Quality Assurance Framework

Transcription

1 Camden Safeguarding Adults Partnership Board Quality Assurance Framework This document sets out a multi-agency approach to quality assurance of adult safeguarding arrangements in Camden. Version 2.1 Effective: October 2015

2 CAMDEN SAFEGUARDING ADULTS PARTNERSHIP BOARD QUALITY ASSURANCE FRAMEWORK Version 2.1 Name of originator/author Name of responsible committee: Date agreed: September 2015 Date issued: October 2015 Review date: October 2017 Target audience: Location Related policies: Sarah Lui, Safeguarding Development Officer Camden SAPB Quality and Performance Sub-Group This framework applies to ALL Camden SAPB Board member organisations. Any organisation in Camden may utilise the partner self-audit tool by agreement with the SAPB. Version Control Sheet Version Date Author Status Comment 1.0 March 2010 Carol O Brien, Safeguarding Approved by SAPB Original document 2.0 Jan Sept 2015 Development Officer Sarah Lui, Safeguarding Development Officer Approved by SAPB Agreed by Q&P sub-group Reviewed, fully revised and updated Updated in line with Care Act 2014 Page 1 of 23

3 CAMDEN SAFEGUARDING ADULTS PARTNERSHIP BOARD QUALITY ASSURANCE FRAMEWORK CONTENTS 1. INTRODUCTION AND BACKGROUND 3 2. WHAT IS A QUALITY ASSURANCE FRAMEWORK? 3 3. UNDERPINNING PRINCIPLES OF THE QAF 4 4. THE FRAMEWORK 5 A) INTEGRATED PERFORMANCE DASHBOARD 7 B) QUALITATIVE FEEDBACK 7 C) DESKTOP REVIEW 7 D) PARTNER SELF-AUDIT TOOL 8 5. REPORTING 8 6. LEARNING AND TAKING ACTION 9 7. GOVERNANCE 9 Page Appendix 1 Partner audit tool and guidance 11 Appendix 2 Acknowledgements 28 Page 2 of 28

4 1. INTRODUCTION AND BACKGROUND 1.1 Section 43(3) of the Care Act 2014 requires Camden Safeguarding Adults Partnership Board (SAPB) to co-ordinate and ensure the effectiveness of what each of its member does in helping and protecting individuals from abuse and neglect and delivering the outcomes that enhance their wellbeing. 1.2 The Care and Support Statutory Guidance (DH, October 2014) elaborates that Camden SAPB should: establish ways of analysing and interrogating data on safeguarding notifications that increase the SAB s understanding of prevalence of abuse and neglect locally that builds up a picture over time; establish how it will hold partners to account and gain assurance of the effectiveness of its arrangements; determine its arrangements for peer review and self-audit; evidence how SAB members have challenged one another and held other boards to account Good practice guidance from the sector 2 suggests that performance or quality assurance framework provides a robust mechanism by which Camden SAPB can discharge these responsibilities and evaluate whether systems are working effectively to help and protect adults from abuse and neglect. 1.4 Since 2010, Camden SAPB s Quality Assurance Framework (QAF) has supported the SAPB and individual partner agencies to understand the effectiveness of safeguarding arrangements in the borough, to identify priorities and make decisions on how we improve safeguarding services, and to help us be more accountable to residents. The QAF has been revised and strengthened to reflect the Board s statutory duties under the Care Act 2014 and the latest good practice across the sector. 2. WHAT IS A QUALITY ASSURANCE FRAMEWORK? 2.1 A QAF evidences whether the right things are being done for the right reasons in the right way, and enables the use of this information to secure greater impact and effectiveness. 2.2 A QAF usually consist of a (rolling) programme of activity, assessment and reporting into the quality and effectiveness of systems, products, arrangements etc. It enables the Board to triangulate a variety of information, both about quantity and quality, from different sources to objectively evaluate the effectiveness of arrangements, rather than relying on a single means of assessment Camden s QAF sits alongside the Board s risk register, Safeguarding Adults Review framework and Establishment Concerns Process as part of a wider approach to quality and performance, and utilises mechanisms for sharing lessons and learning such as practitioner forums, management meetings and training. The QAF will help Camden SAPB and its constituent partner organisations gain assurance that single and multi-agency systems, structures, processes and practice are effective in improving outcomes and experience in the context of safeguarding adults. 2.4 The QAF will be used annually by the SAPB to: 1 Department of Health, (October 2014), Care and Support Statutory Guidance, paragraph (pages ). 2 Such as: Social Care Institute for Excellence, (March 2015), Safeguarding Adults Boards Checklist and Resources; Association of Directors of Adult Social Services (ADASS), (Spring 2015), Top Tips for Directors; and ADASS (March 2013), Safeguarding Adults: Advice and Guidance to Directors of Adult Social Services. 3 ADASS (March 2013), Safeguarding Adults: Advice and Guidance to Directors of Adult Social Services, page 12. Page 3 of 28

5 evidence and gain assurance that safeguarding arrangements in Camden are effective; identify priorities and make decisions on how we improve safeguarding services; hold local agencies to account for their safeguarding work and arrangements; and help us be more accountable to residents. 2.5 Across the partnership, the QAF will facilitate: quarterly monitoring of multi-agency performance data covering prevalence and nature of abuse, activity and effectiveness of responses, and making safeguarding personal. regular gathering of feedback from individuals on their experience of safeguarding and whether it made a difference to their wellbeing. annual gap analysis of Board and multi-agency arrangements against statutory responsibilities and best practice. annual self-assessment of safeguarding arrangements in each individual member agency, to gain assurance of areas that are effective and how to take action on areas requiring improvement; 2.6 Gathering and triangulating this quality intelligence will support the SAPB in: gaining a holistic view of safeguarding arrangements so we can recognise good practice and identify areas that need improvement; being open and transparent across the partnership about risk and things that require improvement; identifying priorities for the Board and individual agencies to feed into the Board safeguarding strategy and individual agency action plans, and; achieving and evidencing continuous improvement over time. 3. UNDERPINNING PRINCIPLES OF THE QAF 3.1 Good quality safeguarding arrangements are underpinned by the following key principles, as defined by the Department of Health 4 and mirrored in Camden SAPB s safeguarding strategy : Key principle Description What this means to people 1. Empowerment People being supported and encouraged to make their own decisions and informed consent. 2. Prevention It is better to take action before harm occurs. 3. Proportionality The least intrusive response appropriate to the risk presented. 4. Protection Support and representation for those in greatest need. 5. Partnership Local solutions through services working with their communities. Communities have a part to play in preventing, detecting and reporting neglect and abuse. 6. Accountability Accountability and transparency in delivering safeguarding. I am asked what I want as the outcomes from the safeguarding process and these directly inform what happens. I receive clear and simple information about what abuse is, how to recognise the signs and what I can do to seek help. I am sure that professionals will work in my best interests as I see them, and professionals will only get involved as much as needed. I get help and support to report abuse and neglect. I get help so that I am able to take part in the safeguarding process to the extent to which I want. I am confident that professionals will work together, with me and my network, to get the best result for me. I know that staff treat any personal and sensitive information in confidence, only sharing what is helpful and necessary. I understand the role of everyone involved in my life and so do they. 4 Department of Health, (October 2014), Care and Support Statutory Guidance, paragraph (page 232). Page 4 of 28

6 3.2 The QAF is also underpinned by the following principles: Openness and transparency: each agency within the SAPB is likely to know where good practice, areas for development and risk lies in its own organisation. The SAPB needs to be assured agencies have identified and acted upon risk and areas of development, or to be enabled to do so as a multi-agency Board. All partners must bring good practice, areas for development and risks to the table so that the Board can agree how they can be mitigated. Some will be single agency actions and some will require multi agency action. Outcomes: good quality safeguarding arrangements should be person-centred, outcomesbased and making a difference, in line with Making Safeguarding Personal i.e. to what degree do our safeguarding arrangements deliver what is important to adults at risk and the outcomes they want to achieve. Triangulation: that different qualitative and quantitative information sources need to be compared and contrasted to cross-verify the data and validate any conclusions being drawn. This will enable the Board more confidently to understand whether arrangements are effective and making a positive difference. 4. THE FRAMEWORK 4.1 In order to measure and seek assurance that safeguarding arrangements in Camden are effective, the QAF seeks to answer three key questions: 1. Are adults at risk safe? 2. Are partners working well together to respond to safeguarding concerns? 3. Do safeguarding arrangements improve outcomes for adults at risk? 4.2 The QAF is based on a quadrant model of evidence collation and analysis activities that bring together a variety of quantitative and qualitative data from a range of sources fig. 1 below and shown in more detail in fig. 2 overleaf. Each quadrant aims to answer different aspects of the three key questions and together give a holistic picture as to the effectiveness of safeguarding services in Camden. Bring together quantitative multi-agency data on: trends in the nature and reporting of abuse; multiagency responses; and outcomes for adults at risk. A) Integrated performance dashboard Collate views/ feedback from customers, carers, families, and staff to understand if our safeguarding arrangements are working, delivering the outcomes B) Qualitative feedback people want and making a difference. Fig. 1 C) SAPB desktop review Look at how well the Board fulfils its statutory duties to understand if partners are working effectively together to keep people safe. D) Partner self-audit tool Evaluate the quality of individual agency safeguarding arrangements and develop action plans to improve how agencies keep people safe Page 5 of 28

7 Fig. 2 Camden SAPB is assured that arrangements are effective and making a positive difference Integrated performance dashboard presented to the SAPB quarterly, using data from across the partnership. Qualitative feedback using staff, carers and customers views along with lessons learned from safeguarding adult reviews. SAPB desktop review to evaluate annually if the partnership is working effectively and fulfilling statutory requirements. Underpinning principles: I statements Partner selfaudit tool to assess individual agency arrangements and develop action plans. Annual challenge/ support event. Year end 1) Lessons learned from cases 2) Action plan and monitor via challenge/ support event 3) Outcomes included in annual report 4) Refreshed priorities in safeguarding strategy Page 6 of 28

8 A) Integrated performance dashboard The aim of the quarterly integrated performance dashboard is to enable the Board to understand the prevalence of abuse/ neglect, highlight themes and trends in safeguarding activity, and identify issues that need addressing in safeguarding arrangements. The dashboard will cover trends in reported abuse, partnership working to respond to safeguarding concerns, and outcomes (whether residents feel safer as a result). The dashboard will use data from across the safeguarding partnership that is already collected and used by individual agency management teams to monitor the effectiveness of their individual safeguarding arrangements. A data mapping exercise was conducted to identify partners data that would be useful/ available to include. It is anticipated that the integrated performance dashboard will be available for use from January B) Qualitative feedback The aim of the qualitative feedback quadrant is to understand if our safeguarding work is making a difference, using the views of customers, carers and staff; using Making Safeguarding Personal outcomes data; and using our case audit findings. Customers, carers and staff views will be captured through: ASCOF feedback interviews with people who have been through the safeguarding process and/ or their carers (to be developed in ) asking: o Did they feel informed and in control of their safeguarding case? o Were they involved and supported in decision-making in the case? o Has safeguarding made them (feel) safer? o Were they satisfied with the outcome of the safeguarding episode? o Were they satisfied with the service; views are on how safeguarding could be improved. Staff views ascertained by conducting 2-3 staff focus groups per annum and acting on findings. Carers and families views ascertained by conducting an annual carers focus group and acting on findings. Information from complaints, grievances and whistleblowing Findings from the quarterly case audit programme on customer views, informed choice, capacity, and protection planning (safety and well-being). Trends and themes from any inspections across the partnership Trends and themes identified and reported back through training delivery Trends and themes from Board s learning log from section 42 enquiries. Trends and themes from Safeguarding Adults Reviews Trends and themes from Prevention of Future Deaths reports C) SAPB desktop review The aim of the desktop review is to understand if the partnership is fulfilling its statutory duties and working effectively. The desktop review will be undertaken annually by the Safeguarding Development Officer on behalf of the Board towards the end of each financial year. The review would include assessment of performance against a specific set of criteria: Gap analysis against statutory requirements and guidance (such as Department of Health (2014) Care and Support Statutory Guidance, and ADASS (2012) Standards for Adult Safeguarding) Fulfilment of the Board s constitution Board operations: o Regularity of meetings o % attendance at each meeting and over the year. o Spread of agencies attending and any long-standing gaps. Timeliness of publication of a safeguarding strategy and high quality of annual report. Progress against safeguarding strategy key priorities % of priorities being RAG rated green. Page 7 of 28

9 Board links with other strategic partnerships such as the Health and Wellbeing Board, Camden Safeguarding Children s Board, the Community Safety Partnership etc. measured by whether the work of the SAPB has been discussed by other partnerships. Success in raising public awareness numbers of events/ posters/ leaflets distributed, and numbers of referrals from self/ family/ friend. Health of the Board budget and multi-agency nature of contributions financially and in-kind. Gap analysis against best practice (e.g. LGA/ ADASS guidance) Any inspections/ peer reviews undertaken, and progress in implementing actions required. Option of a short annual survey of Board members on views of Board effectiveness. D) Partner self-audit tool The aim of the partner self-audit tool is to evaluate the quality of individual agency safeguarding arrangements and develop action plans, by: Using the SAPB quality audit tool (developed by a group led by NHS England and adopted by the SAPB in October 2015 see appendix 1 for the audit tool and guidance) in Winter annually. Option for voluntary sector agencies, and provider organisations to use the audit tool, e.g. via provider forums and/ or commissioners. Completed audit tools and action plans to be submitted to the Board for analysis and identification of key themes by the Safeguarding Development Officer. Challenge event to be run each year as a half-day away day to look at: o Findings of the audit tool analysis and identification of key themes o Each agency s action plan (through peer/ buddy system) and identify further actions/ key areas for development o Agree process for monitoring progress on action plans during the year (e.g. peer review) o Review of progress with safeguarding strategy during the year o Agreement on actions to include in the safeguarding strategy for the year coming. Outcomes of the challenge/ support event to be reported on and signed off at the April SAPB meeting each year, and incorporated into the safeguarding strategy. Action taken in following year by each individual agency to address areas for development in their action plan. 5. REPORTING 5.1 Each quadrant has specific reporting arrangements: Quadrant Frequency Reported to Reported by A) Integrated Quality & Performance Camden Council performance Quarterly sub-group and to SAPB Strategy and Change dashboard B) Qualitative feedback Annually Quality & Performance sub-group and to SAPB Interviews project lead; Safeguarding Development Officer C) Desktop review Annually SAPB D) Partner self-audit tool Annually SAPB and to challenge/support event NHS England Safeguarding Development Officer All partners NHS organisations Page 8 of 28

10 5.2 The overall findings of the QAF will be set out in an annual QAF report from the Quality and Performance (Q&P) sub-group to the SAPB in April each year. This will include the results from each of the quadrants. The report will be drafted by the Safeguarding Development Officer. 5.3 The report will provide for the Board: Summary of the key messages from the information in each quadrant. Triangulation of the available data and intelligence. A holistic view of safeguarding arrangements so that we know how effective they are in Camden. Identification of areas of good practice and areas for improvement. Information on trend and themes in Camden s safeguarding practice. Opportunities to challenge and address areas for development, and agree actions and priorities for individual agencies or for inclusion in the safeguarding strategy. 5.4 The Board may ask the chair of the Q&P sub-group to report more frequently as is needed. 5.5 Findings will also inform the Camden SAPB annual report, published each year in the Autumn. 6. LEARNING AND TAKING ACTION 6.1 The learning will primarily be set out in the QAF report. Action will be taken through the identified areas for development being included in the safeguarding strategy delivery plan for the following year. 6.2 In identifying areas for development, the Board may: Commission further research and exploration into specific areas. Agree action plans and monitoring with individual agencies. Make use of buddying and peer reviewing between agencies to drive improvement. 6.3 In addition, changes may be made to: policies, procedures and processes training and development for staff contracts and service level agreements and monitoring arrangements resources case auditing programmes leaflets, posters and other awareness raising and communications materials. 7. GOVERNANCE 7.1 The QAF will fall under the remit of the Quality and Performance Sub-Group (Q&P), with implementation of individual quadrants delegated as follows: Quadrant A Camden Council Strategy and Change will coordinate the development and quarterly compiling/ reporting of the integrated performance dashboard, including data from partners as advised by the Q&P sub-group. Quadrant B the Q&P sub-group will commission a report with input from: the project lead for implementation of ASCOF feedback interviews; leads for complaints/ grievances/ whistleblowing/ feedback groups; and the Safeguarding Development Officer for the findings of focus groups, case auditing, Safeguarding Adults Reviews etc. Quadrant C the Safeguarding Development Officer will implement the annual desk top review. Page 9 of 28

11 Quadrant D the Q&P sub-group will arrange for all partners to complete the annual partner self-audit tool, and the Safeguarding Development Officer will arrange a challenge and support event. 7.2 Occasionally the sub-group may wish to delegate sections of QAF work out to task and finish groups or other sub-groups as appropriate according to the work required. 7.3 On behalf of the Board the Q&P sub-group will keep this framework under review and may change it to reflect changes in legislation, best practice and to ensure the continuous improvement of safeguarding adults in Camden. 7.4 The Q&P sub-group will formally review the QAF every two years. [END] Page 10 of 28

12 Appendix 1: Partner self-audit tool and guidance 1.0 Introduction Safeguarding Adults at Risk Audit Tool Audit of arrangements in individual organisations to Safeguard and promote the wellbeing of Adults at Risk The Safeguarding Adults at Risk Audit Tool has been developed by the London Chairs of Safeguarding Adults Boards (SABs) network and NHS England London. It reflects statutory guidance and best practice. The aim of this audit tool is to provide all organisations in the Borough with a consistent framework to assess monitor and/or improve their Safeguarding Adults arrangements. In turn this will support the Safeguarding Adult Board (SAB) in ensuring effective safeguarding practice across the Borough. The audit tool is a two-part process: Completion of a self-assessment audit A safeguarding adult board challenge and support event. The purpose of the tool is to provide the SAB with an overview of the Safeguarding Adult arrangements that are in place across the locality identifying: Strengths, in order for good practice can be shared Common areas for improvement where organisations can work together with support from the SAB Single agency issues that need to be addressed Partnership issues that may need to be addressed by the SAB. The audit can be carried out at any time of the year, although it is ideal to aim for the end of the financial year so that findings can feed into the new year s SAB business plan and improvements can be reported in the SAB annual report. NHS England is happy to receive completed audit to support the Clinical Commissioning Group assurance process. London Region Thereafter the SAB will facilitate and monitor improvement via annual Challenge and Support Events and regular SAB meetings as necessary. Page 11 of 28

13 2.0 Completing the self-assessment audit All partner agencies represented on the SAB will be encouraged to complete the self-assessment audit. It can be completed wider if it is felt worthwhile. For example, commissioners may encourage providers such as Care Homes and Domiciliary Home Care providers to complete a self-assessment by using this tool at appropriate provider forums. The tool can be adapted to suit the needs of the sector or organisation. Clinical Commissioning Groups and NHS Providers are advised to complete the audit in full. Questions on commissioning should be completed by CCGs as well as health providers that commission services. These organisations should also complete the other aspects of the audit. Organisations are required to make a judgement as to how well each question is being achieved based on the following rating: GREEN rating AMBER rating RED rating the organisation meets the requirement consistently across the organisation. the requirement is met in part; there may be pockets of excellence and areas for improvement. the organisation does not meet this requirement. Areas with an amber or red rating must be supported by action to be taken to ensure improvement and by whom. Examples of evidence that might be provided have been given however these are only suggestions and will not be relevant for all organisations. The purpose of providing evidence is for the organisation to draw together relevant information for its own assurance. It is unlikely that the SAB will want to review the evidence. The self-assessment audit should be used to help the organisation to improve and strengthen arrangements for safeguarding adults. An open and honest approach is encouraged to enable the organisation to get maximum benefit from the process. 3.0 The Challenge and Support Event. The Challenge and Support Event can help to build a stronger partnership. It is an opportunity for partners to identify what is challenging those most and to support one another by sharing what is working well. Partners are asked to share their self-assessment audit prior to the event. A spread sheet showing the RAG rating for each of the partners against each of the criteria is a helpful way of sharing information. The Challenge and Support Event may be run as a facilitated workshop. It should allow time for partners to present what they are doing well and areas where they are working to improve outcomes. Page 12 of 28

14 The Challenge and Support Event will help to identify: Single agency actions which will be monitored by that agency and updates made to the Board. Partnership issues for action by the SAB or its sub groups. 4.0 Completing the audit and preparing for a Challenge and Support event Discuss with appropriate colleagues/managers where you think you are in relation to each statement which applies to your organisation. Identify key strengths and areas where progress is most needed. Think about any constraints you face. Note down key points of discussion as a helpful reference for future action/discussion Reflect on discussion and agree your position on the rating scales for each statement: o What have you found that is good about your organisation s approach to Safeguarding Adults that you could share with partners? o What have you found that gives you cause for concern- including evidence from safeguarding adult reviews provider level concerns, serious incident investigation or other reviews,as appropriate o It may be helpful to ask organisations to present the top three things where they are doing well and three areas where they need to improve when you get together at a challenge and support event. You will want to consider o How will you review progress on necessary actions on issues of concern? o Should these actions be integrated into other action plans for individual organisations or for the SAB or the Health & Wellbeing Board? Page 13 of 28

15 Organisation: Executive Lead responsible for safeguarding adults: Name of person completing this audit: Name of person authorising this audit: Date audit completed: Name: Tel no: Name: Tel no: Name: Tel no: Designation: Designation: Designation: Date audit authorised: Page 14 of 28

16 Summary of audit findings and identified issues of concern: Actions to be taken Red and Amber areas: Area: Action Lead Date Page 15 of 28

17 Good or best practice examples you would like to highlight Refers to section in audit tool (e.g. A1, F5) Page 16 of 28

18 RAG Rating Camden SAPB Quality Assurance Framework v2.1 Effective From: October 2015 SECTION A: LEADERSHIP, STRATEGY, GOVERNANCE, ORGANISATIONAL CULTURE The boxes within each section can be expanded to facilitate an answer however comprehensive or detailed it may be. A Discussion points/comments Evidence to support RAG rating Additional Action to ensure improvement and by whom Progress or date completed *A1 The organisation has a senior staff member that has the responsibility to champion safeguarding (and where applicable the Mental Capacity Act (MCA) and Prevent) throughout the organisation. They have received up to date training in adult safeguarding legislation, and where appropriate, Prevent and the MCA. The senior staff member keeps senior managers informed of all issues relevant to safeguarding and promoting wellbeing. They have sufficient time and training to carry out this role. The senior staff member may be the designated individual to whom concerns about an adult at risk are reported or there may be an additional role in the organisation for this purpose. This person will have a job description reflecting this specific role. For some Board members this must be further formalised by identification of a Designated Safeguarding Adults Manager (DASM) (Care and Support Statutory Guidance (DH, Oct 2014, para ) and Safeguarding Vulnerable People in the NHS Accountability and Assurance Framework (NHS England, Jul 2015, para 4.2.4)). This DASM role will include oversight of individual complex cases and coordination where concerns are raised. It will include managing adult safeguarding allegations against staff. Please specify the post holder A1 For example, job descriptions *A2 The organisation is committed to safeguarding adults and promoting wellbeing and this is explicitly reflected in the organisation s mission statement/ guiding principles as well as in strategic documents. There is expertise and commitment at all levels within the organisation. The organisation is Care Act compliant, and able to evidence how it is implementing the aims of the organisation s safeguarding strategy. This commitment is reflected in the level of participation of the organisation in actively supporting the SAB in taking actions in the context of its safeguarding strategy and delivery plan. There is an organisational culture such that all staff is aware of their personal responsibility to report concerns and to ensure that poor practice is identified and tackled. A2 For example, organisation s mission statement, strategy and business plans (as appropriate) *A3 There is demonstrable commitment at the internal board level (or equivalent) to safeguarding adults. This includes senior management representation on the SAB (Board members need to be sufficiently senior to commit resources and make strategic decisions) as well as demonstrable commitment to participation in any Safeguarding Adults Review (SAR) undertaken by the SAB. Governance arrangements make relevant connections to support identification of organisational concerns relevant to safeguarding (such as complaints and serious incident reviews). Page 17 of 28

19 The service has a system for reviewing alerts and referrals which is integrated with complaints and serious incidents reporting process and policy. The organisation recognises safeguarding as integral to quality and best practice and the relevant connections are made at all levels between related issues such as dignity in care; equality; balancing choice and safety. Relevant connections are made across a range of reviews (Child Serious Case Review; Domestic Homicide Review. Etc.). A3 For example, governance structure for quality assurance *A4 The organisation evidences candour and openness internally and in its relationship to the SAB. It evidences that it shares learning with partner organisations and internally (as appropriate), that it is transparent about its mistakes when they occur, and that it understands the importance of being open and transparent. It identifies challenges to this open culture and puts plans in place to addresses these (Identify, in the comments/ evidence sections, those challenges and how you intend to address these). A4 For example, policy for openness and candour *A5 The organisation ensures high quality legal advice is made available to staff on both safeguarding adults and the MCA/ Deprivation of Liberty Safeguards (DoLS) including making available to managers and staff regular updates from the Court of Protection. For some organisations a MCA designated lead will be desirable/ required (see for example Safeguarding Vulnerable People in the NHS Accountability and Assurance Framework (NHS England, Jul 2015, para 4.2.5) in respect of CCGs). A5 For example, legal updates/ newsletters for staff; role description designated lead Page 18 of 28

20 RAG Rating Camden SAPB Quality Assurance Framework v2.1 Effective From: October 2015 SECTION B: THE ORGANISATION S RESPONSIBILITIES TOWARDS ADULTS AT RISK ARE CLEAR FOR ALL STAFF AND FOR COMMISSIONED SERVICES The boxes within each section can be expanded to facilitate an answer however comprehensive or detailed it may be. B Discussion points/comments Evidence to support RAG rating Additional Action to ensure compliance and by whom Progress or date completed *B1 Organisational policies make reference to safeguarding adults, the MCA and Prevent. There are specific organisational policies and procedures in place reflecting your organisation s responsibility to safeguard and promote the wellbeing of adults at risk (linking safeguarding adults with the well-being principle, Care Act, section 1). These procedures reflect and cross refer to the Care and Support Statutory Guidance (DH, Oct 2014) (including the core principles set out in paragraph 14.13) and the London Multi Agency Safeguarding Adults Policy and Procedures (2015 draft). Organisational policies and procedures demonstrate that the principles of the MCA are central in safeguarding adults. They include clear lines of accountability, from an individual employee up to the most senior person in your organisation. They include reference to the importance of keeping accurate records as well as guidance to support staff in this. This in turn links in to the organisation s policy on sharing information B1 For example, organisational charts showing adult safeguarding accountability; copies of relevant policy and procedures *B2 Where services are (sub-)commissioned, agreements reflect the requirement between commissioners and providers to have regard to the need to safeguard, and promote the wellbeing of people who use services. Invitations to tender, contracts and contract monitoring reflect this and reflect relevant standards and regulations. There are explicit clauses that hold providers to account for preventing and dealing promptly and appropriately with abuse and neglect. B2 For example, contract templates. *B3 All commissioned services have contracts which require that services can demonstrate that the MCA is complied with, including the use of DoLS. Examples of how the application of the MCA is monitored and how contract monitoring addresses this. Findings are shared with the SAB. There is a strong advocate within the organisation for the MCA/ DoLS who ensures an emphasis on empowerment, autonomy as well as safety including the promotion of Advanced Decision Making. Page 19 of 28

21 B3 For example, contract clauses, contract templates. *B4 All NHS commissioned services are adhering to the NHS standard contract under service conditions 32 in relation to Prevent. For example an identified lead, training, and Channel Panel representation, where appropriate. All relevant organisations/ sectors identified under the Counter Terrorism and Security Act 2015 engage with Counter Terrorism Local Plans, including the duty on all local authority and public bodies to have due regard to the need to prevent people from being drawn into extremism or acts of Terrorism. B4 For example contract clauses and reference in policies/ procedures/ guidance. Training offered/ taken up. *B5 The organisation takes a broad view of what constitutes abuse and evidences learning and engagement with concerns/ issues established as being included under the safeguarding remit in the Care and Support Statutory Guidance (DH, Oct 2014) including: domestic violence; modern slavery; and self-neglect. This is reflected in the organisation s policy. The organisation also demonstrates that it takes steps to prevent abuse and neglect taking place. B5 Case Studies (optional) Please provide two case studies that reflect the application of the above: Case Study 1 For example, local safeguarding strategy/ policy; examples of steps taken in prevention of abuse/ neglect e.g. activity within Quality Surveillance Groups. Case Study 2 Page 20 of 28

22 RAG Rating Camden SAPB Quality Assurance Framework v2.1 Effective From: October 2015 SECTION C: THE ORGANISATION S APPROACH TO WORKFORCE ISSUES REFLECTS A COMMITMENT TO SAFEGUARDING AND PROMOTING THE WELLBEING OF ADULTS AT RISK The boxes within each section can be expanded to facilitate an answer however comprehensive or detailed it may be. C Discussion points/comments Evidence to support RAG rating Additional Action to ensure compliance and by whom Progress or date completed *C1 Your organisation has robust and safe recruitment procedures and practices in line with guidance from the SAB, Saville Recommendations and / or respected sources such as Skills for Care. This includes: policies on when to undertake checks and the level required with the Disclosure and Barring Service (DBS); the responsibility for all staff in relation to safeguarding and promoting wellbeing is stated within all job descriptions; professional standards in relation to safeguarding are underlined; induction standards include the need to ensure new staff are made aware of their responsibilities to safeguard adults at risk and promote wellbeing. C1 For example, HR policy on DBS checks. *C2 The organisation s staff supervision policy supports effective safeguarding. It recognises that skilled and knowledgeable supervision focused on outcomes for adults is critical in safeguarding work. Your organisation has a policy that sets out the frequency that employees in contact with adults at risk receive regular supervision and an appraisal. All staff has regular reviews of practice to ensure they improve over time and are competent to carry out their safeguarding responsibilities. Discussion on safeguarding issues is specifically facilitated in supervision so that staff feels able to raise concerns and are supported in their safeguarding role. C2 For example, supervision policy. *C3 All staff working with adults at risk should receive training appropriate to their role to ensure competence to meet the needs of adults at risk of harm and to respond to safeguarding concerns. It is the responsibility of each organisation to train its own staff. Requirements are set out in the Care and Support Statutory Guidance (DH, Oct 2014, para ff), which highlights the importance of training at all levels within the organisation and that this must be updated regularly to reflect best practice. This will include training on the MCA/ DoLS, as well as (where relevant) Prevent. Training will also embrace links with domestic violence, safeguarding children and equality and diversity issues. A framework to assess competency in safeguarding and the MCA is integrated into existing supervision and appraisal systems. Page 21 of 28

23 C3 For example, competency framework for safeguarding and its application. *C4 Your organisation has written guidance and procedures for handling complaints and allegations against staff and this is clearly accessible to staff. This includes a whistle-blowing policy and a culture that supports staff in raising concerns regarding safeguarding issues. It includes appropriate referral to the DBS and Disclosure and Barring updates. Your organisation has a code of conduct for staff working directly with adults at risk, concerning acceptable and unacceptable behaviour including discrimination and bullying. C4 For example, policy and procedure for complaints against staff *C5 Your organisation has identified in Prevent policies and procedures the process and procedure for managing Prevent concerns raised in relation to staff. Identifying how support for the staff member will be balanced with managing risks to patients and service users both during and following investigations. C5 *C6 Your organisation takes steps to ensure that information is obtained from staff about their experience of working in the service, including the practice of exit interviews. This information is used by the organisation to make improvements. (Note down in the comments/ evidence section key messages and improvements arising from this) C6 For example, policy on exit interviews. *C7 Opportunities for reflective practice enable staff to work confidently and competently with difficult and sensitive situations. C7 For example, HR guidance or policy that supports this. Page 22 of 28

24 RAG Rating Camden SAPB Quality Assurance Framework v2.1 Effective From: October 2015 SECTION D: EFFECTIVE INTER-AGENCY WORKING TO SAFEGUARD AND PROMOTE THE WELLBEING OF ADULTS AT RISK The boxes within each section can be expanded to facilitate an answer however comprehensive or detailed it may be. D Discussion points/comments Evidence to support RAG rating Additional Action to ensure compliance and by whom Progress or date completed *D1 Your organisation is represented at the SAB and/ or its sub-groups. Frequency and participation during attendance at SAB meetings and subgroup meetings is noted. The SAB representative reports back to the right level in the organisation ensuring that the broader organisation engages with the partnership and its objectives. D1 For example, a record of attendance at SAB meetings. *D2 The organisation evidences its engagement and transparency with the partnership in safeguarding adults: in appropriately complying with the London Multi Agency Safeguarding Adults Policy and Procedures (2015, draft) in recognising and reporting adult safeguarding concerns. It engages appropriately in multi-agency efforts to prevent and intervene in safeguarding concerns as (attendance at strategy meetings/ case conferences and finding effective outcomes). D2 For example, organisation s action plan and progress following a SAR. *D3 The organisation evidences that action plans from SARs and Domestic Homicide Reviews (DHRs) nationally and locally drive improvement internally and across the partnership. There is evidence that internal action plans/ learning (e.g. from Serious Incidents, SARs, DHRs and complaints) are shared with the Board to facilitate learning across the partnership. This will include triangulation of data that will inform decision making D3 For example, organisation s action plan and progress following a SAR. *D4 Good information sharing is at the heart of good safeguarding practice. This area is covered by legislation, principally the Data Protection Act Your organisation has policy/ procedure/ guidance setting out clearly the process and principles relating to sharing information across relevant agencies and this is consistent with the legislation. The policy/ procedure/ guidance is in line with the London Multi Agency Safeguarding Page 23 of 28

25 Adults Policy and Procedures (2015, draft) and the Care and Support Statutory Guidance (DH, Oct 2014). It takes account of available protocols/ guidance including: the local SAB information sharing agreement; the Pan London multi-agency sharing information protocol; the SCIE guidance on information sharing; and the seven principles on information sharing set out in Working Together to Safeguard Children. All relevant staff are trained in applying this including in the context of safeguarding adults. Local and national learning from serious case reviews/ SARs informs development and review of the policy/ procedure/ guidance. D4 For example, local information sharing agreement. *D5 Your organisation can demonstrate active engagement with raising alerts and multi-agency partnership working for Prevent, including supporting the Channel process and Prevent strategy groups to ensure individuals are supported and local issues and risks are addressed. D5 For example, a record of alerts raised for Prevent/ referrals to Channel panel. *D6 Your organisation has a focus on the need for preventing abuse and neglect. Measures are in place to minimise the circumstances which make adults vulnerable to abuse. Your organisation works together with other partners to implement quality assurance, robust risk identification and risk management processes in order to prevent concerns escalating to a point where intervention is required under safeguarding adults procedures. This includes commissioners working together to assure themselves of the quality and safety of the organisations they place contracts with. D6 Example, terms of reference of forums/ meetings with providers to improve quality of care. Page 24 of 28

26 RAG Rating Camden SAPB Quality Assurance Framework v2.1 Effective From: October 2015 SECTION E: ADDRESSING ISSUES OF DIVERSITY The boxes within each section can be expanded to facilitate an answer however comprehensive or detailed it may be. E Discussion points/comments Evidence to support RAG rating Additional Action to ensure compliance and by whom Progress or date completed *E1 Your organisation delivers in accordance the public sector Equality Duty. This is used to inform safeguarding strategy, including taking measures to promote equality and reduce inequalities in access to and outcomes from services. E1 For example, data/ information that shows the diversity of the population that access safeguarding services; safeguarding strategy measures address issues of equal access. Page 25 of 28

27 RAG Rating Camden SAPB Quality Assurance Framework v2.1 Effective From: October 2015 SECTION F: THE SERVICE CAN DEMONSTRATE THAT PEOPLE WHO USE SERVICES ARE INFORMED ABOUT SAFEGUARDING ADULTS AND EMPOWERED WITHIN THE ORGANISATION S RESPONSES TO IT The boxes within each section can be expanded to facilitate an answer however comprehensive or detailed it may be. F Discussion points/comments Evidence to support RAG rating Additional Action to ensure compliance and by whom Progress or date completed *F1 The principle of Making Safeguarding Personal is at the heart of the organisation s practice. Person-led and outcome-focused practice in safeguarding is demonstrated. Give examples of how this is demonstrated and the difference it makes. F1 For example, a brief case study *F2 The organisation demonstrates a clear working understanding and evidenced competence in applying the MCA and of the core principles within it. F2 For example, a brief case study. *F3 Your organisation has written information available to adults at risk and their families about safeguarding adults including who to contact if they are concerned about an adult at risk. Arrangements are in place to support those for whom English is not their first language. Information is provided in a range of formats and languages. F3 For example, samples of written information. *F4 Your organisation supports individuals to access their right to an independent advocate where an adult has substantial difficulty in being involved in the safeguarding process and they have no suitable representation or support. (Care and Support Statutory Guidance (DH, Oct 2014) paragraph 14.43). For example, data that shows number of referrals for an advocate Page 26 of 28

28 *F5 Your organisation takes steps to ensure that information is obtained from individuals who use your service about what outcomes they wish from the safeguarding process and whether they have received this. Their experience is recorded and the organisation learns from it. Individuals who use services and their carers/ families also influence and inform more broadly the development of the organisation s strategic approach to safeguarding and related agendas. (Note down in the comments/ evidence section key messages arising from engagement with service users, families, carers, public). F5 For example, a report that summarises what people who use safeguarding services have said. *F6 There is a strong patient/ service user outcome focus within the organisation s quality assurance process and its practice. F6 For example, local safeguarding strategy. Page 27 of 28

29 Appendix 2: Acknowledgements Camden SAPB would like to thank the Board members and Camden Council officers who contributed time and ideas as part of the 2014 Task and Finish Group that reviewed and developed this framework: Hira Bhanderi, Advice and Advocacy Manager, Age UK Camden Sarah Lui, Safeguarding Development Officer, Adult Social Care, Camden Council Althea Mitcham, Information Manager, Adult Social Care, Camden Council Shana Nessa, Outcomes Review Officer, Adult Social Care, Camden Council Rachel Nicholas, Safety Interventions Manager, Community Safety, Camden Council Denise Pittaway, Senior Policy Officer, Housing, Camden Council Lorraine Wiener, Safeguarding Manager, Camden and Islington NHS Mental Health Foundation Trust Helen Willetts, Head of Clinical Practice, Central and North West London NHS Foundation Trust Community Services (Camden) This QAF was developed with the help of similar frameworks shared with Camden SAPB in 2013 and 2015 by Camden Council adult social care and the independent chairs network. This included: Hampshire Safeguarding Adults Board (Nov 2014), Integrated Scorecard Hampshire Safeguarding Adults Board (Feb 2014), Organisational Safeguarding Audit Tool Hampshire Safeguarding Adults Board (Mar 2014), Quality Assurance Framework Independent chairs network (Apr 2013), A framework to support improving effectiveness of safeguarding adults' boards Leicester Safeguarding Adults Board (2014/15), Safeguarding Effectiveness Key Indicators Solihull Safeguarding Adults Board ( ), Quality Assurance Framework Solihull Safeguarding Adults Board, Audit of strategic and organisational arrangements to safeguard and promote the wellbeing of Adults at Risk West Midlands Safeguarding Adult Boards, Performance Framework It was also informed by tools and guidance publicly available on the internet from: London Borough of Barnet London Borough of Barking and Dagenham Southampton Safeguarding Adults Board. The quadrant model is an adaptation of an original model developed by Kalpna Chauhan, Performance and Improvement Manager at Camden Council. The audit tool was developed by NHS England and the London SAB chairs network Page 28 of 28