SECTION 11 Self-Evaluation Toolkit Guidance, Audit Tool and … · 2018-12-10 · Sussex LSCB...

Sussex LSCB Section 11 Self-Evaluation Toolkit, 2014

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SECTION 11 Self-Evaluation Toolkit

Guidance, Audit Tool and Action Plan 2014


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Contents Page Introduction 3

Part 1: Guidance for Completing the Section 11 Audit Tool 6

1. How to complete the s11 audit tool 6

2. Self-assessment RAG rating 6

3. Examples of evidence that can be used to demonstrate compliance with section 11 standards 7 1) Senior management commitment to the importance of safeguarding and promoting children’s welfare 7

2) A clear statement of the agency’s responsibilities towards children is available for all staff 7 3) A clear line of accountability within the organisation for work on safeguarding and promoting the welfare of children 7 4) Service development takes account of the need to safeguard and promote welfare and is informed, where appropriate, 8 by the views of children and families 5) Staff training on safeguarding and promoting the welfare of children for all staff working with or, depending on the agency’s 8 primary functions, in contact with children and families 6) Safer recruitment 8 7) Effective inter-agency working to safeguard and promote the welfare of children 9 8) Information Sharing 9 9) Recognition and response to risk 10

4. Analysis of agency responses and reporting to the Board 11 Part 2: S11 Audit Tool 12 Part 3: S11 Action Plan 25


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1. What is section 11?

Improving the way key people and bodies safeguard and promote the welfare of children is crucial to improving outcomes for children. Section 11 (s11) of the Children Act 2004 places a statutory duty on key organisations to make arrangements to ensure that in discharging their functions they have regard to the need to safeguard and promote the welfare of children.

It is important to remember that s11 does not give agencies any new functions, nor does it override their existing functions. Instead, it requires organisations to carry out their existing functions in a way that takes into account the need to safeguard and promote the welfare of children. The guidance is intended to assist in completing the s11 audit and is based on the statutory guidance Working Together to Safeguard Children, 2013 which details s11 responsibilities. The audit is an opportunity for each agency to demonstrate compliance with this statutory guidance. It provides examples of evidence that may be relevant when considering minimum safeguarding arrangements. This document is designed not only to assist in completing the audit toolkit, but also to provide a multi-agency benchmark through the use of a common language. It is hoped that this will create a more consistent approach to considering safeguarding arrangements, at a strategic level, when addressing expectations across Brighton and Hove, East and West Sussex. However, it is important to remember that the potential examples of evidence are not prescriptive and additional sources of evidence, activities and material may also provide valuable and credible sources of evidence in order to demonstrate compliance.

2. Who does section 11 apply to? In accordance with Working Together to Safeguard Children 2013, s11 compliance is a mandatory requirement for the following key organisations:

Local authorities and district councils that provide children’s and other types of services, including children’s and adult social care services, public health, housing, sport, culture and leisure services, licensing authorities and youth services

NHS organisations including the NHS Commissioning Board, Clinical Commissioning Groups, NHS Trusts and NHS Foundation Trusts

The police, including police and crime commissioners and the chief officer of police for the police area

British Transport Police

The Probation Service – local probation trust

Providers of probation services required under section 3(2) of the Offender Management Act 2007 to act as a relevant partner of a local authority

The Secretary of State in relation to his functions under sections 2 and 3 of the Offender Management Act 2007

Introduction


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Governor of a prison or secure training centre, or in the case of a contracted out prison or secure training centre, its director Youth Offending Team/services

United Kingdom Border Agency (under section 55 of the Borders, Citizenship and Immigration Act 2009)

Contracted services, including those provided by voluntary services However, each of the Sussex Local Safeguarding Children Boards (LSCBs) may require all of their respective member organisations not listed above to also complete the s11 audit. If your agency’s core business is not explicitly and directly to work with children and young people, it will be necessary to consider how your agency does come into contact with them in order to make a judgement about you agency’s systems, structures, ability and capacity to safeguard and promote their welfare. Examples may include how a worker employed by adult services responds to a distressed child when undertaking a home visit to the adult client, or what actions a probation worker might take when working with an offender if concerned about a child. These two examples may be useful to consider, not only about the action the worker might take, but also about whether the wider organisational structure and systems are in place to support any action, i.e. as reflected throughout the Standards. These issues, while likely to be part of your statutory function under s11 of the Children Act 2004, will also apply to services your agency commissions. You will therefore need to consider whether your commissioning arrangements are sufficiently robust and address the need to safeguard and promote the welfare of children based upon these standards.

3. How do we know if section 11 is being implemented properly? Regulation 5 of the Local Safeguarding Children Boards Regulations 2006 requires the LSCB to monitor and evaluate the effectiveness of what is done to safeguard and promote the welfare of children and advising organisations on ways to improve. All organisations will therefore be asked to complete a self assessment and provide evidence of how they comply with s11 when carrying out their day-to-day business. This audit will give an indication of how well organisations are working to keep children safe. The audits will be repeated biennially, and agencies will be asked to develop action plans to address any weaknesses identified. Sussex LSCBs will be looking to see if organisations that provide services for children, parents or families, or work with children, have in place the following:

clear priorities for safeguarding and promoting the welfare of children explicitly stated in key policy documents and commiss ioning strategies;

a clear commitment by senior management to the importance of safeguarding and promoting children’s welfare through both the commissioning and the provision of services;

a culture of listening to and engaging in dialogue with children – seeking their views in ways appropriate to their age and understanding, and taking account of those both in individual decisions and the establishment or development and improvement of services;

http://www.legislation.gov.uk/uksi/2006/90/regulation/5/made


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a clear line of accountability and governance within and across organisations for the commissioning and provision of services designed to safeguard and promote the welfare of children and young people;

recruitment and human resources management procedures and commissioning processes, including contractual arrangements, that take account of the need to safeguard and promote the welfare of children and young people, including arrangements for appropriate checks on new staff and volunteers and adoption of best practice in the recruitment of new staff and volunteers;

a clear understanding of how to work together to help keep children and young people safe online by being adequately equipped to understand, identify and mitigate the risks of new technology;

procedures for dealing with allegations of abuse against members of staff and or, for commissioners, contractual arrangements with providers that ensure these procedures are in place;

arrangements to ensure that all staff undertake appropriate training to equip them to carry out their responsibilities effectively, and keep this up to date by refresher training at regular intervals; and that all staff, including temporary staff and volunteers who work with children, are made aware of both the establishment’s arrangements and their responsibilities for safeguarding and promoting the welfare of children;

policies for safeguarding and promoting the welfare of children (for example, pupils/students), including a child protection policy, effective complaints procedures and procedures that are in accordance with guidance from the local authority and locally agreed inter-agency procedures;

arrangements to work effectively with other organisations to safeguard and promote the welfare of children, including arrangements for sharing information; and

appropriate whistle-blowing procedures and a culture that enables issues about safeguarding and promoting the welfare of children to be addressed.

4. Section 11 self-evaluation toolkit The self-evaluation toolkit includes the following parts:

Part 1: Guidance for completing the section 11 audit tool

Part 2: Section 11 audit tool

Part 3: Section 11 action plan The toolkit will be issued to named individuals by the LSCB Business Manager on behalf of the West Sussex LSCB and should be returned within three months of its receipt.

Further Information If you have any questions, please contact Shona McMinn, LSCB Business Manager.


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1. How to complete the section 11 audit tool The s11 self-evaluation exercise covers nine key areas. Within each of these areas there are a number of standards that the agency should meet.

To complete the tool, evidence should be given that would demonstrate how your agency meets each of the standards. Below are

some examples, which may help you when thinking about how to evidence the ways in which your organisation complies with s11. They are intended as a guide only and are not an exhaustive list.

It is important that the evidence you provide is detailed enough to enable any follow-up work to identify quickly the protocols, guidance or systems that are referred to in the evidence. Any documentary evidence, eg job descriptions, policies, procedures, should be

embedded into the relevant section in the tool. Use the self-assessment rating (section 2) given below to rate how well the organisation meets individual standards within each of

the areas.

The s11 self-evaluation is a supportive process allowing each agency to identify the standards that they meet and those where further actions are needed. If, when completing the tool, you identify areas where your organisation is not complying fully with a standard, please paste this into the action plan (part 3) and fill in the steps needed to meet the standard and the timescales this will be achieved within.

2. Self-assessment RAG rating

The traffic light system relates to how an organisation assesses itself against achieving the minimum standard. If your organisation assesses itself, as red or amber, areas for development need to be recorded along with a timescale for completion on the separate action plan. It is worth noting that the scope of this model does not allow the demonstration of exceeding the minimum requirements. A score of ‘green’, therefore, is understood to mean that the organisation meets the required minimum standard.

RED Indicates that processes are lacking and need to be developed as a matter of urgency in order to meet minimum requirements for a specific standard.

AMBER Indicates that processes are in place but they need to be reviewed or further improved for a specific standard.

GREEN Indicates that the agency meets the standard fully with all processes in place and up to date, at least to the required minimum.

Part 1: Guidance for Completing the Section 11 Audit Tool


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3. Examples of evidence that can be used to demonstrate compliance with section 11 standards 1) Senior management commitment to the importance of safeguarding and promoting children’s welfare

Evidence: 1.1 The name of the person; they are named within the organisation’s child protection policy. 1.2 The role of the designated lead with safeguarding responsibility is advertised regularly, including their job role; regular promotion of role

within and external to organisation; named in safeguarding policies. 1.3 The job description of the designated lead contains roles and responsibilities in relation to safeguarding and promoting welfare of children

and young people; details of the regular training and supervision that they receive. 1.4 Routine audit and evaluation of work undertaken within agency to safeguard and promote the welfare of children, action planning and

implementation to improve standards. 1.5 Checks are made by the commissioning body; relevant information is included in contracts. 2) A clear statement of the agency’s responsibilities towards children is available for all staff

Evidence: 2.1 Child protection policies and procedures are in place and the date of the last review. 2.2 How safeguarding policies/procedures are disseminated to staff (eg in newsletters, emails, inclusion in team meetings, staff training); the

format of the policies/procedures in the workplace and staff’s access to these; policies and procedures are made available to all staff, volunteers, students, trustees and senior managers.

2.3 The names of the e-safety policies that are in place (these should include an e-safety policy and acceptable use policies, one for staff, one for children/young people); e-safety is included within CP procedures; the date of the last review of policies and procedures.

2.4 The organisation has clear complaints and whistle-blowing procedures for service users and staff; these procedures are understandable and easy to follow; how these procedures have been distributed and disseminated; evaluations/audits of the use of the complaints system; information on the expected timescale for responses to complaints; examples/reviews to demonstrate that complaints procedures have been used by adult and child service users and staff; evidence of guidance on how to make a complaint written in child-friendly language and format, eg leaflets, web pages, DVDs, etc.

3) A clear line of accountability within the organisation for work on safeguarding and promoting the welfare of children

Evidence: 3.1 Name of the framework and when this was last reviewed; details of what the framework includes; safeguarding structure document;

evidence of how staff are made aware of this. 3.2 The name of the person to whom each staff member is accountable is documented in staff procedures/welcome pack; examples

demonstrating that staff are aware of the level of accountability they have.


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3.3 Job descriptions and person specifications in place that recognise responsibilities for safeguarding and child protection. Clear written accountability framework that covers individual, professional and organisational accountability and which is widely disseminated.

4) Service development takes account of the need to safeguard and promote welfare and is informed, where appropriate, by the views of children and families.

Evidence: 4.1- Interventions take place at an early point when difficulties and problems are identified; the wishes and feelings of children are 4.4 taken into account in decisions that relate to them; racial heritage, language, religion, faith and disability are taken into account when

working with a child and their family; equality of access to services is monitored, audits undertaken of awareness of thresholds for intervention. Staff feedback is considered in relation to the quality of service provision, e.g. through supervision, training, online methods, questionnaires, forums, etc.

5) Staff training on safeguarding and promoting the welfare of children for all staff working with, or, depending on the agency’s primary functions, in contact with children and families.

Evidence: 5.1 Outline of the induction process and training for new starters; information that is included in an induction folder for new starters; information

on the content of induction training and that it meets all the requirements. 5.2 A record is kept of numbers and percentages of staff who have undertaken training on child protection and who holds this record. 5.3 Details of training available for staff, including multi-agency training; details of training pathways. 5.4 Details of e-safety training and who can access it; staff have a training pathway. 5.5 There is guidance regarding individual or group supervision; evidence that senior managers monitor supervision; the information that staff

receive about any further support that is available. Supervision and management processes are sufficiently challenging. 5.6 How the recommendations from serious case reviews are shared with staff, eg newsletters, staff email updates; evidence of updating staff

about changes to statutory requirements and how this is achieved; examples of how the most recent recommendations/requirements have been shared.

6) Safer recruitment

Evidence: 6.1 A safer recruitment policy is in place. 6.2 Safer recruitment training is provided; records of recruitment panels are maintained by the organisation, including which member on the

panel had completed safer recruitment training; audits of recruitment panels to evaluate compliance.


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6.3/4 Policies and protocols in place which outline the checks to be made before a person is appointed; staff personnel files document all the listed checks that were undertaken and the outcomes of these; audits of personnel files to ensure checks are being carried out appropriately; guidance for commissioned service providers specifying their responsibilities.

6.5 Organisational guidance, policy; name of officer responsible for referral; examples of the work being undertaken. 6.6 Name of the senior officer. 6.7 Information on the procedures used by the organisation when dealing with allegations against staff and volunteers, eg those developed in-

house or county-wide procedures. 6.8 Where incidents are recorded (it is expected that incidents are recorded and stay on individual personnel files for ten years or until

retirement, whichever is longer); retention periods for personnel file (eg provide retention schedule for relevant records). 7) Effective inter-agency working to safeguard and promote the welfare of children

Evidence: 7.1 That a senior officer attends meetings, or sends a deputy. Officers attend operational executive and/or other LSCB sub-groups regularly. 7.2 Policies used to support inter-agency working; where these are located and steps taken to ensure staff are aware of and working to these

policies, eg terms of reference. 7.3 Staff working with children and families attend meetings/panels in relation to individual children, for example, core groups, child protection

conferences, child-in-need meetings, etc. 7.4-7.5 Training and guidance for staff (covers when to make referral and when and how to complete a CAF or Early Help Plan and when to refer

to children and family services). 7.5 Participation in serious case, multi-agency and partnership reviews; if not needed in previous reviews, then this should be documented with

any evidence of involvement in internal reviews/procedural reviews. 7.6 - The procedures in place to cover the aspects listed. 7.7 8) Information Sharing

Evidence: 8.1 Details of the guidance used. 8.2 How guidance and training on information sharing are made available to staff (both at induction and for existing staff). 8.3 Training or guidance available for staff and managers; staff know where to go if they have a query or concern about information sharing. 8.4 Consent to share information and situations when consent is not needed are covered in the training and guidance issued; evidence of

consent and information sharing covered in supervision or appraisals. 8.5-8.6 Outline details of record keeping and information security policies and how they are disseminated to staff; the organisation has a record

retention policy with appropriate retention periods for client and personnel files.


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9) Recognition and response to risk (this is a new section, not previously in the 2012 self-evaluation). Evidence: 9.1 Policies for safeguarding and promoting the welfare of children and young people are compatible with the LSCB’s guidance relating to child sexual exploitation (CSE); preventative work through awareness raising activities or therapeutic outreach, including appropriate literature to target vulnerable young people (eg missing young people) and people whose work places them in a position where they will notice and could report worrying behaviours; codes of practice for staff with direct contact with children/young people at risk of CSE; procedures for reporting safeguarding concerns specifically mention CSE. 9.2 Managers and frontline staff attend LSCB training, or the safeguarding training and refresher training provided by the organisation includes an awareness of CSE, recording and retention of information, gathering evidence and information sharing. 9.3- Guidance/polices; steps taken to ensure staff are aware of and working to policy/guidance on CSE, eg via quality assurance (QA) activity 9.5 or framework. For example, case file audits evaluate whether professionals know when/how to seek help and advice on CSE; they are aware of local protocols; they know how to recognise when a child is at risk of CSE or is being exploited and understand the thresholds and timing for referral; they understand the routes and organisational procedures for referral; they know how to identify concerns about adults who may be perpetrators of sexual exploitation. If relevant, audits also evaluate whether staff know how to monitor online spaces where they have suspicions that a child is being groomed online and whether staff are aware of local geographical areas or locations that perpetrators tend to use to target potential victims. QA activities evaluate whether assessments that address needs and welfare issues relating to children and young people always consider whether the risk of CSE could be a factor and put in place targeted support to minimise risks; work is linked to the response to vulnerable young people, eg missing young people, children regularly absent from education, looked after children, young people misusing substances, etc and to other public protection issues. QA activities evaluate attendance at multi-agency meetings in relation to individual cases; intervention as part of an agreed package of support for someone who is at risk of or suffering sexual exploitation; complying with requests for assistance from the police and other agencies, for example in helping to disrupt activity; proactive information sharing in the best interests of the child. Attach relevant guidance and QA documents to the return.

9.6 Details of the guidance used; how guidance and training are made available to staff; quality assurance activity to ensure compliance with guidance (attach relevant documents as evidence).


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4. Analysis of agency responses and reporting to the Board Each Sussex LSCB will collate responses from organisations participating in the s11 self-evaluation for their area and prepare a report for submission to the Board. The report will look at how well the LSCB area as a whole demonstrates that it can meet each s11 standard. In order to assess LSCB area-wide compliance with standards, the following convention will be used to give an overall RAG rating for each standard for the LSCB as a whole, based on the responses of the participating agencies.

RED More than a third of the agencies (> 33%) taking part rated a specific standard AMBER or RED.

AMBER Between 20 to 33% of agencies rated a specific standard AMBER or RED.

GREEN All agencies rated a specific standard GREEN or only less than 20% of the agencies rated a specific standard AMBER or RED.

For example, if 12 agencies participated in the self-evaluation exercise for the LSCB, and three of the agencies rated themselves ‘amber’ and two rated themselves ‘red’ for standard 6.2 (five agencies in total - 42%), the overall rating for the LSCB as a whole for this standard would be ‘red’. If three of the agencies (25%) rated themselves ‘amber’ or ‘red’ for standard 2.3, the overall rating for the LSCB for this standard would be ‘amber’. If two agencies (17%) rated themselves ‘amber’ or ‘red’ for standard 1.5, the overall rating for the LSCB for this standard would be ‘green’. Individual agency action plans will be monitored periodically by the LSCB and progress reported to the Board until all standards are rated ‘green’ for the LSCB as a whole. In addition, individual agency responses may be audited by other LSCB members in order to provide greater scrutiny through peer review.

The s11 self-evaluation is repeated every two years. Therefore, agencies will be asked to show progress on any standards that had a final rating of ‘amber’ or ‘red’ at the previous self-evaluation.


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Deadline for return of completed audit tool:

Wednesday 30th April 2014

Please return completed audit tool to:

Shona McMinn, LSCB Board Manager, Children’s Safeguarding Unit, Room 24, Durban House,

Durban Road, Bognor Regis, PO22 9RE

External: 0330 222 6686 or Mobile 07702 444045 | E-mail: [email protected]

Name of agency completing audit:

Surrey & Sussex Healthcare

Person responsible for completing

audit:

Sally Stimpson

Contact details:

01737 768511 x 2642

Date of completion/return:

30/04/14

This self-evaluation has been accepted by Fiona Allsop, Chief Nurse who will be responsible for ensuring that the recommendations are implemented and reviewed.

Signature of CEO/Director Insert electronic signature

Part 2: Section 11 Audit Tool

mailto:[email protected]


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STANDARD 1: Senior management commitment to the importance of safeguarding and promoting children’s welfare

Standard the organisation needs to meet

Evidence that the standard has been met, maintained or improved

Final RAG rating in 2012

RAG rating in 2014

Further action needed to meet the standard

1.1 There is a designated lead with overall responsibility for safeguarding throughout the organisation.

Executive Lead for Safeguarding in post. Named Doctor, Nurse and Midwife in post.

Green Green

1.2 Staff are made aware of who the

designated lead for safeguarding is within the organisation.

Through training and via intranet Green Green

1.3 The designated lead for safeguarding has a job description which clearly defines their

roles and responsibilities in relation to safeguarding and promoting the welfare of children and young people; they receive

training and supervision in relation to this role.

Identified in job description Green Green

1.4 Systems are in place to ensure the agency monitors and quality assures

implementation and compliance of child protection and safeguarding standards.

Weekly multidisciplinary safeguarding meetings held and recorded.

Monthly safeguarding peer review meetings. Rolling audit programme.

Amber Amber Ongoing audits to be completed as part of plan. 2 audits underway at

present. 1. Audit of safeguarding notes. 2. Audit of all <1’s attending AE

1.5 When commissioning a service from

another organisation, there are robust mechanisms in place to ensure that they are compliant with s11 requirements

regarding safeguarding and promoting the welfare of children.

N/A N/A N/A


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STANDARD 2: A clear statement of the agency’s responsibilities towards children is available for all staff




RAG rating in 2014


2.1 The agency has written safeguarding policies and procedures that are reviewed regularly (at least every 3 years).

Policy in place and available on the intranet for all staff to access. For review August 2016

Green Green

2.2 All staff and volunteers are made aware of

the safeguarding policies and procedures and how they are applied in practice.

Through training programme Green Green

2.3 The agency has written e-safety policies and procedures that are reviewed regularly.

Internet safety policy in place. Was due for review in 2012

Green Amber Policy to be reviewed

2.4 Effective systems are in place for staff and

service users (adult and child) to make a complaint or for whistle-blowing where they have concerns that action to safeguard has

not been followed in accordance with the agency’s procedures.

Policy in place. For review July 2015 Green Green


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STANDARD 3: A clear line of accountability within the organisation for work on safeguarding and promoting the welfare of children




RAG rating in 2014


3.1 The organisation has a clear accountability framework which covers individual,

professional and organisational accountability for safeguarding children; all staff are aware of the framework.

Organisation wide Policy for Safeguarding and Promoting the Welfare

of Children.

Green Green

3.2 Staff understand to whom they are directly

accountable with regard to child welfare and the level of accountability they have.

Through training and intranet Green Green

3.3 Job descriptions explicitly recognise responsibilities for safeguarding and

promoting the welfare of children. These are explicit about the individual, professional (eg codes of conduct of

professional bodies such as the Nursing and Midwifery Council, Health and Care Professions Council, etc) and

organisational (eg line management) responsibilities.

Job descriptions for Named Staff are explicit

Green Green


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STANDARD 4: Service development takes account of the need to safeguard and promote the welfare of children and is informed, where appropriate, by the views of children and families.




RAG rating in 2014


4.1 There are strategies and systems in place to secure the views of children and families

regarding service provision and service development.

Patient experience monitoring is in place Green Green

4.2 Information provided is in a format and language that can be easily understood by

all service users.

Information is available in different languages and prints

Amber Amber Information sharing leaflets to be available in other languages

4.3 There is an agency awareness and focus on preventative activities in order to reduce the likelihood of children suffering harm.

Promoting healthy children section of notes. Noticeboards in paediatric areas updated

with information.

Amber Amber Review documentation

4.4 There are strategies and systems in place to obtain the views of practitioners as to the effectiveness of agency business delivery

in preventative work as well as safeguarding and promoting the welfare of children.

Training strategy and audit programme Green Green


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STANDARD 5: Staff training on safeguarding and promoting the welfare of children for all staff working with or, depending on the agency’s primary functions, in contact with children and families.




RAG rating in 2014


5.1 An induction process is in place for all staff who have contact with children including:

a) familiarisation with child protection policies b) basic child protection training that

includes: i) how to recognise signs of abuse & neglect

ii) how to respond to any concerns iii) e-safety awareness

Training programme in place for all new staff. All new staff now receive Level 2

training. Training also includes recent issues such

as self harm, asphyxiation. Current SCR recommendations and review of lessons learnt from recent high

profile cases. Recognition of vulnerable families.

Amber Green

5.2 Records are kept of numbers and percentage of staff who have completed

induction and basic child protection training.

All induction training is captured on OLM database.

Figures reported bi -monthly at Trust Meeting

Amber Green

5.3 Additional training (both single- and multi-agency) is available for staff working with

children and young people appropriate to their role.

Training to Level 3 is now being offered in house with significant increase in staff

now being trained. Raised awareness across the Trust of appropriate training required.

All figures now being captured on OLM database and reported bi-monthly at Trust meeting

Green Green

5.4 E-safety awareness training is available for

staff working with children and young people.

E-safety discussed at training. Amber Amber To be formally included in

presentation at Level 2

5.5 All individuals who come into contact with children and young people on an individual

basis have regular, minuted management supervision and can access further support

Staff carrying a caseload of patient have documented supervision sessions. Other

supervision of staff is recorded in patient’s records in safeguarding notes.

Green Green


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STANDARD 5: Staff training on safeguarding and promoting the welfare of children for all staff working with or, depending on the agency’s primary functions, in contact with children and families.




RAG rating in 2014


when required; the work of frontline professionals is scrutinised and challenged effectively through the supervision

processes.

5.6 Staff are kept up to date with statutory requirements and findings from serious case reviews and inspections.

Updates discussed and included bi-monthly in Trust Safeguarding Meeting. Findings and recommendations

presented to staff in clinical and safeguarding meetings.

Amber Amber Trust safeguarding Action Plan to be available to all staff via intranet


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STANDARD 6: Safer recruitment and allegations management




RAG rating in 2014


6.1 Robust recruitment and vetting procedures are in place to help prevent unsuitable people from working with children.

Procedures in place which comply with NHS employers employment checks.

Green Green

6.2 Staff involved in recruitment are suitably trained, eg at least one member on the short listing/interview panel must have

been on safer recruitment training.

Staff attended safer recruitment training March 2014. Recruitment training for managers with specific training for

safeguarding.

Red Green

6.3 All staff who have contact with children, young people and families are properly

selected and have appropriate checks in line with current legislation and guidance:

References are always taken up

Identity and qualifications are verified

Face-to-face interviews are carried out

Previous employment history is checked

The appropriate type of criminal record check from the Disclosure and Barring

Service (DBS) is carried out for all eligible staff, eg enhanced with barred list checks for regulated activities

involving children and/or adults

Any anomalies or discrepancies are taken up

Repeat DBS checks are carried out according to organisational policy

Recruitment policy in place which follows NHS Recruitment Guidelines.

Audit of recruitment procedure undertaken in December 2013

Amber Green

6.4 Records are maintained detailing checks

carried out for employees.

Records maintained Green Green


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STANDARD 6: Safer recruitment and allegations management




RAG rating in 2014


6.5 Procedures and processes are in place to

notify the Disclosure and Barring Service (DBS) of relevant information so that individuals who pose a threat to vulnerable

groups can be identified and barred from working with these groups and ensuring the organisation does not knowingly employ

someone who is barred from working with vulnerable groups.

Procedures in place Green Green

6.6 There is a named senior officer with responsibility for dealing with allegations

against staff and volunteers.

Senior Officer in place Green Green Chief/Deputy Chief Nurse

6.7 There are written procedures for handling allegations against staff and volunteers.

Procedures in place in place Green Green

6.8 Incidents and allegations of abuse are recorded appropriately.

Recorded appropriately Green Green


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STANDARD 7: Effective inter-agency working to safeguard and promote the welfare of children




RAG rating in 2014


7.1 Strong strategic leadership in multi-agency working is demonstrated by regular attendance at LSCB meetings.

Attendance at meetings by Executive Lead and/or Named Staff

Green Green

7.2 Policies are in place locally to support

effective inter-agency working in individual cases. Staff have access to these policies.

Policies in place Green Green

7.3 Staff participate in multi-agency meetings and forums to consider individual children.

Staff arrange multiagency meetings and attend meetings when invited to do so

Green Green

7.4 Staff are able to identify children who would

benefit from additional services and require an Early Help Plan or CAF.

Staff identify children who would benefit

from additional services

Green Green

7.5 Staff are clear about the circumstances in which a referral to Children’s Services is

necessary.

Staff fully aware. Criteria for referring from AE, ward, maternity and NNU all now

available on the intranet.

Green Green

7.6 Staff participate in Serious Case Reviews (SCRs) and Multi-Agency and Partnership Reviews as and when required to do so.

Yes Green Green

7.7 The agency has a clear process for:

gathering the evidence required for

Reviews

embedding Review recommendations into practice

completing actions from Reviews within agreed timescales.

Yes, via the TSCC action plan Green Green


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STANDARD 8: Information sharing




RAG rating in 2014


8.1 The organisation has in place agency-specific guidance on information sharing that is in accordance with Government

guidance at both strategic and operational levels.

Policy in place. Green Green

8.2 This guidance and training are made available to existing and new staff as part

of their induction and ongoing training.

Through yearly Level 2 mandatory training and criteria for sharing

information available on the intranet for all staff to access

Green Green

8.3 All staff who come into contact with children understand the purpose of information

sharing in order to safeguard and promote children’s welfare.

Primarily through training programme.

Increasing numbers of information form generated yearly

Green Green

8.4 Staff are confident about what they can and should do under the law, including how to

obtain consent to share information and when information may be shared even though consent hasn’t been obtained.

Included in mandatory training at Level 2 and 3. Specific guidance given at

supervision sessions. Safeguarding team available for advice

Green Green

8.5 There is a clear and robust recording policy in place that ensures staff maintain an

accurate and clear record of their involvement with a child and family.

Audit currently underway of safeguarding notes

Amber Amber

8.6 Data and information are held appropriately and securely in line with government

guidance.

In place. New secure site for safeguarding photography.

Green Green


of 30

STANDARD 9: Recognition and response to risk (this is a new standard, not previously in the 2012 self-evaluation)


Evidence the standard has been met RAG rating in 2014


Child sexual exploitation (standards 9.1 to 9.5) is a current priority for all three Sussex LSCBs. 9.1 Your organisation is proactive in tackling

child sexual exploitation (CSE), focusing on prevention, early identification and intervention; this includes appropriate

policies or guidelines on responding to CSE and awareness raising and preventative education.

CSE included in Level 3 training to raise awareness

among staff who come into regular contact with children.

Not currently formally included in Level 2 training

Amber To consider inclusion in Level 2

training

9.2 Managers and frontline practitioners in your organisation are provided with training to

recognise key indicators of CSE.

Included in Multidisciplinary Level 3 training Green

9.3 Managers and frontline practitioners in your organisation know how to identify children

at risk of CSE or are being sexually exploited; they know what to do once risks are recognised.

Included in Multidisciplinary Level 3 training Green

9.4 The work to address CSE is integrated into the wider work of your organisation, including addressing risks of CSE in all

assessments.

CSE is not formally addressed in all assessments of children

Red To discuss further Named Dr and at TSCC

9.5 Your organisation works effectively with

other agencies to manage individual cases and to prevent and disrupt CSE.

No evidence that this has been met – no identified

cases as yet. Staff aware of importance and agencies to contact


of 30

STANDARD 9: Recognition and response to risk (this is a new standard, not previously in the 2012 self-evaluation)


Evidence the standard has been met RAG rating in 2014


Consideration of fathers and other significant adult males (standard 9.6) is a finding from local and national serious case reviews.

9.6 Your organisation has specific guidance for practitioners to consider fathers, male

partners and other significant adult males in the family in all assessments addressing the needs and welfare of children and

young people. Note: this is a standard about assessment in general, not specifically

about CSE.

This is addressed on safeguarding notes for all children. I have presented this as part of SCR recommendations at

recent meetings. This is now included in all Level 2 training.

Green


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Name of agency - Surrey and Sussex Healthcare Trust

No

Standard RAG

rating

Action

needed Timescale

Lead officer

and contact details

1.4

Systems are in place to ensure

the agency monitors and quality assures implementation and compliance of child protection

and safeguarding standards.

Amber

To Green

Audits in progress to monitor compliance. Audit of

safeguarding notes and audit of children attending Emergency Department currently in progress. On-

going rolling audit. 16/09/14 – Audits completed of safeguarding notes

and children attending Emergency Department. Also audit of children not being brought to

outpatient appointments completed August 2014 and following Savile recommendations audit to ensure children are not admitted to adult wards

completed September 2014. Audit of maternity safeguarding notes also completed in July 2014.

6 months

Sally Stimpson

01737 768511 ext 2642

2.3

The agency has written e-safety

policies and procedures that are reviewed regularly.

Amber

to Green

Policy to be reviewed. In place but has expired.

16/09/14 Policy reviewed and in date May 2014. E safety addressed in Information Governance

training and safeguarding children training at levels 2 and 3.

6 months Sally Stimpson/IT

Dept 01737 768511 ext 2642

4.1 . There are strategies and Amber Patient experience survey due to start in Paediatric 6 months Sally

Part 3: Section 11 Action Plan


of 30


No

Standard RAG rating

Action needed

Timescale

Lead officer

and contact

details

systems in place to secure the

views of children and families regarding service provision and service development.

areas in next few months.

In process of reviewing possible ways to receive feedback from children’s safeguarding cases from

parents and children 16/09/14 Patient feedback cards available in

paediatric areas including paediatric emergency department. Trust safeguarding committee

exploring use of alternative ways of obtaining feedback. Reviewing Birmingham Children’s Hospital use of an app to encourage feedback from

children and young people.

Stimpson/Joanne

Farrell 01737 768511 ext

2642

4.2

Information provided is in a format and language that can be easily understood by all service

users.

Amber to

Green

Information sharing leaflets to be made available in different languages.

16/09/14 Language line available for all trust staff to use. Importance of not using family interpreters

highlighted in Level 2 safeguarding training

6 months Sally Stimpson 01737 768511 ext

2642

4.3

There is an agency awareness and focus on preventative

activities in order to reduce the likelihood of children suffering harm.

Amber to

Green

Continuous updating of patient information boards. Emergency Department paperwork being reviewed,

health promotion section currently poorly located. 16/09/14 Preventative activities highlighted in all

levels of training. Paperwork will be reviewed at some point but will involve a complete redesign of

6 months Sally Stimpson/Lucie Gamman

01737 768511 ext 2642


of 30


No

Standard RAG rating

Action needed

Timescale

Lead officer

and contact

details

the paediatric accident and emergency paperwork

which is not currently a priority for that department. Patient information boards are regularly updated

with current information to reduce likelihood of children suffering harm.

5.4

E-safety awareness training is available for staff working with

children and young people

Amber to

Green

To include formally in Level 2 mandatory training.

16/09/14 Is now included in Level 2 training. Is also covered in Trust Information Governance training

2 months Sally Stimpson 01737 768511

5.6 Staff are kept up to date with

statutory requirements and findings from serious case reviews and inspections.

Amber Updates being presented in clinical safeguarding

meetings. Attending serious case review learning events. Include reviews and lessons to be learnt in

mandatory training, Level 3. Discuss updating intranet with Trust Safeguarding Children’s action plan.

16/09/14 Lessons from local Serious Case Reviews from Surrey and Sussex have been specifically

presented to staff in key areas. These have included CSE and bruising in non-mobile children.

policy for bruising on intranet. CSE policy to be discussed for addition to hospital intranet.

3 months Sally Stimpson 01737

768511 x 2642

8.5 There is a clear and robust recording policy in place that

ensures staff maintain an accurate and clear record of

Amber

to Green

Audit of documentation standards as part of 1.4.

16/09/14 Audits have been completed and provided


768511 x 2642


of 30


No

Standard RAG rating

Action needed

Timescale

Lead officer

and contact

details their involvement with a child

and family assurance that accurate record keeping is being

maintained. Specific deep dive audit of safeguarding notes by Surrey CCG in February

2014 identified notes reviewed to be outstanding and good.

9.1 Your organisation is proactive in tackling child sexual exploitation

(CSE), focusing on prevention, early identification and intervention; this includes

appropriate policies or guidelines on responding to CSE and awareness raising and

preventative education.

Amber Level 3 training November 2014, speaker arranged to focus on CSE.

Discuss changing Level 2 training to include in programme.

Guidelines and policies to be discussed and uploaded onto intranet.

16/09/14 CSE information now included on Level 2 training and delivered to all trust staff. Ad hoc

training given in key areas including Emergency Department, Paediatrics and Maternity. To work in developing guidelines for intranet.

6 months Sally Stimpson/Catherine

Greenaway/Majeed Jawad 01737 768511

x 2642

9.4 The work to address CSE is

integrated into the wider work of your organisation, including addressing risks of CSE in all

assessments.

Red to

Amber

Discuss with Named Drs and TSCC addressing

CSE in all assessments.

16/09/14 Through training, information about CSE is being integrated into the Trust. CSE is not formally documented in all assessments of children

but staff working in key areas are being trained to recognise vulnerable children, being made aware


768511 x 2642


of 30


No

Standard RAG rating

Action needed

Timescale

Lead officer

and contact

details

of questions that need to be asked to children and

young people with regard to CSE and signs to look for that may raise concern and what to do with

information they obtain.

9.5 Your organisation works effectively with other agencies to manage individual cases and to

prevent and disrupt CSE.

Red to Green

No evidence that this has been met – no identified cases as yet. Staff aware of importance and agencies to contact

16/09/14 Named Nurse has been working with

other agencies to learn how manage individual cases, prevent and disrupt CSE. Has attended briefing and workshops in Surrey and Sussex and

applied to become a “CSE Champion”, with training by Surrey Police to continue to raise awareness of

CSE. Training at all levels now includes specific information on recognising, what to do and how to refer concerns regarding CSE.

Sally Stimpson 01737 768511 x 2642


of 30


No

Standard RAG rating

Action needed

Timescale

Lead officer

and contact

details

SECTION 11 Self-Evaluation Toolkit Guidance, Audit Tool and … · 2018-12-10 · Sussex LSCB...

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