Safeguarding
Adult Safeguarding link
Child & Young People Safeguarding link
Contents:
Introduction
Contacts
Storing Information
Training
MARAC
High Risk Domestic Abuse (HRDA) Meetings
Mental Capacity
MAPPA
Introduction
Safeguarding is a high priority for all practices. GPs / practices have a responsibility to comply with the latest guidance both individually and as contract holders and to ensure all staff undertake the relevant training.
- All practices should be aware of the Intercollegiate documents and their key messages
- All practices need to develop their own policy, for adults and children
- All practices need to have a named safeguarding GP
- The Lead GP should work with the practice manager to ensure all clinical and non- clinical staff are appropriately trained and have regular (at least annual) updates (see Training requirements below)
- Practices should have regular clinical meetings, to discuss children at risk, looked after children, vulnerable adults etc.
- The Lead GP should attend an external update at least every 3 years, inter-agency and multi professional where possible.
Resources:
NHS Somerset Safeguarding
NHS Prevent training and competencies framework
Deprivation of Liberty Safeguarding (DOLS)
Contacts
Adults: Somerset Safeguarding Adults Board - If you are worried about a vulnerable adult and would like our help, please don’t stay silent. Call: 0300 123 2224 Email: adults@somerset.gov.uk. Police: 101 or in an emergency 999. Safeguarding alert form.
Children: Somerset Safeguarding Children Partnership - contact the Family Front Door if you are a Designated Safeguarding Lead or GP and you require real time advice about a child/ren/family you are supporting, or if you are considering making a referral to Children Services but are unsure and want guidance, or to sound out your thinking in a safe space. To contact the Family Front Door call: 0300 123 3078 Contact Us - Somerset Safeguarding Children Partnership
Additional support for Somerset GP practices can be found by contacting the Somerset ICB strategic safeguarding team - call 01935 385182 or email somicb.safeguardingandcla@nhs.net.
To the best of our knowledge these contact details are correct, however we would urge practices to contact their local teams for up-to-date information and named contacts and leads.
Storing Information
There is no clear-cut guidance on storing information from third parties e.g. Case Conference reports or MARAC / MASH / MAPPA information.
The GMC in, Protecting children and young people – GMC (gmc-uk.org), states the following:
“58 You should store information or records from other organisations, such as minutes from child protection conferences, with the child’s or young person’s medical record, or make sure that this information will be available to clinicians who may take over the care of the child or young person. If you provide care for several family members, you should include information about family relationships in their medical records, or links between the records of a child or young person and their parents, siblings or other people they have close contact with.”
The GMC guidance therefore allows both scanning and not scanning of these documents as valid options.
The RCGP Processing and storing of information in primary care guidance (which covers adults and children) states:
“The coding and documentation of safeguarding information on a patient’s record is as important as the coding and documentation of any other significant medical issue such as cancer, diabetes, depression or learning disability for example. Safeguarding information needs to be immediately obvious on a patient’s notes to all health practitioners* who may access those medical notes for the purposes of direct patient care.”
“ALL primary care staff (clinical, secretarial, and administrative) have an equally important role in ensuring safeguarding information is stored correctly on medical records.”
Factors to consider as a practice:
- If information is scanned into the medical record:
- it then forms part of the medical record.
- Would a member of the administrative team who is printing out a complete set of this patient’s notes for an insurance company / solicitor be instantly aware that there is sensitive safeguarding information that needs to be redacted?
- a. e.g. Child Protection Conference Reports or MARAC information – these DO NOT BELONG TO PRIMARY CARE and therefore primary care do not have authorisation to share these notes with anyone.
- b. This also applies to safeguarding information held in consultation notes or 3rd party references.
- If information is stored separately from the patient record
- It is still potentially deemed part of the record and there are significant other risks which means this is not a recommended practice
- It may be unlikely to be accessed in an immediate situation e.g. would a locum, be instantly aware from first glance at the notes/Summary Care Record that there are safeguarding concerns for this child/family/adult?
- If this patient moved practice, would the new primary care team be able to instantly identify from the summary that there are safeguarding concerns?
- They may be unlikely to be sent on to a new GP if the patient re-registers elsewhere.
- They may become mislaid and cause a serious breach in patient confidentiality.
The decision is up to each practice, as to how they handle, code and store this information.
A reasonable approach to consider may be:
- Have a small team handling all safeguarding information as it comes into the practice.
- One staff member responsible for coding and summarising, in conjunction with the Safeguarding Lead.
- All safeguarding information should be coded as Major Active Problems
- All information should be “redacted” to prevent inappropriate sharing.
When releasing notes:
Remember to check for case conference reports as other previous practices may have opted to scan in these reports. There is no clear national guidance on releasing such reports and we can therefore only advise that practitioners seek advice on each individual case to which this applies. You can seek advice from us or more expert advice from your DPO, MDO, your named GP for Safeguarding in your area (see contact details).
More information regarding online access to records with regard to Safeguarding issues can be found on our page Somerset LMC: Medical Records
Coding for safeguarding information – https://elearning.rcgp.org.uk/pluginfile.php/170658/mod_book/chapter/349/RCGP-Safeguarding-Coding-Information-June-2017.pdf
Training
NHS Somerset Safeguarding Training information can be found here.
Do we need all the following if we have included the link above?
It will be expected that all staff have training every three years as a minimum requirement and this should be tailored to the role they fulfil.
E-Learning is an appropriate method of education and training for level 1 and 2 and can be used for level 3 but at level 3 there should also be some team-based learning.
Clinicians should be involved in case-based discussions, significant event reviews etc. where relevant to children and young people or vulnerable adults.
Recommendations from the National Guidance:
- A mandatory session of at least 60 minutes (30 minutes for adults and 30 minutes for children) should be included in the induction of all new staff, to take place within the first 6 weeks. This should provide key safeguarding information and appropriate action to take if there are concerns, to include various aspects of abuse, broad principles of safeguarding and how and where to seek help.
- Level 1 – All staff
- Adults – over a three-year period, all staff should receive refresher training equivalent to a minimum of 2 hours. This should provide key adult safeguarding guidance.
- Children – over a 3 year period all staff should have refresher training equivalent to a minimum of 2 hours. This should provide key safeguarding / child protection information, including about vulnerable groups, different forms of child maltreatment and appropriate action to take if there are concerns
- Level 2 – All practitioners (e.g. phlebotomists, pharmacists) who have regular contact with patients and any clinical or non-clinical staff who have contact with children, however small
- Adults – Over a three-year period, professionals should receive refresher training equivalent to a minimum of 3-4 hours
- Children – over a 3 year period professionals should receive refresher training equivalent to a minimum of 4 hours. This should include multi-disciplinary/multi-agency and scenario-based discussion drawing on case studies.
- Level 3/4 – All clinical staff / registered health care staff working with adults or children, young people, parents or carers engaging in assessing planning intervening and evaluating the needs of adults, children or young people
- Children
- 8 hours within 12 months of starting in post (16 hours for role specific additional knowledge)
- 8 hours minimum over 3 years as a refresher for core knowledge, skills and competencies
- 12-16 hours minimum for those requiring role specific additional knowledge skills and competencies (named / lead roles)
- Adults
- 8 hours minimum within 12 months of starting in post
- 8 hours minimum over 3 years as a refresher – multi-disciplinary and inter-agency.
- 24 hours minimum over 3 years for those requiring role specific additional knowledge skills and competencies (named / lead roles, Level 4)
- Children
To listen to the Somerset Safeguarding Children Partnership podcasts here.
The recommended training, including the necessary core competencies is detailed in the updated inter-collegiate documents Safeguarding Children and Young People: Roles and Competences for Healthcare Staff – Intercollegiate Document and Safeguarding Adults: roles and competences for health care staff – Intercollegiate Document.
The LMC recognise that the requirements are quite onerous, but we would advise that you need to be prepared to meet the required standards of competency, as the intercollegiate documents are referenced in the GMC requirements (below):
GMC Maintaining your knowledge and skills
(click on title for link)
“71 You must develop and maintain the knowledge and skills to protect children and young people at a level that is appropriate to your role. Information about the level of child protection training that is needed for different roles, and how often doctors should receive that training, is provided in Safeguarding children and young people: roles and competences for health care staff [1]. You should also take part in training on how to communicate effectively with a wide range of groups of parents, children and young people.
72 If you work with children and young people, you should reflect regularly on your own performance in protecting children and young people, and your contributions to any teams in which you work. You should ask for, and be prepared to act on, feedback through audit, case discussion, peer review and supervision. You should contact your named or designated professional or lead clinician for advice about opportunities to discuss and learn from child protection cases in your local area.
73 If you work with adults, you should make sure you are able to identify risk factors in their environment that might raise concerns about abuse or neglect and whether patients pose a risk to children or young people close to them.”
[1] Reference is the 2014 not the 2019 intercollegiate document Royal College of Paediatric and Child Health, et al (2014) Safeguarding children and young people: roles and competences for healthcare staff: intercollegiate report (pdf) London, Royal College of Paediatrics and Child Health (likely to updated to reflect the current guidelines).
The LMC feels that the time specific requirement outlined in the intercollegiate document does not take into consideration the working role and pattern of the professional, nor their current level of knowledge and competence, but if questioned, a professional would need to demonstrate how they have maintained their knowledge and skills. It is noted that the learning hours can include case discussion, personal reflection, attendance at case-conferences and are not solely based on course learning.
Additional ways in which professionals can access learning to demonstrate their competencies are shown below.
Training Resources
SSCP multi-agency safeguarding children training offer, see here.
There is FREE e-learning from ‘e-learning for health’ at Levels 1, 2 and 3 for Children’s safeguarding https://www.e-lfh.org.uk/programmes/safeguarding-children/
There is also FREE e-learning at Levels 1, 2 and 3 for Adult Safeguarding https://www.e-lfh.org.uk/programmes/safeguarding-adults/
Here are some other resources:
RCGP e-GP at www.rcgp.org.uk – free to RCGP members (apply for password)
General resources, such as the consultation with the child, under Section 8 Children and Young People; also Safeguarding Children and Young People – 4 modules – Initial “All staff” one and Level 2 (Recognition, Response and Record)
Information on GP Appraisal Safeguarding Requirements https://www.gpappraisals.uk/safeguarding-children.html
PREVENT (free e-learning): https://www.elearning.prevent.homeoffice.gov.uk/edu/screen1.html
Liberty protection safeguards training: Blue Stream Academy have an e-learning module: https://cpduk.co.uk/courses/blue-stream-academy-ltd-deprivation-of-liberty-safeguards-dols
Mental Capacity Act training: Blue Stream Academy have an e-learning module: https://cpduk.co.uk/courses/blue-stream-academy-ltd-mental-capacity-act
FGM (free e-learning): https://www.e-lfh.org.uk/programmes/female-genital-mutilation/
Modern Slavery (free e-learning): https://www.e-lfh.org.uk/programmes/modern-slavery/
Domestic Violence – AVA Against Violence and Abuse (free e-learning): http://elearning.avaproject.org.uk/index.php
We hope that you will also find Somerset Safeguarding Children Partnership Podcast - The P Pod useful.
Somerset Safeguarding Children Partnership Events and Courses
MARAC
MARACs provide a multi-agency response for high-risk domestic abuse victims where up to date risk information is combined with a comprehensive assessment of the victim’s needs. This enables appropriate services to be put in place for all those involved in the case.
Four aims of MARAC
- Safeguard victims of domestic abuse
- Manage perpetrators behaviour
- Safeguard professionals
- Make links with all other safeguarding processes
More information is available at SafeLives and also Somerset Domestic Abuse
A MARAC is a meeting to discuss ways to help victims at high risk of murder or serious harm. Information is shared at the meeting between representatives of the police, health, child protection, housing practitioners, Independent Domestic Violence Advisors (IDVAs), probation and other specialists from the statutory and voluntary sectors.
After sharing all relevant information they have about a victim, their family and the person causing the harm, the representatives discuss options for increasing the safety of the victim and turn these into a co-ordinated action plan. The primary focus of the MARAC is to safeguard the adult victim. The MARAC will also make links with other fora to safeguard children and manage the behaviour of the perpetrator. At the heart of a MARAC is the working assumption that no single agency or individual can see the complete picture of the life of a victim, but all may have insights that are crucial to their safety.
The person at risk does not attend the MARAC but is represented by an Independent Domestic Violence Advisor (IDVA). An IDVA is a named professional case worker for domestic abuse victims whose primary purpose is to address the safety of ‘high risk’ victims and their children, serving as the victim’s main point of contact. The person causing harm of the alleged domestic abuse should not be informed of the meeting or of the referral to MARAC.
In common with safeguarding procedures, MARAC facilitates information sharing about the risks of harm and actions needed to increase safety are agreed creating a risk management plan involving all relevant agencies. MARAC does not replace safeguarding meetings or processes and cases are not discussed in the same level of detail as a safeguarding meeting. MARAC is not an ongoing case management process; cases are discussed once unless there is a new incident over the next 12 months.
The MARAC will help agencies working with children and young people link up efforts to safeguard the abused parent and efforts to safeguard the child, helping them to intervene in vulnerable families before children are placed at significant risk. The MARAC will also help those agencies to work with clients that are not engaging with agencies or need more support by involving other agencies, such as the IDVA service or specialist domestic violence services, to work with the victim.
When someone is experiencing domestic abuse, it’s vital to make an accurate and fast assessment of the danger they’re in, so they can get the right help as quickly as possible. The SafeLives Dash risk checklist is used by a variety of agencies along with Somerset Domestic Abuse - resources for GPs and health professionals. Dash stands for domestic abuse, stalking and ‘honour’-based violence.
The Dash risk checklist can be used for all intimate partner relationships, including LGBT relationships, as well as for ‘honour’-based violence and family violence. It is primarily intended for professionals – both specialist domestic violence workers, such as IDVAs, and other professionals working for mainstream services. It aims to provide a uniform understanding of risk across professions. A high score means the victim is at high risk of murder and/or serious harm and needs urgent help. These victims should get help from an IDVA, and all the relevant local agencies should come together at a MARAC meeting to make a plan to make them safe.
High Risk Domestic Abuse (HRDA) Meetings
HRDA is a local, multi-agency, whole family focused process where information is shared on the highest risk cases of domestic violence and abuse between different statutory and voluntary sector agencies. HRDA builds on the MARAC (Multi-Agency Risk Assessment Conference) model bringing together practitioner meetings and management meetings.
HRDA combines a range of multi-agency functions which complement one another to increase the safety of people experiencing domestic abuse and their families (or known individuals) who are at high risk of harm / future harm and reducing the risk of domestic homicide.
Within the context of domestic abuse, it is recognised that no one agency holds all the information required to effectively assess the needs of victims and their children or to fully assess the risk of serious harm or homicide to victims. Also, in most cases the support of more than one agency is required to ensure the longer-term safety of the victim and their children.
HRDA enables the available information to be safely shared across relevant partner agencies and multi-agency bodies including MAPPA (Multi Agency Public Protection Arrangements) and both child and adult safeguarding conferences, resulting in a clearer picture of the risk level. This also supports a more comprehensive action plan to be developed to identify and agree risks plus mitigating factors with clear ownership to reduce the risk of harm to the victim and their children.
Agencies involved may be:
- Police
- Children Social Care
- Specialist Domestic Abuse Worker
- Adult Social Care
- Health
- Housing
- Probation
- Substance Misuse
- Education
- Specialist domestic violence and abuse services providers
Mental Capacity
Adults have a right to make their own decisions, even decisions which may seem unwise to others. The Mental Capacity Act 2005 is legislation that protects and describes this right, and it also safeguards for those who lack capacity. It is relatively easy to read for a piece of legislation and has a definition on how you can assess capacity.
The Act contains 5 statutory principles:
- A person must be assumed to have capacity unless it is established that they lack capacity.
- A person is not to be treated as unable to make a decision unless all practicable steps to help him to do so have been taken without success.
- A person is not to be treated as unable to make a decision merely because he makes an unwise decision.
- An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests.
- Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is least restrictive of the persons rights and freedom of action.
Any capacity assessment is specific to the decision being assessed and it is specific to that period in time i.e., can they understand on a specific date what a lasting power of attorney means? Can they retain that information long enough to use or weigh that information to help them make that decision and communicate that decision?
(The fact that a person can retain the information relevant to a decision for a short period only does not prevent him/her from being regarded as able to make the decision.)
GPs carry out and refer individuals for treatments and procedures. This should involve making Best Interests Decisions when the person lacks capacity, in conjunction with families, carers (paid and unpaid) or others acting on the person’s behalf. The Best Interests Decision should be well documented in the persons notes and this process should be followed for each treatment or procedure required.
Assessing capacity for such as a lasting power of attorney should only be undertaken if the clinician feels competent to do so (and this may vary depending on how well the patient is known). If there are doubts, suggest a private opinion is sought from a psychiatrist specialising in Older Peoples Mental Health. If an assessment is carried out, then ensure this is well documented. It is advised the person is assessed on their own so they cannot be seen to be influenced by others.
Useful Links:
Assessing Capacity – this is an easy-to-read guide on assessing capacity from the Social Care Institute for Excellence (SCIE)
The Mental Capacity Act 2005 and Mental Capacity (Amendment) Act 2019
https://www.legislation.gov.uk/ukpga/2019/18/enacted
Wessex LMCs: Mental Capacity Act lunch and learn
MAPPA
Multi Agency Public Protection Arrangements
The aim of MAPPA is to manage the risks that violent and sexual offenders pose to the public by managing the risks associated with these categories of offenders. The various agencies share information about offenders under MAPPA in order to assess the level of risk they pose to the public. The “responsible authorities” of the MAPPA include the National Probation Directorate, HM Prison Service and England and Wales Police Forces.
MAPPA is coordinated and supported nationally by the Public Protection Unit within the National Offender Management Service.
The MAPPA Process. . .
Offenders are put into three categories by the above authorities, in conjunction with other agencies, such as health providers and social services:
Category One – All registered sexual offenders (RSOs). Sentence and age thresholds apply, length of time on the register may vary. Registered sexual offenders are required to notify the police of their name, address and personal details under the terms of the Sexual Offences Act 2003.
Category Two – All offenders who have received a custodial sentence of 12 months or more in prison, or detention in hospital, for a violent offence or other sexual offence as listed in Schedule 15 and whilst they remain under probation supervision.
Category Three – Other dangerous offenders, anyone else who poses a "risk of serious harm to the public" who has received a conviction and whose risk would be better managed in a multi-agency setting including domestic abuse related offences and offenders convicted of a sexual or violent offence abroad should be considered for Category 3 . All domestic abuse perpetrators not managed under Categories 1, 2 or 4 are considered for Category 3 management. Those convicted for Controlling or Coercive Behaviour in an Intimate or Family Relationship must be considered for Category 3 as would those with convictions for stalking or who display stalking behaviours if they do not fall into Category 2 management.
Category Four - Terrorist or terrorist risk offender – committed a relevant terrorist offence, is aged 16 and over and / or is convicted of a terrorist related offence with a prison sentence of 12 months+ / detention in youth accommodation for 12months + / suspended sentence of 12 months +.
All relevant offenders are assessed to establish the level of risk of harm they pose to the public. Risk management plans are then worked out for each offender to manage those risks. MAPPA allows agencies to assess and manage offenders on a multi-agency basis by working together, sharing information and meeting as necessary to ensure that effective plans are put in place.
There are three levels of MAPPA management which are based on the level of attention and resources required to put effective plans in place. Levels one and two are solely based on the offence and disposal, while category three is based on previous offending and current risk management.
Level 1 – Ordinary agency management is for offenders who can be managed by one or two agencies, such as the police and Probation, and will involve sharing information about the offender with other agencies if necessary and appropriate. Ninety-five per cent of offenders are managed at this level, usually by a single police or probation officer, although it is the police who are ultimately responsible for managing those under MAPPA.
Level 2 – A local multi-agency management for offenders where the ongoing involvement of several agencies is needed to manage the offender. Once at level 2 there will be regular multi-agency public protection (MAPP) meetings about the offender to develop a coordinated plan.
Level 3 – These are known as Multi-Agency Protection Panels, which are more demanding on resources and aimed at those who are deemed to pose the highest risk of causing serious harm, or whose management is particularly problematic.
A management plan is highly specific to each offender and their offending history, but might include any of the following:
- Accommodation at an Approved Premises (AP) where the offender can be monitored.
- A set of licence conditions such as having contact with children or going within an exclusion zone in a town/city.
- A Civil Order such as a Sex Offender Prevention Order (SOPO) to prevent the offender engaging in certain activities, such as not entering a town where a victim resides or not to have unsupervised contact with children.
- A duty to report to an Offender Manager every week to undertake offending reduction counselling and work as part of their licence.
- In some very extreme cases there may be covert monitoring of offenders to protect the public.
- A disclosure of information to a member of the public for their protection.
Adding information to a patients record in relation to them being on the sex offenders’ register.
This information may be relevant to the provision of care and has potential implications in terms of staff vulnerability and lone working. It does however need to be handled sensitively. It may be that the information has been volunteered by the patient or there is information from a third party. If information is from a third party, it is essential to verify the validity of the information before considering recording it.
If the information is recorded, then there is clear GMC guidance on releasing information to third parties and this should be followed closely should there be any requests for access to medical records/information from third parties.
(see Confidentiality: good practice in handling patient information – ethical guidance – GMC (gmc-uk.org))
With the advent of patient online access to records, it is important to consider redaction and removing from online visibility.
The book ‘Medical Ethics Today: The BMA’s Handbook of ethics and law’ states “should the GP choose to record a particular piece of information, this should be done using the correct ‘read code’. For example, while a patient is on the sex offenders’ register, the appropriate code should be in the record. After the patient has been removed from the register, the record should reflect this change has occurred by removal of the code from display (although it will be retained in the audit trail) and replaced with a code to indicate that the patient has a criminal record.”
Duty to Cooperate
Responsible Authority has a duty to co-operate with the list of agencies known as Duty to Co-operate Agencies (DTC agencies). NHSE/ ICB and NHS providers are included in the list of duty to cooperate agencies. This is a reciprocal duty; the Criminal Justice Act 2003 obliges DTC agencies to co-operate with the RA in establishing arrangements to assess and manage the risks presented by serious sexual, violent and terrorist offenders.
Somerset LMCs Resources on Safeguarding:
Somerset Safeguarding Children Partnership
Somerset Safeguarding Children Partnership Events & Courses
