Standard RED Amber Green Blue. Workforce planning and analysis to meet needs of. particular risk of harm

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1 CQC Outcome Standard RED Amber Blue NUTH Rating Rating 7E 13A 3.2 The service's workforce has the capacity and capability to i) meet the needs of patients who may be at particular risk of harm and ii) respond to safeguarding concerns. Safeguarding adults not identifed within job descriptions and personal development plans. No evidence of workforce awareness of safeguarding adults. Workforce planning and analysis to meet needs of patients who may be at particular risk of harm Cross workforce awareness of safeguarding adults responsibilities Identified staff with specific responsibilities in safeguarding adults - e.g. leadership; investigations & protection planning Adult safeguarding roles and responsibilities specified in job descriptions and personal development plans. Specialist posts/roles to lead and innovate e.g. 'champions' for safeguarding ; mental capacity; dignity in care; dementia; learning disabilities advisors. Arrangements for collaboration and skill sharing with other services e.g. peer led investigation; staff available for consultation by other services Safeguarding adults information is used in wider workforce planning and strategies. Blue SATraining Needs Analysis MDT & Multi agency representation on Safeguarding committee Multi agency training undertaken Dedicated posts in Safeguarding for LD and MCA Safeguarding responsibilities in all Trust nursing JD s Examples of appropriate and timely escalation of concerns. SA training group 13

2 CQC Outcome Standard RED Amber Blue NUTH Rating Rating 3.3 The service provides training to enable the workforce to safeguard adults. No training plan and training not available to Board members Inadequate resources to implement training and development plan. Plan not delivered. Poor attendance to training. No consequences of failing to attend training. All staff volunteers, managers and the board have appropriate knowledge and competence in relation to safeguarding adults. Fully costed and resourced training plan in place and delivered. Training supports the multi agency safeguarding partnership A majority of staff can demonstrate good awareness about adult safeguarding and what to do if they have concerns. Opportunities are available for enhanced training and development in safeguarding adults e.g.investigators; leaders etc. Annual training plan identifies numbers of staff to be trained at different levels; evaluation of training; frequency; format. Training is competence based, promotes best practice principles in safeguarding and is linked to professional development systems. Training is evaluated and updated to incorporate lessons learned Experience of patients/service user informs training. Training information is reported to the service and to LSAB. Annual plan in place progress reported bydashboard for training Trust SA training is competency based in line with national guidance Training evaluated and refreshed regularly Training Activity reportedto LSAB 14

3 CQC Outcome Standard RED Amber Blue NUTH Rating Rating 14C 3.4 The service provides supervision and support for staff involved in safeguarding adults procedures. No supervision or support available, or not at the times needed. Clear policy for supervision and support for adult safeguarding leads, investigators and others involved in investigations. Evidence that staff are receiving appropriate supervison and support in relation to safeguarding adults Evidence of strong support systems in place for any staff members involved in adult safeguarding concerns, issues or investigations.e.g. o peer supervision and development o involvement/leadership in multi agency practice groups o safeguarding mentoring SA Team provide case based supervision in line with Trust Policy to leads investigators and others involved. 12A 12B 12C 3.5 The service has robust recruitment processes in place, including procedures under the Safeguarding Vulnerable Groups Act CRB checks completed as per policy. No process for regularly checking professional registrations are up to date. Disciplinary procedures and procedures for notifications under Safeguarding Vulnerbale Procedures ensure safe recruitment i.e. CRB checks/checks under SVG Act; registration with professional bodies as appropriate; qualifications and references checked. Rigorous recruitment and selection processes to appoint staff with competence to meet the needs of patients including patients who may be at particular risk of harm. Protocols and guidance for safe recruitment of externally employed staff, voluntary workers and students. Partner agencies, patient/user representatives involved in recruitment to safeguarding adults posts. Compliant with all NHS employment standards 15

4 CQC Outcome Standard RED Amber Blue NUTH Rating Rating Groups Act are unclear. No evidence of staff being disciplined or referrals to professional bodies or reporting under SVG Act requirements following disciplinary hearings. 7E 12C 14D 3.6 The service safeguards adults by addressing staff performance concerns. No evidence of managing poor performance. No evidence of staff being disciplined or referrals to professional bodies or reporting under SVG Act requirements following disciplinary hearings. Evidence of staff support and performance management. Evidence of appropriate and successful implementation of disciplinary procedures concerning adult safeguarding risks e.g. theft, abuse, neglect of care, and appropriate referral to professional bodies and notifications in line with SVG Act Whistleblowing policy and procedures are in place and readily accessible for all staff (and volunteers) to report adult safeguarding concerns. Systems in place to support all staff and volunteers who whistleblow and outcomes of whistle blowing activity demonstrates changes in services. Training and support in place for managers involved in disciplinaries includes providing evidence to tribunals. Human Resources audits on staff awareness /attitude to whistleblowing. Blue National Staff Survey feedback Francis Report staff feedbackworkstream Trust SafetyCulture Survey undertaken Case evidence of improvements following whistle blowing 16

5 Section 4: Partnerships & Collaborative Working CQC Outcome Standard RED Amber Blue NUTH Rating Blue 7B 6A 24A 4.1 The service works in partnerships to safeguard adults. No or minimal participation in collaborative work, operationally or strategically. Poor involvement or no contribution to strategic partnerships e.g. LSAB. Inconsistent or inappropriate level representation e.g. unable to make decisions or release resources. Evidence of regular attendance and effective contribution to LSAB, business plans and initiatives. Evidence of collaboration and strategic partnership working e.g. development of joint safeguarding related strategies. Evidence of collaboration and operational partnerships e.g. attendance at strategy meetings; roles within investigation and protection planning Appropriately resourced to actively participate in multiagency and community partnerships e.g. attendance, venues, chairing groups and activities; supporting administration etc. Evidence of leadership within the strategic partnership e.g. developing business plans, chairing committees; leading work programmes Evidence of partners objectives for safeguarding adults influencing change within the service. Service works with partners to improve collaborative working and address any barriers in strategic or operational working. Trust leadership within the LSAB Information sharing protocols Joint work with police and specific information sharing guidance for clinicians. PREVENT work Trust SA leads undertaken specific SA Leadership course 17

6 CQC Outcome Standard RED Amber Blue NUTH Rating 7B 7E 16A 4.2 The service is open and transparent in relation to safeguarding adults. No or minimal evidence of sharing information with partners including the LSAB The service cannot demonstrate a culture of challenge which enables staff to question poor practice from another agency or within their own service. No or limited evidence of communicating with wider stakeholders e.g. public groups about the services safeguarding arrangements Consistent evidence that safeguarding adults concerns are managed in line with multi agency procedures. Safeguarding adults data and information from the service is evidenced in LSAB meeting minutes, reports and annual reports. Reports to partners contain information relating to the services' systems and outcomes for prevention and intervention in safeguarding adults. Serious Case Review reports completed according to LSAB terms of reference. Communication with stakeholders - leaflets, reports, press releases etc The service involves patient/user groups and partner agencies in assuring safeguarding adults information e.g. joint audits. Benchmarks own performance against others and evidences that striving to continually improve. Multi agency template for investigations Trust Contributed to LSAB Safeguarding annual reports and strategic business plan Trust Safeguarding Annual report presented to LSAB& Trust Governors and published on Trust Internet Patient leaflets in place 18

7 (Section 5 relates to Commissioning only) Section 6: Additional Information Question 6.1 Additional Information e.g. examples of best practice that can be shared' or evidence of safeguarding systems or structures that have led to improved safeguarding adults outcomes Strengthening of Adults safeguarding Team Dedicated specialists within SA team for MCA, LD SA Explicit safeguarding management and committee structure which are joint with Children s Safeguarding and multi disciplinary Red Folder system in place for patient safeguarding in clinical notes Electronic flag alert on patient e-record 6.2 Information about any particular organisational challenges a. how these have been overcome b. action plans to address 19

8 Audit Score (Totals) Ratings No of Standards achieving this rating Standard No s Red 0 Amber 2 13 Blue 4 1.2, 2.4, 1.1, 2.1, 2.2, 2.3, 2.5, 2.6, 2.7,2.8, 2.9, 3.3, 3.4, 3.5, 4.2, 3.1, , 4.1, Red Amber Blue 20

9 Action Plan Standard No Description Current Rating (RAGB) Action to be Taken Responsible Due Date 1.1 There is a strategic plan for safeguarding adults and it is an integral part of quality Trust Annual plan needs to be more specific in reference to safeguarding. Quality Account to make reference to safeguarding adults Business and Development Clinical Governance April The services safeguarding strategy, planning and delivery, involves and takes account of patients, users and carers experience Amber To complement existing information and feedback mechanisms the Trust wants to gain more information from vulnerable adults and relatives and carers to evaluate patient experience. To work in partnership with NSAB/Safeguarding Unit to elicit feedback Safeguarding Adults Team Safeguarding Adults Team with NSAB Ongoing 2.1 The service has clear and accessible systems for patients/users and carers to be heard and influence change AS ABOVE 2.1 To explore how patient/carer feedback can be gained and if this is appropriate given vulnerability of client group whilst with Trust Safeguarding Adults Team with NSAB Ongoing with NSAB The service has systems in place to identify and act on risks that have the potential to become a safeguarding adults concern. Service uses information from a range of internal sources Work with clinical governance to further develop interrelationships with health and safety. Safeguarding team and Clinical Governance April The service has clear and Amber Ensuring accessible information available for staff on intranet Safeguarding team Ongoing 21

10 Standard No Description Current Rating (RAGB) Action to be Taken Responsible Due Date accessible systems for patients/users and carers views and concerns to be heard and influence change. 2.5 The service can evidence that the Mental Capacity Act is integral to care and the management of safeguarding concerns. Audit of consent policy and practice to be further developed Ongoing delivery of bespoke specialist training Raise awareness within all professional groups Strengthen documentation that surrounds Capacity Assessment and best interest decision making decisions: Pilot of capacity screening questions with surgical preassessment MCA Lead and Clinical Governance MCA Lead MCA Lead MCA Lead and Clinical Governance MCA Lead Policy under review at present. MCA lead and Legal Services involved Ongoing MCA within level 1 Safeguarding.. Review feasibility of screening for capacity within standard admission procedures MCA lead working with Directorates Dementia screening embedded in line with CQUIN definition Clinical Governance Completed Consent Policy review Clinical Governance January The service has guidance and processes to govern the use of restriction and restraint & where DoLS should be considered. Formalise process to review all DoLs (granted/denied) until patient discharge MCA/DoL lead Ongoing 2.7 Services can demonstrate patient/user led decisions about Consider development of SA core care plan Safeguarding team January

11 Standard No Description Current Rating (RAGB) Action to be Taken Responsible Due Date their safeguarding and that interventions are person centred 2.8 The service has processes to review and benchmark safeguarding alerts and referrals. Closer working with Clinical Governance & Risk Query prompt in SUI template (Is it Safeguarding) Safeguarding team and Clinical Governance April 2014 This is integrated with clinical incident reporting, compliments and complaints. 3.3 The service provides training to enable the workforce to safeguard adults. Provide SA training to Trust Board Safeguarding Team January

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