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Safeguarding Adults and the NHS


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Title: Safeguarding Adults and the NHS

Safeguarding Adults and the NHS
  • Sylvia Manson

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
  • The NHS have a key role in safeguarding adults

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

Primary Driver 1- Government Policy
  • Strengthened regulatory role
  • Break down barriers between Health and Social
  • Increased collaboration across statutory and 3rd
  • 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
  • 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

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

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
  • - 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)

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

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
  • 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

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

We want people to be safe from harm and
exploitation, and in control of their own lives
Safeguarding Adults Pathways
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
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.

Safeguarding is Integral to Quality Outcomes
Clinical Effectiveness
Patient safety
Dignity in Care
Policy areas E.G Dementia Strategy 6
Lives Carers strategy
Patient Experience
Safeguarding as a continuum
Safeguarding activity
Addressing Safeguarding prevention and early
  • Patient empowerment
  • Build resilience factors personal, social,
  • 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

Addressing Safeguarding prevention and early
  • 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
  • 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

Addressing Safeguarding Concerns in Community
  • 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
  • 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?

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

Clinical Governance Safeguarding

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