that will produce a London wide data set which can accurately benchmark safeguarding data with other boroughs. The NHS Digital data collection cannot accurately do this at present as it does not account for how each local authority logs a safeguarding concern or enquiry.

Identify where issues raised through safeguarding concerns could be resolved without s.42 enquiries, and appropriate information and advice provided as safeguarding early intervention and prevention activity. (Appendix 1 for Safeguarding activity data)

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This action will be taken forward to the following year.

6.5 Safeguarding Adult Reviews

Develop and adopt a Safeguarding Adults Review (SAR) protocol so that the partnership can learn and improve safety and wellbeing of Merton residents.

This has been completed and signed off with the board.

Set up a process to manage and deliver the SAR protocol so that staff understand the criteria for a SAR, and how cases can be escalated for consideration by the Operational Sub group.

This will be in place through the operational sub group.

Ensure partner agencies contribute to the SAR processes.

Partners contribute to the process through the operational sub group.

6.6 workforce strategy

Co-ordinate adult safeguarding training and development plans across all partners – share plans and review to ensure a consistent approach to competency expectations (use Bournemouth model/ NHS intercollegiate safeguarding competency model?)

This action will progress through the operational sub group into the next year.

Prioritise legal literacy training across priority staff groups in LA, MHT and CHT (undertaking and managing enquiries?)

LBM will renew their ASC training offer to council staff involving safeguarding and legal update courses. Opportunity for partners to access these courses will be discussed and explored into the next year with the development of a safeguarding board training offer.

Review MCA training to ensure consistent approach across all agencies and use of Toolkit

This will be carried forward to the next year and included within the training discussions.

Consider how to assess that training has had the desired impact in terms of improving staff effectiveness (e.g. via multi agency case file audit?)

This will be the work of the operational sub going forward into the next year.

Independent Chair to lead a review of current strategy and the process for

6.7 MSAB Strategy 2017-20

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The Independent Chair to lead a review of current strategy and the process for developing a new strategy; this will be completed in the autumn of 2017

Consultation is undertaken during 2016/17 and this informs the priorities of the draft strategy for 2017-20.

The safeguarding and mental capacity learning forum will be utilised to ensure consultation with staff regarding the new strategy is completed.

The Multi Agency Pan London Safeguarding Adults at Risk policy and procedures were published in November 2016 and have been adopted by the Board entirely with a local operational protocol being revised which details specific arrangements to Merton.

Board Partners completed the self-audit – Safeguarding Adults at risk audit tool developed by ADASS in relation to their own organisation. This assisted with giving assurance to the board as well as formulating action plans to meet requirements as set out in the audit.

6.8 MSAB Away Day

The board held a planning away day in May 2016, facilitated by Adi Cooper OBE. This was to assist the board with reviewing the 3 year strategy 2014-17 and revising the board actions to ensure they remained relevant.

The notes of the away day were circulated to members and copy of the notes can be requested from the Safeguarding Adults Board Administrator.

The success of this away day ensured that the MSAB were in a position to recruit an independent board chair, develop our SAR Policy and put plans in place to establish an operational sub group which can drive forward the actions from the away day in line with the 3 year strategy.

6.9 TRAINING:

Total number of staff attending safeguarding training this year is 341. The breakdown of course and participant follows:

Raising a concern

85 staff attended this course, 55 participants were LBM staff and 30 were staff from partner agencies.

Undertaking an enquiry

64 LBM staff attended this course.

Managers

26 staff attended this course, 4 were managers from partner agencies.

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Basic Awareness

166 staff attended this course, 69 staff were from partner agencies.

7 PREVENT IN MERTON

7.1 The CCG Designated Safeguarding Adults Professional sits on the Channel Panel chaired by the Community Safety Unit based at Merton Local Authority. It is a multi-agency panel which consist of Health providers- South West London & St Georges Mental Health Trust, CCG, Local Police, Children Services, Local Authority representatives, where possible PREVENT cases are discussed including interventions. The CCG is required to monitor the PREVENT and WORKSHOP TO RAISE AWARENESS OF PREVENT (WRAP) training compliance from commissioned providers on a quarterly basis, which they also send to NHS England via an electronic system UNIFY.

8 MERTON PROVIDER SERVICES

8.1 South West London & St Georges Mental Health Trust

8.2 The safeguarding duties under the Care Act have a legal effect in relation to the Trust. Senior representatives of the Trust who sit on the Safeguarding Adults Board play an important role in the strategic development of adult safeguarding locally.

8.3 The Executive holds the responsibility for ensuring the Trust is safeguarding adults and children are promoting their welfare and wellbeing effective throughout the Trust. They are also responsible for making sure the Trust is represented on the Safeguarding Children’s Board (SCB) and Safeguarding Adults Board (SAB) in boroughs where services are provided.

8.4 It is noted that major external events in 2016/17 heightened the focus on PREVENT. The Trust has provided assurances on training compliance and attendance at channel meetings, as well the management of referral processes and the provision of clinical oversight.

8.5 The annual organisational audit was completed and submitted to the SABs. The audit provides the Trust with a consistent Framework to assess, monitor and improve their Safeguarding Adults arrangements. In turn this supports the Safeguarding Adults Board (SAB) in ensuring effective safeguarding practice across the borough. The SAB “Challenge Events” provided useful opportunity for SABs feedback on the audit. The audit identified actions required and as well as areas of good practice.

8.6 The Making Safeguarding Personal Group (MSP) has continued to meet throughout the year and has made a number of invaluable contributions to service developments. The group has completed a comprehensive and detailed review of staff training, recorded videos for potential use in staff training, trained a Local Authority Social Work Team, ran three workshops at a local conference and delivered presentation to four SABs. The MSP group has been widely distributed across service user organisations and NHS organisations and features as a model of good practice in ADASS guidance document.

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8.7 The Trust Executive requires assurance that allegations made against staff are dealt with through a fair and clear process. These include when complaints, claims and allegations of abuse or neglect (as defined by safeguarding policy and including PREVENT) are made about staff. It is recognised that when a concern is raised about staff it can be a stressful experience.

8.8 A “task and finish” group is developing a protocol for the management of allegations against staff. The group included representatives from the Nursing Directorate, Human Resources and the Employee and Engagement Team. The protocol will include the requirement to refer to Professional Bodies and will be applicable to all staff, managers, senior leadership and executives across all grades and professions, and includes bank and agency staff.

8.9 The Restrictive Practice Group supports restrictive practice by providing assurances that any form of restrictive practice used with any patient is only carried out in the best interests of the patient.

8.9 The Head of Safeguarding has consulted with medical staff, ward managers and nursing leadership to develop the plan for quality improvement initiative (Qii). The focus has been on reducing acts of violence and aggression- including incidents of patient on patient, staff on patient, patient on staff incidents. The Qii is directly informed by the recommendations from last year’s management of patient on patient incidents and Local Authority SAB initiatives. The impact of these changes will be reported quarterly to the Executive Safeguarding Meeting (ESM). Reports will include benchmarking data and statistical process controls.

8.10 There has been 32% increase in safeguarding adults’ alerts to 996 in 2016/17. This should be seen as very positive news, as it suggests increased levels of awareness of safeguarding, and also wider knowledge of how to report safeguarding concerns.

8.11 There were 24% safeguarding adult alerts reported as “Serious Incidents” (SI). The SI and safeguarding process are not fully integrated and NHSE have commissioned a “task and finish” group to develop guidance on application of the processes.

8.12 The Ulysses Systems Administration team have developed new data extraction tools that will provide complete dataset for cases referred to the Local Authorities in 2017/18. The initial data extraction trials only show the proportion of alert referred to the Local Authority. For example, in the first quarter of 2017/18 approximately 88% of alerts were referred to the Local Authority.

8.13 The types or categories of abuse are in similar proportion to 2015/16. This means that the proportion of incidents of physical abuse remains high (36%) and of these, a high proportion (47%) were reported by in-patient services.

8.14 The Trust has reviewed its Workforce Development Plan to ensure compliance with safeguarding adults training. The Safeguarding Adults Level 1 e-learning has been updated to meet the new competence framework. Additional support for complex cases has been available from the safeguarding leads through team meetings, briefings and phone contacts.

8.15 There has been particular focus on PREVENT this year and the PREVENT lead has developed a comprehensive network of key contacts to support inter-agency working. Where cases arise, local managers have been able to link in with these

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key partner. All PREVENT and PREVENT-related concerns are reported on Ulysses. This provides robust governance of all cases. These are reviewed at the weekly Quality Matters meeting with oversight through ESM.

8.16 The Trust are required to provide representation at Channel meetings in any of the NHSE nominated priority boroughs. The Executive has appointed a PREVENT deputy lead to provide cross cover to ensure trust representation at all necessary Channel meetings. NHSE provide external monitoring of PREVENT enquiries cases and training compliance. The Trust submits quarterly returns to both NHSE and the CCG lead using the new Unity 2 System.

8.17 There has been a comprehensive review of the Workforce Development Plan with a new schedule of “Workshop To Raise Awareness of PREVENT” (WRAP) and “Basic PREVENT awareness (BPAT) sessions being put in place. This has been undertaken in close liaison with NHSE PREVENT leads.

8.18 The Trust has been fully engaged with the multi-agency review of two incidents, with a further 2 pending in Safeguarding Adults Reviews (SARs) of which two in Richmond and two in Wandsworth.

9 PRIORITIES FOR 2017/18

Policy Review to embed Making Safeguarding Personal group recommendations and to take account of the latest statutory and practice guidance

Improve data quality- support staff training initiatives through “Ulysses User Group”

Develop inter-agency protocols for SAB and SAB sub groups and other key forum

Reduce incidents of violence and aggression

Enhance workforce competence

9.1 All the objectives set in 2016/17 were achieved and completed within the agree time scale.

10 CENTRAL LONDON COMMUNITY HEALTHCARE NHS TRUST

10.1 Central London Community Healthcare NHS Trust (CLCH) Board should be assured that during 2016/17 arrangements were in place to safeguard and protect all those accessing and using CLCH services, including children, young people and adults.

10.2 CLCH demonstrated safeguarding adult’s assurance in 2016/17 by having in place:-

CLCH Board Executive Lead for safeguarding (Chief Nurse) who along with the Director of Nursing and Quality, Deputy Chief Nurse and Head of Safeguarding, provide strategic leadership and support within CLCH.

Safeguarding governance arrangements including CLCH Safeguarding Committee, chaired by the Chief Nurse or her deputy in an established and effective forum, where safeguarding concerns and risks are discussed and reviewed with external partners in attendance.

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Patient Safety and Risk Group and Quality Committee, reports inform the CLCH Board about safeguarding incidents, investigations and outcomes for patients on a monthly, quarterly and annual basis.

Active involvement with the Local Safeguarding Boards, including developing Board priorities, procedures and working arrangements to safeguard and protect vulnerable people, at both an operational and strategic level.

Multi-agency partnership working arrangements that ensure CLCH engagement and contribution to Section 42 (Care Act, 2014) enquiries and Best Interest meetings (MCA, 2005)

Processes to assure CLCH staff fulfil their statutory duties under the Channel/PREVENT agenda.

Systems to support staff ion acknowledging their statutory duty to cooperate in reporting cases of human trafficking and modern slavery, in line with the Modern Slavery Act (2015)

Robust safeguarding training programme to ensure CLCH staff have received the requisite “essential –to- role” safeguarding training, including Mental Capacity Act (MCA)/Deprivation of Liberty Safeguards (DoLS) training.

Safeguarding supervision, both mandatory and ad hoc delivered by the safeguarding team has supported staff in decision making and prioritising the needs and wishes of children, young people and adults, where there is a high level of complexity, risk and vulnerability. An audit of safeguarding supervision for health visitors and school nurses in 2015 identified that CLCH staff valued safeguarding supervision.

Robust recruitment process that include pre-employment clearance for all new staff, including enhanced Disclosure and Barring Service (DBS) checks. CLCH achieved 100% compliance with DBS checks and has in place policies regarding recruitment6, chaperoning and whistleblowing.

10.3 Competencies and training levels commensurate to role for safeguarding adults which is currently determined by the Social Care Institute for Excellence, but Intercollegiate Guidance agreed by NHS England is due to be published later in 2017.

10.4 Training compliance is monitored centrally and reported to the CLCH Board. Safeguarding training is a key performance indicator (KPI) which is reported to the CCG on a quarterly basis.

10.5 Safeguarding training compliance for 2016/17 improved due to introduction of a Level 1 Statutory and Mandatory Training Booklet and increased provision of training sessions across the Trust. A compliance of 97.17% was achieved in Level 1 and 88.45% Level 2 safeguarding adults training.

10.6 Embedding the Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) into clinical practice remains an ongoing objective. MCA/DoLS training is delivered “in-house” by the Adults Safeguarding Leads in tandem with Level 1 and 2 adult safeguarding training. The aim of this training is to ensure staff are aware of their duty to protect the rights and freedoms of all service users.

10.7 Following an audit in early 2016, bespoke training was undertaken with staff to embed MCA assessment, DoLS and consent for treatment for all staff delivering

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treatment to patients in receipt of community services and improve record keeping in respect of recording MCA/consent issues.

10.8 The actions from the audit was completed in June 2016 and a re-audited in November/December 2016. The MCA training packages was reviewed, Adults at Risk/MCA Policy was updated and Restrictive Intervention Policy was developed in 2016.

10.9 CLCH has responded appropriately to the PREVENT strategy (2011) by ensuring there is a CLCH PREVENT Lead, assuring PREVENT awareness training is delivered in all safeguarding training packages and completed a training needs analysis to identify key staff requiring a higher level of PREVENT training (WRAP3) dependent on their roles and responsibilities.

10.10 CLCH achieved an organisational compliance 84% by end of March 2017, with NHS England compliance set at 85% by April 2018. During 2016/17, the safeguarding team attended PREVENT train the trainers training and they have increased the number of competent trainers within the safeguarding team.

10.11 In 2016/17, CLCH made 2 referrals to PREVENT but sought advice from PREVENT coordinators more regularly regarding young people and adults who appeared vulnerable and at risk. The Trust submits quarterly reports to NHS England regarding PREVENT referrals and number of staff trained.

10.12 In the wake of recent terrorist attacks in 2016/17, the CLCH safeguarding team have cascaded information regarding PREVENT and the need for staff to be vigilant in protecting themselves and the public.

10.13 Safeguarding supervision has been undertaken with CLCH practitioners working in adult services who are managing complex cases. The supervision policy has been reviewed to standardise the approach across the Trust and to include a restorative model for supervision and caseload tracker to assure oversight of safeguarding cases by both safeguarding practitioners and mangers to regular review risk assessment and positive outcomes for adults at risks.

10.14 in 2016/17 a total of 251 incidents were reported by CLCH staff which identified possible safeguarding concerns about both adults and children. These incidents were reviewed by the member of the CLCH Quality and Safety team, Safeguarding team, Violence and Aggression Lead, Divisional Managers and Line Managers.

10.15 In line with CLCH policy, 48 hour meetings in relation to significant concerns were chaired by the Director of Nursing and Quality/Deputy Chief Nurse and the level of investigation required agreed. The safeguarding team were involved in a variety of cases such as grade 3 and 4 pressure ulcers, concerns about professional practice, Information Governance (IG) breach in relation to multi-agency minutes with personal identifiable information.

10.16 Information was presented to the relevant Safeguarding Adults Board (SAB) and CCG, with internal scrutiny via the CLCH Quality and Safeguarding Committee. Many of the incidents reported were in relation to other healthcare providers or situations outside CLCH remit or control for example- allegations of omissions of care by a healthcare provider. However, this demonstrates CLCH staff act on

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concerns and take their duty to protect service users from harm and abuse seriously.

11 CLCH PRIORITIES FOR 2017/18

To streamline their systems and work more efficiently and effectively as a team

To seek input from service users to develop safeguarding leaflets and resources

To contribute to the work of the CLCH Board in providing assurance to CCGs

To grow and develop as a team and influence to make a difference to the lives of adults at risk of neglect and abuse

To review monitoring and assurance arrangements, including safeguarding compliance

To support CLCH staff in identifying, assessing and responding appropriately to vulnerability and abusive situations to ensure the safety and wellbeing of adults.

11.1 The introduction of a safeguarding work plan which has structured and focused the team’s work, systems and policies has ensured CLCH have focused on their objectives and met these in 2016/17.

12 MERTON CCG PRIORITIES FOR 2017/18

12.1 During the course of 2017/18 Merton CCG priorities for Safeguarding Adults will be to have:-

The oversight of all safeguarding activity will be undertaken by the Director of Quality and Governance and the new Merton and Wandsworth Safeguarding Committee as the result of the merger of both Merton and Wandsworth CCGs.

The Designated Safeguarding Adults Professional will maintain the responsibilities around Safeguarding Adults Boards sub group arrangements and will work in conjunction with the Children Safeguarding Designated Professionals.

The Designated Safeguarding Adults Professional will continue to work with providers who are not meeting trajectory targets to give them advice and support to help them to meet training standards and training compliance of 85%

The Designated Safeguarding Adults Professional will continue to provide help and support for the completion of the South West London and St George’s Mental Health Trust’s completion of the thematic review.

Merton and Wandsworth CCGs will continue to have oversight of the provider services safeguarding activities including Care Homes across both Merton and Wandsworth in order to be assured that they are able to meet Care Quality Commission (CQC) and other relevant standards for registration and prepared for potential inspection in terms of safeguarding activity.

To review and have a single Safeguarding Adults Policy and Mental Capacity Act & Deprivation of Liberty Safeguards Policy across both Merton and Wandsworth

To have a joint training strategy for both Adults and Children to ensure that both Merton and Wandsworth CCG workforce are compliant with all mandatory training including PREVENT.

The Designated Safeguarding Adults Professional will work with the main commissioned providers and other Designated Safeguarding Professionals to develop and agree a Safeguarding Health Outcomes Framework (SHOF) across South West London Alliance as a consistent reporting framework for commissioned

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services to provide robust assurance to the CCG to demonstrate that they are discharging their statutory safeguarding duties.

13 CONCLUSION

Safeguarding and promoting the welfare and wellbeing of adults are important areas of practice, potentially being high risk for both individual adult and organisations. The Care Act (2014) which is underpinned by the Human Rights Act (1998) affords protection and support to adults at risk, creating a legal framework for agencies and individuals with responsibilities for adults safeguarding to co-operate on working together to keep adults at risk safe. Under the Section 42 of the Care Act a Local Authority has a duty of enquiry when there is a reasonable belief that an adult in its area has care and support needs, is experiencing, or at risk of abuse and neglect and is unable to safeguard themselves as a result of their care and support needs.

The duties and responsibilities of health providers, commissioners and regulators is well documented in statutory guidance, with a requirement for there to be a board level focus on the needs of adults across health and that all health organisations include safeguarding adults as an integral part of their governance arrangements.

CCGs continue to carry significant responsibility for the whole health economy within their area, whilst commissioning for health services across that economy that is increasingly complex. CCGs are committed to safeguarding and promoting the welfare of children, young people and adults and so their commissioning intentions reflect the needs of that population across both Wandsworth and Merton CCGs. Safeguarding Professionals continue to make every effort to ensure that adults at risks receive high quality services that contribute to their safety and wellbeing, whilst building networks and developing and forging relationship with other commissioning organisations in order to influence decision makers and manage risks as they emerge.

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REFERENCES

Merton Joint Strategic Needs Assessment 2014: Merton Council

APPENDIX 1

London Borough of Merton

Subject to NHS Digital Validation, the SAC data return for the year 2016/2017 is displayed

below.

Diagram 2: Safeguarding activity in London Borough of Merton

This table demonstrates that 18% of safeguarding concerns reported to LBM, went on to

sec.42 safeguarding enquires. This may appear to be low but what it can suggest is that

the borough receives high number of safeguarding concerns and once screened, are

either not a safeguarding concern by definition of the Care Act 2014 or are managed at the

first stage and not appropriate to proceed further into enquiries. The total number of

safeguarding concerns is similar to previous years, for example 2015/2016 at total of 557

were reported, there was an increase this year of 32 concerns.

Diagram 3: Reported categories of abuse

Table SG1f

Counts of Safeguarding Activity Count

Total Number of Safeguarding Concerns 589

Total Number of Section 42 Safeguarding Enquiries 104

Total Number of Other Safeguarding Enquiries 14

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This table demonstrates the reported categories of abuse. The SAC does not require mandatory reporting of the categories in grey, LBM do collect this and will be in reportable data form when Mosaic system is functioning. Neglect is the highest reported category of abuse, followed by physical abuse then financial abuse. This has been the categories reported consistently in previous years and offer no new themes or patterns in LBM. Diagram 4: Reported categories by location of abuse

This table shows that abuse or the risk of abuse is likely to within a residential care home

or persons own home. Again, this is consistent to previous years and offers no new

themes in relation to activity in the borough.

Diagram 5: Mental Capacity status for individual subject to s.42 enquiries

Table SG2a

Counts of Enquiries by Type and Source of Risk

Service

Provider

Other - Known

to Individual

Other -

Unknown to

Individual

Service

Provider

Other -

Known to

Individual

Other -

Unknown to

Individual

Total

Section 42

Total

Other

Physical Abuse 8 8 7 23 0

Sexual Abuse 0 0 4 4 0

Psychological Abuse 5 6 3 14 0

Financial or Material Abuse 3 14 2 19 0

Discriminatory Abuse 1 0 1 2 0

Organisational Abuse 5 1 5 11 0

Neglect and Acts of Omission 17 11 12 40 0

Domestic Abuse 0 0

Sexual Exploitation 0 0

Modern Slavery 0 0

Self-Neglect 0 0

SOURCE OF RISK

Concluded Section 42 Enquiries Other Concluded Enquiries

SOURCE OF RISK

Table SG2b

Counts of Enquiries by Location and Source of Risk

Service

Provider

Other - Known

to Individual

Other -

Unknown to

Individual

Service

Provider

Other -

Known to

Individual

Other -

Unknown to

Individual

Total

Section 42

Total

Other

Own Home 9 21 9 39 0

In the community (excluding community services) 1 2 1 4 0

In a community service 1 0 4 5 0

Care Home - Nursing 0 0 0 0 0

Care Home - Residential 17 8 10 35 0

Hospital - Acute 0 0 0 0 0

Hospital - Mental Health 0 0 0 0 0

Hospital - Community 0 0 0 0 0

Other 0 2 3 5 0

SOURCE OF RISK SOURCE OF RISK

Concluded Section 42 Enquiries Other Concluded Enquiries

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This table demonstrates that the mental capacity of an individual in relation to partaking in

safeguarding enquires is either that they lacked capacity or is not recorded. These

findings do not appear to offer a clear picture to how mental capacity is assessed to

whether a person consents to a safeguarding enquiry. This may be something the board

may want to consider in relation to multi agency audits, mental capacity set as a theme.

DEPRIVATION OF LIBERTY SAFEGUARDS (DOLS) DATA

This graph shows that number of DOLS requests received is increasing every year,

although this was a slight increase by 19 authorisation requests. This may show that

applications are rising but not significantly which may indicate applications are at a steady

pace with no indication or further significant increases.

Table SG3a

Mental Capacity Table for Concluded Section 42 Safeguarding Enquiries

For each enquiry, was the adult at risk lacking capacity to make decisions

related to the safeguarding enquiry?18-64 65-74 75-84 85-94 95+ Not Known Total

Yes, they lacked capacity 11 3 6 8 2 0 30

No, they did not lack capacity 11 4 2 5 1 0 23

Don’t know 2 1 2 0 1 0 6

Not recorded 14 1 5 7 2 0 29

Of the enquiries recorded as Yes in row 1 of this table, in how many of these

cases was support provided by an advocate, family or friend?9 2 6 6 0 0 23

Age Group

2015/2016, 651

2016/2017, 670

640

645

650

655

660

665

670

675

2015/2016 2016/2017

Total DOLS Authorisation Requests

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In 15/16 there were 516 DOLs completed – there was no allocation list at that time and,

the rest were either abandoned, duplicated, or DOLS criteria not met (i.e not authorised)

In 16/17 there were 289 DOLs completed with 199 on the allocation list, the reason for

creation of the allocation list was due to a change in the safeguarding team and availability

of full time assessors. LBM have also ceased using independent BIA’s unless there is a

valid reason to (e.g conflict of interest), therefore ASC staff that are BIA’s complete

approx. 2 BIA assessments a month as part of their caseload of work.

For both care home and hospital, the number of authorisation requests has increased slightly for Care and Nursing Homes. The above shows that Hospital authorisation requests have increased further this year. This could be due to hospital staff becoming more aware of DOLS and increased numbers of adults admitted that meet the criteria

0

10

20

30

40

50

60

70

2015/2016 2016/2017

DOLS Authorisation Requests submitted by Hospitals

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Mental Health continues to be the highest reported client group of people subject to a

DOLS authorisation request. This includes Dementia and other cognitive conditions. This

is consistent with national figures and is expected due to the nature of the DOLS process.

Mental Health62%

Physical Disability

16%

Learning Disability

22%

DOLS Authorisations by Client Group 2015/2016

Mental Health66%

Physical Disability

14%

Learning Disability

20%

DOLS Authorisations by Client Group 2016/2017