SAFEGUARDING ADULTS AND LEARNING DISABILITIES

Transcription

1 SAFEGUARDING ADULTS AND LEARNING DISABILITIES ANNUAL REPORT FOR 1 ST OCTOBER ST MARCH

2 Contents 1. Introduction 3 2. Sherwood Forest Hospitals NHS Foundation Trust 4 Safeguarding Adults Board Page 3. Serious Case Review (SCR) 5 4. Care Quality Commission (CQC) 6 5. Essence of Care Benchmark Vulnerable Adults Safety 6 6. Audit of Safeguarding policy 6 7. Training 7 8. Referrals for Safeguarding 8 9. Deprivation of Liberty Safeguards Learning Disability Update Conclusion Plans for the Next Year 13 Appendix 1 Safeguarding Work Plans 15 Appendix 2 Learning Disability work plan 17 2

3 1. Introduction Since the introduction of the safeguarding nurse role, an annual report has been presented to the Trust Board in October of each year. The last annual report was presented to the October 2011 Trust Board. To bring the reporting in line with the publication of other annual reports, it was agreed a safeguarding adults and learning disabilities annual report would be presented as soon as possible after the end of the financial year. This report covers a six month period (Oct 11-March 12). The 2012/13 annual report will be presented in 12 months time, with quarterly progress reports continuing via the Executive Director of Nursing Quality and Safety Trust Board Report. 1.1 National Context The No Secrets document published by the Department of Health in 2000 gave guidance to encourage agencies to work together, and for them to produce multi-ageny policies for the protection of vulnerable adults, providing a national framework of standards for good practice. No Secrets defined a vulnerable adult as a person aged 18 years or over who is, or may be, in need of community care services by reason of mental health or disability, age or illness, who is or may be unable to take care of him or herself, or unable to protect him or herself against significant harm or exploitation. Abuse was defined in No Secrets as the violation of an individual s human and civil rights by any other person or persons. No Secrets document was consulted on in From this review the Department of Health published four documents (March 2011):- Safeguarding Adults: The role of the Health Service Practitioners. Safeguarding Adults: The Role of Health Service Managers and their Boards Safeguarding Adults: The Role of NHS Commissioners Safeguarding Adults and the role of the Health Services. Analysis of the Impact on Equality The Government reforms put patients and the quality of their care at the heart of the NHS. The Government s commitment to patient choice, control and accountability includes support and protection for those in the most vulnerable situations. Health services have responsibilities for the safety and well being of all their patients. However, they have particular duties for those patients who are less able to protect themselves from harm, neglect or abuse, for example impaired mental capacity. Safeguarding Adults is an integral part of patient care. Duties to safeguard patients are required by professional regulators, service regulators and supported by law. 1.2 Safeguarding Adults is shaped into six principles:- 1. Empowerment - Presumption of person led decisions and consent 2. Protection - Support and representation for those in greatest need 3. Prevention - Prevention of harm and abuse is a primary objective 4. Proportionality - Proportionality and least intrusive response appropriate to the risk presented. 3

4 5. Partnerships - Local solutions through services working with communities 6. Accountability - Accountability and transparency in delivering safeguarding 1.3 Recurrent themes from high profile inquires Themes taken from: Death by Indifference Mencap 2007 Mid Staffordshire NHS foundation Trust public enquiry 2010 Care and compassion Health Service Ombudsman 2011 Patients are not empowered to make choices about their care and protection Patients voices are not heard Neglect and abuse arise in the absence of effective prevention and early warning systems. Neglect and abuse is not always recognised by healthcare staff. Lack of transparency and openness in investigation- incidents are not well managed through multi-agency procedures. Safeguarding Adults is seen as the responsibility of others. In 2012 Mencap updated their report Death by Indifference with the launch of Death by Indifference: 74 Deaths and Counting. The report looked at progress since the publication of the original report. It confirmed that although some positive steps have been taken in the NHS, many health care professionals are still failing to provide adequate care to people with learning disabilities. The common findings in this report were: Failure to meet basic care needs. (featured in 26 complaints) Poor communication between families and hospital staff. (featured in 24 complaints) Delays in diagnosis & starting treatment. (featured in 26 complaints) Failure to recognise pain. (featured in 11 complaints) Inappropriate use of Do Not Resuscitate orders (featured in 5 complaints) 2. Sherwood Forest Hospitals NHS Foundation Trust s Safeguarding Adults Board Nottinghamshire has a Multi-Agency Safeguarding Adults Board (NSAB). The aim of this board is to work in partnership to safeguard and promote the welfare of vulnerable adults in Nottinghamshire. The Executive Director of Nursing and Quality represents Sherwood Forest Hospitals NHS Foundation Trust at this Board. This board works to the Nottingham and Nottinghamshire Multi-Agency Safeguarding Adults policy. This document ensures a framework of consistency to protect those individuals in our society who are vulnerable. Sherwood Forest Hospitals NHS Foundation Trust (SFHFT) has a Safeguarding Adults Board chaired by the Executive Director of Nursing and Quality. This board supports a zero tolerance approach to abuse and neglect throughout the Trust. Vulnerable adults should enjoy the same rights as others in respect of access to care and treatment provided by public agencies. This board has produced a local policy to be used within the Trust in line with the Nottinghamshire policy. 4

5 The Board meets on a monthly basis; there is a multidisciplinary, multi-agency membership. There has been excellent attendance for the last six months. A Non Executive Director regularly attends the Board, supporting the safeguarding work. The Safeguarding Adults Board reports quarterly to the Clinical Governance Committee (which in turn reports to the Audit Committee) and yearly to the Nottinghamshire Safeguarding Adults Board. 2.1 The following outputs have been supported and driven by the Safeguarding Adults Board:- A second Safeguarding Nurse has been employed to support the community hospitals and the dementia ward. Production of an e-learning training package for Safeguarding Adults and a module on basic learning disability awareness to enable all staff to have increased access to training at a time that is convenient to them. A review of the self-assessment markers of good practice tool. This has been presented at the Nottinghamshire Safeguarding Adults Board. The East Midlands SHA has produced a self-assessment for healthcare organisations. The completed self-assessments are being used to benchmark safeguarding adults in the East Midlands. This document has been completed; a peer review has taken place and submitted. An assurance meeting has place with the Trust, PCT and SHA and an action plan produced which is monitored by the board. East Midlands SHA have produced a self assessment framework for learning disabilities. This assessment was completed for June A second Vulnerable Adults study day (three times a year) ran on the 23rd March This day is to raise awareness of the care needs of vulnerable adults admitted to and discharged from the Trust. The need for this training has been highlighted from safeguarding concerns raised. A proactive drive to increase Mental Capacity Act and Deprivation of Liberty training in light of the Care Quality Commission (CQC) concerns. Training was reported to be above 85% of relevant staff when the CQC visited in April An audit of the safeguarding policy which has led to a review of the safeguarding documentation. An audit of the staffs knowledge of the safeguarding policy and a change to training. 3. Serious Case Reviews (SCR)/ Domestic Homicide Reviews 3.1 There have been no newly initiated Independent management review s (IMR) for serious case reviews There have been five Domestic Homicide reviews commissioned in Nottinghamshire. The Trust has been approached for information in three: An Independent management review (IMR) of one case was requested. The Safeguarding Adult Advisor has completed this. There were no specific recommendations for the Trust to implement. The Trust was requested to give minimal information in the second no IMR was required. The Trust had no involvement in the third review. 5

6 4. Care Quality Commission (CQC) Following the Care Quality Commission (CQC) visit to the Trust in October 2011, a moderate concern was apportioned in relation to Outcome 2: Consent to Care and Treatment. Overall the CQC concluded that patients could not be confident that there were effective systems in place to ensure that assessments of capacity were undertaken when appropriate, to ensure that decisions were being made in the best interests of patients who lacked capacity. To ensure these concerns were addressed a number of actions were instigated: An external review of safeguarding and mental capacity documentation was undertaken by a senior nurse from Sheffield PCT. Based upon her recommendations more simplified documentation has been tested Additional training was undertaken, particularly with Emergency Admission Staff, Medial Staff and Dementia Ward Staff Two internal audits were commissioned to assess the reasons for the theory practice gap and to advise on new training methodology. An action plan has been formulated and many actions already addressed. Increased time as been allocated for safeguarding and MCA training at induction and mandatory training. Training methodology has moved from booklets to face to face scenario based teaching (based upon feedback from Medical Managers Forum). Since the new Safeguarding Nurse commenced in January she has concentrated on training staff in their wards and departments by working with them to relate MCA to their practice. This was because the main feedback during the CQC work was that staff did not feel confident or competent to undertake assessments and complete the paperwork, leading to referrals. 5. Essence of Care Benchmark Vulnerable Adults Safety This benchmark was audited in October 2010 and again in November Results from November 2011 indicated that 94% of all factors were of a high standard. However although all areas scored over 70% indicating no Trust action plan was necessary the bench mark leads have concerns that the questions did not give a true representation of what is happening in practice, particularly in light of the CQC findings. The bench mark leads are reviewing the questions to make adaptations and improve them. Further information is available in the bench mark report for the safety of vulnerable adults. 6. Audit of the safeguarding policy. The first audit of adherence to the Safeguarding Adults Policy was undertaken; there were some areas of good practice and areas for improvement mainly in the safeguarding documentation. This has been reviewed as part of the actions from the audit. 6

7 7. Training 7.1 Safeguarding training This takes place on: Orientation day Mandatory Update training day Medical Training sessions Ward/department based half hour training sessions take place. The number of staff trained during the reported period was: 1291 Mandatory: 1058 Face to Face: 233 Total percentage of staff trained: October % December % February % 7.2 Mental Capacity Act and Deprivation of Liberty training Training takes place on the: Nurse induction. Mandatory update training Medical Training sessions Ward/department based training. MCA e-learning training package. The number of staff trained during the reported period is: 1379 Mandatory 1058 Face to Face 281 E-learning: 40 Percentage of staff trained: October % December % February % The Mental Capacity Act states everyone working with and/or caring for an adult who may lack capacity to make a specific decision must comply with the act. Two Vulnerable adults days have taken place of which 72 staff attended, The days receive excellent evaluations as case scenarios are used to enable attendants to relate theory to practice. 7

8 8. Referrals for safeguarding Through the official safeguarding referral system to Adult Social Care and Health (ASCH), there have been 25 patients referred from Trust staff where safeguarding concerns were considered. Of the 25 referrals:- 21 were for older patients over the age of were for patients with a learning disability. 2 for patients with physical disabilities. The types of alleged abuse reported were: Type of abuse Number of Cases Outcome Physical Abuse 12 4 cases were substantiated (abuse did occur) 2 cases were not substantiated. 4 cases have no outcome currently available. 1 case is still being investigated 1 case was not taken forward as advised by the ASCH Financial Abuse 3 2 cases were substantiated (abuse did occur) 1 case was not taken forward as advised by ASCH. Neglect or acts of omission 10 2 cases were substantiated (abuse did occur) 4 cases were not substantiated. 2 cases have no outcome currently available. 2 cases was not taken forward as advised by ASCH 8.1 Number of safeguarding referrals by ward or department A&E Newark A&E KMH EAU Ward 36 Ward 51 Ward 52 Ward 53 Ward 31 Ward 22 Ward 21 Ward 24 Ward 12 OT 8

9 All these cases were referred to Adult Social Care and Health (ASCH). Since October the Safeguarding Adults team have been asked to review 110 patients, which have not necessitated referral to ASCH for Safeguarding. As a result of these referrals, actions taken by the Safeguarding Adult Advisor have been: To liaise with Adult Social Care and Health, community nurses and other health professionals to ensure they are aware of the issues in planning future care for the patient. Discussion with the PCT safeguarding lead re; patients admitted from Nursing Homes/Residential Homes. The PCT safeguarding lead visits the Care Homes. Discussing concerns with patients Advise on mental capacity, best interest and individual care planning. Advise on restraint/ restriction of patients and deprivation of liberties. 8.2 Safeguarding concerns against the Trust There have been four official safeguarding concerns reported where the Trust was the alleged perpetrator: One referral for sexual abuse: This was investigated but there was no evidence that the abuse happened Three referrals were made against the Trust for neglect: One regarding the discharge of a patient without the correct medical investigations carried out. This was investigated and lessons learnt by the individuals involved. One regarding medications not reviewed prior to discharge. This was investigated and lessons learnt by the individuals involved. One where a patient did not receive their essential medications, this was investigated and appropriate actions taken. 9. Deprivation of Liberty Safeguards The Deprivation of Liberty Safeguards came into effect in April Awareness training is included in MCA training sessions and within the e-learning package. There have been 2 referrals to the PCT for an authorisation between October 1 st 2011 and March 31 st The outcomes were:- One patient regained capacity so the process was stopped. One patient was deprived of their liberty until discharged. Although the referrals and training are continuing there is an increased awareness as clinical staffs are considering the Deprivation of Liberty Safeguards when discussing patients with the Safeguarding Adult Advisor. During 2012/13 we are planning to benchmark this referral number against other Trusts of the same size. 9

10 10. Learning Disability (LD) Update Referrals to Learning Disability Nurse Specialist During Q3 and Q4 there were 109 referrals received to the Learning Disability Nurse Specialist from SFH trust staff and community colleagues. Reasons for referrals were varied some reasons were Extra support required in hospital (1:1) Mental Capacity Act issues/concerns Management on ward/department Discharge concerns Communication support Planning for inpatient stay or out patient appointment (reasonable adjustments needed) This graph shows where referrals were received from; 45 were SFH staff and 64 were family carers or community workers Oct Nov Dec Jan Feb Mar Community Hospital This table shows the referrals received from the wards/areas Area Number of referrals Emergency Department 4 Emergency Assessment Unit 14 Ward 12 trauma/ortho 3 Ward 21 surgery 2 Ward 23 cardio 1 Ward 33 medicine 1 Ward 35 medicine 1 Ward 43 respiratory 3 Ward 44 respiratory 3 Ward 52 HCOP 2 Ward 53 stroke 1 Out patients 7 Site coordinator 1 Newark Hospital (wards) 2 10

11 This is consistent with information we know nationally; people with learning disabilities attend hospital via emergency routes hence more referrals made from emergency department and emergency assessment unit. Gender of people referred Oct Nov Dec Jan Feb Mar Male Female Unknown Age of patients referred Oct Nov Dec Jan Feb Mar over When a referral is received by the learning disability nurse specialist support may be given in different ways; advice on action needed by ward staff, liaison with the ward and community colleagues, reasonable adjustments to services. This next graph looks at some of the actions Flag HTLA RDSA 0 Oct Nov Dec Jan Feb Mar Flagging System This is an electronic alert that can be added to the Patient Administration System to alert ward staff to the patients Learning disability needs. This flag is mentioned to staff on training sessions and staff are signposted to the processes to be used in hospital. 11

12 Hospital Traffic Light Assessment This is a person centred communication tool that supports the ward staff to key information about the patient, how to support the patient and their likes and dislikes. Risk, Dependency & Support Assessment This is a tool used to identify the support needs of patients. It can support the case for providing additional staff support where there is a risk that ward staffing will prove inadequate to safely meet the needs of the patient Learning Disability Steering Group Sherwood Forest Hospitals NHS trust has a Learning Disability Steering Group which meets 4 times a year. The group consists of 3-4 service users, 2 carers, 1 public member, Heads of Nursing & departments. The group monitors the trusts Learning Disability work plan, inputs information for the self assessment framework which feeds into the Joint Strategic Needs Assessment. The trusts Learning Disability steering group also actions any issues highlighted from either local CHANGE/LINK groups or the Learning Disability partnership Board. The group has worked on the following during 2011/2012 Development of an easier read appointments letter; we are in the process of deciding at how this can be distributed. Part of the planning group looking at an adult changing places toilet in KMH Development of easier read patient survey Task and finish group work to make an alert card which will be passed to staff hospital staff to raise awareness of reasonable adjustments need, to look at making an information accessible to people with LD. Formulating an easy read Quality Account Document The learning disability steering group report to the Diversity and Inclusivity committee and Safeguarding Adult s board The Ambulance Service & Me East Midlands Ambulance Service (EMAS) have a learning disability forum. Sherwood Forest Foundation Trust Learning Disability steering group service users were involved in making a CD ROM and workbook with the EMAS forum for people with a LD. The aim of the project was to provide support for people with LD who might need to use an ambulance. The CD ROM provides information on when you might need an ambulance, how to call for an ambulance, what happens when an ambulance arrives and where you go once you enter the ambulance. This will be used to; promote health and wellbeing, discuss health problems and planning, aid understanding for use of emergency services and to help reduce high volume service users. The CD ROM was launched in December 2011; the packs were distributed to day services, community learning disability teams, assessment & treatment teams and to primary & secondary care teams across the region. 12

13 10.4 Learning Disability Awareness Training Training takes place on the: New Nurse and Health Care Assistant induction (face to face) Mandatory training programme (from April 2012, booklet & Quiz) E learning package being developed for 2012/2013 Induction programme October November 2011 No programme December 2011 No Programme January February 2012 No LD cover March Training figures will improve now it s on the mandatory programme and when the e- learning package is up and running Learning Disability Audit 11. Conclusion An audit is currently underway to look at the effectiveness of the role of the learning disability nurse specialist. This audit will review compliance with the Learning Disability Policy and Mental Capacity Act Policy for patients with a LD, the number of staff trained in Learning Disability awareness, the number of compliments, incidents and complaints received and the number of people flagged. A considerable amount of work has progressed throughout the six months, including the appointment of another safeguarding nurse. The profile for Safeguarding Adults has become high within the Trust particularly with the support of the CQC work. The Trust is currently compliant against Outcome 2, but is aware that a lot of work is required to sustain the momentum and ensure safeguarding, mental capacity assessment and the support for patients with learning disabilities is embedded. Over the last six months there has been a focus on embedding the mental capacity act into practice to ensure Trust staff have the knowledge so that vulnerable people who lack the capacity to consent to their care and treatment receive equality and best care. The two internal audits have enabled an understanding of the concerns and have helped to shape an action plan which will ensure the Trust remains compliant in both Outcome 2 and Outcome 7 (Safeguarding) 12. Plans for the next year. The main priorities for the next 12 months are:- To ensure the Trust is delivering all the markers of best practice as identified by the SHA self assessment. To link the safeguarding strategy with the harm-free care programme that is currently being scoped (i.e. medicines management, pressure ulcers, falls, VTE and UTI). To implement the Safeguarding and learning disability e- learning package. This will enable staff to have increased access to training. 13

14 To continue the rolling programme of training for the wards and departments, with a particular emphasis on MCA to ensure this is embedded in clinical practice. To ensure there is a greater awareness of Vulnerable Adults throughout the Trust To continue to develop relationships with the wider healthcare community, focusing on ensuring effective communication of vulnerable patients care needs. To complete a Provider Compliance Assessment document for Outcome 2 and 7 and test the CQC internal assessment process For the safeguarding work plan from October see appendix 1 For Learning Disability Work plan from October see appendix 2 Authors Jane Freezer Safeguarding Nurse Advisor Claire Henley Learning Disability Nurse Specialist Written for and Edited by Susan Bowler, Executive Director of Nursing and Quality 14

15 Appendix 1 Safeguarding Vulnerable Adults Work Plan 2011/12 Objective Action By whom Timescale Outcome/progress To improve training options for Safeguarding Adults To improve communication of care needs for people with Dementia To improve patient care for high volume service users. To ensure the relevant Trust staff receive Prevent training as part of the government s CONTEST strategy, which focuses on individuals who may be vulnerable to the threat of violent extremism and terrorism. To ensure the SFHFT Safeguarding Adults, MCA and DOL policy are in line with Nottinghamshire policies. To have a Trust safeguarding strategy for Children and Adults. To produce an e-learning training package in conjunction with Nottingham University Hospitals (NUH) To decide on and embed the use of a communication tool e.g. This is me To identify vulnerable patients who are high volume service users and develop care for these patients Safeguarding Adult Advisor to attend the training. To risk assess the Trust/Plan away forward. Jane Freezer March st meeting set up. Company agreed NUH IT system not compatible with the e learning platform E learning now being progressed for SFHFT. Jane Freezer/ Adele Bonsall. Julie Smith/ Jane Freezer Jane Freezer Jane Freezer/ Emergency Planning Team/ Human Resources. March 2012 June 2012 October 2011 December 2012 Being developed as part of Dementia Strategy Safeguarding Adult Advisor to attend meeting with PCT The training has been completed. Strategy agreed. To commence training at mandatory training with specific training for EAU and ED staff Policies to be updated Jane Freezer February 2012 Policies are in place. In the process of being updated. To develop a Trust safeguarding strategy for Children and Adults. Sue Spanswick / Jane Freezer December 2011 Completed 15

16 To assess the MCA is embedded in practice Audit of staff knowledge of Safeguarding To ensure the current safeguarding documentation is effective. To comply with the Care Quality Commission (CQC) Outcomes To have a Trust Domestic Violence policy, linking into Safeguarding Children and Adults policy. To improve communication links with MARRAC To improve communication of vulnerable patients care needs between agencies. Audit the use of MCA Audit method to be agreed and carried out. Audit Essence of Care Benchmark Review the use of the safeguarding documentation To ensure the relevant actions from the CQC action plan are completed To Develop a policy Domestic Violence policy To ensure the Trust is represented at MARRAC To work with the wider community to look at pathways for improvement. Jane Freezer/ Audit and Research team SFHFT Safeguarding Adults Board Jane Freezer/ Trust Safeguarding Adults Board Jane Freezer/ Claire Henley/ Trust s Safeguarding Adults Board September 2012 April 2012 September 2012 March 2012 and August 2012 Draft audit completed. Actions being agreed Audit completed. Actions being agreed Policy Audit completed Documentation being reviewed as part of actions. Actions implemented as part of CQC Action Plan. Currently formulating PCA and testing new assessment process (July 12) Julie Smith January 2012 Draft policy in progress Julie Smith December 2011 Domestic Violence nurse represents the Trust. Completed Jane Freezer January 2012 Attendance at ASCH. Regular meetings with social services in place. Cross district working in place. 16

17 Learning Disability Work Plan April 2012 Does the trust have a mechanism in place to identify and flag patients with a learning disability and a protocol to ensure that pathways of care are reasonably adjusted to meet the health needs of these patients. CQC Score 3 Action By whom Timescale Outcome/update LD alert on Patient administration system (PAS) Claire Henley Completed Implemented LD Recurrent Admission Patient Alert Alert sticker and proforma in Medical records for patients on PAS LD Policy and adjusted pathways to be implemented across the trust Data & Information sharing with others to populate LD PAS & RAPA Clinical coding needs to represent LD better (F819 currently) Flag to be added to system one whiteboard for ED & Outpatients Claire Henley Completed Implemented Claire Henley Completed Implemented Claire Henley Completed Implemented Marie McGahey (strategic LD HF lead & Public Health) December 2012 No further looking at process to share info at health appointment Cheryl Beardsley April 2012 Meeting to discuss Chris Dickens May 2012 In accordance with the disability equality duty of the disability discrimination act (2005), does the trust provide readily available comprehensive information (jointly designed and agreed by people with learning disabilities, representative local bodies and/or local advocacy organisations) to patients with learning disabilities about the following, Treatment options, Complaints procedure, Appointments, CQC 2 Score 3 Action By whom Timescale Outcome/update Intranet to signpost Claire Henley Completed Completed to easy health site Hospital Communication Book to be used across all sites Cheryl Beardsley Completed Completed Internet to link to the My health vision DVD Purchase a range of Easier read resources to be held in KMH library Steve Jardine Completed Completed Claire Henley & Gemma Del Toro Completed Completed Easier read PALS Sally Dore & Claire Completed Completed

18 leaflet Safeguarding Easier read leaflet Easier read Claire Henley & appointment letters Ann Gray to be implemented across the trust Task & finish group LD steering Group Feb 2013 to start accessible information project. (DVD, Leaflets) Does the trust have protocols in place to provide support for family carers who support patients with learning disabilities, including the provision of information regarding learning disabilities, relevant legislation and carer s rights? (To include mental capacity act 2007, disability discrimination act 1995 and the carers act 1995) CQC 3 Henley Jane Freezer Completed Completed September 2012 Process in place will be more robust on new system 18 Score 3 Action By whom Timescale Outcome/update Development of a carers best practice guide Sally Dore & Claire Henley October 2011 Draft copy developed. Training plan covering carer issues Carers leaflet to be completed LD policy guide to KMH staff role, carer s role. LD policy guide to KMH staff role, carer s role. Carers Group October 2011 Sally Dore undertaking training Carers Group October 2011 Completed Claire Henley October 2011 Completed Claire Henley October 2011 Completed Doe s the trust have protocols in place to routinely include training on learning disability awareness, relevant legislation (MCA, DDA, carers act) human rights, communication techniques, for working with people with learning disabilities and person centred approaches in staff development and/or induction programmes for all staff CC 4 Score 4 Action By whom Timescale Outcome/update LD awareness training on induction programme Claire Henley Monthly Ongoing Implemented Ward training on Risk assessment & pathway for getting additional support Extended LD awareness session (2.5 Hours) with patient support (twice yearly) LD awareness on Mandatory update programme Claire Henley January 2012 To discuss at PAG Claire Henley & Patient rep Ongoing Dates to be confirmed Claire Henley April 2012 Booklet & quiz completed

19 Develop a Elearning package for medic s, find funding for package Dementia & LD (downs) highlighted on trust training. Mental Capacity Act on induction, mandatory and elearning package. Claire Henley April mtg to look at first draft Julie Spizer February 2012 Completed Jane Freezer Completed Completed Does the trust have protocols in place to encourage representation of people with learning disabilities and their family carers within trust boards, local groups and other relevant forums, which seek to incorporate their views and interests in the planning and development of health services? CQC 5 Score 4 Action By whom Timescale Outcome/update Participation in the Big Health days feedback to inform trust Claire Henley Sally Dore June 2011 Completed Learning Disability Steering group to monitor work plan. Representation at Learning Disability Partnership Board Meetings, Better Health Group Meeting, Local CHANGE Group. Cheryl Beardsley Ongoing Last checked on Aug 2011 Next check May 2012 Claire Henley Ongoing Ongoing Does the trust have protocols in place to regularly audit its practices for patients with learning disabilities and to demonstrate the findings in routine public reports? CQC 6 Action By whom Timescale Outcome Essence of care benchmark audit Safety of Vulnerable Patients. Jane Freezer & Claire Henley Completed Nov 2011 Audit to be developed for LD policy Learning Disability Nurse Specialist Audit of role. Equality Act 2010 in place Score 4 To reaudit in March wards Claire Henley Dec 2011 Audit proposal agreed Dec 2011 and underway Claire Henley Starts Nov 2011 April 2011 Deborah Lister Completed Completed 19

20 (1) Protocols/mechanisms are not in place (2) Protocols/mechanisms are in place but have not yet been implemented (3) Protocols/mechanisms are in place but are only partially implemented (4) Protocols/mechanisms are in place and fully implemented 20