mandatory safeguarding form level 3, 4, 5 · pdf file · 2016-12-22mandatory...

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MANDATORY SAFEGUARDING FORM LEVEL 3, 4, 5

Internal Agency Investigation Report

This form requires completion within 28 days of the alert being

raised.

Single Agency x Multi Agency

Section 1: Internal investigator details

Name Fran Edwards

Role Registered Manager at Clough Home Care support ltd

Date 31.7.2016

Contact Number 0161 477 1234

Name & Address of Employer Clough Home Care Support 245 Stockport Road Stockport

Section 2: Personal details of the adult at risk

Name Teresa Walters

D.O.B. 1.3.41

CareFirst Number E1234567

Gender Female

Address 35 Bankhill close, Heaton Mersey, Stockport

Contact number O161 123 4567

Ethnicity White Irish

GP Name and contact details Dr Whitehall Heaton Norris Medical Centre Ashgrove road

Is the adult at risk deceased?

Yes No x

If yes, please state date of death

Level 3 x Level 4 Level 5

Information in this document is used for example and reference purposes only and does not represent any scenario or factual information of any kind.

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Long term health conditions of adult at risk

Vascular dementia Hearing impairment

Section 3: Capacity

Does the adult at risk have capacity to consent to the investigation?

Yes x No

If yes, does the service user consent to the investigation?

Yes x No

If no, is it in the individual’s best interest for the safeguarding investigation to proceed?

Yes No

If no, has the risk to other adults at risk been considered and the investigating continuing?

Yes No

Please provide details of how the capacity assessment and best interest process was completed

Teresa has a diagnosis of vascular dementia and has fluctuating capacity with regard to decision making and understanding information given to her. I met with Teresa on 29.7.2016 in the morning. There is no indication to when the best time is to speak to Teresa. I met with Teresa in her flat and introduced myself. To maximise Teresa’s understanding, I ensured I followed her preferred method of communication and faced Teresa when I spoke to her, speaking slowly and clearly. I discussed the incident which Teresa was able to recall. Teresa was able to understand the information which was being shared with her. Teresa weighed up the information and as result gave consent to the investigation taking place. Teresa consented to sharing the information with her daughter.

Is the adult at risk deprived of their liberty or subject to any restrictions?

Yes No x

If yes, please provide details

Is the adult at risk a carer? Yes No x

Details of cared for

Name

Address

CareFirst number (if known)


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Is the adult at risk subject to Deprivation of Liberty Safeguard?

Yes No x

If not, has it been considered?

Yes No x

Section 4: Communication

Are there any communication difficulties for the adult at risk?

Yes x No

If yes, please provide details

Teresa has a hearing difficulty. She doesn’t need to use hearing aids at present. Teresa’s preferred method of communication is for people to face her straight on so she is able to watch their lips move. It is important that staff speak clearly and slowly. This supports Teresa to understand what is being communicated and maintains her sense of independence and dignity.

MAKING SAFEGUARDING PERSONAL

Section 5: Views

Please evidence the views of the adult at risk including the preferred outcome

I spoke to Teresa about the incident and what she would like as an outcome following the investigation. Teresa said she understood the carers get busy but doesn’t want to be in bed in until lunch time as she gets bored and likes to watch her morning programmes which she sometimes misses if she’s still in bed. Teresa said she looks forward to the carers coming in the morning and is ready to get out of bed as she has been in bed all night. Teresa stated she now feels worried if the carers are going to turn up and when her daughter has arrived. She would rather be up and ready when her daughter arrives. Teresa also said she feels hungry and is ready for a nice cup of tea in the morning and doesn’t want to wait for it. Teresa does have access to a jug of water through the night. In terms of outcomes, Teresa would like her morning call to happen on time so she can be up and ready for her day. Teresa consented for me to talk to her daughter Bev. Bev was upset on seeing her mum still in bed when she has visited at lunch time and was concerned that she had not had anything to eat or drink. This was the second time this week it has happened and it also happened a couple of times the previous week although Bev can’t recall the dates. Luckily Teresa has phoned Bev to come round when carers have not turned up or Bev has popped in to see her mum. Bev stated her mum felt unimportant and upset at being ‘forgotten’.


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Bev would like some reassurance from Clough Home Care that morning calls will happen each day at the agreed time for her mum to be supported out of bed and have her breakfast. Bev stated it is just the morning visits where the issues have been, the lunch and bed calls are fine.

Section 6: Details of the incident including perpetrator

Date of incident 25th and 27th July

Details of the alerter Daughter raised concerns to Clough Home Care who identified that this required internal investigation

Name Beverley Caven

Brief description of alleged abuse 2 missed morning home visits by carers to provide personal care and food and drink.

Category of alleged abuse (please circle all categories that are alleged)

Physical Financial Psychological Neglect Acts of omission Sexual Discriminatory Organisational

Details of the alleged incident

During the 25th and 27th July, Teresa’s daughter reported two incidents of missed morning calls. The morning calls are commissioned to take place at approx. 7.30am. However carers have failed to turn up for the morning call on the stated dates. This happened a couple of times the previous week but Bev was not sure of the dates and at the time as she had got her mum up at about 12.30pm she didn’t think to report it. This has resulted in Teresa calling her daughter to come round or Bev has popped in to visit and found her mum still in bed. Teresa was physically fine of these occasions and had access to water to drink but had gone a period of time without food.

Was the incident witnessed?

Yes x No

If yes, by whom?

By Daughter who has found her mum still in bed late morning.

Who has the referrer spoken to? e.g. police/CQC/DBS, please include dates

Bev reported to Deputy Manager who reported to Registered Manager on 25th July. Clough Home Care support identified this should be investigation and raised a Level 3 alert via the contact centre on 25th July. Reported to CQC as a notification on 26th July. Conversation with Teresa on the 26th July. Conversation with daughter Beverley on the 27th July


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Have any injuries been sustained by the adult at risk?

Yes No x

Details of injuries and any treatment required (e.g. GP, Mastercall, ED)

IF YES CONTACT ASC CONTACT CENTRE ON 0161 217 6029 to request a review

Is this the first instance of abuse alleged by this perpetrator

Yes No x

If no, is the incident of a similar nature?

If it is of a similar nature, please detail what actions are in place to ensure adequate safeguards are in place? This is the first time a concern has been raised to the manager but this is not the first incident which has occurred as the previous week a missed call had occurred. Manager investigated as part of concern and concluded a 3rd missed visit had occurred in on the 16th July 2016 which had not been reported to the Manager by the daughter.

Name of the alleged perpetrator Richard Wilson

Is the individual an employee?

Yes No x

If yes, what is their role in the organisation?

Is the alleged perpetrator another resident?

Yes No x

If yes, are they at risk themselves?

Yes No x

CareFirst number (if known)

Do they require a review?

Yes No x


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Section 7: Risk Assessment and Protection Plans

Have you completed/updated a risk assessment/care plan

Yes x No

If yes, date completed 3rd August 2016

If no, please complete/update the risk assessment/care plan

Section 8: Outcome

Please evidence how this outcome was determined

Missed call took place on the 23th and 25th July.

Daughter called Clough Home Care office on the 25th July.

Registered Manager commenced investigation on the 25th July into concerns and viewed rotas, care call schedules and care notes for the two dates in question.

Care call schedule indicates care calls were missed due to a new care staff member not being clear how to use care calling system as the induction was not detailed enough to support new staff members learning.

New member of staff was on rota to complete these calls which were missed.

Interviewed the staff on duty for the calls missed who was new to the role.

Looked at induction which the new staff member received from the Deputy Manager. The new staff member had received an induction on the use of internal systems including the care call schedule however this part of the induction was brief.

Unable to view care call schedule from the previous week as this had been deleted/destroyed by the Deputy Manager.

Checked care notes from the previous week as daughter stated this happened a couple of times the previous week. Care notes indicate no care call took place on one day on the 16th July however care notes for the morning call were present for all the other days.

No quality checks had been completed by the Deputy Manager with regard to ensuring the care call schedule completed and no one is missed. This should take place during handover.

Allegation of neglect The evidence I have collated is the care call schedule for the two dates in question which indicate the care call was missed due to an over sight by the carer on shift. Call from daughter who informed the Deputy Manager that she has had to help her mother out of bed twice this week. Checked care notes which indicate further no care took place on the stated dates as well as the 16th July as no care notes for morning call present. Therefore it is evident the care calls did not take place as commissioned. Outcome Substantiated Allegation of psychological abuse Teresa stated she now worries if the carers are going to turn up for her morning call and if she will have to call her daughter for help. Teresa’s daughter Bev feels although she doesn’t mind helping her mum up she feels this has a negative impact on her mums dignity and stated her mum felt unimportant about being forgotten and a bit upset

Following the investigation is the alleged

Substantiated x

Partly Substantiated

Not Substantiated

Not determined/inconclusive


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Outcome Substantiated Allegation of organisational abuse On reviewing the induction for new staff and agency staff it was clear the part of internal systems including how to use the care call schedule was inadequate and not detailed enough. It was also evident internal quality checks were not being used by ensuring the care call schedules were checked by the Deputy Manager at handover. The Deputy Manager had also failed to maintain documentation for evidence as part of the Quality assurance processes. Outcome Substantiated Actions taken

Review meeting with Teresa and daughter to discuss ensuring Teresa has her morning visit at the agreed time by regular care staff. This will be monitored by the Registered Manager to ensure care calls take place for a two month period.

Agreed review of the safeguarding in 2 months to discuss if there are any further actions and to ensure Teresa and Bev feel confident with the service.

Looked if call for other service users had been missed which was not the case as care notes indicate calls took place.

Induction for new staff and agency has been revised which now includes a more detailed induction on how to follow the care call schedule

The new staff member who was on duty has now received a more detailed induction and is confident how to use the care call system. They also shadowed an experienced worker for a couple of days to build confidence.

New staff member receiving additional supervision until Manager is confident they are clear on the care call system. This is formally documented.

Local policy developed with regard to quality assurance checks including the checking of care call schedules by the Deputy Manager at handover and ensuring the retention of care call documentation for a two month period before it is destroyed.

Met formally with Deputy Manager regarding concerns of record keeping and quality checks. Outcome provided to Deputy Manager in writing.

Team meeting held on the 31st July to refresh teams knowledge of completing care call schedules and other key documentation.

I am satisfied that I have undertaken this investigation thoroughly, and have put in place a

proportionate response to the incident detailed above.

Signature F. Edwards

Date 03.08.16


mandatory safeguarding form level 3, 4, 5 · pdf file · 2016-12-22mandatory...

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