A meeting of the Governing Body of NHS Bromley Clinical Commissioning Group - NHS Bromley CCG
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Southof
A meeting of the Governing Body East London Sector
NHS Bromley Clinical Commissioning Group
March 2018
ENCLOSURE 7
CARE QUALITY COMMISSION REVIEW OF HEALTH SERVICES FOR CHILDREN
LOOKED-AFTER AND SAFEGUARDING IN BROMLEY
SUMMARY:
On Monday 16th - 20th October 2017 the Care Quality Commission (CQC) undertook a full Safeguarding
and Children Looked-after Review of Bromley health services. The Care Quality Commission (CQC) has a
legal requirement to make sure that health and social care services provide people with safe, effective,
compassionate and high-quality care. A rolling programme of reviews is undertaken to fulfil this role.
The week started with a strategic Bromley overview for the lead inspector Liz Fox and her team, staff from
across the health system and the London Borough of Bromley Children’s Services, including Public
Health. The CQC also reviews health services commissioned by Public Health as these services have a
significant role in safeguarding and promoting the welfare of children and young people e.g. school
nurses, health visitors and contraceptive services (Section 48 of the Health and Social Care Act, 2008). In
addition, ‘Change Grow Lives,’ the Drug and Alcohol Service for Children and adults commissioned by
Public Health was also reviewed, similarly due to the significant risks drug and alcohol issues can impact
on families. The organisations visited are listed in Appendix 1.
Broadly, the review found that across the health economy they found committed professionals and staff
with good examples of partnership working and innovative working where staff improved outcomes
through service development. The report also identified areas that needed continued development such
as improving information sharing and information technology across services so that vulnerable children
are highly visible within the health system and can be safeguarded.
BACKGROUND:
The central purpose of this inspection was to undertake a targeted review of how well local health
services – whether commissioned by Bromley Clinical Commissioning (BCCG), NHS England or London
Borough of Bromley (LBB) - identify, help, protect and provide child-centred care, whilst ensuring that
children’s health needs are effectively met. Inspectors evaluated the quality and impact of local health
arrangements for safeguarding children and improving health outcomes for children who are looked after.
This included mapping the child’s journey at all stages – from pre- birth through to their transition to
adulthood, and from the point of their entering to leaving care.
Inspectors visited services, spoke with children and their families, staff, clinicians and safeguarding leads
as they evaluated safeguarding practice, service provision and governance arrangements whilst tracking
a child or young person’s journey through services. They also observed how IT systems worked. The
inspection framework is based on the following key lines of enquiry:
Clinical Chair: Dr Andrew Parson 1 Chief Officer: Dr Angela Bhan The experiences and views of children and their families.
The quality and effectiveness of safeguarding arrangements in health services
The quality of health services and outcomes for children who are looked after and care leavers.
Health leadership and assurance of local safeguarding and looked after children arrangements
including.
Nine cases were selected by provider organisations (three from each) (Midwifery, Health Visiting and
Child & Adolescent Mental Health Services (CAMHs) that met the criteria provided and each case had to
include multi-disciplinary involvement and had to have been referred to the Multiagency Safeguarding Hub
(MASH); chronologies were created for each case. In total the inspectors reviewed 90 case records. Any
issues identified during the inspection were shared during the morning ‘Keeping in Touch’ (KIT) meetings
between the lead inspector and Head/Designated Nurse Safeguarding Children (SGC). These issues
were shared with providers who responded immediately by troubleshooting, providing risk assessments
and trajectories.
KEY THEMES:
Examples of ‘What People Told Us’
Parents spoke very positively about the care received. “We felt cared for …the staff go above and
beyond”. They described how the midwives had explained risk and benefits to help them make
decisions.
“CAMHS have done a significant piece of work with her and it has taken over a year for them to get
her to a place where she is ready for the service to be effective.”
Bromley Changes received a referral from children’s social care in relation to a young person’s
alcohol use and binge drinking. The young person was autistic so the worker looked at the best
way to adapt the sessions to meet the young person needs, such as delivering very short focused
sessions. There has been a very positive outcome for this young person with greatly reduced binge
drinking. The worker is now supporting the young person as they prepare to apply for a job.
Although there were no direct quotes from children and young people, inspectors scanned records
and identified best practice which led to improved health outcomes for some of the most vulnerable
children and young people.
Across the health system they found committed professionals and staff with good examples of partnership
working and innovative working where staff improved outcomes through service development. The areas
reviewed included:
Early Help
Child in Need
Child Protection
Looked-after Children
Leadership and Management
Governance
Training and supervision
Clinical Chair: Dr Andrew Parson 2 Chief Officer: Dr Angela BhanSummary of key themes:
Assessments
Children and young people benefit from timely assessments of their clinical needs when attending
urgent or emergency care at Princess Royal University Hospital (PRUH).
Bromley Healthcare provides a comprehensive and flexible service which includes a Young Person
Clinic (under 25yrs).
Perinatal Mental Health Service was well developed with a rigorous removal-in process and risk
assessment.
Midwifery services – safeguarding leadership strong, good links to specialist midwives (Mental
Health, Drug and Alcohol); women seen alone for domestic abuse mandatory questions (though
need to ask more than once).
Bromley Changes is working successfully with primary care; schools and ED at PRUH to ensure
the service supports professionals and have strengthened referral pathways are in place to help
ensure effective early and robust assessments.
Assessments of a child’s home environment and their safety by health visitors are not always
robust. This was reflected in case records seen and included a lack of chronologies or genograms.
Inspectors were not assured the health needs of electively home educated children were being
effectively overseen and met.
Children presenting to the PRUH in severe mental health crises often wait too long for a CAMHs
assessment and subsequent discharge or transfer to a specialist setting.
Admin and IT processes
The identification of vulnerable CYP at the Urgent Care Centre (UCC) and Emergency Department
(ED) is not robust. Currently the IT systems for these services at the PRUH do not communicate
with each other. A paper-based system is in place between the two services.
Lack of shared IT between midwives and adult mental health services
Recruitment and resources - a longstanding vacancy for a Bromley HealthCare liaison health visitor
has limited information sharing between PRUH and health visitors about children’s attendances.
Leadership, management and governance
Good commitment by CCG to working with the local authority to improve outcomes for children and
young people.
BCCG designated professionals offer strong leadership within the organisation and robust
governance oversight across the health economy. Their profile is high with senior partner agencies.
development of the GP Services Safeguarding Children Local Enhanced Services template and the
Health Economy Safeguarding/Children Looked-after dataset led by the Designated Nurse
Safeguarding Children.
Named nurse and specialist midwives at the PRUH lead on promoting good safeguarding practice
and have well developed multiagency working relationships.
The safeguarding lead practitioners within both the adult and young people’s substance misuse
services provide robust oversight of each service.
The changes in commissioning arrangements for the five to-19 year service has reduced the
opportunity for the sexual health advisors to refer young people to a ‘school nurse’ for more
universal focused health advice or ongoing support within the school setting. It is too early to say if
this will have any longer term impact on the interdisciplinary working and supporting young people
with their health needs.
Clinical Chair: Dr Andrew Parson 3 Chief Officer: Dr Angela Bhan The Bromley Healthcare Children Looked-after Team is well led. Initial Health Assessments are not
always completed within statutory timescales. Review Health Assessments were seen to be
particularly strong.
Training and supervision
Most provider organisations, (with the exception of King’s College NHS Trust) evidenced their
workforce were appropriately trained in safeguarding. The oversight of exceptions takes place
within the BCCG Safeguarding Executive Group.
Further clarity and evidence needed to provide assurance that midwives and other clinical staff
comply with statutory guidance on number of hours multi-disciplinary and interagency training
required three yearly.
A number of recommendations were made and Bromley CCG and health providers are already making
improvements in many of these areas.
Next steps
A combined Health System SMARTER Action Plan and separate Public Health Action Plan were collated
and shared with the CQC and signed off on by the CQC on the 12th March 2018. The CQC governance
and quality assurance of the action plan will be overseen by the local area team going forward. Our efforts
are now focused on delivering these recommended improvements.
Governance
The combined Health Action Plan will be overseen and monitored via the following governance
arrangements:
BCCG Governing Body – six monthly.
BCCG Safeguarding Executive Group – strategic oversight quarterly. Recommendations and
actions integrated into the BCCG Safeguarding Children/Children Looked-after Strategic and
Operational Work Plan.
BCCG Quality Assurance Sub-committee – quarterly Safeguarding Children/Children Looked-after
reports.
Operational oversight of action plan via the Safeguarding Children Health Economy Forum; bi-
monthly.
BCCG Contract and Mobilisation meetings for contractual escalation and monitoring.
Bromley Safeguarding Children Board (BSCB) Quality Assurance Performance Management
Subgroup – bi-monthly.
Supervision of named safeguarding professionals by designated professionals.
COMMITTEE INVOLVEMENT:
The committees or working groups (with dates) that have discussed this report or issues prior to
submission to the GB:
Discussed at the Quality Assurance Subcommittee on 26th October 2017 and 22nd February 2018.
Discussed at the Senior Management Team meeting
Clinical Chair: Dr Andrew Parson 4 Chief Officer: Dr Angela Bhan London Borough of Bromley Children’s Services Improvement Board – 23.02.18
RECOMMENDATIONS:
The Governing Body is asked: To Discuss and note this report and action plan.
APPENDIX 1
Services visited as part of the CQC Bromley Safeguarding and Children Looked-after Services
Children Looked-after Service - Bromley Healthcare
Bromley Multiagency Safeguarding Hub (MASH)
Greenbrook Urgent Care Centre - Princess Royal University Hospital
Emergency Department at Princess Royal University Hospital (incl. children’s ward)
Maternity at Princess Royal University Hospital
Contraceptive Services - Bromley Healthcare (Beckenham Beacon)
Sexual Health & Genitourinary Medicine (GUM) (Beckenham Beacon)
King’s College NHS Foundation Trust)
Child & Adolescent Mental Health Services - Oxleas NHS Foundation Trust
Bromley Adult and Children’s Substance Misuse Services (Change Grow Live)
Health Visiting and Health Support to Schools Service 0 – 19 service Bromley Healthcare and
Oxleas NHS Foundation Trust
Adult Mental Health Services – Oxleas NHS Foundation Trust
GP Practices x3.
AUTHOR CONTACT: DIRECTOR CONTACT:
Name: Sadie McClue Name: Sonia Colwill
Position: Designated Nurse Safeguarding Position: Director of Governance, Quality and
Children Patient Safety
E-Mail: BROCCG.ContactUs@nhs.net E-Mail: BROCCG.ContactUs@nhs.net
Clinical Chair: Dr Andrew Parson 5 Chief Officer: Dr Angela BhanBromley CCG Health Systems Action Plan for the Care Quality Commission
Report Title CQC Review of Health Services for Children Looked After and Safeguarding in Bromley
th
Date of Publication of 29 January 2018
report
Ref. Organisation/ Recommendation Actions Lead Outcomes Completion Date RAG
Service rating
1.1 Bromley CCG GPs are supported to • Enhanced Community Named GP Audit of case conference April 2018
effectively share Service to continue in reports to include quality
information about 2018/19 with coding and use of correct Emis
parent/carer and children recommendations and audit template.
held in their records that of annual self-assessments
impacts on the child’s by Named GP Enhanced Community April 2018
wellbeing. This will inform Service document for
child protection reports • Training on referrals and 2018/19 to be rolled out
and multiagency decision reports to GPs at Academic
making. Half Day in January 2018 Named GP to audit use of April 2019
Enhanced Community
• Ensure use of correct Emis Service via the self-
template for case conference assessment questionnaire.
report is fully embedded January 2018
Academic Half day
1.2 Bromley CCG CCG safeguarding leads • New health professional role Designated Single robust multiagency September 2018
should review and in development. To be co-located Professionals CSE risk assessment tool
maintain oversight of the with Bromley Local Authority which addresses the health
consistency and quality of Atlas team to scope and evaluate needs of children who are
CSE risk assessment tools the interface between health and at risk of sexual exploitation
in use in the health other agencies around CSE to be developed and
economy, benchmarking agenda ratified.
against the LSCB CSE
CQC Action Plan v6
1tools. Staff will be trained in how October 2018
to use this across the
health economy
Undertake an audit to
assess staff use of the tool
1.3 Bromley CCG GPs review IHA and RHA • Named GP to liaise with Designated Dr Named GP and Designated March 2018
plans to inform their Designated Dr for CLA in CLA/ Named Dr CLA to meet and
interactions with CLA and order to discuss the GP discuss
CCG processes assess timeliness of sharing of
the impact of the work. IHA/RHA reports with GPs IHA/RHA codes to be April 2018
included in 2018/19 ECS
• Enhanced Community March 2019
Service for 2018/19 requires Named GP to audit usage
that GPs code IHA/RHA to of IHA/RHA codes via the
facilitate identification of self-assessment
CLA. questionnaire. July 2018
• CLA workshop at GP Audit to be undertaken by
Academic Half Day 17.1.18 CLA nurses at RHA,
to promote understanding of exploring experiences of
the role of the GP with CLA CYP and their carers of
processes and to help GPs services received by GP
to consider the risks to these services and about
vulnerable children during ensuring health
their assessments. recommendations have
been acted upon.
1.4 Bromley CCG GPs use current and • Enhanced Community Updates to Enhanced April 2018
relevant coding as Service (previously known as Named GP Community Service
recommended in the CCG Local Enhanced Service) to document
Local Enhanced Service continue in 2018/19 with
for safeguarding children coding recommendations Named GP to audit usage April 2019
agreement and quality and audit of annual self of codes via the self-
assurance processes to assessments by Named GP assessment questionnaire.
CQC Action Plan v6
2support compliance
• Explanation of coding for Named GP to liaise with
vulnerable child to be added Local Authority Heads of March 2018
to Enhanced Community Service
Services
• Work with Local Authority to
ensure that notification of
children no longer subject to
CLA legislation and children
no longer subject to a child
protection plan is shared with
the GP.
• Audit of usage of coding by
case reviews at practice
leads ½ days
1.5 Bromley CCG Record keeping and IT • Bromley healthcare and Designated Training in use of IT February 2018
systems across Bromley Oxleas have agreed that the Professionals systems provided to
Health economy support safeguarding advisers from Bromley Healthcare and to
effective information each organisation will have Oxleas safeguarding
sharing; appropriate access to one another’s advisers.
flagging/ alerts; access to record keeping systems to
safeguarding records and ensure that appropriate
multiagency plans so information is accessed in a
vulnerable children are timely way across their
highly visible and can be organisations.
safeguarded.
• The following issues were
resolved during the CQC
inspection. Immediate action
was taken following the
technical issue with flagging
during the implementation of
a new version of Rio in
Oxleas. Immediate action
CQC Action Plan v6
3was taken in relation to data
cleansing in Bromley
Healthcare IT systems. The
Princess Royal University
Hospital Safeguarding
template in A+E was
amended to ensure that the
safeguarding section was
mandatory.
2.1 Bromley CCG Work with NHSE so that • New Models of Care Children & The enhanced BBG CYP October 2017
and Oxleas children and young people delivered closer to home, Young People’s mental health liaison
in Bromley have timely with improved assessment Commissioner service is to be situated
access to specialist mental and bed management across the Queen Elizabeth
health care close to home. pathways. and Princess Royal
University hospital sites
and will provide support
• Increased Out of Hours and accept referrals for
capacity to assess CYP CYP presenting with a
mental health needs through mental health crisis at A&E,
the A&E CDU, UCC, paediatric Q2 2018
wards and Health Based
Places of Safety (HBPoS)
• The agreed staffing outside of working hours.
establishment to support the
service across the three
boroughs is detailed below:
Post
Consultant Psychiatrist
(0.6wte)
Band 8a Clinical Lead
(1 wte)
Band 7 Clinical Staff
(2.5 wte)
TOTAL
CQC Action Plan v6
4• The service is to be fully
operational from the hours of
4pm to 12midnight Monday
to Sunday including bank
holidays, with daytime
specialist CAMHS team crisis
response remaining in place
from Monday to Friday.
2.1 Oxleas Work with NHSE so that • To progress the Executive Lead- Monitoring systems are The
CAMHS children and young people implementation of the South Stephen being set up for the whole implementation is
in Bromley have timely London Partnership New Whitmore CYP population in the SLP on-going;
access to specialist mental Care Model. Specifically, to Beverley Mack area accessing Trier 4 progress to be
health care close to their monitor access to CAMHS & Jacqui CAMHS beds. Bromley reviewed
home. beds for Bromley CYP to Pointon data will be available in due quarterly.
ensure there is equitable course.
access to inpatient care.
‘Leadership and Since the programme start
Management: Access to (October 2017), there has
Tier 4 CAMHS for CYP been a 25% increase in
who need in-patient or south London beds being
crises care is not meeting accessed by South London
local demand and is an CYP.
area for development. We
heard strategic plans are
progressing through senior
management to strengthen
the approach to CAMHS
tier 4, bed management
and out of hours’ crisis
response through a South
East London borough
approach. It is, however,
too early to assess the
impact of this collaborative
work’ (P 13, para 2.9)
CQC Action Plan v6
53.1 Bromley CCG/ Consistent and sufficient See recommendation 5.4
Bromley health presence in the
Healthcare MASH is available to
enable full contribution to
multi-agency decision
making.
4.1 PRUH PRUH IT systems in each • Symphony IT system to be CP-IS project Symphony is on target to June 2018
clinical area can identify updated in March 2018 and lead/CP-IS be updated in March. There
and flag vulnerable CP-IS installed May 2018. implementati has been progress with the
children on the electronic on group Trust’s IT suppliers and
record. • CP-IS implementation plan some of the issues with
includes training for staff. installing CP-IS overcome.
The ED child review meeting Staff training will start the
will monitor children flagged beginning of March.
by CP-IS.
4.2 PRUH ED records are completed • An anomaly on the IT system
and the Trust has when children had been IT has addressed the February
assurance through robust brought into ED by anomaly. 2018
governance arrangements. ambulance allowed the
safeguarding screen to
remain incomplete; the ED IT
team are addressing this ED lead
anomaly. Consultant
/Matron ED
• The weekly ED meeting is The ED safeguarding
reviewing ED records and meeting will continue to
completing a Datix if a monitor the completion of April 2018
safeguarding screen is records until the Symphony
incomplete. Staffs have been update has been
sent a reminder to complete completed.
records.
4.3 PRUH Maternity staff routinely • Midwives are speaking to Safeguarding Changes have been made February
asks questions about women about domestic Midwife to DV risk assessment. A 2018
domestic abuse abuse at booking, 28 weeks, reminder has been sent to
throughout the episode of 34 weeks & on completion of staff.
care and answers are post-natal care. This will be
recorded and subject to recorded on Badgernet; a red
CQC Action Plan v6
6managerial oversight as alert will appear on the
per NICE guidance. screen if this is not
completed. A records audit
will be completed in June June 2018
2018.
4.4 PRUH Maternity staffs are • Bromley CSE risk
competent in identifying, assessment tool will be CSE risk assessment has
recording and uploaded to Badgernet and been updated on February
safeguarding those replace the King’s risk Badgernet and YP 2018
experiencing or a risk of assessment form. midwives notified of the
CSE, CSE screening and Completion is mandatory for changes.
risk assessment tools are all pregnant young persons
on the electronic record. under 18 years. The Young
Persons’ midwives have
been notified of these Safeguarding
changes (they have Midwife Midwives are receiving
previously undertaken training during their annual
enhanced CSE training). safeguarding update.
• Midwives will be notified
about the changes and
training provided by the December
specialist midwife for 2018
safeguarding during the
midwives annual
safeguarding update.
4.5 PRUH Safeguarding referrals to • Safeguarding referrals to Senior The audit will be carried bi- March 2018
social care are quality social care will be audited for clinical nurse annually and presented to & October
assured. quality, including the specialist the Trust’s Safeguarding 2018
application of BSCB safeguarding Children Committee.
thresholds, bi-annually and March 2018
presented to the Trust’s & October
Safeguarding Children 2018
Committee.
4.6 PRUH Record keeping and IT • The Trust will work with the Named Work on IT systems and March 2018
systems across Bromley CCG to examine this doctor/ information sharing will be
health economy support recommendation Named nurse addressed with the health
information sharing. economy at the Health
CQC Action Plan v6
7Forum
4.7 PRUH The Trust must ensure • The Trust has moved to a EDT are developing LEAP March 2018
they can identify new system for statutory and with the suppliers to ensure
practitioner attendance at mandatory training system that individual practitioner
safeguarding training ‘LEAP’, the system provides attendance is available for
through robust training data by clinical service such Education, analysis.
needs analysis and as ED, paediatrics, maternity. Development
compliance data. Midwives attend a 3 yearly & Training
update and an annual department
enhanced training session.
• EDT is developing LEAP with
the suppliers to ensure that
individual practitioner
attendance is available for
analysis.
5.1 Bromley Children and young people Paediatric liaison to be recruited Sharon Completed December
Healthcare who attend emergency to Smith/ 2017
and urgent care are Natalie Completed February
enabled by information • Access to RIO Warman 2018
sharing to be followed up Discussed with Sonia May 2018
by the most appropriate • Review of the existing model Colwell. Individual in post
professional. to ensure that the current and commenced
provision promotes the most employment in January
effective method of 2018.
safeguarding children
To agree with service
evaluation model and gap
analysis.
Agreed TORs with external
reviewers that includes
safeguarding
representative from the
RCN
CQC Action Plan v6
85.4 Bromley Consistent presence within • Ensure effective cover with Natalie Immediate
Healthcare the MASH. the safeguarding team Warman
• To Datix and escalate to the Immediate
Director if there is a No incidents have occurred
possibility of MASH not
having presence and monitor
incidents Completed February 2018 February
2018
• Review activity in the MASH
of the health advisors Completed February 2018 February
2018
• Business case to be External review
completed for headroom commissioned and
agreeing TORs April 2018
• For external review to include
MASH
5.5 Bromley Safeguarding referrals are • Audit of safeguarding Named nurse April 2018
Healthcare quality assured referrals to LA for
safeguarding
• Audit of MASH referrals 2 audits completed April 2018
• Learning and outcomes
feedback to internal May 2018
safeguarding children’s
meeting
June 2018
• Learning and outcomes
feedback to the executive
and the board
5.6 Bromley CLA team to set • To continue to work with LA CLA team Completed 100% achieved December
Healthcare trajectories for Individual to identify blockages in for Q3 2017
Health Assessment (IHA) delaying IHA’s achieving
CQC Action Plan v6
9compliance with LA performance for IHA
5.7 Bromley Ensure that physical and • Review as part of Training CLA team Ongoing February
Healthcare emotional needs for Needs Assessment (TNA) for and learning 2018
asylum seeking children the team and
are fully understood by development
practitioners who • Source specialist March 2018
undertake IHA and Review training/provider following
Health Assessment (RHA) TNA CCG for
Designated
• Provide training doctor March 2018
5.8 Bromley CLA electronic record • For all referrals to be CLA team Completed December
Healthcare contains all information for uploaded in to the child’s 2017
pertaining to the child record
Completed December
• All IHA assessments to be 2017
uploaded into the child’s
records
5.9 Bromley Quality assurance • For CLA team to have Quality team This will be discussed at March 2018
Healthcare processes to benchmark records reviewed as part of a the BHC CLA team meeting
IHA and RHA are quality assurance visit from on 16.01.2018
developed Quality team
Findings from the thematic March 2018
• Audit of assessment both dip sampling to be
IHA and RHA to ensure that discussed at the CLA
quality of records meet health forum.
appropriate safeguarding and
records standards
5.10 Bromley Record keeping and IT • ISA with Oxleas Natalie Completed December
Healthcare systems support effective Warman 2017
information sharing so
vulnerable children can be • ISA with GPs Completed December
safeguarded 2017
CQC Action Plan v6
10• Training for staff to RIO and Completed February
EMIS to enable MASH 2018
workers to view records
• To support the work with the Continue to support Ongoing
CP-IS however this is co-
ordinated by the CCG
5.11 Bromley CLA formal supervision • For formal supervision to be CLA team Completed December
Healthcare implemented within the documented at all times in 2017
client records the clients records
• An audit on all children
discussed in supervision Re-audit in 6 months
between November 2017 to
end of February 2018 and
can confirm that 100% of
supervision records were
documented within the child's
record.
6.1 Oxleas Children in Need • All HVs to be introduced to Executive Risks to child identified with March
0-4 Service Practitioners records Oxleas Safeguarding Lead- plan of intervention /April2018
clearly reflect how the Supervision model. The Stephen identified.
home environment is child’s case record is Whitmore
impacting on the wellbeing reviewed routinely by the
of the child, quality Supervisor. The ‘resilience Jane
assurance of this should model ‘of analysis will include Downing/
form part of supervision reflection on the impact of Rachel
practice. the child’s environment. Lanlokun
The standard record /Annie Still
proforma to be used for The standard record
recording safeguarding proforma is already being End of July
supervision used in Safeguarding 2018
Supervision with HVs. It is
anticipated that compliance
figures for HV supervision
will have reached over 80%
by end of Q4.
CQC Action Plan v6
11Audit to be undertaken July
2018
6.2 Oxleas The use of chronologies • Findings from CLAS review Executive Meeting with each of the 3 End April
0 – 4 Service and genograms is routine to be shared at the 3 locality Lead - locality Teams have been 2018
within the health visiting. Team meetings. This will Stephen set up for April 3rd 4th and
include discussion re the use Whitmore 10th. Bromley
of a chronology to assist Team
analysis when there are Jane Recording of chronology
emerging concerns and the Downing can be either through be by Blenheim
use of the genogram word /Denise using the significant event Team
proforma. Neath function on RiO or using a
• Chronology format to be word proforma depending Beckenham
discussed and use of the on the purpose of the Team
genogram guidance. chronology
‘Bromley health visitors do • Genogram template to be Jane March 2018
not routinely use sent to Operational Leads to Downing/
chronologies or share with their teams. Where a Denise
genograms to support their genogram is required it will be Neath
safeguarding activity. In completed and uploaded as a
Oxleas, there is not a word document.
consistent approach
across commissioned
health visiting services.
Management accept
routine use of chronologies
is an area for development
in health visitor services in
order to ensure effective
risk assessment and
oversight of a child’s
vulnerability’.
6.3 Oxleas Children and young people To complete recruitment and Executive Recruitment process is June 2018
CAMHS have increased timely implement the new CYP MH lead- underway and on track
access to specialist Liaison service Stephen
CAMHS support and care Whitmore
CQC Action Plan v6
12to assess their mental
health within the acute Sheena
setting. Gohal &
Beverley
Mack
‘Arrangements for children
presenting to the PRUH in
severe mental health
crises do not meet the
needs of the young
person.
Children and young
people often wait for too
long for a CAMHS
assessment and
subsequent discharge or
transfer to a specialist
setting. It is reassuring that
the ED and the ward use
registered mental health
nurse to look after the
children and young people
when they are at their
most vulnerable.
6.4 Oxleas CAMHS staffs are • Oxleas Risk Assessment Executive The work is underway, and End March
CAMHS competent in identifying Tool and SAFEGUARD Lead- will be fully completed by 2018
potential CSE and Pneumonic (Pan London Stephen the end of March 2018 at
articulating risk within CSE Protocol) to be re- Whitmore which point we can agree a
records and on referral to circulated to all clinicians and Jacqui way to test the confidence
children’s social care so to be addressed in team Pointon of staff in this area.
children and young people meetings. The tool is available for
can be effectively staff to use on RiO.
safeguarded.
‘CAMHS professionals
have started to use the
CSE tool to help inform
their assessment of risks
CQC Action Plan v6
13for the safety and
wellbeing of children and
young people but practice
is not yet sufficiently
embedded, or effectively
used to inform referrals to
children’s social care’. This
needs to be measurable
and some evidence to
provide assurance that this
is sufficiently embedded
and has increased the
number of referrals to
children's social care.
6.5 Oxleas Safeguarding referrals to • CAMHS to implement a QA Executive Template to capture End April
CAMHS children’s social care are process in Bromley CAMHS lead – process has been 2018
quality assured to support (manager/ supervisor/senior) Stephen developed. Plan to
organisational learning and to review all safeguarding Whitmore implement within the
a consistent standard in referrals to CSC prior to service
meeting thresholds. being submitted to the MASH Jacqui
Pointon
Oxleas ‘Quality assurance • Discuss referrals at Locality Tim Sowter 01/03/18 Guidance on how April 2018
AMH processes are to support Team meeting with CLAS to make a referral to CSC
learning and identify trends feedback. Referrals to be re- circulated to Team
was variable across reviewed by operational March 2018
Leads for discussion at
provider services. A robust leads but not if to do so
quality assurance process service meetings. Clinicians
causes delay.
would provide oversight of to seek advice from Leads
referrals and support a if necessary.
consistent standard to
better meet thresholds Existing practice of Ongoing
when considering actions submitting all referrals to
to protect vulnerable Head of Safeguarding for
children and young
quantitative and qualitative
people.’
monitoring will continue and
has been reinforced in
Safeguarding Children
CQC Action Plan v6
14Policy and procedures.
Oxleas • Guidance ‘How to make a Ruth 01/03/18 Guidance sent to March 2018
AMH good referral to CSC’ to be Ashworth TS for circulation to Service
sent to Team managers for Leads
discussion at Team meetings
and resend to Safeguarding 08/03/18 Bromley
Champions. Champions forum to
discuss findings from CLAS
review and reinforce
available help for making
referrals to CSC.
6.6 Oxleas Record keeping and IT • Key people in BHC and Executive ISA agreed and signed January
0-4 Service systems across Bromley Oxleas to be given access to Lead - 2018
health economy support each other’s electronic Stephen
effective information record systems EMIS and Whitmore
sharing; appropriate RIO
flagging / alerts; access to • Information sharing Jane
safeguarding records and agreement between Oxleas Downing
multi-agency plans so and BHC to be agreed and Julie Lucas March 2018
vulnerable children are signed off by both agencies. and BHC Training
highly visible and can be Natalie dates have
safeguarded. Warman been set up
in February
‘We heard of a number of 2018
IT systems incompatibility
across Bromley. It is
recognised through
serious case reviews this
can lead to barriers in • Training on Rio and
timely sharing or access to authorised access to be Jane Lawful and timely
information. completed Downing information sharing BHC End of March
Practitioners who need to • BHC access to Rio. /Lorraine Safeguarding Team 2018
work together do not have • Oxleas access to EMIS. Thomas includes LAC and MASH
access to the each other’s • Complete staff training and Natalie
client record. Examples documentation. Warman,
CQC Action Plan v6
15include urgent care/PRHU, RiO team
BHC/Oxleas (MASH).
KCFT/Oxleas (perinatal
mental health).
Oxleas We also identified • Screenshots and Jane Dates have been agreed HV teams to
0-4 Service inaccuracies in the guidance for completion Downing/ with RiO team to meet with be trained
flagging systems in a of Oxleas Safeguarding Jacqui HV teams to discuss during March
number of services, which Children form and Pointon Safeguarding forms on 2018
reduces practitioner’s flagging system to be RiO
abilities to work in circulated to all MASH
partnership with statutory practitioners. Health
agencies in the care of the professional
child. The CCG and trained Jan
provider organisation 2018
recognise the challenges
and some work has taken
place to mitigate risk’.
CAMHS • Screenshots and guidance Jane The above training package End March
for completion of Oxleas Downing/ to be made available to 2018
Safeguarding Children form Jacqui CAMHS practitioners.
and flagging system to be Pointon
circulated to all practitioners.
• Internal changes to CAMHS Executive This work is underway and End March
pathway so that all referrals Lead- on track 2018
are accepted and the first Stephen
appointment identifies and Whitmore.
agrees treatment pathway for Jacqui
CYP / family. Pointon
CQC Action Plan v6
167.1 Oxleas Oxleas and Kings College • Meeting to be arranged Estelle Frost Perinatal Mental Health and End of March
AMH Hospital between Kings College Tim Sowter AMH services to review 2018
Care records are shared Midwifery service, Perinatal current information sharing
appropriately so that Mental Health and AMH Specialist pathways by the
practitioners from both services to review current Midwife
organisations are able to information sharing PRUH
offer a co-ordinated pathways.
approach to care and
management of risk.
‘The lack of shared IT
means that midwives and
adult mental health
practitioners are unable to
access patient records of
expectant women that both
services are working with.
It is important that
vulnerable expectant
women with mental
concerns receive a co-
ordinated approach to their
care and that risk is
managed appropriately’.
8.1 Oxleas CAMHS and Bromley Y • Develop with the Wellbeing Executive This work is underway and End March
CAMHS ensure the process and Service and implement a Lead- on track 2018
quality of information shared referral form for CYP Stephen
sharing at point of progressing from the Whitmore
handover consistently Wellbeing Service to Jacqui
meets the child’s needs. Specialist CAMHS Pointon
‘Care pathways between
Bromley Community
Health and Wellbeing
service (Bromley Y) and
CAMHS remain an area
for development. Current • Internal changes to CAMHS Executive This work is underway and End March
arrangements do not pathway so that all referrals Lead- on track 2018
consistently support a are accepted and the first Stephen
CQC Action Plan v6
17smooth and timely appointment identifies and Whitmore
response for children and agrees treatment pathway for Jacqui
young people with more CYP / family. Pointon
complex/longer term
needs. New arrangements
for strengthening handover
to CAMHS tier 3 are still
being embedded and
referral seen did not
demonstrate consistent
use of the referral form, or
evidence it is being used
to best effect. We saw
examples of requests for
additional information
being needed to support
decision making and
identify the appropriate
treatment pathways, this
can then impact on the
timeliness of the child or
young person accessing
the right care at the right
time’. (Page 14 para 2.11).
CQC Action Plan v6
18London Borough of Bromley Public Health Services Combined CQC Action Plan February 2018
Recommendation 6.1 Children in Need
Practitioners records clearly reflect how the home environment is impacting on the wellbeing of the child, quality assurance of this should form part of
supervision practice.
‘Assessments of a child’s home environment and their safety carried out by health visitors are not always robust. Case records seen demonstrated that
practitioners concerns did not always articulate strongly enough the impact of the home environment on the child or reflect the child’s voice. Recording of the
information can assist the practitioner to identify emerging or existing signs of neglect’.
Ref 0-4 Action Executiv Operatio Comple Evidence Progress Outcome
Universal e lead nal lead tion
Service date
6.1 0-4 All HVs to be introduced to Oxleas Stephen Jane March Q4 HV
Service Safeguarding Supervision model. The Whitemo Downing 2018 supervision
child’s case record is reviewed routinely re /Denise compliance
by Supervisor.The ‘resilience model ‘ of Neath fiqures.
analysis will include reflection on the
impact of the child’s environment.
Standard record proforma to be used.
Sample of records will be audited to Denise July Record
ensure information on home environment Neath 2018 keeping
is recorded in all records audit.
Recommendation 6.2
The use of chronologies and genograms is routine within the health visiting
‘Bromley health visitors do not routinely use chronologies or genograms to support their safeguarding activity. In Oxleas, there is not a consistent approach
across commissioned health visiting services. Management accept routine use of chronologies is an area for development in health visitor services in order to
ensure effective risk assessment and oversight of a child’s vulnerability’.
Ref 0-4 Action Executiv Operatio Completion Evidence Progress Outcome
Universal e lead nal lead date
Service
6.2 0-4 Findings from CLAS review to be shared at Stephen Jane May 2018 Minutes
Service the 3 locality Team meetings. This will Whitemo Downing of
include discussion re the use of a re /Denise Bromley team 7th meetings
chronology to assist analysis when there Neath March
are emerging concerns. and GenograLondon Borough of Bromley Public Health Services Combined CQC Action Plan February 2018
Chronology format to be discussed and Operatio Bleinheim Team m
th
use of the genogram guidance nal Leads 13 March template
Genogram template to be sent to Beckenham
Team TBC
Operational Leads to share with their
teams. Where a genogram is required it
will be completed and uploaded as a word
document.
Recommendation 6.6
Record keeping and IT systems across Bromley health economy support effective information sharing; appropriate flagging / alerts; access to safeguarding
records and multi-agency plans so vulnerable children are highly visible and can be safeguarded
‘We heard of a number of IT system incompatibility across Bromley. It is recognised through serious case reviews this can lead to barriers in timely sharing or
access to information. Practitioners who need to work together do not have access to the each other’s client record. Examples include urgent care/PRHU,
BHC/Oxleas (MASH). KCFT/Oxleas (perinatal mental health). We also identified inaccuracies in the flagging systems in a number of services, which reduces
practitioner’s abilities to work in partnership with statutory agencies in the care of the child. The CCG and provider organisation recognise the challenges and
some work has taken place to mitigate risk’.
Ref 0-4 Action Executiv Operational Completion Evidence Progres Outcom
Universal e lead lead date s e
Service
6.6 0-4 Key people in BHC and Oxleas to be given Stephen Maria Tanner March 2018
Service access to each other’s electronic record Whitemo /Rachel
Lanlokun/ Jane
systems EMIS and RIO re Downing
Information Sharing agreement between Julie Lucas/Jane January 2018 ISA Comple
Oxleas and BHC to be agreed and signed Downing/ Maria Document te
off by both agencies Tanner
BHC access to RiO Jane January 2018 Evidence of Comple
Downing access via
Complete staff training and sponsorship
te
documentation weekly
reporting.London Borough of Bromley Public Health Services Combined CQC Action Plan February 2018
Oxleas Access to EMIS Jane March 2018
Training and documentation to be Downing Training dates
completed set up in
February 2018
MASH Health
Professional
Trained Jan
2018
6.6 0-4 Screenshots and guidance for completion Jane March 2018
service of Oxleas Safeguarding Children form and Downing
and flagging system to be circulated to all /Jacqui
CAMHS practitioners. Pointon/
Denise Neath
Recommendation 6.5
Safeguarding referrals to children’s social care are quality assured to support organisational learning and a consistent standard in meeting thresholds.
‘Quality assurance processes to support learning and identify trends was variable across provider services. A robust quality assurance process would provide
oversight of referrals and support a consistent standard to better meet thresholds when considering actions to protect vulnerable children and young people’.
Ref 0-4 universal Action Executive Operational Completion Evidence Progress Outcome
service lead lead date
6.5 0 – 4 Service Discuss referrals at Stephen Denise Neath End March
Locality Team meeting Whitmore 2018
with CLAS feedback. Dates as per
Referrals to be R6.6
reviewed by
operational leads but
not if to do so causes
delay.London Borough of Bromley Public Health Services Combined CQC Action Plan February 2018
BHC CQC Action Plan for safeguarding February 2018
Recommendation Actions Person responsible Time frame Updated progress
BHC work with the LA To continue to work with LA and The Home Felicity Akers and March 2018
to ensure that the Educated Team, identifying home educated Sharon Smith
Health Support for children.
Schools Service (HSSS)
have access to data on Named safeguarding nurse to work with LA with Ongoing Continue to support
home educated currently known children.
children
Once data is identified, work on a joint process in March 2018
which this data is shared monthly and monitor
the number of children.
A business case model has evolved from LA. March 2018
Waiting approval from CCG to recruit staff to
support home educated children until March
2019 when the contract ends.
BHC work with the LA Work with LA to inform processes implemented Felicity Akers and March 2018
to ensure that Health through our Care Sharon Smith
support for schools are Co-ordination Centre, to ensure input from all
able to input into relevant children’s service into EHCP. This will
children’s EHCP include HSSS.
The HSSS are routinely Ensure schools and social care are informed of Felicity Akers and March 2018
informed of children the criteria to refer to HSSS where children have a Sharon Smith
and young people with known, unmet health need.
additional needs and
vulnerability so any This has been discussed with David Dare, Head of
on-going care and Safeguarding and the Children’s Disability Service February 2018 Completed
safeguarding concerns at LBB.
can be addressed by
the HSSS It is suggested that Social Workers allocated to OngoingLondon Borough of Bromley Public Health Services Combined CQC Action Plan February 2018
the families, would send invitations to the HSSS
safeguarding email
address, BROMH.SNSafeguarding@nhs.net which
would identify the families to the service.
Referral rates to be measured.
Liaise with safeguarding advisors, to identify
possible cases where children may have required March 2018
HSSS and were missed and lessons learnt from
cases missed. OngoingLondon Borough of Bromley Public Health Services Combined CQC Action Plan February 2018
CGL Action Plan
Recommendation Action Exec Operati Completion Evidence Outcome
utive onal date
lead lead
9.1 Work with the 9.1 CGL services are arranging to meet with Servi David Currently Contract monitoring Recomme
local authority MAP Beverley Brown (Chair of the MAP) by end Feb 18, ce Dunkle ongoing report ndations
to enhance to discuss partnership work - including attending Man y with will be
information sharing the MAPs in 2018. CGL will attend the MAP to do a ager completion shared
for young people presentation on the service to further strengthen date by end with the
who are at risk by the knowledge and understanding of the service of April teams and
developing and with other professionals who attend the MAP. Will incorporat
embedding a formal also set up a referral pathway between the ed into
communication services. this plan
pathway as well as
The YP and adults service are linked with local our
authority safeguarding services. To re-enforce safeguardi
referral pathways the following actions will take ng
place: procedure
s.
Presentations to the local safeguarding teams to
take place with follow up meetings annually.
An initial meeting and presentation has been
delivered to the ATLAS team by DD. A follow up
meeting to discuss partnership working and
referral pathways with both YP and Adults service
to be arranged within 12 weeks.
Safeguarding 9.2 All referrals to social care are to be checked by Servi DD Currently To be discussed in
referrals to the services’ Safeguarding Leads to make sure they ce (Bromley ongoing IGTM within both
children’s social are consistent and they are quality assured in Man Changes) within services to highlight the
care are quality meeting current thresholds. ager and AL service. good practice currently
(Bromley
assured to support taking place betweenLondon Borough of Bromley Public Health Services Combined CQC Action Plan February 2018
organisational Drug and both services.
learning and a Alcohol
Service)
consistent standard Quarterly audit by
in meeting safeguarding leads to
thresholds. monitor compliance
The electronic 9.3 All BDAS staff will be informed to upload Servi Service Within two Team meeting minutes,
record is a documents and cross reference to corresponding ce manag weeks of supervisions, Inter-
comprehensive case notes onto the CRIIS case management Man er CQC report Governance meeting.
composite of system; this will be communicated to the staff ager receipt. An audit will take place
information through team meetings, individual supervision by the Safeguarding
including sessions and Information Governance Team Lead (quarterly) to
documents that Meeting. make sure staff are
relate to the keeping an electronic
persons care. record which is a
comprehensive
composite of
information including
documents that relate
to the persons care. lYou can also read
