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Safeguarding Annual
Report
April 2011 – March 2012
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1.
INTRODUCTION
CQC believes that safeguarding children, young people and adults is about
the individual, their rights and choices, and keeping people safe from abusive
or potentially abusive situations, particularly when circumstances may put
them in a vulnerable position, for however long.
Safeguarding is therefore a priority for CQC. Any form of abuse, harm or
neglect is unacceptable and should not be tolerated, by the provider, the
commissioner, staff, the regulators, or by members of the public or allied
professionals who may become aware of such incidents.
CQC understands the important role it can play alongside partners in striving
to reduce the risk of abuse from occurring in the first instance, in dealing with
incidents when they do occur, and supporting people in the aftermath.
Over the last 12 months CQC has undertaken a significant amount of activity
relating to safeguarding. In addition, CQC’s safeguarding processes have
been subject to both internal and external review and scrutiny following the
uncovering of abuse at Winterbourne View, a service in South West England
for people with learning disabilities.
CQC has learned from the events at Winterbourne View and identified what
we could have done differently and what improvements could be made to our
own and the wider system to safeguard people. Using this learning, we have
devised a Collaborative Safeguarding Development Plan to help promote an
organisation-wide approach to improving the way we work.
This report provides an overview of the safeguarding activity and
improvement work that we have undertaken in 2011-12.
2.
POLICY
2.1
Adult safeguarding
Unlike safeguarding children, there are currently no distinct responsibilities in
Statute for adult safeguarding. Instead, arrangements for safeguarding adults
fall under the Department of Health policy framework, the No Secrets
guidance (2000). This gives councils the responsibility for establishing and
co-ordinating local multi-agency procedures for responding to allegations of
abuse. Councils will need to work with a range of partners such as
commissioners and providers of health and social care, regulators, the police,
and other agencies.
Even so, as No Secrets is guidance rather than law, it has been interpreted
differently by England’s 152 councils, many of which have adopted their own
approaches to implement action. As a result, there is no nationally consistent
approach to safeguarding adults. Nor is there a duty for councils and other
bodies to co-operate with each other. In other words, these are currently
voluntary rather than compulsory arrangements.
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National safeguarding policy has developed this year following a review of
adult social care law by the Law Commission in 2011. The coalition
government published a Statement of Government Policy on Adult
Safeguarding in May 2011. This outlined the government’s intention to place
Safeguarding Adult Boards on a new statutory footing, which was one of the
review’s recommendations. Until new legislation is passed, however, No
Secrets remains the underpinning policy in this area. The White Paper on
Care and Support reform and the draft Care and Support Bill published in July
2012 contain proposals to make the government’s policy intention law. This
will be subject to the passing of legislation.
2.2
Children’s Safeguarding
One of the key events relating to children’s safeguarding this year took place
in May 2011, when Professor Eileen Munro published her third and final report
on child protection in England.
Professor Munro was very critical of many aspects of the current child
protection system. Her report highlighted that there is too much emphasis on
procedures and recording and that the extensive statutory guidance, targets
and local rules they limit professionals’ ability to stay child centred and to
exercise professional judgement. There is also a failure to learn adequately
from serious cases due to the tendency to focus on human rather than for
example systemic error.
Professor Munro’s report raised concerns that the demands of the inspection
system had contributed to undue weight being given to policies and
procedures and that the focus on the child had been lost. Despite these
criticisms, Professor Munro was clear that inspection is crucial to provide
external scrutiny of the child protection system. But in her view inspections
should focus on the effectiveness of the contributions of all local services,
including health, to the protection of children and they should examine the
child’s journey from the point he or she needs to receive help.
In response to this, a new programme of inspections will commence in June
2013 and these will be focused on the effectiveness of the contributions of all
local services to the protection of children. The programme will involve CQC;
Ofsted; Her Majesty’s Inspectorate of Prisons; Her Majesty’s Inspectorate of
Probation; Her Majesty’s Inspectorate of Constabulary; and Her Majesty’s
Crown Prosecution Inspectorate. Over three years the Inspectorates will
together inspect services within all 152 local authority areas in England.
CQC’s role will be to inspect and explore the effectiveness of the contribution
of health services to the protection and wellbeing of children. The
responsibility for inspecting children’s social care rests with Ofsted.
A consultation on the scope and proposed inspection framework will launch in
July 2012.
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Another development following Professor Munro’s report is the revision of the
statutory guidance Working Together to Safeguard Children, which took into
account her recommendation that central control should be reduced to enable
local areas to be more flexible in their arrangements to protect children. The
guide, which is now significantly shorter than the current statutory guidance,
describes what is expected of organisations individually and jointly to
safeguard and promote the welfare of children. It is currently out for
consultation.
In parallel, and as a consequence of the NHS reforms contained in the Health
and Social Care Act 2012, the Department of Health is currently developing
an Accountability Framework for the NHS contribution to safeguarding
children. This will set out the proposed roles and responsibilities of the new
NHS bodies. This new framework will be clarified in the revised Working
Together to Safeguard Children.
3.
OPERATIONAL ACTIVITY
3.1
What we did in 2011/12
Safeguarding adults
Safeguarding featured strongly in our regulatory activity in 2011/12. The
range of our activity across the government’s sixteen Essential Standards of
safety and quality in 2011/12 is shown in Figure 1 below.
This shows that we undertook inspection activity against Outcome 7
(Safeguarding) at over 12,000 locations. Approximately 90% of locations we
inspected were assessed as compliant with the Safeguarding standard. It
should be noted that the highest level of activity in assessments and site visits
(including follow up visits to reassess compliance) occurred against the
Safeguarding outcome. This demonstrates the strength of our commitment
around safeguarding and protecting people.
Where services were not compliant we used the range of our enforcement
powers to ensure improvements were made, following up where necessary.
For example, for significant risks, we issued 43 warning notices in 2011/12 on
the Safeguarding outcome.
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Figure 1: Summary of Regulatory Activity (locations and compliance) across the Essential
Standards in 2011/12
% Compl i ant
Number of l ocati ons i nspected
Average compl i ance
Average number of l ocati ons i nspected
100%
16000
90%
14000
80%
12000
70%
10000
60%
50%
8000
40%
6000
30%
4000
20%
2000
10%
9 - Mgt of medicines
21 - Records
10 - Premises
4 - Care and welfare
14 - Supporting staff
16 - Assessing and
monitoring
13 - Staffing
8 - Cleanliness
7 - Safeguarding
12 - Workers
requirements
2 - Consent
5 - Nutrition
1 - Respecting and
involving
11 - Equipment
17 - Complaints
0
6 - Cooperation
0%
Alerts and concerns
Intelligence about safeguarding is categorised in two ways: alerts are where
we are the first to receive information; concerns are where we are not the first
to receive information, but we can use the information in our regulatory work.
During the first 8 months of 2011/12 there was a trend of an increasing
monthly number of safeguarding alerts, from 23 in April 2011 to 117 in
November, with a peak of 156 in June. From November referrals levelled out
for the remainder of the year. The increase may be partly due to issues
around Winterbourne View and the resulting publicity or to efforts we made to
raise the profile of safeguarding and how people could inform us of concerns.
Safeguarding concerns averaged around 1,500 per month, with a peak of
over 2,100 in June 2011.
Information from safeguarding alerts and concerns is reviewed every month
by our Safeguarding Committee and feedback on information and analysis is
provided through regions to local teams who can act on specific issues
identified.
More detail, including a monthly breakdown of figures, is at Appendix 1.
3.2
What we found
The main themes which emerged from our inspection activity were:
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The vast majority of providers were acting well to keep people safe
from the risk of harm and abuse and were compliant with the
Safeguarding standard
A minority of providers needed to improve their approach to
safeguarding, particularly with regard to quality assurance,
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3.3
monitoring or governance. This required action from CQC to lever
the necessary improvements
Some services required improvement to staff attitudes, in basic
procedures or in staff training to ensure people being cared for were
treated properly and with dignity and respect
Risks were identified in the inappropriate use of restraint in services
caring for people with learning disabilities or who had a mental
health condition. Also, some staff had a poor understanding of
restraint
Information-sharing between agencies is still in need of
improvement. For example, in NHS services, there can be a lack of
clarity about responsibilities and procedures, so that some cases
are not referred to the local authority safeguarding team or the
police where it would have been appropriate to do so.
Finally, lessons from safeguarding incidents are not always used to
improve practice, so there is a risk of an incident happening again
Safeguarding children
Joint working
In July 2012, we completed a three year programme of safeguarding and
looked after children’s inspections which we conducted jointly with Ofsted.
Every local authority in England was included in the programme and we
inspected every health organisation within each local authority area. This
involved 152 inspections for which a joint CQC/Ofsted report was published,
with a supplementary, more detailed, health report also being produced. Both
reports contained recommendations for improvement for health, social care
and their partnership arrangements.
Inspection findings varied across the country, with some areas demonstrating
good and outstanding practice in safeguarding children. Areas of strength
included:

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Co-location of health and social care practitioners, which has driven
improvements in communication and information sharing about
children at risk from harm
Health visitor liaison arrangements where all admissions to accident
and emergency, urgent care and walk-in centres are reviewed by
health visitors and any concerns followed up within the community.
This includes admission of adults with mental health, substance
misuse, alcohol abuse and domestic violence issues where children
within the household may be at risk.
Comprehensive health promotion programmes being offered to
children and young people in areas such as sexual health,
substance misuse, and alcohol misuse, which are reducing
incidences of risk taking behaviours in young people and reducing
the rate of teenage conceptions
Improvements in the rates of immunisations, dental checks and
health reviews that are identifying and addressing health needs and
improving health outcomes for children looked after
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Some areas were found to be inadequate in safeguarding children and/or the
care of looked after children. Weaknesses included:
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Involvement of general practitioners in child protection processes is
under-developed in many areas
Levels of safeguarding training in PCTs and acute hospitals are
below the standards outlined in statutory guidance
Computer based information systems are incompatible in some
areas, preventing information about children at risk, or children who
are subject to child protection plans, being shared promptly
between social care and health, and between acute health, mental
health and community health practitioners
Significant delays in some areas for children and young people
accessing services provided by Child and Adolescent Mental Health
Services (CAHMS)
Where weaknesses were found, recommendations for improvements were
made and health trusts were required to submit action plans detailing how and
when improvements will be made. These action plans were followed up by
regional staff.
3.4
Information and Intelligence
How we gather and use information and intelligence is one of the critical
elements in ensuring that people who use regulated services are protected
from the risk of abuse and harm. It is also vital that through the information
we hold we identify any patterns and trends that may suggest providers are
not meeting the relevant Essential Standards of Quality and Safety and
therefore not securing or maintaining people’s safety. We continue to develop
our information management system to provide us with a more consistent
approach to how we process, assess and pass on safeguarding information.
This remains a priority for 2012/13.
3.5
Mental Health Act Operations
Over the last 12 months we have made significant progress in ensuring a
more consistent and appropriate response to safeguarding information
received by Mental Health Act Operations (MHAO). This improvement work
has included:
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training all relevant staff in safeguarding
managing safeguarding information within our customer relationship
management system. This has resulted in improved communication of
safeguarding information between MHAO and compliance teams
clarifying the role of Second Opinion Appointed Doctors (SOADs) and
Mental Health Act Commissioners (MHACs) in safeguarding: MHAO
assess information received from SOADs and MHACs and refer
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safeguarding issues on to our inspectors who monitor compliance of
the service concerned
3.6
Partnership Working
In December 2011 we began an internal and external consultation process on
our Safeguarding Protocol. The original protocol was launched in June 2010
and was developed primarily for our staff to describe our role in children’s and
adults’ safeguarding. The formal review of the protocol has provided the
opportunity to reflect on our practices, the experience of a number of complex
cases as well as to engage with stakeholders. We received a considerable
amount of useful feedback through the consultation which helped us revise
the protocol and provide greater clarity on:

what our operational staff do if they witness abuse in a registered
service
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when we make a safeguarding referral to the local authority and/or
police

how to establish effective working relationships and dialogue with other
agencies involved in safeguarding issues, including attendance at local
safeguarding boards and greater involvement in serious case reviews
We have also strengthened our work and liaison with stakeholders through,
for example, meetings with the safeguarding leads from the Association of
Directors of Adult Social Services (ADASS) and the Department of Health
Safeguarding Advisory Board.
3.7
Quality Assurance
Our review of safeguarding activity identified the need to establish greater
assurances around quality in our safeguarding work. Up to September 2011
we had mainly locally-driven approaches to quality assurance. From that date
we conducted a series of random checks to see how well we handled and
used safeguarding information throughout the process. Any concerns about
practice were raised promptly with the Inspector or Manager to address. We
set out in a national report the regional issues and themes we found.
To take this work forward, we have started to develop a Safeguarding Quality
Assurance Framework. We have identified three possible constituents of a
safeguarding quality assurance system that include:
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Management information
Management assurance
Objective Audit
This Framework will be subject to further consultation to ensure it fits with our
wider management assurance system.
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3.8
Safeguarding Leads Network
We have established a network of safeguarding leads across regions and our
business functions, including pharmacy, mental health act operations,
children’s inspections and operations intelligence. Adult safeguarding leads
from the Department of Health have attended our regular meetings which aim
to:
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exchange information about operational safeguarding issues
act as a conduit of adult and children’s safeguarding information and
Deprivation of Liberty Safeguards work
help develop and influence our safeguarding policies
Over the last year the network has contributed significantly to the
implementation of training on safeguarding as well as to how we record
safeguarding information.
The network has also played a pivotal role in disseminating the lessons learnt
from serious case reviews and Winterbourne View to staff around the country.
3.9
Equipping our staff
Training
Ensuring that staff receive effective training in safeguarding issues is key to
our objective of keeping people who use services safe. In 2011/12 we further
improved and enhanced our safeguarding training. All CQC staff have
received training in basic awareness of safeguarding. It is important that all
staff have at least a fundamental understanding of safeguarding and their role
in it. All new compliance inspectors now receive a full day dedicated to
safeguarding training that involves both policy and practical elements, and
their feedback has shown this training to have been very welcome and useful.
In addition. relevant existing compliance and mental health act operations
staff have completed safeguarding training.
Over and above this, recognising the breadth of safeguarding, additional staff
training has been developed which includes:
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tailored specialised programmes for all staff in our National Customer
Services Centre
a mandatory electronic learning package about Deprivation of Liberty
Safeguards made available to all staff who need this in their day to day
work
safeguarding training package for Regional Intelligence and Evidence
Officers
enhanced Safeguarding electronic-learning package for our frontline
staff
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Our training sets out expectations for individuals in a range of roles around
the organisation.
We plan to develop our approach further to include how to feed back to
people and organisations who make safeguarding referrals to CQC to explain
our role, the next steps we or partners take, and how we feed learning back
into the organisation.
4.
WINTERBOURNE VIEW
The Winterbourne View case (May 2011)involved appalling abuse at a private
hospital in South West England which cared for people with learning
disabilities. We did not act as promptly or effectively as we should have when
a whistleblower contacted us with information about the service.
We conducted three unannounced inspections of the service and prevented it
from admitting any more people. When the hospital closed, we worked with
local partners, such as the council, to ensure that alternative placements were
found for people who lived at Winterbourne View.
We also inspected all the provider’s other services and took action where we
found them not to comply with our essential standards of safety and quality.
To learn lessons from what had gone wrong, we set up an internal
management review and have already begun to address recommendations
arising from this. We will use them as a baseline to measure improvements in
our own processes and procedures to improve our regulatory model. The
safeguarding recommendations have been integrated into our Safeguarding
Development Plan with progress monitored via the Safeguarding Committee.
[DQ Amanda: should we include these or say what these are?]
In addition, the Department of Health has commissioned a review of events at
Winterbourne View Private Hospital.
The local council is leading an independently chaired Serious Case Review,
involving the police, the NHS, and local authorities. This is expected to report
in August 2012.
5. SERIOUS CASE REVIEWS
When a child or adult dies or is seriously hurt through known or suspected
abuse or neglect, a Serious Case Review (SCR) is held. The SCR openly
and critically examines the involvement of local agencies such as councils,
PCTs, care providers, CQC, the police and others. The aim is to establish
whether there are lessons to be learnt from the circumstances of the case
about the way in which local professionals and agencies work together to
safeguard adults or children at risk. The result should be used to inform and
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improve local inter‐agency procedures and practice to help prevent similar
cases occurring in future.
CQC contributes to and learns from SCRs, in particular where they relate to a
service we regulate. There are, however, significant differences between the
actions that can be taken in children’s and adults’ cases due to the different
laws that apply in each situation. The commissioning and follow up of SCRs
is the responsibility of local safeguarding boards, and this is consistent
practice across both adult and children reviews.
CQC is not routinely a member of SCR panels. We do, however, follow the
progress of the review, taking into account and using the intelligence arising
from them to ensure we can promptly and effectively assess risks to children
and adults who use services we regulate. We take appropriate action to keep
people safe where risks are at a level which causes concern.
Learning for the organisation and how we acted on it
Many of the recommendations from serious case reviews have been
addressed through our revised methodology. Lessons learnt from serious
case reviews and inspections are fed back to compliance teams through our
safeguarding leads network. Some of the lessons learnt have included;
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improving our management review process to ensure people with
relevant expertise such as legal or pharmacy attend to increase the
robustness of the process
when inspectors hand over portfolios, the new inspector is fully
appraised of safeguarding issues and other risks so they hit the ground
running
identifying a relationship lead for corporate providers to enable good
communication and the ability to take an overview of risks across the
whole provider
need for identification of service level outliers in relation to death
notifications so that patterns and risks can be identified and appropriate
action taken
improved communications with local safeguarding boards and serious
case review panels so that area-wide issues can be raised where
necessary and inspection activities can be better co-ordinated
6. CONCLUSION
In summary, 2011/12 gave us the opportunity to reflect on how we could
improve our safeguarding activity and processes further to reduce the risk to
and increase protection for people in circumstances which may make them
vulnerable.
We sought to incorporate learning – particularly from Winterbourne View - into
our approach to inspections and enforcement, using information from whistle
blowers and other intelligence to help assess risks to people using services.
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We acted to lever change and ensured providers who were not giving safe
care improved to at least the level of our essential standard on Safeguarding
by using a range of enforcement actions.
We improved our whistle blowing procedures and record keeping to maintain
and increase our effectiveness as a partner in local safeguarding
arrangements, responding promptly and appropriately and sharing information
with organisations that needed to know.
As a result of our work in 2011/12, we now have a stronger base from which
to move forward in 2012/13. Key priorities for this period include:
1. Further strengthening of data, intelligence and information flows to
better inform our regulatory work around safeguarding
2. Maintaining strong engagement with partner organisations and
stakeholders as structural changes take place across health and social
care, to help ensure no gaps appear in the safeguarding safety net
3. Strengthening internal processes and Quality Assurance to help ensure
that the right action happens at the right time with regard to
safeguarding
4. Adopting and incorporating the learning from the Winterbourne View
case, including from our own Internal Management Review and the
Serious Case Review (when it reports later in the year) to help continue
to protect people who may be at risk of abuse
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Appendix 1: Safeguarding Reporting Summary 2011/12
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