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REPORT

Board of Directors

Date: 20 May 2020

Subject: Safeguarding Annual Report 2019-2020

Presented by: Angela Hansen – Chief Nurse

Purpose of Paper: For Assurance

Executive Summary:

This Safeguarding Annual Report provides an overview of safeguarding activity within the Trust during 2019-2020 and assurance relating to the scoping; development and implementation of safeguarding related processes.

Safeguarding activity has continued to rise across the Trust in 2019/20. A number of improvement projects have been identified to ensure continuing safeguarding demand will be met.

Safeguarding Training – The publication of the child and adult intercollegiate document (Royal College of Nursing, 2019), made recommendations of the required levels of safeguarding training. Safeguarding Manager together with the Learning and Development Lead have reviewed this and as a result all PES patient facing staff are now being trained to level 3 safeguarding. In addition, staff identified on the Training Needs Analysis (TNA) as requiring level 3 safeguarding training will continue to receive this training. Level 2 training is overseen in collaboration with the Safeguarding Team by the Learning and Development Team. A bespoke safeguarding training session is also being written.

Safeguarding Case Reviews – The Safeguarding Team continue to be involved in serious case reviews, safeguarding adult reviews and domestic homicide reviews. NWAS has particular learning in relation to concealed and denied pregnancy which has been incorporated into the level 3 safeguarding training.

Safeguarding Assurance Framework – This has been submitted to the Commissioners and an evidence request has been received, which is being completed to support the assurance framework.

Project Emerald is the title of the safeguarding innovation project which will introduce a new platform for the recording of safeguarding concerns. The new platform will replace the current Eriss system.

Updates on safeguarding are reported regularly to the

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Safety Management Group, to provide a detailed overview of the safeguarding activity within the Trust.

The Safeguarding Team currently has a number of low level risks recorded on the corporate risk register.

2962 – There is a risk that staff are not receiving level 1 and 2 safeguarding training in a timely manner in line with the Intercollegiate document. This risk is currently scored as a 6.

2963 - There is a risk that safeguarding governance is not managed by the Safeguarding Team in NHS 111 which could result in standards, processes and support are not sufficient within NHS 111 and integrated urgent care safeguarding. This risk is currently scored as a 4.

2978 – There is a risk that CP-IS is not compatible with the current NWAS systems. NHS Digital are working with the Trust to overcome the digital issues. This risk is currently scored as a 3.The Safeguarding Management Team will continue to scrutinise these risks and take actions to reduce them and mitigate against further issues.

Recommendations, decisions or actions sought:

The Board of Directors is recommended to;

Note the contents and approve the Safeguarding Annual Report 2019-20

Link to Strategic Goals: Right Care ☒ Right Time ☒

Right Place ☒ Every Time ☒

Link to Board Assurance Framework (Strategic Risks):

SR11

If the COVID-19 pandemic continues for an extended period, then the Trust will be unable to deliver its strategic objectives during 2020/21.

☒

Are there any Equality Related Impacts:

Previously Submitted to:

Quality and Performance Committee

Date: 18 May 2020

Outcome: Recommended to the Board of Directors for assurance and approval.

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- THIS PAGE IS INTENTIONALLY BLANK -

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1. PURPOSE

1.1 The purpose of this report is to provide the Board of Directors with an overview of safeguarding activity during 2019-2020. The achievements are set against the Right Care Strategy and ambitions taken from the forward plan 2020-21.

2. BACKGROUND

2.1

2.2

Safeguarding child and adult standards are determined nationally for NHS Provider organisations and are monitored via the regulator (Care Quality Commission) and via audits. In addition to safeguarding practice and processes the audit standards relate to policies and procedures, HR and recruitment processes, and leadership. The specific standards are contained within:

Safeguarding Assurance Framework (SAF) which is presented annually to the lead Commissioners.

Mersey Internal Audit Agency (MIAA) who conduct safeguarding audits on behalf of the Trust Audit Committee and have been auditing bi-annually.

Care Quality Commission (CQC) inspection of the Trust including safeguarding arrangements took place in 2018 and 2020.

Safeguarding activity has continued to increase significantly in 2019-2020 across the trust against a backdrop of increasing activity within the Paramedic Emergency Services (PES) and within 111. Chart 1 demonstrates the number of safeguarding concerns raised during the past 12 months. The reduction in safeguarding calls in March reflected the Coronavirus pandemic, this reduction is mirrored in safeguarding activity experienced by both child and adult Social Care.

Chart 1 – Numbers of notifications

Concerns

raised Apr-19

May-19

Jun-19

Jul-19

Aug-19

Sep-19

Oct-19

Nov-19

Dec-19

Jan-20

Feb-20

Mar-20

Adult 4288 4490 4367 4596 4735 4433 4735 4485 4714 5061 4652 3858

Child 1105 1192 1166 1131 1145 1166 1107 1029 1117 1211 1262 951

Total 5393 5682 5533 5727 5880 5599 5842 5514 5831 6272 5914 4809

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Chart 2 Breakdown of notifications by service area

2.3 2.4

Safeguarding Team The Safeguarding team comprises of one whole time equivalent (wte) Band 8a Safeguarding Manager (Named Professional for adults and children) and three wte Band 6 dedicated Safeguarding Practitioners. One for each geographical area of the Trust, Cumbria & Lancashire, Greater Manchester and Cheshire & Mersey. The practitioners report directly to the Safeguarding Manager, and are an integral part of the Clinical Safety team. The Clinical Safety team is managed by the Head of Clinical Safety who reports to the Chief Nurse. The team are also supported by 2.75 wte Band 3 Clinical Safety administrators. Capacity of the Clinical Safety administrators continues to be monitored and the split in role means that the administrators do not always have the capacity to carry out more in depth analysis work to support the Safeguarding team. The Safeguarding Practitioners are engaged with the Quality Business groups, the localised PES/111 Learning Lessons forums and the Patient Transport Senior Management Team meetings to share safeguarding data, lessons to be learned and patient stories, to improve practice. Right Care Strategy In 2018 the Right Care Strategy for the Trust was implemented. This is a five year Strategy with key milestones for each year based on pillars of quality. The number of safeguarding concerns being reported to local authorities by NWAS has continued to rise during 2019/2020. Safeguarding training has remained a high priority for the safeguarding team. A large number of face to face level 3 safeguarding training sessions have been delivered over the past 12 months by the team, these sessions have been well received with positive feedback. Learning from safeguarding incidents remains at the forefront of the safeguarding agenda. Learning is collated through the individual PES/111 learning forums, the corporate learning tracker and the PTS learning tracker. Monitoring of these incidents allows for identification of any themes and trends. Wider learning from published safeguarding reports allows for proactive information sharing, to Trust staff, to highlight changes in practice and emerging safeguarding trends. A joint frequent caller and safeguarding database has been designed in collaboration with the Frequent Caller Manager which enables both teams to capture the most frequent callers and the safeguarding repeat concerns, on a weekly basis. This collaborative working allows for the most vulnerable and at risk patients to be identified. Proactive work then takes place between the Trust and Social Care or directly with patients.

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2.5 2.6 2.7

The Right Care Strategy Safeguarding ambitions 2019-20 – Pillars of Quality Goals:

Training compliance for Levels 2, 3, & 4 is compliant with the recently reviewed Training Needs Analysis. The team are currently reviewing the new Training Needs Analysis to match competencies against skill set and staff grades.

Safeguarding performance metrics reported on a dashboard – this ensures greater detail and scrutiny to provide increased assurance. The safeguarding dashboard has been designed and is functioning. The dashboard gives easy oversight of the numbers of safeguarding concerns that are raised. Currently this data can be broken down into area, day/month activity. The replacement of the ERIS system with a new safeguarding platform will allow for more in depth recording and reporting.

Systems for linking, flagging, monitoring and responding to repeat referrals with

escalation to SMT & stakeholders, as appropriate. The Frequent Caller Manager and the

Safeguarding Manager have worked in collaboration to design the joint frequent caller

and safeguarding repeat caller recording platform.

Safeguarding Audit Compliance Throughout the year safeguarding standards are audited to ensure the safeguarding process is effective and robust. 2019 has seen the introduction of audits for consent and repeat safeguarding concerns. A separate consent audit paper is to be produced during 2020/21, for presentation to the Safety Management Group. Repeat safeguarding concerns are monitored for children. If 3 safeguarding concerns are identified for a child, the Safeguarding Practitioner for that area contacts the relevant Social Care team in order to obtain feedback on the current situation of the child. Safeguarding Concerns Rejections The Safeguarding team monitor the concerns that are rejected by Adult and Children’s Social Care Services. The largest number of rejections continue to be for patients who are suffering with mental ill health. The Safeguarding Manager has continued to work with the Mental Health and Dementia lead, and alternative pathways are now available for patients who are suffering with mental health. The safeguarding concern form is being changed to reflect this and will be rolled out with the introduction of the Adastra system. The Mental health and dementia lead has given assurances that crisis care services are available across the majority of the Trust geographical footprint. If dedicated mental health services are not available, Trust staff are directed to notify the patients GP. The Safeguarding Manager has made enquiries at the National Ambulance Safeguarding Group (NASG) regarding hear and treat capacity assessments. The findings from NASG is that no ambulance service currently has a hear and treat capacity assessment. The Safeguarding Manager and the Advanced Practitioner for Mental Health have started discussions in relation to the development of a hear and treat capacity assessment for clinicians. Training Level 2 and 3 training is included in the mandatory training delivery for PES, and level 1 and 2 is delivered for the PTS service. Figures that are reported on a monthly basis as a rolling programme include the safeguarding module compliance. The end of year training figures for compliance for Level 1 & 2 training was 82% across the Trust, for Level 3 77.25% and for Level 4 100%. The Safeguarding team continue to work with the corporate Learning and Development Department and local Service Delivery areas to improve the compliance figures. Level 3 safeguarding training has been subject to significant review in 2019, and an

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2.8

agreement has been reached with the Learning and Development team that level 3 safeguarding training will be delivered via mandatory training from January 2020. Level 3 training is written by the Safeguarding Team and mapped against the Intercollegiate Document and the National Training Guidance. The Intercollegiate document recommends that all Paramedics should be trained to level 3 in safeguarding. However, due to the way in which mandatory training is delivered within the Trust both Emergency Medical Technicians (EMT) and Paramedics are receiving level 3 safeguarding training. Although it is not a requirement for EMTs to receive level 3 training this provides improved assurance with regards to the consistency and focus of safeguarding training. The Safeguarding team has monitored the level 3 compliance over the past 12 months, and have escalated those staff members who have not attended level 3 safeguarding training. Escalation to management ensures that sufficient staffing can be planned to ensure adequate safeguarding advice is available. The safeguarding team has dedicated a number of hours to deliver train the trainer sessions to the Clinical Practice Trainers (CPT). Collaborative working between the two internal teams helps to ensure relevant and appropriate safeguarding training is being delivered across the whole Trust. Centralised training of the CPT’s ensures Trust wide consistency is applied to safeguarding training. The Safeguarding Manager, the Head of Clinical Safety and the Chief Nurse all attend level 4 training as the Trust ‘Named’ Professionals for safeguarding. The information gathered from such training is cascaded through the Trust and enables the frontline staff to be empowered with the most up to date information in their local area. The Safeguarding Manager and the Head of Clinical Safety attend the National Ambulance Safeguarding Groups (NASG). Engagement with NASG ensures the Trust are abreast with safeguarding activity nationally amongst fellow ambulance Trusts. Best practice activity is shared and the group acts as a support network for the Safeguarding Team. Safeguarding supervision is gained from the national group by both attendees. Safeguarding supervision is carried out both within the safeguarding team and sought from external sources within the local safeguarding arena. A programme of safeguarding supervision for all staff is currently being scoped and the proposal is that safeguarding supervision will take place during clinical contact sessions. Safeguarding supervision provides the Practitioners and Managers with the opportunity to ensure that the team’s practice and training are up to date, and that the safeguarding agenda is clearly understood. In addition, the Safeguarding team visit front line service areas on a regular basis through quality sector visits to raise safeguarding awareness and support staff engagement. The Safeguarding Practitioners continue to work hard to maintain the visibility of the Safeguarding team. In addition to the quality sector visits, the safeguarding team also attend bespoke Senior Paramedic Team Leader away days and engage with the Trust university partners to deliver training. Safeguarding Board Engagement Increased notifications, improved visibility and Board engagement has resulted in increased numbers of requests to be involved in Safeguarding Adult Reviews, Domestic Homicide Reviews, Serious Case Reviews, Learning Disability Reviews and Strategy Meetings. During 2019/2020 the Safeguarding team were involved in 161 safeguarding reviews, these are collated into the following sub categories; 70 adult reviews, 67 child reviews and 24 domestic homicide reviews. In direct comparison 2018/19 saw the Team engage in 155 safeguarding reviews.

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2.9

The Safeguarding team work alongside senior managers and clinicians to ensure engagement with the Boards is visible and specific to local needs. There are currently 46 Safeguarding Boards across the geographical footprint of North West Ambulance Service and the team have committed to attend each board, as a minimum, once per year, or, as per local board request. Board engagement is monitored by the Safeguarding Team. Each ‘Local Safeguarding Board’ is formally written to on an annual basis by the Safeguarding Manager to inform them of our commitment to engagement and to establish good working relationships in each area. In addition, practitioners and managers are involved in Local Safeguarding Board sub-groups. Engagement includes:

Child Death Overview Panel

Rapid Response Meetings

Alternative Life Threatening Event meetings

Serious Case Review Groups

Safeguarding Adults Review Groups

Front line visits with local board members

Wider stakeholder meetings

County leadership groups

Multi-agency review meetings following the Sudden Unexplained Death of a Child (SUDC).

Serious Case Reviews, Safeguarding Adult Reviews and Domestic Homicide Reviews (DHR) Engagement with both children and adult safeguarding boards remains a priority. The Safeguarding team are committed to working collaboratively to ensure the safety of patients and the implementation of multi-agency learning (see charts 4, 5 and 6). These lessons are captured in the individual reports, and then disseminated through the corporate learning forum, the regional learning forums, directly with the staff involved, via the Trust wide weekly regional bulletins and built into the mandatory training scenarios. Chart 4 – Number of Serious Case Reviews per month and area for 2019/2020

0

2

4

6

8

10

12

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

Serious Case Reviews (Child)

GM

C&M

C&L

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2.10 2.11

Chart 5 – Chart to show the number of Safeguarding adult reviews commissioned by area for 2019/2020

Chart 6- Information in relation to the number of Domestic Homicide Reviews by area for 2019/2020

All SCR, SAR and DHR’s are reported to the NWAS Board through the ‘reportable events’ paper which is presented on a bi monthly basis. Safeguarding activity is also reported at the regional quality business groups and via the Safety Management Group. PREVENT During 2019-2020 the Trust has made 16 PREVENT referrals to the regional anti-terrorism teams. Feedback has been received for some of the referrals made and this has been fed back to the Trust staff as appropriate.. WRAP 3 continues to be delivered to all staff at induction and the Safeguarding team provide an annual update to the Learning and Development team for training purposes. The update for this training cycle has been incorporated into a scenario. Project Emerald Project Emerald is the title for the safeguarding and digital innovation programme, which has been in the planning and development process during the latter part of 2019. The purpose of Project Emerald is to introduce an alternative process for raising safeguarding concerns. The current system Eriss is an external programme which is costly to the Trust and rigid in its make-up. It was recognised that the current Eriss safeguarding process would not be able to continue to meet the increasing number of safeguarding concerns that are being raised. The impact of telephone referral is significant, specifically the time taken to answer calls has been particularly problematic. This has impacted on the availability of clinicians to

0

2

4

6

8

10

12

14

16

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

Safeguarding Adult Reviews

GM

C&M

C&L

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

Domestic Homicide Reviews

GM

CM

CL

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2.12 2.13 2.14

respond to emergencies. A further issue has emerged which relates to the number of dropped calls that were being recorded. Despite best efforts NWAS have no assurance that the call makers have called back which potentially could leave patients at risk of harm from abuse. This issues was added to the risk register (2709). The digital platform which will replace Eriss is still being procured. The safeguarding platform has been designed and tested. The safeguarding concern pages have been updated to reflect the current information requirements of Social Care departments. The changes to the safeguarding system will give Trust staff the ability to raise their own safeguarding concerns which will be shared with the relevant Social Care team. Quality will be one of the focuses during the testing phase of the project. The redesign of the safeguarding concern forms will also allow for more accurate data collection and reporting. There is a dedicated Project Emerald team who have been instrumental in the design and of the process. The project will be tested and analysed prior to full implementation by the end of 2020. Child Protection Information Sharing (CP-IS) Child Protection Information Sharing System (CP-IS) has gone live (successfully) this year within the NHS 111 Service and UCD. CP-IS will continue to be rolled out as part of the national programme with NHS Digital and NHS England, and will include the 999 Emergency and Urgent Care Services informing staff of safeguarding concerns. Safeguarding flags are being added to the Eriss system to enable call takers to highlight concerns to staff at the time of the call. During the year there have been 103 safeguarding flags placed, this is an increase on the previous year when 72 flags were placed. Local Authority Designated Officers (LADO) The Safeguarding Manager receives enquiries from the LADO. These enquiries are in relation to members of Trust staff or volunteers. Enquiries are received when the LADO has information in relation to a member of staff which may mean that they pose a potential risk to Trust patients. The Safeguarding Manager liaises with the HR Manager and the Sector Manager in relation to the information, and a risk assessment is completed and actions agreed. 18 allegations against staff were received in 2019/20, which were investigated. Feedback was provided to the LADO. On the rare occasion that a member of staff is dismissed by the Trust, HR Managers may need to complete a disclosure and barring form. Allegations against staff may also come into the Trust from other sources and on occasions do not come directly into the safeguarding team. It is the responsibility of the receiving member of Trust management to share this information with the Safeguarding Manager. Achievements 2019-2020

2 new Safeguarding Practitioners have been recruited to cover the Cumbria and Lancashire and the Greater Manchester areas. The practitioners are a welcome addition to the team which had been experiencing significant pressure due to staffing vacancies.

The Safeguarding Team continue to work with NHS 111 service to ensure high levels of safeguarding assurance can be given to the senior leadership team.

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2.15

The Trust were partially inspected by the CQC, and the safeguarding leads were interviewed by a CQC Inspector, in addition to providing evidence. The Trust are awaiting the final report from the inspection.

Project Emerald has been designed and tested, and the safeguarding concern sheet has been streamlined. There has been a working group in place for the latter half of the year, and a testing timetable has been agreed. Following a rigorous testing process Project Emerald will be rolled out across the Trust.

Numerous level 3 safeguarding face to face courses have been delivered by the safeguarding team to assure high levels of escalation processes are available.

The Trust is committed to the safeguarding of adults with learning disabilities and are engaged with the LeDeR programme which makes all deaths involving adults with learning disabilities notifiable. The learning disabilities mortality review aims to make improvements to the lives of people with learning disabilities. The LeDeR programme was set up following a recommendation from the CIPOLD, funded by the Department of Health, to investigate the premature deaths of people with learning disabilities.

Ambitions 2020-2021

Management and leadership of the safeguarding activity within NHS 111 services to be streamlined under the corporate safeguarding team remit.

Increase the size of the safeguarding team to include an additional Practitioner to oversee the safeguarding activity within the Clinical Hub and NHS 111 services.

Move to a fully electronic safeguarding concern raising system. Project Emerald will continue and allow for this ambition to be achieved.

Establish a Safeguarding Champions Network across the Trust to provide support to all staff including PES, PTS, 111 and EOC staff.

Develop a system for sharing information with schools for children who are identified as suffering from an adverse childhood experience. This work is underway and has been presented to the Digital Design Forum. The Safeguarding Manager is working with the IT team to continue to develop this.

To monitor repeat adult concerns and engage with Adult Social Care agencies to offer a holistic, multi-agency approach.

Continued engagement in the Serious Case Review process and the development of level 3 training modules using lessons learned from the reviews. When a child or adult review is completed a report is produced by the commissioning Safeguarding Board, included in the report is any learning that has been identified. The Safeguarding Manager will ensure that this learning is applied to the Trust’s safeguarding processes where relevant.

The Safeguarding Manager and the Chief Nurse will engage with all of the regional safeguarding systems lead groups. These groups have been setup to have input from all aspects of health to ensure safe consistent safeguarding approaches are taking place across large geographical areas.

To develop early help safeguarding contacts with multi-agency partners to allow safeguarding concerns to reach the appropriate Social Care Teams.

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3. LEGAL and/or GOVERNANCE IMPLICATIONS

3.1 The Trust has a statutory duty to comply with:

The Children’s Act 1989; 2004

The Care Act 2014

The Serious Crimes Act 2015

Mental Capacity Act 2005

Mental Health Act 1983; 2007

Deprivation of Liberty Safeguards: Codes of Practice (2008).

Health & Social Care Act (2008)

Care Quality Commission’s Registration Standards.

Modern Slavery Act 2015

Female Genital Mutilation Act 2003; 2015

4. RECOMMENDATIONS

4.1 The Board of Directors is recommended to;

Note the assurance provided and approve the report.