Principle 1 of the Mental Capacity Act is the presumption of mental capacity. However, if a person’s mental capacity to make decisions is in doubt, professionals MUST follow the MCA.

Please see here for brief guidance on making an MCA assessment: Assessing Capacity and Making Best Interests Decisions under the Mental Capacity Act (MCA)

And for further resources to help in difficult situations involving fluctuating capacity, worries about Lasting Power of Attorney concerns etc, as discussed at the latest PLT, see here: Mental Capacity Assessments Resources – Protected Learning Time – March 2021

Do not also forget that someone may have capacity to make a decision but be influenced by coercion or control, which may lead them to voice a decision that conflicts with their best interests. These cases are complex and it may be possible to discuss how best to help the individual whilst maintaining their confidentiality by seeking advice from the Community Harm and Exploitation Hub or SEL ICB Southwark Safeguarding Team.

Adult Safeguarding referrals have 3 streams. To report a concern about an adult with care and support needs who is experiencing or is at risk of abuse or neglect, please use the form below and contact Southwark Adult Social Care, choosing the team most appropriate to the individual’s circumstances:

Adult Safeguarding Referral Form

If you are unsure which team would be most appropriate for your patient, we have recently been advised that GPs can also now email referrals into a single point of contact safeguardingadultscoordinator@southwark.gov.uk

Once safeguarding referrals are received by this team they will be signposted to the most relevant team.

When adult social care screen the safeguarding referrals they use the following criteria

Specific adult safeguarding duties apply to any adult who:

• Has care and support needs, and
• Is experiencing, or is at risk of, abuse or neglect, and
• Is unable to protect themselves from either the risk of, or the experience of abuse or neglect, because of those needs.

The adult who is referred must meet all three of the above criteria to receive a statutory safeguarding response. To make your referral effective it is important to try to outline why your patient fulfils these criteria.

If in doubt, please still make a referral or discuss with the duty social worker.

The Royal College of General Practitioners has useful guidance on making a safeguarding referral to your local Safeguarding Team.

It is important to understand that there may well be vulnerable individuals that need your support and signposting to other services that will not meet the threshold for a safeguarding intervention from Adult Social Care. If you are not certain whether your patient falls into one of these categories, then you can contact social services or the ICB Safeguarding team for advice.

We have recently been advised that a social worker making a decision on your referral should contact you with feedback on their decision, even if your referral is deemed not to meet the threshold. If you do not receive feedback, please contact the Adult Social Care Team, and if you still have no luck, pass this to us at the ICB, and we will take this higher.

General enquiries to Local Authority

In relation to policies and processes that the Local Authority have for safeguarding adults in Southwark, contact the Southwark Council Adults Safeguarding Team

Tel: 020 7525 1754  – Fax: 020 7525 1711

Safeguarding Adults Team, PO Box 64529, London, SE1P 5LX

ICB Safeguarding Leads

If you are not sure how to manage a case, need help identifying the right pathway, or have struck significant barriers in onward referral that you would like help resolving, you may want to seek help from us:

NHS Southwark Adult Safeguarding Designated Nurse Florence Acquah (available for non-urgent advice, working Monday-Friday 9-5pm)

NHS Southwark Named GP Adult Safeguarding, Megan Morris​ (available for non-urgent advice via email, working in ICB role on Wednesdays)

Refuge

Refuge is our new local domestic abuse service. All new referrals (including for IRIS)  should be submitted to sdas@refuge.org.uk. The telephone number to discuss a referral has changed to 0118 214 7150.

Alongside essential support and advocacy for current victims of domestic abuse, the service includes Child Therapeutic Programme, Perpetrator Programme, Counselling and Sanctuary Scheme.

The service offer broadly remains, with some minor changes in form of delivery:

Survivor advocacy support | Sanctuary scheme | Survivors group work programme | Counselling (Bede House will be delivering this service) | Children’s Therapeutic Support (Bede House will be delivering this service) | Perpetrators Service.

Please see referral form and information pack attached.

Domestic abuse can be emotional, physical, or financial. Refer any man or woman aged 16 years or over who would like help whether the perpetrator is a family member, co-habiting flatmate, or intimate partner. Survivors can make self-referrals or one can come from you, the clinician.

All identified cases of domestic abuse and violence within a young family environment (where the survivor has children), whether child present or not, meets the threshold for a MASH referral, and should be made by you, after discussing with the survivor. See Children’s safeguarding page for further details.

If you think that the case you are concerned about is particularly HIGH RISK, you should consider making a referral for a MARAC (Multi Agency Risk Assessment Conference), with (ideally) or without the survivor’s consent – and under no circumstances informing the perpetrator. Please see separate MARAC section for further guidance.

Read the NICE guidance on Domestic Violence and Abuse.

Routine enquiry

In antenatal, postnatal, reproductive care, sexual health, alcohol or drug misuse, mental health, children’s and vulnerable adults’ consultations, trained staff should ask service users whether they have experienced domestic violence and abuse. This should be a routine part of good clinical practice, even where there are no indicators of such violence and abuse.

Sadly cases of domestic abuse have risen in the Covid-19 pandemic, and with face-to-face access restricted for some time in primary care, we have had to be particularly careful and vigilant in our remote consultations, to try to ensure the safety of victims, and identify and help them if they are in need.

IRIS

This is a general practice based domestic abuse training, support and referral programme for primary care staff and provides care pathways for all adult patients living with abuse and their children. IRIS is centred in partnership work between primary care and specialist third sector agencies to deliver essential services and close the historical gap between the two sectors. Ultimately IRIS improves the quality of care for patients experiencing DVA and fulfils the moral, legal and economic case for addressing DVA in general practice.  IRIS has been running in Southwark for several years, but many practices are still not enrolled.

For more information on the IRIS programme please visit their website.

IRIS training is still being offered to practices, and they would welcome referrals and interest in signing up to training from practices who are not yet part of their network in Southwark.

For all practices it may also be helpful to consider the Safe Lives Guidance for GPs, which, in particular, explains the importance of a designated person in the practice to lead on any response to Domestic Abuse.

24 Hour National Domestic Violence Helpline

0808 2000 247
www.nationaldahelpline.org.uk

London Survivor’s Gateway

Help for Victims and Survivors of Rape, Sexual Assault, Sexual Abuse (current or historic) or any form of Sexual Violence

0808 801 0860
www.survivorsgateway.london

The Havens

The Havens are specialist centres in London for people who have been raped or sexually assaulted. For urgent advice and appointments:

020 3299 6900
www.thehavens.org.uk

Resources for healthcare professionals

Online resources to help develop your skills in managing patients who may be victims of domestic abuse:

Patient – Domestic Violence: How to Report Domestic Abuse and Violence. Includes an outline of open and closed questions to use when consulting.

Royal College of General Practitioners Adult Safeguarding website and toolkit has a good directory of resources for GPs.

Safelives has a Pathfinder Toolkit for GPs as well as a series of Spotlights on groups of domestic abuse victims who may be ‘hidden’ from services or who may face additional barriers to services.

MARAC is a meeting where information is shared on the highest risk domestic abuse cases between representatives of local police, health, child protection, housing practitioners, Independent Domestic Violence Advisors (IDVAs) and other specialists from the statutory and voluntary sectors. A victim/survivor should be referred to the relevant MARAC if they are an adult (16+) who resides in the borough and are at high risk of domestic violence from their adult (16+) partner, ex-partner or family member, regardless of gender or sexuality.

After sharing all relevant information they have about a victim/survivor, the representatives discuss options for increasing the safety of the victim/survivor and turn these into a co-ordinated action plan.  The main focus of the MARAC is on managing the risk to the adult victim/survivor but in doing this it will also consider other family members including any children involved and managing the behaviour of the perpetrator.  Information shared at the MARAC is confidential and is only used for the purpose of reducing the risk of harm to those at risk.

At the heart of a MARAC is the working assumption that no single agency or individual can see the complete picture of the life of a victim, but all may have insights that are crucial to their safety.  The victim/survivor does not attend the meeting but is represented by an IDVA (Independent Domestic Violence Advisor) who speaks on their behalf.  Consent of the victim/survivor is preferred but not compulsory for a MARAC referral to be made.  The Perpetrator of abuse should not be informed of the MARAC Referral.

Cases are referred for a one-off discussion at a MARAC.  The MARAC is not an agency and does not have a case management function.  The responsibility to take appropriate actions rests with individual agencies; it is not transferred to the MARAC.  When referring to the MARAC staff should continue to work with the victim/survivor to reduce risk and make appropriate safeguarding referrals.

For more information or to make a referral please contact Southwark’s MARAC Co-ordinator on: Marac@southwark.gov.uk

Multi Agency Risk Assessment Conference (MARAC) Referral Form

MAPPA is in place to ensure the successful management of violent and sexual offenders.  It is a set of arrangements for supervising people in the community after they leave prison.  Anyone convicted of a violent or sexual offence will be subject to MAPPA.

For further details visit the Government Multi-agency public protection arrangements (MAPPA): Guidance.

Change Grow Live provides specialist help and support managing drug and alcohol addiction for people in Southwark. Change Grow Live work with South London and Maudsley NHS Foundation Trust to provide specialist psychiatric support for patients with Dual Diagnosis)

For referrals or more information contact:

020 3404 7699
CGL.southwark@cgl.org.uk
www.changegrowlive.org

Difficulties/differences in the way people with Learning Disabilities are able to communicate are important to recognise, and reasonable adjustments made to accommodate this.

One development we are working on is the plan to incorporate the idea of a “Health Passport” into the review and consultation process for LD heath checks – which outlines patient preferences on communication, how they may express pain, carer information etc.

GSTT AWLD team already use a Hospital Passport for patients when they attend secondary care. We are looking to use the same in primary care (details will follow).

In the meantime, here is an example of a Hospital Passport used at the Royal Free Hospital.

The aim of Prevent is to ensure that there are preventative strategies in place across all agencies to support and divert people who may be susceptible to exploitation in the form of radicalisation, before they become directly involved in any illegal activity relating to acts of violence or terrorism.

Health is a key partner in the Prevent agenda and raising awareness of Prevent among front line staff providing health care is crucial.

In Southwark, practitioners can make a referral or raise initial concerns by contacting prevent@southwark.gov.uk and this can be done anonymously without identifying the individual concerned, if necessary.

The latest National Prevent Referral Form was published December 2019, and this should be used to make any referrals to Prevent in Southwark.

New Updated Prevent Referral Form Dec 2019.docx

Prevent awareness training is part of NHS SEL ICB’s mandatory training programme.  NHS SEL ICB would also encourage all staff working within primary care to complete this training.

Please find links to relevant e-learning below:

• E- Learning for Health (e-LFH) Preventing Radicalisation Level 1 & 2
• Home Office Prevent e-learning

Please find another useful resource below:

• NHS England Information sharing and information governance for Prevent within the NHS

The Prevent Strategy 2011 addresses all forms of terrorism and non-violent extremism which can create an atmosphere conducive to terrorism and can popularise views which terrorists then exploit. Prevent deals with all kinds of terrorist threats to the United Kingdom. The aim of Prevent is to stop people from becoming terrorists (often referred to as being radicalised) or supporting terrorism. It operates in the pre-criminal space before any criminal activity has taken place.

Channel is an early intervention process similar to other safeguarding initiatives designed to divert people away from drugs, gangs or knife crime. It is aimed at those most at risk of being attracted towards support for or involvement in terrorist related activity. It is about diverting vulnerable people away from any potential threat at an early stage, before any crime has been committed. You can refer individuals to Channel, with their consent, to access support and help from a truly multi-agency team that aims to help vulnerable people at risk of being radicalised.

If you are concerned about someone or would like to refer them to Channel, you can contact Ben.Taylor@southwark.gov.uk (Prevent Co-ordinator, Southwark Council) or phone 0207 525 1378

Modern slavery is the exploitation of children and adults for use as commodities. It takes a number of different forms, encompassing slavery, servitude, forced labour and human trafficking. It is illegal and abusive. The impact on the health and wellbeing of victims is serious and long-lasting. The ICB is committed to supporting the Government’s effort to end this illegal practice.

The Home Office estimates there are 13,000 victims and survivors of modern slavery in the UK; 55% of these are female and 35% of all victims are trafficked for sexual exploitation.

It is our duty to be aware of, and alert to the signs of slavery or exploitation. Victims who present in healthcare settings may have little or no engagement with any other services. We therefore have an important role to play in identifying these people. Only through raising concerns can we enable the authorities to take action.

Please click on the link below to access a leaflet for healthcare professionals on identifying and supporting victims of modern slavery

Modern Slavery Guidance for Health Workers

There is a new pathway for any GP referrals into the Local Authority where it is suspected that someone may be a victim of Modern Day Slavery.

In the past there has been difficulty accessing support from the Local Authority Safeguarding Teams as these victims do not often fall into the recognised statutory criteria for an Adult Safeguarding referral, although they are clearly in a vulnerable situation.

However, there is now a dedicated team in the Local Authority to handle these “non-statutory” cases. The referral will be triaged, confirmed cases can be referred into the National Referral Mechanism for additional support (as the Local Authority are “first responders”), and/or some initial advice may be given.

It is recommended by the Modern Day Slavery team that a GP completes a standard Adult Safeguarding Referral form and then emails this to modernslaveryreferrals@southwak.gov.uk

NHS England has published a web page which outlines what modern slavery is and the impact that it has on victims. It also includes a short film aimed at all NHS staff, including practical examples of what to look out for and what action all NHS staff should take. This web page can be found here: https://www.england.nhs.uk/ourwork/safeguarding/our-work/modern-slavery/

NHS England has also published a blog on the website as a call to action for all NHS staff. The blog will be flagged with national and trade media and can be found here: https://www.england.nhs.uk/2016/10/hillary-garratt/

There are lots of other resources available to help healthcare professionals understand their responsibilities around modern slavery. You may find some of the resources below helpful:

Anti-Slavery

UK Government Modern Slavery Collection

e-Learning

e-Learning for Healthcare – Modern Slavery​

Everyone living in the UK, regardless of their immigration status, or ability to provide proof of address or ID, is entitled to free primary healthcare, and to register with a GP. Despite this, many people get wrongly turned away from registering at GP practices. It is important that Southwark GP Practices are open to people seeking new registration, as for some this may be their only opportunity to seek the help they need (for instance if they are victims of modern slavery or trafficking). Language should also not be a barrier to registration.

Southwark is endorsing an initiative set up by Doctors of the World which practices are encouraged to sign up to, to promote inclusivity. Southwark is proud to have the largest number of practices already signed up to the scheme. Being part of this growing network and declaring your practice a “Safe Surgery” entitles the practice to free training for practice staff as well as access to an advice hotline on complex cases that may, for instance, require referral to secondary care. For more information, follow this link

If you would like advice about a patient who is hoarding you can contact the Hoarding panel on hoarding.notifications@southwark.gov.uk or visit their help with hoarding web page.

Southwark is the only borough to develop a holistic programme alongside other services which specifically supports those with a hoarding disorder. SLAM doctors have collaborated with London Fire Brigade to run a regular Support Group for people with Hoarding Disorder which meets every Thursday 13.30 – 15.00 at Dockhead Fire Station, 8, Wolsely Street, SE1 2BP. Patients can drop in without referral. For more information contact Dr Victoria Bream on 0203 228 2431

You can refer someone for a home fire safety visit with London Fire Brigade by clicking here.

Other support for people with hoarding disorder is available through the Mind Lambeth and Southwark teams by clicking here.

If you think you have a patient with care and support needs who died or came to significant harm through abuse or neglect and you believe there to have been failings in multi-agency working then you should consider referring them into the SAR process.

Please use this form to refer your case and send the completed form to SSAB@southwark.gov.uk for consideration.

Support for developing adult safeguarding policies and procedures

A practice policy should reflect the processes and outcomes required by the organisation in order to discharge their safeguarding duties. As these processes can vary according to the structure of the practice and staff within, it is difficult to create a policy which fits every practice. A policy is not meant as a situational guide as regular training provides this.

The following templates are available for practices to review and adapt accordingly:

• A template policy, updated 2019, was put together by our team, incorporating latest guidelines and local recommendations, which can be used as a framework on which to build your own policies.
• The RCGP Safeguarding Adults at Risk of Harm Toolkit also provides a template policy and useful information about many issues around Adult Safeguarding and is a valuable resource.

In addition, The Care Act compliance checklist and the Care Act implications briefing in the documents box below provide guidance on ensuring that your adults safeguarding policies and processes are compliant with the Care Act 2014.

Social Care Institute for Excellence has useful information about  Adult Safeguarding Practice, and also application of the Mental Capacity Act in their Mental Capacity Act Directory.

If you have further queries about how to put together your Adult Safeguarding Practice Policy, please contact

Florence Acquah,  Designated Nurse for Adult Safeguarding – florence.acquah@nhs.net 

or Megan Morris, Named GP for Adult Safeguarding – meganmorris@nhs.net

It is important that primary care teams keep up to date with safeguarding training to the correct level, and abreast of local services available to support vulnerable adults.

The RCN published the first edition of the Intercollegiate Document on Roles and Competencies for Healthcare Staff in August 2018, which outlined the first formal guidelines on minimum training requirements in Adult Safeguarding.

Required training levels

• Level 1- all practice staff who do not have direct contact with patients
• Level 2- all staff who have direct contact with patients, carers and members of the public, including reception staff and Practice Managers
• ​Level 3- all GPs and Practice Nurses. Also suitable for Practice Managers and Health Care Assistants once Level 2 achieved ideally. Practice Safeguarding Leads currently only need training up to this level, but will be expected to engage in quarterly Practice Lead Forums to broaden their knowledge.

Training requirements guidance document safeguarding adults

Safeguarding Level 3 training can, in part, be achieved through attendance at annual safeguarding PLTs (now held over Microsoft Teams).

We have also continued to provide Safeguarding Lead forums via Microsoft Teams and hope that practice leads are then able to disseminate what they have learnt to their practices.

However, there are many other ways that GPs and practice staff can maintain their competencies up to Level 3. In particular, there are many online courses and resources available, but it is particularly important to also remember that experiential learning is a crucial aspect of level 3 competencies, which can be reflected upon on a practice or individual level.

• Intercollegiate Document – Adult Safeguarding: Roles and Competences for Health Care Staff (Aug 2018)
• Social Care Institute for Excellence (SCIE) has many useful resources and E-learning available on the Mental Capacity Act, and DOLS, amongst other things (although be aware that DOLS legislation is soon to change).
• Health Education England has free online Safeguarding Level 3 modules
• Many (if not all) practices also use Bluestream Academy, which also has Level 3 training modules.
• My Learning Source is set up by Southwark Council and offers Southwark based multi-agency Safeguarding Training sessions which are free to all Southwark practices, but individuals need to register themselves for access, and spaces are limited. (We have asked if additional online webinar courses may be offered in the near future)

Incorporating Experiential Learning

Training should be relevant to the role and responsibilities of the individual. This may be made up of a variety of learning opportunities (including face to face training, audits, e-learning, SEAs and case-based discussions), and this is recognised by the Appraisals Team and CQC.

Safeguarding Practice Lead Forum

This is a quarterly meeting open to all Practice Safeguarding Leads. It is an opportunity to meet and learn more deeply about local services and discuss cases and issues specific to the local area, and incorporates topics relevant to safeguarding adults and children. Case discussion constitutes an important element of level 3 training. For further details and to confirm attendance please contact s.gayle@nhs.net or meganmorris@nhs.net

Help stop adult abuse -leaflets and posters with information and advice about safeguarding adults.​

• Stop adult abuse leaflet
• Stop adult abuse leaflet – easy read version
• Stop adult abuse posters