Basildon review

To set up a working group with key services to consider how best to raise awareness of possible safeguarding issues when they are identified and implement a mechanism for sharing information with relevant officers within other services. This will not only assist in ensuring that we provide the appropriate support and services to vulnerable individuals but that we protect Council Officers by ensuring they are fully aware of all the relevant information, providing duty of care to officers in the course of their duties.

Identify process for sharing of information amongst internal departments with regards to victims and perpetrators who are subject to MAPPA and MARAC arrangements. This will not only assist in ensuring that we provide the appropriate support and services to vulnerable individuals but that we protect Council Officers by ensuring they are fully aware of all the relevant information, providing duty of care to officers in the course of their duties.

Raise awareness with 3rd Tier Service Managers of the importance of accurately checking records and databases, including liaising with officers who are out on the ground, when requests for information are received.

3rd Tier Service Managers identifying their service has been involved with the victim and/or the perpetrator to provide an analysis of this involvement to the officer leading the IMR, this is in addition to the provision of records and is to include an executive summary of the effectiveness of the service delivery, chronology, conclusion and if necessary recommendations for improvements to be made. A template to be produced by Community Safety Manager to aid this process.

Identify a process for 3rd Tier Service Managers to notify Basildon Council’s Manager of Audit & Risk, when officers are asked to give statements directly by the Police or other agencies, relating to incidents which occur during the course of their Council duties.

Consider and review Basildon Council’s domestic abuse and vulnerable adult policies with a view to identifying training needs and requirements of all staff, including enhanced training for key officers and front line services and regular refresher training.

Council Tax Visiting Officers to carry QB50 (note books) to record details of their visits, including not only the result of the visit, but who was present at the property at the time of the visit.

Council Tax Visiting Officers to undertake property detail checks of Council’s databases prior to carrying out site visits to reduce risk of harm to themselves and others. This is to take place with immediate effect.

Raise awareness amongst all staff of the process for providing information directly to the Police and other agencies relating incidents which occur during the course of their Council duties.

That consideration should be made at all Mental Health Assessments to incorporating Domestic Abuse questions/enquires, whether there is a previous history or not. Deliberation would also need to be given to follow-up visits for the completion of the DASH risk assessment tool, and who would be responsible for doing that, if the person is not detained and/or declines a service.

The other area previously identified is a more joined-up approach to Domestic Abuse training for AMHP’s. These actions would need to be led by the Mental Health Service and discussed in a multi-agency forum, there would need to be evidence provided as to the advantages or disadvantages of adopting this approach to Domestic Abuse and Mental Health Assessments.

Offender Managers should adopt an investigative approach to offender management and seek independent verification of information pertaining to risk management. For example, checking offence / intelligence details with the police or that a case has been referred to MARAC.

Offender Managers to review the risk assessment and risk management plan after a significant event, for example a domestic violence incident.

Managers-Offender Management in South Delivery Unit to continue to monitor the working arrangements with CJMHT to ensure that there is appropriate liaison.

Children and Families Policy in respect of Schedule 1 and Risk to Children procedures should be followed in all relevant cases and decisions are appropriately recorded on the case record.

Offender Manager (Courts) to follow the relevant practice instruction when offenders who are subject to current order/licence appear in court.

Protocols regarding signing off customers for non engagement to be reviewed. Complex cases to be escalated to Head for approval as with evictions.

Incomes policy to include referral to floating support provider after rent arrears have been triggered at first formal stage.

Lessons learnt and recommendations arising from report to be agreed with Safeguarding Advisory Group.

Family Mosaic to consider how they manage complex cases where there is multi-disciplinary involvement internally.

Investigation required into why the neighbourhood dispute was not recorded in front office/Northgate.

Review the current EDAAT contractual arrangements with all involved partner agencies by May 2013 to ensure that the Open Road’s co-ordinating role is effectively communicating overall Action Plans, which include and reflect the work of other drug service agencies such as CDAS’s and WDP, and also contain evidence of joint assessments, reviews and decision making.

Open Road to undertake a review of its case file procedure by April 2013 to ensure that there is an improved co-ordination between files kept on the same individual partaking in different interventions.

Open Road to pursue whether it is appropriate to develop a greater and deeper understanding and knowledge of Domestic Violence, particularly in relation to safeguarding victims and assessing and managing the risks posed by perpetrators, and decide by end of March 2013 the level of future involvement.

Open Road to consider possible involvement in all Community Safety Partnerships Domestic Violence Forums across Essex by February 2013 with a view to having new arrangements in place by April 2013.

Open Road to look at Domestic Violence training opportunities for managers, staff and volunteers by March 2013 for possible inclusion in Open Road’s Training Plan for 2013/4.

The Trust should ensure that the principles of the dual diagnosis policy are being followed by the Criminal Justice Mental Health Team and the Basildon Community Mental Health Team so that a person who has substance misuse issues but is presenting with mental health needs should be assessed and provided with appropriate interventions by the assessing clinician from Mental Health Services.

The Basildon CMHT Manager must ensure that the referrer and the G.P. are always informed of the outcome of a referral regardless of the outcome.

Reinforce restrictions on children being brought to services

That risk assessment training is provided

That risk assessment documentation is reviewed and its implementation is clarified through specific training

That DASH tools and processes are introduced into the standard working practices and is supported by training provided following a clear analysis of need

That partnership working between the Inside Out team and MARAC is explored and defined

That a schedule of audits across the project is planned and includes an examination of the case notes

That the quality of case management and record keeping is more effectively monitored and managed through clarified expectations of the supervision process

That the appropriate Essex-wide partnership / board monitors; • the number of patients in drug treatment services in south Essex who are also being treated for a personality disorder and / or a diagnosed mental health illness; and • the number of patients in drug treatment and who have an identified personality disorder and are receiving an appropriate treatment.

That the Essex Health and Wellbeing Board consider the issues raised in this DHR and in particular the vulnerability of those people who have not received a formal mental health diagnosis, but may be suffering from a personality disorder or a mental health illness as a result of known childhood trauma.

That in light of the findings of this DHR, the Essex Safeguarding Board considers reviewing and broadening the definition of a "vulnerable adult" to include adults with complex needs.

That consideration be given to the establishment of a national database which records all incidents related to mental health concerns. This might include reports of concern to the Police (hoax calls, victims of domestic abuse expressing concern), mental health assessments undertaken by CMHS or agencies working out of hours, diagnoses of mental health issues including anxiety and depression. This database would allow local CMHS to identify residents where the frequency of incidents was increasing or the severity and risk was increasing above established thresholds and triggering an automatic welfare check or care response to the patient and potentially also the carer.

That EDAAT consider the findings of this DHR, with particular reference to the risk assessment forms and comprehensive assessment forms that are completed by drug treatment agencies across Essex; and that they ensure that all staff are aware of the importance of identifying the underlying concerns of the client; and have the training and experience to link the history of the client to the current issues in order that the treatment plan can fully address the needs of the client.

That all agencies involved in programmes with perpetrators of domestic abuse consider joint working with tailored drug and alcohol programmes, specifically designed for domestic abuse perpetrators.

That a tailored drug and alcohol treatment programme is delivered to those clients who present for treatment and are identified as having been childhood witnesses of serious domestic abuse.

That a review is undertaken into drug testing protocols to ensure that the most effective methods are being used in south Essex, and that results are shared between agencies in accordance with the current contract arrangements.

That all agencies address internal processes that are currently dependent on the self reporting of the client, without checks or verification processes in place.

That efforts are made to progress the establishment of the Essex Multi-Agency Information Sharing Hub (MASH) to enable health and care agencies to share appropriate information that may help to identify individuals in crisis in future.

That information sharing protocols are developed between agencies not included in the MASH project, to enable the sharing of relevant information that may reduce the risk of harm to staff, clients and others.

That all agencies take opportunities to arrange appropriate multiagency meetings to discuss clients causing concern and are themselves committed to attending or contributing to multiagency meetings when their partner agencies invite them to attend.

That all agencies commit to support the current care coordination roles of the G.P. so that the G.P’s are aware of all mental health concerns identified by other health professionals, even if no formal diagnosis is identified.

That arrangements are put in place to ensure that AMHPs are able to access relevant and timely information prior to Mental Health Act assessments, including those completed out of normal working hours.

That all agencies review their processes to identify when the next of kin might be providing information that reflects their own lack of understanding of the situation faced by their family member, rather than a true picture of the needs of the client.

That arrangements are put in place to offer specialist care and support to all families, including any children that experience a domestic homicide, for as long as they need it, in order that they may heal from their experiences and not suffer long term consequences that could blight the rest of their lives.

That the Essex Domestic Abuse Strategy Group builds a strong relationship with HM Coroner’s Office to support the joint working of DHRs and HM Coroner in future DHRs.

That the Essex Domestic Abuse Board considers the learning from this DHR process and uses it to inform the Essex guidance for future DHRs.