Safeguarding Adults and the NHS

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Safeguarding Adults and the NHS

• Sylvia Manson

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Introduction Review of No Secrets

• Our society is redefining how we enable adults to
  be safe from harm and abuse.
• No Secrets is being reviewed to provide a
  framework and principles that can guide local
  practice
• The NHS have a key role in safeguarding adults

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Drivers for Change
Safeguarding Adults Vision
Safeguarding Adults Principles
No Secrets 2
Specific Guidance

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Primary Driver 1- Government Policy

• Strengthened regulatory role
• Break down barriers between Health and Social
  Care
• Increased collaboration across statutory and 3rd
  sector
• Decisions closer to people GP consortia
• Quality of care - Patient Safety
• Quality Innovation Prevention Productivity
• Outcome focused

• Shift power from state to local communities and
  individuals
• Big Society greater involvement of voluntary
  agencies and communities
• Maximise autonomy - limited state intervention
• Accountability to patients
• Democratic legitimacy
• Informed choice control
• no decision about me without me

AFFORDABILITY
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Primary Driver 2 - Legislative Framework

• Existing Legislation
• Human Rights Act 1998
• Mental Capacity Act 2005 amended 2007
• NHS Community Care Act 1990
• Health and Social Care Act 2008 regulation
  direct payments
• Equalities Act 2010 
• Domestic Violence Crimes and Victims Act 2004
• SVG Act
• and the rest!
• Law Commission Review April 2011
• Social Care Bill Autumn 2011

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Case Law

• Limitations of Local Authority duty and authority
• - to investigate, act where person lacks
  capacity, support, guide, inform and involve
  police where necessary Justice Hedley Re Z
  (Local Authority Duty (2004) EWHC 2817 (Fam).
• - to support not to control. Court authority
  required before any attempt to control, coerce
  Justice Munby -A C 2010 EWHC 978 (Fam)
• Best Interest and Risk Enablement
• - sensible risk appraisal not striving to avoid
  all risk.. in particular to achieve the vital
  good of the elderly or vulnerable persons
  happiness. What good is making someone safer if
  it merely makes them miserable? Justice Munby MM
  (An Adult) (2007) EWHC 2003 (Fam), (2009)
• Use of Inherent Jurisdiction for those with
  Capacity
• - Capacitated persons ability and free choice
  to make decisions and give true consent may be
  impaired if under constraint, coersion, undue
  influence. Court may be asked to intervene but
  jurisdiction will be used sparingly and only to
  enable the person to make decisions without the
  external pressures
• Re SA (2005) EWHC 2942 (Fam)(Case related to
  forced marriage) Justice Munby
• (JE 2009 unreported)
•  

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Primary Driver 3 No Secrets Consultation

• People experiencing safeguarding reported
• They got lost in the system
• Safeguarding should not be at the cost of other
  qualities of life
• Wanted to be listened to and to make choices
• They are not children
• General
• Prevention pro active safeguarding system
• Balance protection and levels of intervention
  enable people to take considered risk.

• The NHS
• Struggling to engage with safeguarding seen as
  the LA responsibility
• Failure to recognise safeguarding concerns arise
  in NHS care
• Need to create culture of openness and learning
• Need for leadership and accountability
• Need to integrate clinical governance and
  safeguarding

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Primary Driver 4 Learning from Inquests,
Inquiries Research

• Steven Hoskins 2006- failures in identifying
  vulnerability risk indicators partnerships
  information sharing eligibility criteria
  assessment of decision making capacity
• Fiona Pilkington 2007 failures in identifying
  vulnerability risk indicators failure to share
  information and refer on
• Margaret Panting 2001 self determination
  balanced with duty of care

• Mid Staffordshire failures to focus on quality
  failure to listen to patients need for early
  warning systems role of commissioners and
  regulators - failure to use intelligent
  information
• Death by Indifference institutional
  discrimination led to deaths
• Cornwall Partnership NHS Trust 2006 inadequate
  arrangements to protect vulnerable adults staff
  largely unaware of what constituted abuse.
• Shipman Inquiry 2004 Kerr Haslam 2005
• Etc Etc

• AEA Prevalence Study 2007
• Womens Aid Making the Links Disabled Women and
  Domestic Violence 2008
• Domestic Abuse in older women University of
  Sheffield ( Autumn 2010)
• CSCI/HCC research restrictive care
  institutional abuse
• Demographic Change National Office Statistics

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Distilling the Primary Drivers

• For Individuals
• Choice and control
• Enablement
• Full and informed consent
• Representation and making best interests decision
  for those lacking capacity.
• Least intrusive means

• For Services and Systems
• Focus on prevention
• Limited intervention - proportionality
• Partnerships and cooperation
• Greater community involvement
• Managing across plurality of providers and under
  new commissioning systems
• Accountability for quality of services to
  public , commissioners and regulators
• Systems need to be affordable

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We want people to be safe from harm and
exploitation, and in control of their own lives
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Safeguarding Adults Pathways
FAMILY LIFE AND COMMUNITIES SAFEGUARDING PATHWAY SERVICES SAFEGUARDING PATHWAY
Prevention safer communities strategies user enablement and empowerment stay safe initiatives Personalised care plans -risk enablement plans etc. Vigilant neighbourhoods Big society safeguarding as everyones business Prevention commissioning for quality monitoring and early intervention Integrated clinical governance systems service planning - health and wellbeing partnerships supporting self funders and Personal Budget holders as commissioners People and communities hold services to account
Responses Person defined outcome, consent, representation Proportionality Levels of response advice mediation single agency multi agency statutory interventions etc Responses Person defined outcome for decisions affecting the person Duty to address service failures and protect others Proportionality of response role of commissioners and regulators internal or independent investigation
Restoration for individual e.g. counselling justice for source of harm e.g. support to a carer Restoration for individual service improvement
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What does this mean for the NHS?

• The NHS have a key role to play in their own
  services -preventing harm occurring and
  responding effectively where harm occurs
• The NHS also have a key role in supporting
  adults at risk within their own communities and
  within other services.

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Safeguarding is Integral to Quality Outcomes
Clinical Effectiveness
Patient safety
Dignity in Care
Safeguarding
Policy areas E.G Dementia Strategy 6
Lives Carers strategy
Prevention
Patient Experience
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Safeguarding as a continuum
Safeguarding activity
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Addressing Safeguarding prevention and early
intervention

• Patient empowerment
• Build resilience factors personal, social,
  environmental
• Maximise decision making
• Minimise the impact of disability/condition
  Aids adaptations assistive technology relapse
  prevention planning
• Person centred planning - risk enablement Stay
  safe personal plans
• Effective communication - Information , choices
• Promote advance planning LPA Advance
  decisions statements of preference
• Access to complaints
• Patient involvement in service /strategic
  planning review
• Prevention/early intervention in the care
• ID higher risk patients person centred care
  planning support with eating drinking
• Safe physical environments
• What are high risk areas of care? Pressure ulcer
  care? Discharge?
• ID risks in environment

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Addressing Safeguarding prevention and early
intervention

• Care and Environment
• Identify patients at greater risk of harm - e.g.
  assistance to eat and drink pressure care
  communication needs enhanced discharge planning
  privacy dignity consent advocacy
  requirements?
• How is use of restriction and restraint governed?
• How are carers identified carers assessments
  and support plans?
• What are your organisations critical points of
  care? e.g. Pressure ulcers medication
  discharge capacity and capability of staff
  managing challenging patient behaviours
• Which wards/services present highest risk?
• How is clinical governance informing
  preventative/early intervention?
• How do commissioners know that quality care is
  being delivered?
• Strategic partnerships Wellbeing and Health
  Safer Communities
• Prevention/early intervention in the care
• ID higher risk patients person centred care
  planning support with eating drinking
• Safe physical environments
• What are high risk areas of care? Pressure ulcer
  care? Discharge?
• ID risks in environment

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Addressing Safeguarding Concerns in Community
Pathway

• What is the patients desired outcome and how can
  they be supported to achieve this?
• Does the patient have capacity to make decisions
  about their safeguarding? Maximise involvement
  representation
• Who else may be at risk of harm?
• Who needs to be involved?
• Relationship with the patient
• Clinical/ specialist skills knowledge required
• Roles responsibilities required for
  investigation risk assessment
  support/protection plan review
• Single agency or multi agency?
• How do we know we have improved the outcome for
  the patient?

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Addressing Safeguarding Concerns in Services

• How are concerns identified and managed ?
• How are complaints and incidents integrated
  within safeguarding?
• How are decisions made about when to refer?
• How do you work with local multi agency
  safeguarding partners?
• - Cooperation
• Accountability
• Proportionality
• How are decisions made within your interagency
  procedures about internal or independent
  investigation? Whats the role of commissioners
  and regulators in this?
• How is the patient supported throughout?
• How do we know we have improved the outcome for
  the patient?
• How do we know lessons learned have improved
  outcomes?

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Clinical Governance Safeguarding

Serious case review - IMRs
Serious Incident - reporting investigation
Safeguarding Procedures
Preventative /Early Intervention Safeguarding
Clinical incident e.g. near miss
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Making it Happen Leadership and Workforce
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Making it Happen - Assurance Accountability
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Safeguarding is the business of the NHS