TOWER HAMLETS GP SAFEGUARDING HANDBOOK
Improving Standards
Dr. Dimple Varma
Previous named GP for Safeguarding Children, NHS Tower Hamlets
Updated by Dr Emma Tukmachi (December 2013)
Named GP for Safeguarding Children, NHS Tower Hamlets
Revisions made by Dr Rebecca Scott (May 2014)
Named GP for Safeguarding Children, NHS Tower Hamlets
April 2014
Version 1.4

TOWER HAMLETS GP SAFEGUARDING HANDBOOK
INTRODUCTION
This Handbook has been produced with the aim of providing support and information for Practice Safeguarding Leads in Tower Hamlets. Guidance on best practice with regards to clinical and administrative procedures has been provided, in line with published evidence and guidance from local and national Serious Case Reviews.
Acknowledgments from Dr Dimple Varma
I would like to express my sincere thanks to all members of the Safeguarding
Children Committee, Dr. Phillip Bennett-Richards and the Primary Care Directorate at NHS Tower Hamlets who have provided me with valuable contributions, advice and editing of this document.
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK
ROLES & RESPONSIBILITIES OF PRACTICE LEADS FOR SAFEGUARDING
CHILDREN ....................................................................................................... 4
ADVICE WHEN CHILDREN JOIN THE PRACTICE ................................................ 6
EMPLOYMENT ................................................................................................ 8
RECORD KEEPING .......................................................................................... 10
COMMUNICATION ........................................................................................ 13
STAFF TRAINING & DEVELOPMENT ............................................................... 15
MAKING A REFERRAL .................................................................................... 20
SAFEGUARDING CHILDREN AND DOMESTIC ABUSE .................................... 233
FABRICATED OR INDUCED ILLNESS ............................................................. 244
CHILDREN NOT IN THE EDUCTION SYSTEM ................................................. 244
CHILDREN WHO PRESENT AT HEALTH SETTINGS WHO HAVE RUN AWAY
FROM HOME OR A LOCAL AUTHORITY CARE HOME ................................... 244
RESTRAINT POLICY ALSO KNOWN AS POSITIVE HANDLING POLICY ............. 255
EARLY HELP AND TOWER HAMLETS FAMILY WELLBEING MODEL ............... 256
CHILDREN SUBJECT TO STATUTORY REQUIREMENTS .................................. 277
THE COMMON ASSESSMENT FRAMEWORK (CAF) ...................................... 288
SHARING INFORMATION ............................................................................. 288
CASE CONFERENCES ..................................................................................... 31
APPENDIX A: WHAT IS PARENTAL
RESPONSIBILITY?31.......................................32
APPENDIX B: RECOMMENDED SAFEGUARDING READ CODES FOR USE IN
PRIMARY CARE
RECORDS……………………………………………………………………………333
APPENDIX C: CHILD CONCERN REPORTING FORM………………………………………36
APPENDIX D: NETWORK CHECK: REQUEST FOR INFORMATION ………………...38
APPENDIX E: USEFUL WEBSITES………………………………………………………………… 39
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK
The Practice Lead for Safeguarding Children in each general practice will have an important role in ensuring there is an agreed standard of safeguarding children processes within each practice which will reduce risks to their registered child population. Good practice in Safeguarding will involve development of robust administrative and clinical procedures and routines.
We recommend that each Practice Safeguarding Lead:

Acts as a point of contact for external agencies on Safeguarding/Child protection matters

Disseminates safeguarding/child protection information to all practice members

Acts as a point of contact for practice members to bring any concerns that they have and record it

Is aware of all safeguarding issues and queries within the practice. This does not necessarily mean he/she deals with every child protection case as this is best dealt with by the usual doctor/nurse but the Practice Lead will have been informed of the case and will be able to oversee and advise

Ensures that practice colleagues receive adequate support and supervision when dealing with child protection

Ensures that the practice is aware of and has due regard of the contractual and clinical governance guidance on safeguarding children/child protection

Ensures that the practice team completes incident forms and analysis of significant events

Ensures that preventative measures are in effect such as recruitment procedures

Has a proactive approach to determine training needs, administering and delivering additional training for colleagues in the practice

Undertakes regular review of current policies or operating procedures and make recommendations for change or improvements as necessary

Ensures a detailed log is kept of all child or staff protection issues, even if at the time no further action is deemed necessary
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK

Ensures that medical records of those families with safeguarding issues are kept updated and reviewed on a regular basis

To work collaboratively with the Named GP for Safeguarding Children including providing information to facilitate training opportunities and identify areas for practice improvement
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Advice when children join the
Practice

All children that are registered with the practice should ideally have an adult with parental responsibility (see Appendix A ) registered with them.

A child registration should NOT be declined if there is no one with parental responsibility who can register
– it is generally safer to register first and then seek advice from the Practice Safeguarding Lead/ Practice Manager. This situation may alert you to a private fostering arrangement.

Children who are in a private fostering arrangement are more vulnerable to abuse . All private foster carers who look after a child for longer than 28 days need to be formally assessed for suitability by Children’s Social Care and need to be referred to them 1 .

There is no requirement to confirm the identity of people wanting to register with a practice. Practices cannot turn people away if they do not have sufficient ID evidence available, for purposes of safeguarding children, it is important that every effort is made to confirm the identity of those registering the child and their relationship to that child 2 .
 As much information as possible about the child’s household should be collected at registration. Adults and older adolescents living with the child have an impact on the care of the child. This can be in a positive way by providing support and resources or in a negative way, if they pose a threat to the safety of the child 3

Knowledge of where the child attends school is useful when informationsharing is required, and to know that a child is registered at a school.

The health visitor should be informed of all newly registered children 5 years and below.
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Advice when children join the
Practice
KEY PRACTICE GUIDANCE

When adults register at the practice, it is important to routinely ask about dependants, including children and any caring responsibilities.

When children or adults register elsewhere, it is advisable to check whether there are children at this address who remain registered. If still registered then this information should be flagged and passed to the attention of the Practice
Safeguarding Lead.

Information collected at the time of registration should include as much detail as possible about all members of the household.

When registering, the address of the household should ideally match exactly.
This will allow all members of the household to appear together when electronically searched.
 The child’s school (if school age) should be recorded on the electronic record: this can help to facilitate quicker identification of allocated school nurses

The linked Health Visitor should be informed of all children registered who are
5 years and below.
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Employment
Practices should have robust recruitment and vetting procedures in place for all staff working with children or who handle information about children, in line with the NHS
Employment Check Standards 4 and other national and local guidance. The NHS
Employment Check Standards cover the following areas:






Verification of identity checks
Right to work checks
Registration and qualification checks
Employment history and reference checks
Criminal record checks
Occupational health checks
Recruitment and vetting procedures should apply to all staff working at practices whether permanent staff, staff on fixed-term contracts, temporary staff, volunteers, students, trainees, contractors and highly mobile staff employed through an agency
(locums).
The recommended minimum for clinical and administrative staff includes: -
1. Appropriate level of Criminal Records Bureau screen as outlined in the NHS
Employers publication on Criminal Record Checks July 2010.
2. Two references (followed up).
3. Proof of identity- primary identification requires photographic identification e.g. current UK, EU and other nationalities passport (UK or overseas), UK Birth
Certificate, marriage and civil partnership certificate if there has been a name change.
4. For clinical staff, proof of registration and where appropriate, indemnity cover.
It is the responsibility of the Practice to ensure that patients and their medical records are safe.
It is anticipated that the Care Quality Commission requirements will identify standards related to employment.
Levels of disclosure/ types of CRB checks
A CRB check is required for jobs defined as ‘regulated positions’ by the Criminal
Justice and Court Services Act 2000. A Standard Disclosure is required for posts that have regular contact with children or vulnerable adults. An Enhanced Disclosure is for posts involving greater contact with children or vulnerable adults.
Standard disclosures show all convictions held on the police national computer, including spent convictions, together with cautions, reprimands or final warnings held
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Employment on that computer. For work with children, it includes checks on the Department of
Health and Department for Education and skills lists of people who should not work with children. Standard Disclosures are needed where there is such regular contact, but the job does not involve directly working with, caring for, or supervising children or vulnerable adults – such as a job as a domestic, catering or maintenance worker.
Enhanced Disclosures contain all the information provided by a Standard
Disclosure, but also include information held on local police records which the police consider relevant to the post to be held. Like Standard Disclosures, they relate to a specific job or role only. An Enhanced Disclosure is required for jobs which involve regularly caring for, training, supervising, or being in sole charge of children or vulnerable adults.

For staff who do not meet the criteria for standard or enhanced disclosure, a basic disclosure is required.

For those working consistently with children and young people it is considered good practice to recheck every 3 years . However this remains an organisational decision 4 .

It is important to discuss any disclosures as a result of CRB checks at a
Practice level. Where there is any concern about safeguarding, sharing of information with appropriate bodies is advisable.

Any gaps in employment history should be checked and accounted for, qualifications checked and references are verified and properly recorded in staff files. It is important that practices which employ people to work with children and the vulnerable adopt safe recruitment procedures which help to deter, reject or identify people who might abuse the vulnerable.

Employment checks also apply to GP locums who should also have up to date Enhanced CRB disclosure. This can be confirmed with the registered
Performers’ List.

It is the responsibility of external contractors to CRB check their staff. It is advisable to seek confirmation of this with the contractor.
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Record Keeping

All clinicians should be aware of good practice in comprehensive and accurate record-keeping.
5

Many serious case reviews recommend better record-keeping.

When dealing with safeguarding issues, clear, accurate, comprehensive and contemporaneous notes are essential. Where action is required, one should include a plan of care identifying who has responsibility.
 Concerns about a child’s welfare should always be recorded whether or not further action is taken.

A comprehensive and accurate record will help practitioners when the patient’s care is scrutinised for whatever reason. Any discussions about a child’s welfare should be recorded including telephone conversations, any decisions that are made, and the reasons behind the decisions.

Notes should clearly show the difference between information given by the child or carers, your own direct observations, and any subsequent interpretation or assessment of the situation.

Information should be included in the medical records about any adult in contact with a child with a risk factor for child abuse. For example the presence of severe long-term mental illness, drug and alcohol dependence, domestic violence, or a forensic history should alert the clinician to enquire about dependent children in the household.

In addition, when a A&E letter about a child is received particularly if it is about an injury, untoward event or a DNA letter from the Paediatrics
Outpatients, it is goo d practice to review the child’s record for safeguarding issues.

Sharing such information within the team is also advisable e.g. Health Visitors for under 5’s.

When children have been referred to social services for safeguarding concerns, notification that the referral has been received should be scanned into the child / affected children
’s record.
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Record Keeping
KEY PRACTICE GUIDANCE

All relevant practice staff should know the recommended list of Safeguarding
Children READ codes (see Appendix B ) and use it consistently. This will ensure the Practice develops a register of vulnerable families.

The Practice Safeguarding Lead should review all records with Safeguarding
Children READ codes regularly to review safeguarding issues. Child health clinics are a good opportunity to review cases with safeguarding concerns where the whole team is present and concerns and plans for the family can be discussed. It is important to follow up on any children who have been referred to social services and a multi-disciplinary approach is very useful for this.

The relationship and identity of any accompanying person with the child in a consultation should be recorded 6 .

Any adult with parental responsibility giving consent for immunisations, procedures or intimate examinations in a consultation should be recorded, to include their name and relationship to the child 7 .

The full set of case conference reports should be scanned into all affected children’s records and parents’ or carers’ records, under appropriate READ codes. These reports should be printed out from the electronic record and included in the paper records when notes are transferred to the new practice 8 .

The Practice should have a method of identifying records in which there are case conference reports as there will be third party information present which will need to be removed in the event that the record is requested by the patient. This process should be helped by using recommended Safeguarding
READ codes.

The Practice should have a DNA policy which sets out a method of highlighting letters which indicate a child has not attended (DNA) for specialist review, immunisations or other follow-up and have a system of follow-up 9 .

The Practice should have a method of highlighting A&E attendances of children which may be of significance for safeguarding, and a system of follow-up and communication with the Health Visiting team for children below
5.
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Record Keeping
Recording Case Conference Minutes in General Practice Records 10
Scan in full minutes a
Scan in a summary
Read code significant details
Date of destruction of entered information b
(if available)
Child(ren)
Other children
Yes
No c
Yes
Yes
Yes
Yes
Full minutes and summary at age 26, but read coding to remain in medical record
(‘Connected’ but not subject of conference)
Adults report named in No c Yes Yes Full minutes and summary when
‘index’ child reaches
26, but read coding to remain in medical record a destroy the hard copy once it has been scanned in
– do not store separately b in line with Records Management: NHS Code of Practice Part 2 Annex D1 p11 c note sufficient social care case number and contact details in the electronic record, so that original full report could be requested from sender if required
N.B. The above guidance on destroying of scanned in case conference notes is a recommendation.
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TOWER HAMLETS GP SAFEGARDING HANDBOOK: Communication/Information
Sharing
GPs have a statutory duty to co-operate with other agencies if there are concerns about a child’s safety or welfare 11 .
Many serious case reviews recommend improved communication between and within agencies 12 . Sharing information is vital to build up a picture of a child and family and this is necessary in order to support a family as well as safeguard the child.
Verbal communication is as important as written communication but all conversations should be recorded carefully in the medical records afterwards.
The principles of information sharing with relation to the Data Protection Act 13 will aid practitioners in deciding when and how to share relevant information 14 .
KEY PRACTICE GUIDANCE

The practice should have a policy on handling requests to share information on vulnerable children from external agencies. Requests from Social Services should be given to the practice in writing.

The Practice is represented at case conferences concerning children registered with them. Practices are often represented by attached Health
Visitors. If unable to attend, the GP would send a report (even if this is to report that the Practice holds no relevant information). Where the GP is unable to attend, a telephone or face to face discussion between the GP and
Health Visitor should also be recorded.
 All clinical staff are aware of how and when to refer to Children’s Social Care and when to expect feedback from their referral 15 .
At present, the current route of communication is via the CAF form (agreed with the family). A new, hopefully more user-friendly CAF may be developed in the near future. Urgent child protection referrals will need to be phoned
( see Safeguarding Contact Sheet – Useful Numbers ) and followed by a written referral ( see: When to Refer ).

The Practice informs their practice population of their information sharing policy with regards to Safeguarding Children.

Where there are concerns, it is considered good practice to alert the Out of
Hours Services of children who are at risk so that they are aware of the situation and update this information as required.

The Practice should meet with their linked Health Visitor to discuss vulnerable families. Recommendations have been that they should be a
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TOWER HAMLETS GP SAFEGARDING HANDBOOK: Communication/Information
Sharing minimum of every 6 weeks 16 . More frequent communication should occur depending on clinical concern. GPs should have systems in place for sharing information regularly with health visitors about at-risk children.
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Staff training & development
All doctors and other practice staff working with children, parents and other adults in contact with children should be able to recognize, and know how to act upon, signs that a child may be at risk of abuse or neglect, both in a home environment and in residential and other institutions 17, 18 .
All new members of staff should complete the requisite level of safeguarding training as organised by NHS Tower Hamlets*.
Practices should address child protection procedures in their induction programmes for new staff including locum staff. Current staff members should ensure that updates are completed within the recommended time frame.
Mandatory
Safeguarding training
Duration Staff group Mandatory
Updates
Level 1 90 mins Staff working in a non public facing role
Every 3 years
Level 2 3 hours All clinical staff that have any contact with parents, children and young people
(incorporates Level 1 training)
Every 3 years
Level 3 3 hours All staff working predominantly with children, young people and parents including all GPs.
(N.B. Need to have completed level 3 training within 3 months of completing Level 2).
Every 3 years
* Accreditation of previous safeguarding children training:
If a new member of staff has attended safeguarding children training within the last 3 years within another organisation and are able to demonstrate that they have met the required safeguarding competencies commensurate to their role, the practice Safeguarding Lead should contact the Safeguarding
Children Team to discuss whether it is necessary for that member of staff to attend the mandatory course before the update/refresher is due.
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Staff training & development
Dates and details of training requirements can be found from

Ekramul Hoque ( ekramul.hoque@nhs.net
),

on the Safeguarding Training pages in the Education section on the GP intranet http://gp.towerhamletsccg.nhs.uk/education.htm

or by emailing Rebecca Scott r.scott2@nhs.net
Inter-agency Training
Interagency training should complement single agency training. Training delivered on an inter-agency basis is a highly effective way of promoting a common and shared understanding of the respective roles and responsibilities of different professionals and contributes to effective working relationships 19 .
There are a range of different inter-agency training courses at Level 2 and 3 which are co-ordinated by the Local Safeguarding Children Board (LSCB)
Training & Workforce Development Subgroup. They can be accessed free of charge to staff working within NHS Tower Hamlets, Tower Hamlets
Community Health Services once required single agency training has been done
Multi agency courses run by the LSCB Include:

Domestic Abuse: Introduction and Advanced

Safeguarding Children & Young People from being exploited on the
Internet

Working with Bangladeshi Children and Families

Safeguarding African Children and Families

Impact of Parents with Mental Health Problems and Safeguarding
Children

Working with Resistant / Reluctant Parents & Carers
For further information regarding the course availability, dates, target groups and how to book a place, please refer to the Tower Hamlets LSCB Interagency training brochure on their website : http://www.childrenandfamiliestrust.co.uk/the-lscb/training/
Safeguarding Updates
All staff will be expected to attend the requisite level of training every three years. In addition to attending mandatory updates, subject specific training/awareness sessions and face to face training will be offered at frequent intervals throughout the year by the Safeguarding team.
The Safeguarding Children Team will also provide information regarding any changes in legislation, policy and practice.
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Staff training & development
SUPERVISION
The safeguarding team are delivering supervision sessions on a lap basis every 3-4 months.
However, if you have individual concerns please call for further advice:
Designated Doctor for child protection: Dr Owen Hanmer / On call doctor Tel:
0208 9803510
Designated Nurse for child protection: Rob Mills Tel: 02036882501, mobile
07951 489421
Non urgent advice by email (can take up to 5 working days for a response) julia.moody@nhs.net
The LSCB (local safeguarding children’s board) e-learning modules include:

Introduction to The Common Assessment Framework

Information Sharing

Integrated Working

Safeguarding Children

Working with Parents

Introduction and overview of the Family Wellbeing Model. www.childrenandfamiliestrust.co.uk/family-wellbeing-model/training-andfurther-support/ e-Learning for Healthcare (e-LfH) e-LfH is a Department of Health Programme for the training of the NHS workforce. Its e-learning resource, Safeguarding Children and Young People was developed by the Royal College of Paediatrics and Child Health
(RCPCH) in partnership with e-LfH and is free to health and social care professionals. The programme covers national levels 1,2 &3 for safeguarding children but this has to be supplemented by face to face teaching sessions. http://e-lfh.org.uk/
Child Protection in Practice
Child Protection in Practice is an e-learning programme designed by the
Royal College of Paediatrics and Child Health (RCPCH), the NSPCC and the
Advanced Life Support Group (ALSG).
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Staff training & development
It provides trainees with competencies required for on-going child protection practice. There are facilitated online discussion forums for some topics so that trainees can share experiences with peers and with senior colleagues.
The programme is only available to RCPCH members that are registered on the site, and so has not been quality assured by the Safeguarding Children
Team. http://www.alsg.org/uk/CPiP
Safer recruitment e-learning for people in the wider children and young people's workforce
This module has been developed by the Children’s Workforce Development
Council and is aimed at anyone recruiting people to work with children and young people, in the public, private or voluntary sectors.
The safer recruitment training is required to ensure that correct decisions are made during the recruitment process to ensure that unsuitable people are not given the opportunity to access children and young people. http://www.cwdcouncil.org.uk/safeguarding/safer-recruitment
Child Protection Awareness in Health
Child Protection Awareness in Health is available through the National
Learning Management System (NLMS) that is available to all NHS staff with a record on ESR.
Their programmes are funded by Strategic Health Authorities and are free for NHS staff. Registration that involves giving an NHS work email address is required.
This course is an online tutorial comprising four modules with each module taking approximately 10 minutes to complete.
The Safeguarding Children Team has quality assured the course as suitable for corporate induction, have prepared a guide to its use and undertake to provide certificates to staff that complete the course. The course and guide are signposted in the Safeguarding Children Team project site on the intranet. http://www.corelearningunit.nhs.uk/
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Staff training & development
KEY PRACTICE GUIDANCE

The Practice should have a Child Protection Policy and Procedures in place and ensure that all staff has access to it. A template policy that practices may wish to look at has been drawn up by the British Medical
Association 20 .

All staff undergoing training are expected to keep a learning log for their appraisals and/ or personal development.

There is at least one whole practice meeting a year to discuss the safeguarding of children within the practice. The purpose of this meeting is to make sure all members of staff are fully aware of the practice policy and know what to do if they are worried a child is being abused or neglected. The meeting should also review any significant events in safeguarding and review the practice policy.

The Practice Safeguarding Children Lead should cascade any information received about Safeguarding Children to all relevant practice staff (please refer to Roles & Responsibilities of Practice
Leads for Safeguarding Children ).

The Practice Lead will have access to regular updates and group mentoring with the Named GP for Safeguarding Children as set out in the Safeguarding Children Training Strategy for General Practice.

All members of staff undergo child protection training at least once every three years. Lead professionals engage with the multi-agency training provided by the Local Safeguarding Children Board/ Child
Protection Committee

The practice discusses and records at least one clinical incident involving safeguarding children 21
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Making a referral
When to refer:
A referral to Children’s Social Care should always be made in the following circumstances 22 .
• Any allegation of sexual abuse
• Physical injury caused by assault or neglect which may or may not require medical attention
• Incidents of physical abuse that alone are unlikely to constitute significant harm but taken into consideration with other factors may do so
• Children who suffer from persistent neglect
• Children who live in an environment which is likely to have an adverse impact on their emotional development
• Where parents’ own emotional impoverishment affects their ability to meet their child’s emotional and/or physical needs regardless of material/financial circumstances and assistance
• Where parents’ circumstances are affecting their capacity to meet the child’s needs because of domestic abuse, drug and/or alcohol misuse, mental health problems, previous convictions for offences against children
• A child living in a household with, or having significant contact with, a person at risk of sexual offending
• A child under 13 who is sexually active
• An abandoned child
• Bruising to an immobile baby
• Pregnancy where children have been previously removed
• Suspicion of fabricated or induced illness.
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Making a referral
KEY PRACTICE GUIDANCE

Practices should have a protocol in place for notifying concerns
( Appendix C 23 ).

The concern may need to be discussed with a more experienced colleague e.g. Designated or Named Doctor/Nurse in order to clarify the seriousness and urgency of the situation

If, following discussion there are still concerns, consideration should be given to consulting the duty officer at the social care office for advice.
This can be done by presenting a ‘what if’ scenario without necessarily naming the child in question. This discussion should be recorded by both parties in a retrievable form.

In most situations, concerns should be discussed with the child or young person (as appropriate to their age and understanding) and with their parents, whose agreement should be sought prior to a referral being made. However, agreement should not be sought if doing so would place the child or young person at risk of significant harm.

If there are immediate concerns about the safety of a child or young person, a referral should be made by telephone to Children’s Social
Care. At the end of any discussion or dialogue about a child or young person, the referrer must record the decision in their records.

Telephone referrals should be followed up in writing within 48 hours by the referrer.

If concerns are not immediate, but it is believed that a child or young person is a child in need, who may also be in need of protection, a referral should be made in writing. Where a CAF has been completed by the referring agency this will form the basis of the referral. Where necessary, the assessment should be updated in order to ensure that the most recent information is passed to Children’s Social Care.

Acknowledgment of the referral should be scanned into the affected child / children’s notes
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Making a referral
If a member of the public contacts a member of staff with information regarding the possible abuse of a child, the member of staff must act on this information. This could be in the following ways:

Escalate within the practice

Discuss with the safeguarding Children Team

Refer to the Integrated Pathways and Support Team (IPST) on Tel:
0207 364 5601/ 5606 /3859 /2972. Outside of office hours (17.00 -
09.00, Weekends and Bank Holidays): Tel: 0207 364 4079
If you have reason to believe that a child is in imminent danger of harm the police should be called using the 999 emergency services number.
If the child / young person is known to the service information regarding the incident must be recorded within the health record.
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Domestic Abuse
Domestic abuse is controlling behaviour involving physical, sexual, emotional, psychological and financial abuse of adults within all kinds of current or former intimate and close family relationships. (Tower Hamlets Domestic Violence
Action Team)
The issue of children living with domestic abuse is now recognised as a matter for concern in its own right by both government and key children’s services agencies. The Adoption and Children Act 2002 s.120 amended The
Children Act 1989 definition of significant harm in Sect. 31 of the 1989 Act
(care and supervision orders), to include: “impairment suffered from seeing or hearing the ill-treatment of another".
In Tower Hamlets children are present in the household in 70 – 80% of recorded cases of domestic abuse and 62% of known high risk cases.
Domestic abuse was a feature in over 600 referrals made to Tower hamlets
Children’s Social Care in 2010 (LBTH 2011).
All of the five Every Child Matters outcomes can be adversely affected for a child living with domestic violence and abuse and the impact is usually on every aspect of a child’s life. The impact of domestic violence and abuse on an individual child will vary according to the child’s resilience and the strengths and weaknesses of their particular circumstances.
It is important that all health professionals are aware of the potential impact of domestic abuse on a child known to be living within such circumstances.
Relevant staff should be adequately trained and supported to enable them to make routine enquiries of women who they treat or come into contact with as part of their practice.
Tower Hamlets LSCB have developed a local LSCB Guidance on safeguarding children at risk from domestic violence which must be followed in all cases where children are identified.
The following additional guidance is also available: London Safeguarding
Children Board supplementary procedure for domestic violence, Responding to Domestic Abuse: a handbook for healthcare professionals, Improving
Safety, Reducing Harm: a practical toolkit for frontline practitioners
23

TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Fabricated or Induced
Illness
The term ‘Fabricated or Induced Illness’ encompasses many different situations in which children are presented as ‘sick’ but where illness has arisen as a result of a parent/carers actions in inducing an illness or by fabricating an illness by telling a story of symptoms which lead Health
Professionals to believe the child has an illness. These include five key forms of parent/carer behaviour:

Pretence of illness (e.g. feigning symptoms)

Fabrication of illness or medical history

Inducement of illness

Exaggeration of genuine illness

Enforced invalidism
Further guidance is available within the BLT Guidelines for Dealing with
Fabricated or Induced illness1, the HM Gov supplementary guidance
“Safeguarding Children in Whom Illness is Fabricated or Induced” (2008) and the Royal College of Paediatrics and Child Health (RCPCH) report
“Fabricated or Induced Illness by Carers: A Practical Guide for Paediatricians
(2009), WT Guidance 2010 Chapter 6.6 P.192 and LCCP 2010 Ch. 5.13
P.159.
It is a legal requirement that all children of school age receive an education.
Any child of school age found not to be in the education system must be notified to Tower Hamlets Pupil Services.
Healthcare staff have a responsibility to inform the Police (999) and the Local
Authority (Inter-agency referral form) if they are aware that a child / young person has run away from home or a Local Authority Care Home.
Further guidance is available at: DCSF 2009 , LCPP 200
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Restraint Policy
Restraint is where a child is being held, moved or prevented from moving, against their will, because not to do so would result in injury to themselves or others, or would cause significant damage to property. Restraint must always be used as a last resort, when all other methods of controlling the situation have been tried and failed. Restraint should never be used as a punishment or to bring about compliance (except where there is a risk of injury).
Only employees who are properly trained in restraint techniques should carry it out. A person should be restrained for the shortest period necessary to bring the situation under control.
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Early Help & Family
Wellbeing Model
The Tower Hamlets Family Wellbeing Model is a model for everyone who works with children, young people and parents/ carers in Tower Hamlets to help them work together to provide the most effective support for children and their families.
The purpose of the Family Wellbeing Model is to support children, young people and families to achieve their full potential by detailing a coordinated approach to delivering services for all families across all levels of need.
This conceptual model describes how we respond to children and young people across three levels of need:

Universal – Services provided as of right to all children and/or parents/carers e.g. Maternity services; Health Visiting;
Children’s Centres; GP and Dental services; Housing services and Education.

Targeted – Services for children and their families with additional and vulnerable needs that go beyond what is on offer in our universal services e.g. Therapy services, Child
Development Team, extra support for parents in the early years, behaviour support or additional help with learning in school.

Specialist - Where the needs of the child and their family are so great that intensive or complex intervention is required to keep them safe or to ensure their continued development. These services often have a statutory element to them e.g. Children’s
Social Care; Youth Offending Service; SEN services and
CAMHs.
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Children Subject to
Statutory Requirements
A child is defined as being ‘in need’ if
:-

He is unlikely to achieve or maintain, or to have the opportunity of achieving or maintaining, a reasonable standard of health or development without the provision for him of services by a local authority under this Part;

That their health or development is likely to be significantly impaired, or further impaired, without the provision for them of such services.

They are disabled. Children Act 1989 (Sect. 17).
Child In Need Referrals (Sect.17)
All Child in Need referrals must be made to the respecti ve Children’s Social
Care teams as detailed above on a completed CAF Assessment which additionally details why Child In Need Services are being requested.
Children who are suffering or likely to suffer significant harm.
A child is defined as being in need of protection if:-
 ‘there is reasonable cause to suspect that a child is suffering, or is likely to suffer significant harm’ Children Act 1989 (Sect. 47).

The definition of significant harm was amended under the Child
Adoption Act 2002 to include: ‘impairment suffered from seeing or hearing the illtreatment of another’ Adoption and Children Act 2002
(Sect. 120)
Child Protection Referrals (Sect.47)
Where there are clear allegations, evidence, or strong suspicion of abuse, there must be NO DELAY in making the referral.
All child protection referrals must be made using the Tower Hamlets Interagency Referral Form.
In an emergency, the referral can be made over the telephone but must then be confirmed in writing within 48 hours.
Any child protection referral must not interfere with or delay the management of the child’s immediate or ongoing health needs).
If you have reason to believe that a child is in imminent danger of harm the police should be called using the 999 emergency services number.
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: The CAF and Sharing
Information
The CAF is a standardised tool to understand the strengths and needs of a child or young person. At its simplest, the CAF is a guided conversation with a child, young person and their parents. It provides a series of standard headings to ensure all areas of the child’s development, and any other factors that may affect this, are taken into consideration when looking at the strengths and needs of a child or young person. It requires practitioners to engage with a child or young person and their parents to gather and analyse information using a standardised format. Where additional needs are identified, the next step in the CAF process is to draw up an agreed list of actions to address those additional needs.
In most cases, a CAF assessment will need to be undertaken to assess need on entry to targeted services and plan effective, coordinated actions for families however, there are exceptions within Health.
If however, the needs of the child are clear and only requires referral to an additional service within health, a CAF assessment may not always need to be undertaken. For further information, please refer to the Family Wellbeing
Model Decision Tree. http://www.childrenandfamiliestrust.co.uk/family-wellbeing-model/
 In England and Wales, the Children’s Acts of 1989 and 2004 give GPs a statutory duty to co-operate with other agencies (Children Act 1989 section 27, 2004 section 11) if there are concerns about a child’s safety or welfare.

Health authorities (PCOs) (section 47.9) have a duty to assist local authorities (Social/Childcare Services) with enquiries, named Doctors for child protection can be powerful advocates for this function.

The Children, Schools and Families Act 2010 section 8 amends The
Children Act 2004 providing further statutory requirements for information sharing when the LSCB requires such information to allow it to carry out its functions adding Section 14b see www.legislation.gov.uk/ukpga/2010/978010542103/section/8.
This means that the default position is that the practice will share information with Social Care and not doing so maybe legally indefensible.
General Principles
The ‘Seven Golden Rules’ of information sharing are set out in the government guidance, Information Sharing: Pocket Guide. This guidance is
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: The CAF and Sharing
Information applicable to all professionals charged with the responsibility of sharing information, including in child protection scenarios.
1. The Data Protection Act is not a barrier to sharing information but provides a framework to ensure personal information about living persons is shared appropriately.
2. Be open and honest with the person/family from the outset about why, what, how and with whom information will be shared and seek their agreement, unless it is unsafe or inappropriate to do so.
3. Seek advice if you have any doubt, without disclosing the identity of the person if possible.
4. Share with consent where appropriate and where possible, respect the wishes of those who do not consent to share confidential information.
You may still share information without consent, if, in your judgement, that lack of consent can be overridden by the public interest. You will need to base your judgement on the facts of the case.
5. Consider safety and well-being, base your information sharing decisions on considerations of the safety and well-being of the person and others who may be affected by their actions. Necessary, proportionate, relevant, accurate, timely and secure, ensure that the information you share is necessary for the purpose for which you are sharing it, is shared only with those people who need to have it, is accurate and up to date, is shared in a timely fashion and is shared securely.
6. Keep a record of your concerns, the reasons for them and decisions whether it is to share information or not. If you decide to share, then record what you have shared, with whom and for what purpose.
GMC Guidance
The General Medical Council offers guidance on Confidentiality and
Information Sharing which is regularly reviewed. The GMC advises that the first duty of doctors is to make the care of their patients their first concern:
• When treating children and young people, doctors must also consider parents and others close to them, but t he patient must be the doctor’s first concern
• When treating adults who care for, or pose risks to, children and young people, the adult patient must be the doctor’s first concern, but doctors must also consider and act in the best interests of children and young people
GMC 2007: 0-18 years
This might be phrased: “see the adult behind the child” and “see the child behind the adult”
Consent should be sought to disclosures unless:
• that would undermine the purpose of the disclosure [such as fabricated &
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: The CAF and Sharing
Information induced illness and sexual abuse]
• action must be taken quickly because delay would put the child at further risk of harm
• it is impracticable to gain consent
When asked for information about a child or family, practice staff should consider the following:
• Identity: check identity of the enquirer to see if they have a bona fide reason to request information. Call back the switchboard or ask for a faxed request on headed notepaper
• Purpose: ask about the exact purpose of the inquiry. What are the concerns?
• Consent: does the family know that there are enquiries about them? Have they consented and if not why not? Consent is not necessary if there is felt to be a risk of harm to the child from seeking it. Receiving a signed consent form from Social Services does not imply consent given to you to share. If this doesn’t cause harmful delay, you may also wish to seek consent from the family
• Need-to-know basis, give information only to those who need to know
• Proportionality, give just enough information for the purpose of the enquiry and no more. This may mean relevant information about parents/carers
• Keep a record, make sure that you record the details of the information sharing, including the identity of the person you are sharing information with, the reason for sharing and whether consent has been obtained and if not why not
GMC advice includes:
• Sharing information with the right people can help to protect children and young people from harm and ensure that they get the help they need. It can also reduce the number of times they are asked the same questions by different professionals. By asking for their consent to share relevant information, you are showing them respect and involving them in decisions about their care
• If a child or young person does not agree to disclosure there are still circumstances in which you should disclose information: a. when there is an overriding public interest in the disclosure b. when you judge that the disclosure is in the best interests of a child or young person who does not have the maturity or understanding to make a decision about disclosure c. when disclosure is required by law.
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Case Conferences
The contribution of GPs to safeguarding children is important. Dissemination of information regarding the case should be a priority whether attendance or not is possible, a report should be submitted ( Appendix C & D ).
General points for preparing reports
The Assessment Framework Tool 24 recommends a triangle model of assessment:
 Child’s developmental needs

Parenting capacity

Family & Environmental Factors
Consider:

A chronology of significant events and agency and professional contact with the child and family

Missed appointments with GP, Practices Nurse, and Midwife

Failed immunisations

Missed hospital appointments

Education: discuss with School Nurse or Health Visitor

Parental mental health or substance abuse

Ability of the carer to parent [disability, physical or intellectual]

Evidence of domestic violence

Cruelty to animals in the family

Are both parents registered with the practice?

Who has parental responsibility?

Share the report with the child if old enough, and the parents where appropriate

The expressed views, wishes and feelings of the child, parents and other family members should be documented where appropriate
Please see document ‘Universal children’s report format and guidance’ for further advice http://gp.towerhamletsccg.nhs.uk/clinical-services/universalchildrens-report.htm
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Appendix A
Parental responsibility (PR) is where an adult is responsible for the care and well-being of their child and can make important decisions about the following points for example:
 food
 clothing
 education
 home
 medical treatment.
Who has parental responsibility?
A married couple who have children together both automatically have parental responsibility. Parental responsibility continues after divorce.
Mothers automatically have parental responsibility. Where the parents are not married, the unmarried father has parental responsibility if:

His name is registered on the birth certificate - this is the case for births registered after 1 December 2003. Fathers can re-register if their names have not been placed on the birth certificate before this date.

He later marries the mother.

Both parents have signed an authorised parental responsibility agreement.

He obtains a parental responsibility order from the court.

He obtains a residence order from the court.

He becomes the child's guardian.
Others, such as grandparents and stepparents, do not have parental responsibility. They can acquire it by:

Being appointed as a guardian to care for a child if their parent dies.

Obtaining a residence order from the court for a child to live with them.

Adopting the child.
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Appendix B
Recommended codes filed under Significant Active Problems
For children who are deemed to be vulnerable* 13IF1(Vulnerable child)
For the family members of that child
For children with a protection plan
13IQ (Vulnerable child in family)
13Iv (subject to child protection plan)
– preferred code or 13IM(child on protection register)
13Is (Child in Need) For children subject to a Child Protection Plan or a
Child in Need Plan, as advised by Social Services
For parents of child with protection plan
For siblings of child on protection plan
13IM (child on protection register)
13IN (family member on
Child Protection
Register) note relationship to patient and computer number of index child
For Looked After children (including those under private fostering arrangements)
13IV (Looked after child-
Children [Scotland] Act
1995)
*A child would be thought to be vulnerable to harm if there are 1 or more features in the child or the family which are known risk factors for abuse. These factors do not mean necessarily that the child is at risk but they alert professionals to be more vigilant.
These risk factors include:
Domestic violence in the family, mental illness affecting the carers, drug or alcohol abuse affecting the carers, frequent non-attendance for child or parent, poor
33

TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Appendix B immunization record, child or parent disability, families needing additional health visiting, past or current involvement with social services for safeguarding issues.
Children with a protection plan should have both Vulnerable child code (13IF1) as well as 13Iv 13IM codes as active significant problems . A brief description of the reason e.g. neglect, emotional abuse, should be put into the text. After the child has come off the protection plan, the Vulnerable child code should remain on the records as Active Significant Problem for at least 1 year and then moved to
Significant Past problem thereafter if there are no further concerns. All family members should have 13IQ code for the same period.
The 13IF1 and 13IQ codes should be reviewed regularly to see if they need to remain filed as Active or to be moved to Past Significant problem. It is recommended that a list of patients with these codes be printed every 3 months and their records reviewed.
Case conference reports
These should be scanned onto all affected children’s records under the READ code
13Iv or 13IM as Problem Title, so that there is continuity under that problem title.
Under “Additional”, use READ code 64c (child protection procedure) to locate case conference notes.
The case conference reports should also be scanned into parents’ or carers’ notes.
The paper copy should be copied into all affected children’s paper Lloyd George records (or when the records leave the practice, the scanned case conference reports should also be printed out.
Contacts with Social Services
Referrals to Social Services 8HHB (referral to social services)
Social Worker involved
(this is useful to convey link/prompt to sensitive information that could then be entered as free text)
Reports sent to social services
13G4 (social worker involved)
9b0k (social services report)
These codes to be filed under “Additional” and under 13IF1 or 13IQ codes in the
Problem Title.
For children in Need who have a Common Assessment Form (CAF)
Use Vulnerable child codes i.e. 13IF1 and 13IQ .
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Appendix B
Other useful codes
Domestic violence
14X8 (victim of DV) ; 14X3 (history of DV) to include record of perpetrating violence, children exposed to DV: witnessed
(can be entered as free text)
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Appendix C
Date, time and place of
The (insert name of Practice) Surgery
Child Concern Reporting Form disclosure, suspicion, allegation or actual, incident of abuse
Name and position of person about whom report, complaint or allegation is made
Name and age of child involved
Nature of incident, complaint or allegation (continue on a separate sheet if necessary)
What questions did you ask the child (continue on a separate sheet if necessary)?
What did the child do/say
(continue on a separate sheet if necessary)?
Action taken (continue on a separate sheet if necessary)
If Police or Children’s Social
Care Services contacted, name, position and telephone number of person handling the case and date and time referred
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Appendix C
If the decision was taken not to consult with a relevant statutory agency, why was this decision taken?
Name and position of person completing the form
Contact telephone number
Signature of person completing the form
Print Name
Date & time completed
Notes – This template can be used as a means of recording concerns in the c hild’s notes or as a record of practice discussion/clinical incident
1. No matter what happens to a suspicion, allegation or actual incident of abuse (that is whether or not it is processed through a statutory agency or not) all details must be recorded.
2. If for any reason it is decided not to consult with a relevant statutory agency, a full explanation of why must be documented.
3. Recording should be factual that is no reference made to your own subjective opinions.
4. Records should be kept completely confidential and secure (always locked away) and only shared with those who need to know about the suspicion, allegation or actual incident of abuse.
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Appendix D
NETWORK CHECK- REQUEST FOR INFORMATION RECORD OF
CHILD’S HEALTH DEVELOPMENT
Child’s Name:
Child’s D.O.B.:
Child’s Address:
Is the child up to date with immunisations?

Yes

No
If not, why?
When was the child last seen at the surgery, and why?
Date:
Reason:
Does the child have any chronic health concerns?

Yes

No
If yes, please give details, and comment on how this impacts on the child’s general health and well being
DRAFT
Has the child ever had any previous health concerns?

Yes

No
If yes, please give details
Please comment on the child’s general development:
Please comment on the child’s social presentation:
Any other concerns regarding this child or their family, including parenting capacity and engagement with services:
Any other information:
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: Appendix E
USEFUL WEBSITES
Every Child Matters: http://www.everychildmatters.gov.uk/
Department of Children, school and families: http://www.dcsf.gov.uk/ - useful up-to-date information on Contact point, CAF
Working Together to Safeguard Children 2006: http://www.dcsf.gov.uk/everychildmatters/resources-and-practice/IG00060/
London Child Protection procedures: http://www.londonscb.gov.uk/files/procedures/london_cp_procedures_v.3_pri
nt__10.01.08.pdf
Child protection – a Toolkit for Doctors: http://www.bma.org.uk/ethics/consent_and_capacity/childprotectiontoolkit.jsp
When to Suspect Child Maltreatment: http://www.nice.org.uk/CG89
What to do if you are worried a child is being abused – Every Child Matters: http://www.dcsf.gov.uk/everychildmatters/resources-and-practice/IG00182/
Children’s Act 2004:
DRAFT http://www.opsi.gov.uk/acts/acts2004/ukpga_20040031_en_1
National Society for the Prevention of Cruelty to Children http://www.nspcc.org.uk
Royal College of General Practitioners’ Safeguarding Children Toolkit: http://www.rcgp.org.uk/clinical_and_research/circ/safeguarding_children_toolk it.aspx
Information Sharing http://www.governornet.co.uk/linkAttachments/Information%20sharing%20gui dance%20for%20practitioners%20and%20managers.pdf
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TOWER HAMLETS GP SAFEGUARDING HANDBOOK: References
1.
Section 3.45, All London Safeguarding Procedures, 2007
2.
Serious Case Review J and L Executive Summary, London Borough of
Lewisham, 2009: recommendation no.4.3.27
3.
NHS Lewisham Safeguarding Children Standards in General Practice.
Dr. Chen
4.
NHS Employment Check Standards www.nhsemployers.org
5.
GMC, Good medical Practice, 2006
6.
Serious Case Review J and L Executive Summary, London Borough of
Lewisham, 2009: recommendation no. 4.3.27
7.
Children Act 1989, Section 2
8.
Lamming Report, Recommendation No. 78: Within a given location, health professionals should work from a single set of records for each child. (paragraph 11.39)
9.
Serious Case Review K, London Borough of Lewisham, 2009, Health recommendation
DRAFT
10.
General Practice Resources and Communications for East Sussex
Downs and Weald
11.
Children’s Acts of 1989 and 2004; (Children Act 1989 section 27)
12.
Beyond Blame: Child abuse tragedies revisited. Reder, Duncan, and
Gray, 1993. Routledge
13.
Data Protection Act 1988
14.
Information Sharing : Pocket Guide HM Government October 2008
15.
London Child Protection procedures, 2006, Section 4.5.6
16.
Serious Case Review C, London Borough of Lewisham, 2009, Health recommendation
17.
Children Act 2004, Section 11
18.
GMC guidance 0-18 Guidance for Doctors
19.
The Intercollegiate Guidance Safeguarding Children and Young
People: Roles and Competences for Health Care Staff April 2006
40

TOWER HAMLETS GP SAFEGUARDING HANDBOOK: References
20.
BMA Child Protection Toolkit www. bma.org.uk
21.
Safeguarding Children & Young People in General Practice: A Toolkit;
NSPCC & RCGP, 2007 p.33
22.
London Safeguarding Children Board, 2007 (paragraph 6.4) www.londonscb.gov.uk
23.
Wessex LMCS Child Protection Procedure template document.
December 2009 www.wessexlmcs.com/page102.html
24.
Framework for the Assessment of Children in Need and their Families
DH, DFEE 2000
DRAFT
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