Bromley Clinical Commissioning Group. Safeguarding Adults. Annual report April 2016 to March DRAFT v 2.9

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1 Bromley Clinical Commissioning Group Safeguarding Adults Annual report April 2016 to March 2017 DRAFT v 2.9 Claire Lewin, Designated Nurse Adult Safeguarding, October

2 Table of Contents Purpose of report... 3 Introduction... 3 Prevalence of safeguarding adult activity in Bromley... 4 Summary of safeguarding adults key achievements Particular areas of achievement... 7 Overview of GP Safeguarding Adults Training... 7 Safeguarding in Service Procurements... 7 Domestic Abuse Primary Care IRIS Project... 8 Bromley Safeguarding Adults Board (BSAB)... 9 Conclusions & Priorities BCCG safeguarding adults work planned for 2017/ Appendix A: Case Studies References

3 Purpose of report The purpose of this report is to provide assurance to the Bromley Clinical Commissioning Group (BCCG) Governing Body that its statutory duties and requirements and Safeguarding Strategy for safeguarding adults at risk of abuse or neglect were met during 2016/17. It sets out the strategic objectives achieved in 2016/17, and the plans for safeguarding adults in 2017/18. Introduction Bromley is the largest London borough by area. The latest estimate of the resident population of Bromley is 326,560, having risen by 28,235 since It is predicted to expand still further over the next ten years. BCCG s approach to adult safeguarding is underpinned by quality and contracting systems and processes that aim to reduce the risk of harm and respond quickly to any concerns. CCGs have a duty to take measures to safeguard patients who are unable to protect themselves from abuse and neglect in their commissioned services and across the local health economy. This includes working within a multi-agency framework to take measures to reduce the risk of neglect and abuse and responding where abuse has occurred or is suspected of occurring. BCCG is a statutory member of the Bromley Safeguarding Adults Board (BSAB) following the implementation of the Care Act 2014, and is active on the Board and all its sub-committees. 1 Data from the Bromley Joint Strategic Needs Assessment

4 Prevalence of safeguarding adult activity in Bromley 2 Figure 1: Number of safeguarding concerns raised within London Borough of Bromley Adult Social Care Figure 2: Gender of individuals involved in safeguarding concerns and enquiries (%) 2 Data taken from the BSAB Annual Report 2016/17 (hyperlink to follow) 4

5 Figure 3: Type of abuse (%) Figure 4: Location of abuse (%) 5

6 Summary of safeguarding adults key achievements In its Annual Report for BCCG set out a work plan for against which it made the following key achievements, which meet and exceed the work plan: Developed a Bromley CCG Integrated Safeguarding Strategy and the Children and Young People, Children Looked After and Adults at Risk. The strategy outlines workstreams set by the safeguarding teams within the CCG, and incorporates workstreams set by both the Children and Adults Safeguarding Boards. Developed a Safeguarding Commissioning Framework and applied it in practice in several procurements. This enables Bromley CCG to strengthen its assurance processes for safeguarding in the commissioning and contract monitoring of health services. Lead health representative implementing and completing the Bromley Domestic Homicide Review action plan which arose from the murder of a Bromley woman by her partner. Worked with other CCGs and our commissioned NHS providers to develop a dashboard to collect safeguarding adults performance data. Member of several NHS England (London) safeguarding forums, including Safeguarding Adults and CCG Leads. Strengthened working arrangements with commissioned health providers safeguarding leads to improve the timely and proportionate response when abuse or neglect have occurred. Recruited a GP Champion to lead on supporting GPs with adult safeguarding. Recruited clinical GP support for Bromley s Identification and Referral to Improve Safety (IRIS) project, strengthening GP responses to domestic abuse. We have successfully achieved the target of reaching 25 GP practices. All of these practices are now under the IRIS 25 commissioned services, and have access to the IRIS referral pathway. Supported and monitored Bromley Healthcare and Oxleas NHS Foundation Trust s audit of Mental Capacity Act assessment activity and compliance. We also support ongoing safeguarding practice within the Priory hospital. 6

7 Particular areas of achievement Overview of GP Safeguarding Adults Training Since the CCG s appointment of the GP Safeguarding Adult Champion, the role has worked closely with the CCG s Safeguarding Adult Manager to deliver a pilot programme of adult safeguarding training, aimed at level 3, for clinical professionals working in GP practices. Three separate evening sessions were held in 2016/17. Training content was in part determined by requests from GPs following earlier training sessions. Topics covered in 2016/17 included: The Care Act 2014 Referral criteria Mental capacity awareness and assessment Domestic abuse (co-delivered by Victim Support) Rogue traders (co-delivered by the London Borough of Bromley Trading Standards Team) The training evaluation to date has been extremely positive, with participants reporting increased awareness of the coercion of adults at risk. Safeguarding in Service Procurements The CCG Safeguarding Team is heavily involved in the procurement process, including service specifications, bidder evaluation panels and mobilisation meetings. In order to give consistency and transparency to safeguarding within its commissioning, contract monitoring and procurement processes the CCG produced a Safeguarding Procurement Standards document that all providers/potential providers need to review alongside the CCG Quality Assurance Framework. The training delivery method was interactive, allowing for open discussion regarding referral thresholds, criteria, and understanding which type of abuse may have occurred. All training sessions incorporated case-based discussion. 7

8 Domestic Abuse Primary Care IRIS Project In January 2017 the IRIS Team attended a GP Academic Half Day, where they delivered a short presentation on the IRIS project, which provides education on domestic abuse, along with casework and advocacy within GP practices. This was hugely successful and there was a high uptake of the subsequent training. The most important factor to note is how many referrals have been made to the Independent Domestic Violence Advocate (IDVA) since the project was re-launched in November Up to March 2017, IRIS had 20 referrals from GP practices, seeing an increase in referrals each week. The majority of the referrals have been high-risk, and 6 referrals have met the threshold to be referred into the Multi Agency Risk Assessment Conference (MARAC). Of one of these referrals, the client finally reported 5 years of ongoing rape and sexual abuse by her partner. The IRIS IDVA Educator (IDVA-E) supports survivors by providing crisis intervention work, including risk assessment, safety planning, support through the criminal justice system, court support, and multiagency working with agencies such as social services and police. The IDVA-E will also advocate for survivors with agencies such as children s services to ensure the survivors wishes and feelings are heard. Additionally, the IDVA-E provides a safe place for the survivor to talk; being believed is a huge first step to overcoming the abuse. Both the Mayor s Office for Policing and Crime (MOPAC) and the CCG have committed to funding the IRIS IDVA Educator role until March The safeguarding team will put a proposal to the CCG to consider funding a similar model to IRIS for domestic abuse support across primary care in Bromley. Quotes from clients: Thank you so much for all your help; you ve been my light at the end of the tunnel Even after speaking to you once, I feel so much better to know someone cares Having you to talk to has given me the strength to make these changes Quotes from GPs The training should be mandatory for all NHS staff Knowing the IDVA-E provides an amazing element to supporting patients, we are able to say we know her and trust her IRIS has allowed us to transform how we support patients 8

9 Bromley Safeguarding Adults Board (BSAB) Highlights from the executive summary of the BSAB Annual Report for 2016/17: [hyperlink to report to follow] The Board have continued to work hard to ensure that we are serving vulnerable residents. At the end of last year we released our Strategy, which outlines our work programme for the next three years. The Care Act 2014 and six safeguarding principles continue to drive a lot of our work; most notably the Act widened the scope of abuse to include self-neglect, domestic violence and modern slavery. In response to this, we have already achieved key successes by establishing links with the hoarding panel and developing the Bromley Violence Against Women and Girls (VAWG) strategy and training programme. Going forward we will continue to focus on and implement important safeguarding processes. This includes Making Safeguarding Personal, which ensures that person centred outcomes are achieved for safeguarding and identifying cases that may require investigation by the SAR, to identify learning points that will drive better safeguarding practice. During we put specific focus on scamming, fire reduction and learning disabilities. The Board and its partners have successfully worked with the London Fire Brigade (LFB) to undertake home fire safety visits, provided training on fraud and doorstop crime and monitored the Learning Disability Mortality Review (LeDeR). 9

10 Providers self- assessments Bromley CCG s three main providers (Bromley Healthcare Community Interest Company, Kings College Hospital NHS Foundation Trust and Oxleas NHS Foundation Trust) are represented at the Bromley Safeguarding Adults Board and are active in its sub-committees. Combined with BCCG s involvement in their internal safeguarding committees, and their involvement in the BCCG Safeguarding Executive meetings, this gives BCCG assurance of their strategic and operational safeguarding adult performance. The following extracts are drawn from the Annual Report of each organisation. Bromley Healthcare Bromley Healthcare is the community health care provider commissioned by Bromley CCG which provides a wide range of services across Bromley. Key Achievements: We had three Clinical Quality Commission (CQC) inspections throughout the year that rated safety as good and reported that safeguarding was embedded across the organisation. Staff reported that they knew who to contact for safeguarding advice and support, were up to date in their training and could locate the appropriate policies. We introduced vulnerability panels to support staff where there may be safeguarding concerns. The panels are chaired by the Director of Nursing and supported by the safer care team and safeguarding leads with a think family approach. The panels have been successful when needing to escalate multi-agency concerns between providers as well as ensuring plans are in place to mitigate any further harm to patients or vulnerable carers. A domestic violence gap analysis resulted in a targeted action plan to improve staff confidence in all areas of domestic abuse. The Child and Adult Safeguarding Leads collaborated to deliver integrated domestic abuse and violence training programmes for staff at all levels. A full review of domestic violence resources was undertaken and now includes specialist resources for victims and perpetrators of abuse. Adult safeguarding training remains above 85% for 2016/17 and a range of supervision models to embed safeguarding practice was planned. An external audit commissioned by the CCG demonstrated that there had been an increased level of understanding of mental capacity, 10

11 though improvements needed to be made in recording capacity. Bromley Healthcare has redesigned its templates to improve accuracy of documentation Safeguarding Adults work planned for 2017/18: To review and improve the quality of capacity assessments. To identify how to reduce avoidable pressure ulcers and ensure that any learning is appropriately disseminated to staff. To address the issue of neglect by improving our understanding and ability to identify the problem at an early stage. Natalie Warman, Director of Nursing, Therapies and Quality Assurance Oxleas NHS Foundation Trust Oxleas is commissioned by LBB as provider of specialist mental health care in Bromley as well as providing health care for people with learning disabilities. Key Achievements: We set up a mortality review group which reviews the deaths of all those under the care of the organisation; referrals to SAR groups can be made from this group. The Trust also has a regular embedding learning patient safety group where all action plans from serious incident investigations are presented and discussed. We strengthened policies and procedures in relation to safeguarding adults over 2016/17. With additional staffing; it was possible to raise awareness of safeguarding across the whole organisation. Staff visited in-patient and community services to talk about safeguarding and to deliver updated information including flow charts on safeguarding responsibilities and actions for staff. The Trust s safeguarding adults policy was updated following the implementation of the Care Act We commenced a review of safeguarding training. We were able to provide training which correlated with level 1 and 2, and on Mental Capacity Act, Deprivation of Liberty Safeguards and Prevent (radicalisation) competencies. Safeguarding Adults work planned for 2017/18: Continue to promote the use of safeguarding forms and develop a reporting system to be able to analyse the data in a more meaningful way at organisational, borough and team level. To work with the Patient Safety Team and the Patient Advice and Liaison Service (PALS) and Complaints Team to ensure that safeguarding adult concerns are identified as part of any investigation. To review the current training provision and safeguarding adult resource in light of the Intercollegiate Guidance (once ratified). 11

12 To ensure regular and appropriate representation from the new directorates to the Safeguarding Adults Board (SAB) and subgroups. Lisa Moylan, Head of Mental Health Legislation and Safeguarding Adults Kings College Hospital NHS Foundation Trust King s College Hospital NHS Foundation Trust (KCH) is the acute health provider which, since 2013, has included the two hospitals in the borough, the Princess Royal University Hospital and Orpington Hospital. Key Achievements: To improve training compliance in safeguarding adults level 2-4 a new e-learning platform was launched, which has been accessed by a range of healthcare professionals. We reviewed all our safeguarding policies to ensure that they are in line with the Care Act Funding was identified and approved for a support worker who was tasked with monitoring Deprivation of Liberty Safeguards (DoLS) referrals. Trust activity in safeguarding adults remains stable with a greater number of referrals in the last year converting to safeguarding adult concerns being reported to the local authority. There was also a significant increase in the number of DoLS applications. This may be a result of greater understanding of safeguarding adults by staff and there being more staff that are able to manage safeguarding concerns. Safeguarding Adults work planned for 2017/18: As part of a review of Mental Capacity Act (MCA) practice in the Trust, a new policy and assessment documentation to support and evidence MCA assessments, will be launched in the autumn to ensure that staff are evidencing the application of the Act in practice. We have worked with NHS England to develop a training plan to ensure appropriate staff have access to Prevent level 3 (Workshop to Raise Awareness of Prevent- WRAP) training. The training will be launched across the Trust in September All our safeguarding policies have been reviewed and are being ratified, with the intention of being rolled out in the autumn. Paula Townsend, Corporate Director of Nursing 12

13 Conclusions & Priorities Within the CCG and its commissioned providers, 2016/17 was characterised by work to implement and embed legislative changes during 2015/16, including the Care Act. BCCG also worked hard to ensure that primary care colleagues were made aware of the new environment and supported to implement improvements in safeguarding adults in general and in particular areas such as the Mental Capacity Act and domestic abuse. Improve the dissemination of learning from safeguarding reviews and how this impacts on healthcare practice. Ensure that providers respond appropriately to the increasing impact of Making Safeguarding Personal in practice. Further strengthen the safeguarding agenda within primary care. Expand the existing child safeguarding GP Enhanced Service (GPES) to include adult safeguarding. BCCG safeguarding adults work planned for 2017/18 Review and evaluate the effectiveness of the Community Services procurement. Develop how we analyse and triangulate the Bromley CCG health economy safeguarding performance data, and increase the focus on its outcomes. Continue to embed national, pan-london and local safeguarding guidance. Ensure that there is a safeguarding focus in future joint commissioning arrangements. Increase influence and impact of health agencies across partnerships and to provide challenge where appropriate. 13

14 Appendix A: Case Studies Case Study 1: Domestic Abuse Survivor The client suffered years of emotional abuse at the hands of her husband. Three months ago her husband physically assaulted her on several occasions mainly by grabbing her around the throat and by pinning her to the wall and floor. The client suffered two sprained fingers from this assault as well as bruising to her body and throat. This was the first time she decided to access a domestic abuse service. Her husband was arrested but released on bail. The client decided she had enough of the abuse she had experienced and continued through the criminal justice system. The client disclosed to her GP, who had undergone IRIS training, about the ongoing abuse, and this is what prompted a referral into the IRIS project. The client reported her case to the police after carrying out some empowerment work with the IDVA. The client s case was deemed as high risk by the Police, and they finished their investigation swiftly. Within 6 weeks the client was presenting at court for her husband s trial as he pleaded not guilty in his plea hearing. During this time, the IDVA worked with the client to ensure her safety as her husband was out on bail. A personalised safety plan was carried out. The IDVA included in this a referral to London Fire Brigade as well as Victim Support s Home Security Service. The client s husband was convicted of GBH. The client was left feeling positive about her future, and more importantly empowered to continue with her life. 14

15 Case Study 2: Fraud JB was a vulnerable elderly man who lived alone in his own property, which was in a state of disrepair, making him a target for fraudsters. He was visited by a man claiming to be a builder, who offered to carry out repairs on the property. He offered a deal to JB, implying that he would not have to pay any money up front for the work, with the money being taken if the property was sold, or from the estate in the event of JB s death. In fact, the agreement JB was tricked into signing was a deed of gift, which effectively gave the house to the fraudster. Work had been in progress for some six months before Trading Standards received an anonymous telephone call suggesting concern for the safety of JB. It was found that he had been removed from the house and taken to Lincolnshire, where he was living in a caravan in totally unsuitable conditions. JB was immediately rehoused, as the fraudster was still the legal owner of his house. Multi-agency work took place to resolve the case, including Trading Standards, adult safeguarding, Victim Support, housing, health services, and Bromley CID. Victim Support prepared Mr Bell for the trial during which he gave evidence under special measures legislation because of his vulnerability. He was able to give his evidence via video link. The fraudster was convicted and imprisoned for 5 years. JB s house was returned to his possession, but he opted to remain where he had been rehoused, as he felt safe and secure there. 15

16 Case Study 3: Hoarding AA and BB have been together for over 30 years. They have no family or friends. Throughout their relationship there has been a history of severe alcohol abuse by them both, and occasional domestic violence. They are now in their early 60's and both have significant physical and mental health issues in which alcohol abuse and poor nutrition have played a part. Both are incontinent, have pressure ulcers, have poor mobility, and are prone to falls. They both have a history of hospitalisations and self-discharges against medical advice. BB also has multiple sclerosis (MS). AA owns their home. It has deteriorated due to their extremely unsanitary behaviour, their extreme hoarding, their rescuing of stray cats and their refusal to allow cleaning services in the property. The property is largely inaccessible, including the bathroom and most bedrooms, with cat faeces and decaying food stuffs on floors and surfaces. The couple are very opposed to outside intervention, particularly from Social Services. Only BHC District Nurses have any positive relationship with them. They are both felt to have capacity. The case was discussed at the BHC Vulnerability Panel (and subsequently the multi-agency Hoarding Panel), and an action plan drawn up that used healthcare staff as the bridge-head whilst acknowledging that AA & BB wished to stay together as a couple living in their home. The action plan was multi-agency, and progressed at a pace that the couple could tolerate and engage with. Their consent for involvement by agencies was achieved one task at a time. This approach resulted in a deep clean of their home (40 sacks of refuse in one day alone), acceptance of on-going support from a home care service, and a greater acceptance of professional support from medical, social care, environmental health and the fire service. 16

17 References Bromley Joint Strategic Needs Assessment 2016 Bromley Safeguarding Adults Board Annual Report 2016/17 Bromley Healthcare Adult Safeguarding Annual Report 2016/17 King s College Hospital NHS Foundation Trust Adult Safeguarding Annual Report 2016/17 Oxleas NHS Foundation Trust Adult Safeguarding Annual Report 2016/17 Care Act