1. . Safeguarding Adults update Protecting adults from abuse and neglect.

2. Margaret Panting (1923 to 2001) 78yrs Steven Hoskin (1967- 2007) 40 years

3. Care Act 2014 From April 1 st 2015. Protecting Adults will be Law. Section 14 of the Act No longer “vulnerable” adults definition.

4. The safeguarding duties; apply to an adult who: has needs for care and support (whether or not the local authority is meeting any of those needs) and; is experiencing, or at risk of, abuse or neglect; and as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.

5. Safeguarding (2005) - umbrella term; Empowerment - Presumption of person led decisions and informed consent. Protection - Support and representation for those in greatest need. Prevention - It is better to take action before harm occurs. Proportionality – Proportionate and least intrusive response appropriate to the risk presented. Partnership - Local solutions through services working with their communities. Communities have a part to play in preventing, detecting and reporting neglect and abuse. Accountability - Accountability and transparency in delivering safeguarding.

6. 10 Categories of Abuse Physical Abuse Neglect Discrimination Sexual abuse Financial abuse Psychological abuse Organisational abuse *Domestic Abuse *Modern Slavery *Self Neglect

7. Self- Neglect Definition: Self-neglect – this covers a wide range of behaviour; neglecting to care for one’s personal hygiene, health or surroundings and includes behaviour such as hoarding that causes a risk of harm. Cases of severe self-neglect require management of the balance between protecting the adult from self-neglect against their right to self-determination is a serious challenge. It is not unusual for people to refuse a particular form of care due to lack of insight into the need for intervention. Examples may be: A person sends away a home care worker who is tasked to do cleaning or prepare a meal. A person is incontinent but is reluctant to wear pads. A person with diabetes refuses their insulin injection. All cases of self-neglect recognised in the acute hospital must be referred to Safeguarding Adults Team.

8. 8 Responding to a Disclosure; Ask the Adult what they want to happen? Follow the Trust’s safeguarding flowchart. Outcomes could be; Ring Police. Adult protection referral. Increase in Package of care Referral to Domestic violence advocate Referral for GP or Community matron to follow up Referral to Adult social care for social worker for assessment.

9. Level 5 Level 4 Level 3 Level 2 Saf Level 1 Level Level 1 – universal services Level 2 – Case management, complaints, discharge planning. Level 3 – risk assessment, risk management, complex discharges. Level 4 – Adult Protection (referral to the Council) Level 5 – Safeguarding Adults Review (when adults die).

10. 10 Level 4 – Adult Protection (abuse and neglect) The Role of the Alerter/Referrer. RECOGNISE /RESPOND/REPORT If necessary call the police (abuse and neglect is a criminal offence). Ensure immediate safety of patient. Preserve forensic evidence Speak with your line manager – inform the patient – contact Trust’s safeguarding adults team. Hand write a report

11. 11

12. Adult Protection referrals against the Trust. * Poor discharges, no discharge information, no communication with those looking after the patient post discharge, and they are unable to communicate for themselves. * Not giving prescribed medication while an inpatient – patient here for 20 hours. *Patient sent home without recommencing Package of Care. Protection from abuse and neglect

13. 13 Organisational Abuse Mid Staffordshire hospital – public enquiry into the abuse at an acute general hospital. There was a failure; Focus on quality Failure to listen to patients Failure of the role of the regulator.

14. 14 Organisational Abuse continued Mid Staffordshire hospital – public enquiry of the abuse in the acute general hospital. Although, no specific reference to safeguarding; safeguards have been instigated to prevent another mid staffs. Francis emphasises the importance of Candour, Openness and Transparency for hospitals. Focus on listening to patients. CQC have improved their inspections, so there is focus on Quality. Raising Awareness in the Public Interest policy.

15. Safeguarding Adults Named Nurse Zoe Cooper – 01872 252446 - Bleep 3048

16. Email. Learning.disabilities@cornwall.nhs.uk For Out of hours leave referrals on answer phone the clinical site co- ordinators. Acute Liaison Nurses for Learning Disabilities and / or Autism. Daniella Rubio-Mayer 07827 903729 Bleep 3054 Tristan Coombe 07827 903729 Bleep 3095 Jane Rees 07765 221848 Bleep 3053 Learning Disabilities and Autism

17. F or deliberate self harm, mental health assessments or urgent mental health concerns contact the Psychiatric Liaison Team via: Bodmin Hospital Switchboard Ext 1300 For out of hours support contact the Clinical Site Co-ordinators via Switchboard. F o r s u p p o rt, a d vi c e a n d in fo r m at io n w it h re g ar d s to p at ie nt s w it h a di a g n o s e d o r s u s p e ct e d m e nt al ill n e s s o r c o n c er n s w it h re g ar d to a p at ie nt s m e nt al c a p a ci ty c o nt a ct : Lerryn Hogg - Specialist Nurse for Mental Health and Wellbeing and Mental Capacity Via: Ext 2446 or Mobile 07789 876247 Lerryn.hogg@rcht.cornwall.nhs.uk Lerryn.hogg@rcht.cornwall.nhs.uk Mental Health and Mental Capacity

18. Independent Domestic Violence Advocate (IDVA) The IDVA is based at RCHT in the safeguarding adults team Anna Onslow - 07435 752497 Out of Hours leave a message or contact REACH on: 03007774777

19. Ground Rules Confidentiality Be sensitive to the views and experiences of others – Challenge the opinion not the person Any personal issues around this subject please contact us after the session – or use following contact number/links; REACH Project – 01872 241711 www.twelvescompany.co.uk

20. Definition of Domestic Abuse “Any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality. This can encompass, but is not limited to, the following types of abuse: psychological physical sexual financial Emotional New Government Definition 2013 “Any incident or pattern of incidents of controlling, coercive or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality. This can encompass, but is not limited to, the following types of abuse: psychological physical sexual financial Emotional New Government Definition 2013

21. “Central to the capability required of all NHS staff is the ability to understand the risk factors for, and recognise the signs of, violence and abuse – not all of which are obvious. Clinicians should be more open to the possibility that violence or abuse is an underlying cause of the problems of the patient in front of them.” [Role of NHS Taskforce Report]

22. Some Stats/facts We know that there are 7,000 plus Domestic Violence incidents reported to the police in Cornwall each year. We know that over 50% of Domestic Violence victims don’t report to the police.

23. 1 in 4 women and 1 in 6 men will experience DA in their lifetime 2 women each week are killed as a result of DV 35 – the number of times on average that a woman is assaulted before she will report to the police A victim will present in E.D approx 30 times before they are killed 3 women a week kill themselves as a result of DA, a further 30 try to. 90% of children are in the same or next room when DA takes place.

24. Scenario Girl meet boyfriend at 15 years old. She was now 18 years. IDVA met her in ED (Risk assessment). Partner very controlling, take her to work, tell her what clothes to wear, monitor phone calls (high risk factors). IDVA assessed young girl as high risk - She was at risk of significant harm or death. She referred her to MARAC meeting. MARAC plan; alert on address, and IDVA remained in telephone conversation with victim at work, giving support and advice.

25. MARAC Multi-Agency Risk Assessment Conference Victims referred to a MARAC are of the highest risk with the potential to sustain imminent and serious injury, or to be killed. Monthly meetings which take place in each local area. Currently chaired by the police. Statutory and Voluntary agencies work together to discuss reducing risk and increasing safety for victims of DA. The MARAC considers the HIGHEST risk cases in order to develop a coordinated safety plan. This plan may include protection/help for any children or adults (including the perpetrator) at risk. MARAC ALERT SYSTEM IN HOSPITAL Victims referred to a MARAC are of the highest risk with the potential to sustain imminent and serious injury, or to be killed. Monthly meetings which take place in each local area. Currently chaired by the police. Statutory and Voluntary agencies work together to discuss reducing risk and increasing safety for victims of DA. The MARAC considers the HIGHEST risk cases in order to develop a coordinated safety plan. This plan may include protection/help for any children or adults (including the perpetrator) at risk. MARAC ALERT SYSTEM IN HOSPITAL

26. Why Don’t they leave? Thinking he/she will change Fear – afraid of repercussions/Threats Don’t want to leave the family home/area/work Don’t want to disrupt the children Nowhere to go/Finances Love & Attachment (Stockholm & trauma bonding) Family/religious pressure not to leave/Shame Believing the violence has been a ‘one off’ Previous experience of reporting/seeking help – police/social care involvement

27. To Work effectively with victims of Domestic Abuse, we MUST have an understanding of why people remain in abusive relationships or don’t seek help. You tube link; Leslie Morgan Steiner; Why DV victims don’t leave.

28. Safety Never ask about domestic violence when anybody else is present – this includes partners, older children and other members of the family. You should try and find a way of seeing the patient alone even if they insist on someone else staying with them. Ensure privacy – make sure that you cannot be overheard. Never advise a person to leave their partner; victims are at high risk of injury or murder when they leave a violent partner.

29. Some Possible Indicators of Domestic Abuse Late booking/non-attendance at clinic appointments Repeated attendances Non-compliance with treatment regimes/early or self discharge Minimisation of signs of violence on the body Repeat presentation with depression, anxiety, self harm, psychosomatic symptoms Constant presence of partner at examinations who may answer for the patient and be unwilling to leave the room Patient is evasive or reluctant to speak in front of or disagree with her/his partner

30. Health Based Scenario https://www.youtube.com/watch?v=WgWbPK1L_v0 What would you do? What risk factors can you identify?

31. Case Study - ‘Mary’ 74 year old woman admitted to RCHT June 2013 following assault by husband - disclosed to health staff. Engaged with IDVA; Risk assessment, Safety Plan, MARAC and Adult safeguarding discussed (not ready to leave relationship). No report to police as fearful of being judged for alcohol use. On discharge from RCHT, referral into MARAC and Safeguarding Alert made – processes used to safeguard without raising risk– agreed Social worker would not alert abuser to DA disclosures but use health issues as reason for intervention with whole family. Mary re-admitted to RCHT again Mar 2014 – further disclosures of DA, fear levels increased, IDVA liaised with Social worker to ascertain patterns of continued controlling behaviour. With Marys consent IDVA, social care and partner agencies worked together to increase Mary’s confidence and find her alternative, safe, supported housing. Fear levels have decreased, minimal SAFE contact has been maintained with her family.

32. Further Training If in your role you are required to have Child Protection level 3; You must have Domestic Abuse, Stalking and Harassment and Honour Based Violence (DASH) awareness training - 1 day training. Please contact lucy@twelvescompany.co.uk lucy@twelvescompany.co.uk

33. The Mental Capacity Act 2005 The Mental Capacity Act (The Act) 2005 came into force in England and Wales in 2007. The Act provides a statutory framework for assessing whether a person, aged 16 or above, has the mental capacity to make certain decisions ‘…a person lacks capacity in relation to a matter if at the material time he is unable to make a decision for himself in relation to the matter because of an impairment of, or disturbance in the functioning of, the mind or brain.’

34. https://www.youtube.com/watch?v=syhKx6pxkxw

35. The 5 Principles of the MCA 1.3. 2.5. 4.

36. Decision Maker The decision maker is the person proposing the treatment or intervention. Anyone may be a decision maker and anyone can assess capacity, for example: Wash and shave – Healthcare assistant Catheter insertion – Nurse Surgery – Consultant Discharge package or care / location – Onward Care Blanket statements such as “Mr Smith lacks capacity” or “Mr Smith does not have capacity to decide on treatment” are not acceptable. Mr Smith maybe able to consent to some treatment but not others.

37. Level 1: Day to day decisions Activities of daily living, observations and simple diagnostic tests – record in nursing notes Level 2: More complex decisions Invasive procedures, complex diagnostic tests, treatments, self discharge – Level 2 MCA sticker Level 3: Significant decisions Serious medical treatment – Level 3 MCA form and Consent form 4 Assessing capacity

38. Level 2 stickers are available from EROS (CHA3065) Level 3 forms and Consent form 4s are available on the intranet

39. There are two questions to be asked if you are assessing a person’s capacity. This two-stage test must be used, and you must be able to show it has been used. Is there an impairment of, or disturbance in, the functioning of the person’s mind or brain? If so: Is the impairment or disturbance sufficient to cause the person to be unable to make that particular decision at the relevant time? Assessing capacity

40. A Person must be able to: Understand the information Retain the information Use or weigh the information Communicate the decision Failure on any one part indicates a lack of capacity to make the specific decision at that particular time Reasonable belief is sufficient

41. A decision made on the behalf of someone should always be in their BEST INTERESTS

42. Best Interest Decisions Consider if capacity may be regained in the future… if so wait! Consider the patients past and present wishes, beliefs and values Consult people who have an interest in the welfare of the patient Encourage the person to participate… even if they lack capacity Consider less restrictive options Do not solely base the decision on age, appearance or behaviour Do not be motivated by a desire to bring about the persons death

43. Independent Mental Capacity Advocates - IMCA IMCAs referrals must be made when: A person has been assessed as lacking capacity to make a major decision about serious medical treatment or a longer- term accommodation move and they have no family or friends to consult with Referrals can be made by telephone on 0845 2799019 or referral forms are available on the RCHT intranet or the SEAP website: www.seap.org.uk/imca

44. Deprivation of Liberty Safeguards The deprivation of liberty safeguards (DOLS) provide legal protection for those vulnerable people who are, or may become, deprived of their liberty within the meaning of Article 5 of the European Convention of Human Rights (ECHR) in a hospital or care home, whether placed under public or private arrangements. The safeguards exist to provide a proper legal process and suitable protection in those circumstances where deprivation of liberty appears to be unavoidable, in a person’s own best interests.

45. Eligibility The person is 18 or over The person assessed as suffering from a mental disorder The person has been assessed as lacking capacity to make decisions about their admission to hospital The person does not have any other existing authority for decision making in place which relates to the DOLS The person is not detained under the Mental Health Act (or could be e.g. 5/2) The person needs to be deprived of their liberty, in their best interests, to prevent harm to themselves

46. The way the a Deprivation of Liberty is defined changed significantly on the 19 th of March 2014 The Cheshire West Ruling ://www.youtube.com/watch?v=Nq1G9C7hKWk ://www.youtube.com/watch?v=Nq1G9C7hKWk Pre Cheshire West Intensity v Degree Clinicians judgement Compliance Post Cheshire West The ‘Acid test’

47. According to the law (specifically recent case law, known as Cheshire West) the ‘acid test’ to determine if there is a Deprivation of Liberty is: - Does the person have a mental disorder? "mental disorder means any disorder or disability of the mind" MHA 1983 (amended 2007) - Is the patient under continuous supervision and control and not free to leave? Due to the hospital environment all patients in an acute hospital are under continuous supervision and control.

48. Whether the person is trying or able to leave and the purpose of the treatment is not relevant… “A gilded cage is still a cage” If the patient meets the acid test they are deprived of their liberty and this must be authorised by law. As a result many patients who would not have been considered for DOLS prior to the Cheshire West judgement are now, according to the law, Deprived of their Liberty.

49. It is the responsibility of the clinical team caring for the patient to apply for a DOLS authorisation. The DOLS application forms can be found on the RCHT website, the ‘Sister’s shelf’, or requested form the RCHT Safeguarding adults team. Completed DOLS applications must be sent to both: dolsapplication@cornwall.gov.uk RCHT.Dols@Cornwall.NHS.UK Trust signatories for DoLS forms are: Medical staff (ST3 and above), Ward Managers, Nurse in Charge, Matrons, Site Coordinators and Specialist Nurses

50. The patient must have a Mental Capacity Assessment indicating they lack the capacity to consent to their admission The patient and their NOK must be given a letter informing them about the DOLS and an accompanying information leaflet. The Trust has a legal duty to provide this information. The patient must also be given a verbal explanation and this should be documented in the medical records. All the paperwork required will be emailed in response to an application, it can also be found on the RCHT intranet, ‘Sister’s Shelf’ or requested form the adult safeguarding team.

51. We are here to help! Various tools are available on the RCHT intranet to support the correct application of the Mental Capacity Act For advice and support contact: Lerryn Hogg - Specialist Nurse for Mental Health and Wellbeing Ext 2638 Mobile 07789 876247 GroupWise: Lerryn.hogg@rcht.cornwall.nhs.ukLerryn.hogg@rcht.cornwall.nhs.uk Out of Hours contact the Clinical Site Co-ordinators

52. Mental Health Awareness

53. Definition of Mental Health “Mental health is a state of well-being in which every individual realises his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.” "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.“ 2014

54. True or False? 1.1 in 10 adults will experience a mental health problem in any given year 2.1 in 10 young people will experience a mental health problem in any given year 3.People with mental health illnesses are usually violent and unpredictable 4.Discrimination against people with mental health problems has reduced significantly in recent years

55. Mental Health in RCHT ¼ of acute inpatients have mental health problems Patients with a physical illness are up to 4 times more likely to develop a mental illness Patients admitted to a acute setting have a 28% chance of also having a diagnosable psychiatric disorder (NHS Confederation 2009)

56. 41% of patients admitted to a acute setting have symptoms of anxiety or depression Treating the mental health needs of acute inpatients has a direct impact on the recovery of their physical health Most patients who frequently re-attend the Emergency Department do so because of an untreated mental health problem (NHS Confederation 2009) Mental Health in RCHT

58. What should you do? Assess for risk of suicide or harm Listen nonjudgmentally Give reassurance and information Encourage appropriate professional help Encourage self-help and other support strategies

59. Mental Health Act 1983 The Mental Health Act 1983 provides a legal framework for the detention of people who are deemed to be suffering from mental disorders. ‘Mental disorder’ means any disorder or disability of the mind The powers within the Act are mainly used to assess and treat these disorders. Only a small proportion of people with mental health issues will ever be detained under the Act

60. Sections of the MHA The most commonly Used sections of the MHA are: Section 5(2): Doctors Holding Power – 72 hours Section 136 and Section 135: Police power – 72 hours Section 2: Admission for assessment – 28 days Section 3: Admission for treatment – 6 months Section 17: Leave of absence – as prescribed

61. If you would like more support, information or bespoke training with regards to any aspect of mental health contact: Lerryn Hogg Specialist Nurse Mental Health and Wellbeing Contact: ext 2638 or 07789 876247 Lerryn.hogg@rcht.cornwall.nhs.uk Psychiatric Liaison Team Contact: ext 1300, Bodmin Hospital Switchboard Out of hours: Clinical Site Co-ordinators Contact: via Switchboard. Lerryn.hogg@rcht.cornwall.nhs.uk

62. . Safeguarding Adults Level 2 Protecting adults from abuse and neglect.

63. Recognising and responding to potential abuse and neglect scenarios

64. The Law Everyone is entitled to the protection of the law and access to justice. Conduct that amounts to neglect and abuse such as physical or sexual assault or rape, psychological abuse or hate crime, wilful neglect, unlawful imprisonment, theft and fraud and some forms of discrimination can constitute specific criminal offences under various legislation. (reference Care Act: Section 14.70) Practitioners and managers who suspect that a adult has been the victim of criminal behaviour or is at risk must, therefore, inform the Police immediately. If you are aware of somebody whose health and/or safety is at immediate risk due to physical illness or injury then you should phone 999 and ask for the Police in the case of immediate safety (such as threats of violence.)

65. Scenario 1 89 year old lady presents to the ward assaulted with a glass bottle and frying pan by the friend she lived with, she demonstrated varying capacity for different decisions. What would you do? What is your safety plan? What level using the threshold guidance? What other agencies might you involve? Does this fit any categories of abuse? Does the patient fit definition for safeguarding duties?

66. Scenario 2 Gentleman in 50’s presented unwell on a number of occasions. He is fit and well no disabilities, no cognitive impairment and not in receipt of any service. Finally blood results showed he had high toxic levels of rat poisoning in his blood. He said he didn’t know how this had happen, but didn’t want to report to police or let his partner know about it. How could you ensure his safety if he was not agreeing for help? Think about patient confidentially…Think about the risk to him and others What other agencies could you offer him? What is your safety plan? Does the patient fit definition for safeguarding duties? If he does; What level using the threshold guidance? What other agencies might you involve? Does this fit any categories of abuse?

67. Scenario 3 Husband brought wife with dementia into the emergency department (ED) with suspected arm injury after pushing her over, when she was trying to wash clothes in the toilet. Husband was remorseful. No injury noted and patient was medically fit for discharge straight from ED. Patient upset by ED environment, she didn’t understand why she was there. She was not showing any signs of being scared of husband. Who would you call for advice? What are the risks? Who could you call to find out additional background about home circumstances? Does the patient fit definition for safeguarding duties? What level using the threshold guidance? What other agencies might you involve? Does this fit any categories of abuse?

68. Scenario 4 You observe a patient’s son getting her to sign cheque for £300. Patient is confused while being treated for urine infection. You challenge the son about this; he says it is ok, as his mum has told her bank about him and he has access to her account. What is your safety plan? Does he really have access to her account? Does the patient fit definition for safeguarding duties? What level using the threshold guidance? What other agencies might you involve? Does this fit any categories of abuse? Is there another way to approach this other than making a Adult Protection alert or ringing the police?

69. Scenario 5 93year old patient arrived unconscious, son arrives to see her, stating her partner of 101 years has been overdosing her on her medication. What is your safety plan? Does the patient fit definition for safeguarding duties? What level using the threshold guidance? What other agencies might you involve? Does this fit any categories of abuse? What would you advise the son?

70. Scenario 6 You receive a phone-call from the fire crew that your patient is a hoarder and it took 16 crew to remove items from his house to get him out of the house and into ambulance. He is now medically fit for discharge and wants to go home, he refuses referral to adult social care for support. He has capacity to understand discharge home, no impairments, no disabilities and he may need services, but refuses. Who would you call for advice? What are the risks? Does the patient fit definition for safeguarding duties? What level using the threshold guidance? What other agencies might you involve? Does this fit any categories of abuse? Do you let the patient go home? Could you apply for a DOLs to keep him in hospital?

71. Scenario 7 Adult with mild learning disabilities arrives to emergency department with cut to his arm, you notice recent cigarette burns on his arm. You also remember seeing him in the department a number of times over the past few weeks. He is unkempt, and doesn’t want to call anyone for help or advice. Would you call anyone for advice? What are the risks? Who could you call to find out additional background about home circumstances? Does the patient fit definition for safeguarding duties? What level using the threshold guidance? What other agencies might you involve? Does this fit any categories of abuse?

72. Scenario 8 Elderly man brought to Emergency Department after grandson, who is his full time carer, took a bite out of his ear. The grandson has been arrested, and the patient who has capacity is upset and distressed by the incident. What is your safety plan? Who is now going to provide care after discharge? Does the patient fit definition for safeguarding duties? What level using the threshold guidance? What other agencies might you involve? Does this fit any categories of abuse? What support can you offer the patient?

73. Scenario 9 Patient under section 3 of Mental Health Act states her carer has been taking money from her. She has evidence from bank statements and the carer has her bank card. What would you advise would be the first action? Does the patient fit definition for safeguarding duties? What level using the threshold guidance? Does this fit any categories of abuse? Who would the lead agency be in this?

74. Scenario 10 You are a theatre practitioner and a patient with Learning Disabilities arrives into theatre already anaesthetised. When you remove her underwear she had huge bruising to her sacrum and vulva area. Who would you speak to first? Does the patient fit definition for safeguarding duties? What level using the threshold guidance? What other agencies might you involve? Does this fit any categories of abuse?

75. Three things to Remember; 1.Any Adult protection referral to the Council must be discussed with the Trust’s safeguarding adults team or out of hours the site co-ordinators. 2.If Domestic abuse is suspected or disclosed and children are a member of that family, you must make a Child Protection referral to the MARU. If you would like support please contact the Trust’s Child Protection Nurse or the IDVA. 3.You must contact Lerryn Hogg if you have a Patient ‘sectioned’ under the MHA in your area. Patients with mental health issues may require reasonable adjustments to access health care services, please contact Lerryn Hogg so support can be offered and arranged.