Think Family Safeguarding children safeguarding adults capacity and

Think Family Safeguarding children, safeguarding adults, capacity and consent Working together for a healthier Nottingham

Group agreement • Please listen to, and respect others, challenge statements not people • Confidentiality and accountability • Turn phone off or to silent • Issues discussed may be upsetting, please take ‘time out’ if you need to and … • Discuss any concerns with your manager, supervisor • Seek advice from safeguarding team Working together for a healthier Nottingham

Learning Outcomes Respond appropriately to actual or suspected abuse • Know what constitutes abuse • Aware of what happens when things go wrong • Appreciate that Values & Behaviours can prevent abuse • Recognise your individual responsibilities • Awareness of what information can be shared & with whom Understand consent and capacity • Be able to describe what consent is • Know who can consent Working together for a healthier Nottingham

Learning Outcomes • Be able to recognise a patient who lacks the capacity to consent to a decision • Know who can assess capacity • Understand how to make a ‘best interests’ decision • Know how to treat a patient who lacks capacity and is refusing treatment • Recognise your individual professional responsibilities • Know the 5 principles of the Mental Capacity Act (2005) Working together for a healthier Nottingham

What is think family structures are dynamic and varied far beyond those defined by blood relationships or partners. Family is often constituted by the individuals themselves and is unique to their diverse and individual needs, including class, culture, race, ethnicity, religion and sexuality. Whilst the nature of ‘Family’ will change, the importance of understanding how it impacts on the person and the interdependence of individual support and wellbeing remains vital. This understanding is not constrained by a legal definition of ‘family’. safeguarding is everybody’s business and has put measures in place to protect those least able to protect themselves. For the Trust, ‘Think Family’ means securing better outcomes for children, young people, adults and families by co-ordinating the support they receive from all services delivered by health services and their partners Working together for a healthier Nottingham

Scenario Jimmy is a four year old boy brought to the surgery by his mum Tracey. He has a scald to his chest and left arm. A history is given that he was in the care of mum and he spilt water from a kettle whilst making her a cup of tea. On speaking with the family the nurse note that Mum shows little understanding around the risks to a young child making hot drinks. Tracey is 30 weeks pregnant and when staff speak to her she is noted to have bruising to her face and arm. Tracey’s mum Stella has dementia and Tracey is finding it increasingly difficult to cope due to her increased confusion and challenging behaviour. Tracey is worried about her mum because she has lost a lot of weight and is refusing to eat Working together for a healthier Nottingham

Are you concerned? Pause and Think • What are you worried about? • We will now look at categories of abuse and then think about where Jimmy, Tracey & Stella may fit within these Working together for a healthier Nottingham

Categories of Abuse 1. 2. 3. 4. Physical Abuse Sexual Abuse Psychological (Emotional) Abuse Neglect Additional categories for adults § Financial § Modern slavery § Discriminatory abuse § Organisational abuse § Self neglect § Domestic violence Working together for a healthier Nottingham

Physical Abuse • • • Hitting/kicking/biting Strangling/suffocating Shaking Hair pulling Burning/scalding Poisoning Rough handling Unreasonable Restraint Fabricated or induced illness Working together for a healthier Nottingham

Sexual Abuse Forcing or enticing someone to take part in sexual activities, whether or not they are aware of what is happening. May involve; • • Rape/Sexual Assault Touching Teasing Language/Images Photography Exploitation Coercion Female genital mutiliation Working together for a healthier Nottingham

Psychological (Emotional) Abuse The persistent ill treatment of a person, causing severe and ongoing adverse effects. May include; • • • Bullying Intimidation Verbal Attacks Behaviour that effects the well being of the individual Coercion/exploitation Witness domestic abuse between carers Working together for a healthier Nottingham

Neglect A person’s well-being is being impaired and care needs are not met. Persistent failure to meet needs may result in impairment to health or development. May include; • • Nutrition/hydration Warmth/comfort Compassion/emotional wellbeing Timely and appropriate response to care needs Working together for a healthier Nottingham

Financial or Material Abuse • Theft • Fraud of • Exploitation Working together for a healthier Nottingham • • • Property Possessions Savings (& Income) Benefits Inheritance

Discriminatory Abuse Unequal treatment, lack of respect, forms of harassment, poor care or exclusion from services based on; • • Race Religion Age Gender Sexual Orientation Disability Culture Working together for a healthier Nottingham

Hate Crimes • According to Action on Elder abuse there are 500 000 victims of elder abuse each year. • There were 43, 748 hate crimes recorded by the police in 2011 to 2012, of which: • 35, 816 (82%) were race hate crimes • 1, 621 (4%) were religion hate crimes • 4, 252 (10%) were sexual orientation hate crimes • 1, 744 (4%) were disability hate crimes • 315 (1%) were transgender hate crimes Working together for a healthier Nottingham

Nottingham Figures 2011/2012 • • • Race - 542 Religon - 18 Sexual Orientation - 78 Disability - 42 Transgender - 0 Working together for a healthier Nottingham

Perpetrators • Perpetrators of abuse & neglect are often in a position of Trust eg family member or carer • Abuse has the potential to happen anywhere • Peoples own home • Care Homes • Hospitals • Day centre • Nursery Working together for a healthier Nottingham

Organisational Abuse • • • Repeated instances of poor care or neglect or poor professional practice in an institution such as a hospital or care home or care provided in a persons own home. May include: Poor professional practice and care Unprofessional medication practices Lack of privacy Lack of personal possessions Lack of choice and flexibility in daily routine (meals, bedtime etc) Sensory deprivation (hearing aids, spectacles, noise) Working together for a healthier Nottingham

Self neglect • This covers a wide range of behaviour such as neglecting to care for one’s personal hygiene, health or surrounding's and includes behaviour such as hoarding Working together for a healthier Nottingham

Domestic Violence • Domestic Violence is now a category of abuse identified in the Care Act 2014. • Significant proportion of safeguarding referrals are for people who are experiencing domestic abuse • These people are adults with care and support needs Working together for a healthier Nottingham

Scenario Tracey is asked about the bruising to her face and arm and becomes quite defensive. On direct questions about domestic abuse she becomes tearful and discloses that she has been experiencing violence and controlling behaviour from her partner Nigel. He is the father of the unborn baby but not Jimmy. Nigel, Tracey and Jimmy live together in a house which is a few doors away from her mums house. Stella’s dementia has declined rapidly and now lives in a Care Home. Working together for a healthier Nottingham

Disclosure of abuse Pause and Think • How should you respond to the information being shared with you? • What should be done with this information? Let’s have a look at what we can learn about these issues and what actions we should be taking… Working together for a healthier Nottingham

If you receive a disclosure of abuse • Remain calm • Listen carefully • Explain you need to share the information • Explain that further steps will be handled sensitively • Record what you have been told in patient’s words Working together for a healthier Nottingham

If you receive a disclosure of abuse • • • Working together for a healthier Nottingham DO NOT Stop or interrupt a story of significant events Ask questions or press for details Show signs of shock or disbelief Contact the alleged perpetrator Make promises you are unable to keep Be judgemental

Sources of stress that may impact upon families § Substance misuse and Alcohol/Drugs § Social exclusion § Severe financial difficulties § Homelessness § Mental illness § Disability § Domestic violence Working together for a healthier Nottingham

Domestic Abuse - definition Any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members, regardless of gender or sexuality. This can encompass psychological, physical, sexual, financial and emotional abuse. It also includes honour based violence, female genital mutilation and forced marriages Home office March 2013 Working together for a healthier Nottingham

Domestic abuse – what we know • • • Under reported / recorded , hidden crime. 1 in 4 women 1 in 6 men Half of gay and bisexual men 2 -3 women are killed per week 1 man killed every 17 days Risk increased when disclosing/wanting to leave relationship Increasing risk in teenagers Children witnessing domestic abuse suffer from emotional harm, and increased risk of neglect, physical and sexual abuse • 50% of disabled women will experience domestic abuse Working together for a healthier Nottingham

Scenario She shares that she is very frightened of Nigel, he is getting more violent and it is more frequent, he has tried to strangle her on three occasions, will not let her use her phone, has made threats to kill Jimmy and Stella and uses cannabis and excessive alcohol. He is currently on bail for assault of his brother. Tracey also discloses that she is self harming and thinking about suicide. She was using cannabis regularly before she found out she was pregnant and has now cut down her use. What can you do to help? . Working together for a healthier Nottingham

MARAC AIMS • Multi agency Risk Assessment Conference • Reduce the risk of serious harm or homicide • Increased safety, health and well being of the survivor and any children. • Share information about concerns • Actions – agencies attending are accountable for actions • Agencies support survivor Working together for a healthier Nottingham

Referral pathways • • Nottingham City patients Complete DASH form Fax to DART Sign post to services eg IRIS Project • Nottinghamshire County/out of area patients complete DASH form • Children’s social care referral to MASH or out of area social care • Sign post to services • Seek advice from manager and safeguarding team as required Working together for a healthier Nottingham

Drug and alcohol misuse • Effects in pregnancy on the unborn baby • Inconsistency in prioritising needs of child • Inappropriate expectations/roles placed on child • Reduced parenting ability whilst under the influence of a substance • Safety issues e. g. driving, supervision, and the child's access to drugs, alcohol or equipment • Financial impact - may lead to criminal activity Working together for a healthier Nottingham

Mental Health • May impact on a carer’s ability to respond to the needs of a child or adult • Can adversely affect the development, behaviour, emotional wellbeing and in some cases safety of children (approximately 6000 young people every year) • The majority of mentally ill parent’s/carer’s do not intentionally abuse …. however parenting/caring capacity and ensuring safety can potentially be compromised Working together for a healthier Nottingham

Pause and Think • Thinking about Jimmy and the unborn baby what else should happen to ensure their safety and wellbeing Working together for a healthier Nottingham

Action to take if worried about a child • • • Ensure safety of child Talk to patient, parents or carers if appropriate Discuss with manager Get advice and support from the Safeguarding Team Check if child protection plan/previous concern If suspicions remain, and Social Care thresholds met, you have a personal responsibility to inform Social Care/Police Provide, within 24 hours, a written referral Escalation procedure to follow if not in agreement with decisions made in partner agencies Attend Red Card meeting Share information as appropriate and in line with local policies Document clearly Working together for a healthier Nottingham

Scenario About a month later Stella has a visit from the Practice Nurse from the GP surgery. She is very dehydrated and has grade two pressure ulcers to her sacrum and both heels. Her clothes are quite dirty and she has dirt under her finger nails. She also has what look like fingertip bruising to both arms Are you concerned and if so why –discuss in your groups. Working together for a healthier Nottingham

Are you concerned? Pause and Think • What are you worried about? • Think back to the categories of abuse, where does Stella fit within these? • What should you do? Working together for a healthier Nottingham

Documentation and Information Sharing Pause and Think Consider the family we have been discussing and think about the following; • What needs to be documented and where? • What is relevant information? • Who should you disclose information to? Working together for a healthier Nottingham

Documentation and Information Sharing : Key Principles • Document concerns, observations, disclosures and action taken – remember to sign, print name, date and time • For children if referral made to social care confirm in writing- copy in medical records, to safeguarding team, GP/HV/CMW as needed • Information disclosed belongs to the agency (not to the individual staff member) • Consent is not needed to share if protecting a child, vulnerable adult or public interest • Information should not be shared any more widely than is necessary to ensure safety and wellbeing Working together for a healthier Nottingham

Scenario The Nurse contacts the GP and they wants to admit Stella to hospital but: Whilst in the home Stella has become increasingly confused and is refusing to go into hospital. She does not appear to understand what is happening to her or the concerns for her well being; despite all efforts by medical and nursing staff to explain their concerns. Staff are have concerns about Stella’s ability to consent to or refuse care and treatment. Working together for a healthier Nottingham

Stop and Think • What is consent? Working together for a healthier Nottingham

Stop and Think • What has to be in place for a person to give consent? Working together for a healthier Nottingham

When do you need to get consent from a patient? • For everything Working together for a healthier Nottingham

Types of Consent? • Implied • Verbal • written Working together for a healthier Nottingham

What happens when a patient is unable to give consent? • This may be because they lack capacity to consent in this situation we need alternative lawful authority to provide care and treatment. Which is provided by The Mental Capacity Act Working together for a healthier Nottingham

There are many reasons why someone may lack capacity including: • • A stroke or brain injury Dementia A learning disability Confusion, drowsiness or unconsciousness because of an illness or the treatment of it • Chronic or acute Alcohol/ Drug abuse • A mental health problem Working together for a healthier Nottingham

When is it that someone lacks capacity to consent? 2 s If you have any doubts that the patient is able to: tag – Understand e te st o – Retain f ca pac – Weigh up ity – Communicate Working together for a healthier Nottingham

Who can assess capacity? Anyone working with and/or caring for someone who may lack capacity to make decisions – – – – Health. Care Assistants Nurses/Midwives Occupational Therapists Physiotherapists Doctors Radiographers Speech and Language Therapists etc Working together for a healthier Nottingham

Independent Mental Capacity Advocate (IMCA) • They are to help vulnerable adults who do not have family or friends that it would be appropriate to consult with when: • When making decisions about serious medical treatment or and changes to their accommodation • They will support the person and represent their views. • IMCA’s have the right to see relevant health & social care records Working together for a healthier Nottingham

What do I document? 1. What is the decision to be made 2. Reason for stages I (diagnosis) and 2 3. What you have considered & with whom 4. What your propose to do e. g. Stella’s Care plan could say: ‘Stella has a diagnosis of Alzheimer's. She is unable to understand her medication needs. After consultation with medical staff about the medication Stella requires and after discussions with the pharmacist and family. Nursing staff at the home will administer Stella’s medication covertly. Working together for a healthier Nottingham

Scenario Stella is very confused and is constantly calling out and looking for Tracey. She paces the home and has become increasingly aggressive and has hit carers and other residents. She has had a number of un witnessed falls at the home and in order to keep her safe she has a member of staff assigned to her on 1 -2 -1 basis throughout the day and is checked hourly at night. Working together for a healthier Nottingham

Restraint and restrictions Pause and think • What should we consider when thinking about Stella? • What might need to happen next? Working together for a healthier Nottingham

Restraint and restrictions can be used if……. • The person lacks capacity (properly assessed) • The restraint is necessary to protect them from harm or permit ‘best interests’ treatment • The restraint must be proportionate Working together for a healthier Nottingham

Restraint and restrictions Physical- Physically holding, moving or blocking a patients movement Mechanical- involves use of equipment, mittens, bed rails, using furniture to stop someone from getting up from a chair Technological- tagging, pressure pads, CCTV, door alarms. Chemical- using medications to restrain. Psychological – constantly telling someone to sit down Working together for a healthier Nottingham

Serious Case Reviews and Domestic Homicide Reviews • http: //nottinghamcity. gov. uk/ncaspb • http: //www. nottinghamcity. gov. uk/ncscb • http: //www. nottinghamcdp. com/ Working together for a healthier Nottingham

Deprivation of Liberty Safeguards (2009) • Amendment to MCA following Bournewood Case • If a patient is subject to restraints and restrictions which are frequent, cumulative and ongoing may need to consider Do. LS • Do. LS process provides external scrutiny of restraints and restrictions of movement Working together for a healthier Nottingham

DOLS- post Cheshire West • The person is admitted to an acute trust inpatient setting. • The person lacks capacity to consent to their stay in hospital. • The person is under continuous supervisions and control AND is not free to leave. • Contact Safeguarding Adults Team- 61627/ 07812268216 Working together for a healthier Nottingham

Contact details for referrals: • Nottingham City Adult Social Care: Single Point of Access Tel: 0300 3333 • Nottinghamshire County Multi Agency Hub (MASH) Tel: 0300 500 8090 Safeguarding Service Clifton Cornerstone Tel: 01158786403 Out of Hours Tel: 07973 451097 • Nottingham City Safeguarding children; Tel: 0115 876 4800 Nottinghamshire County Multi Agency Hub (MASH) Tel: 0300 500 8090 Working together for a healthier Nottingham • See intranet pages for further information and policies/guidelines

CCG Contacts • Adult Safeguarding • Bella Furse, Designated Adult Safeguarding Manager Tel 9249924 ext, 61627 • Rhonda Christian, safeguarding Adults Practitioner Tel: 8839205 • Childrens Safeguarding • Sandra Morrell, Designated Nurse Tel, 8839472 • Alyson Packham Associate Designated Nurse Tel, 9249924 ext, 62990 • Tina Hymas Taylor Associate Designated Nurse Tel, 9249924 ext, 62990 • Caroline Brown & Damian Wood Designated Doctors Tel, 9249924 ext 62990 Working together for a healthier Nottingham