Bristol review

The Home Office reviews both the title of Domestic Homicide Reviews and the content of its Guidance document in the context of deaths occurring from suicide.

As part of the consideration of the DHR process, greater flexibility could be given to Community Safety Partnerships to only review those suicides where Domestic Abuse appears to have been a significant and primary influence on the decision of the person to take their own life.

The Community Safety Partnership to consider how it prioritises and delivers its services, and those for whom it can no longer provide.

Partners to consider whether alternative routes to detox may decrease risk, particularly in cases of domestic abuse. Staff should and can challenge where only traditional routes to detox are being considered/offered.

Domestic Abuse training for all staff. (Not limited to domestic abuse services)

Training – risk management planning specific to domestic abuse. (Not limited to domestic abuse services)

Ensure a Trauma Informed Approach in all Supported Housing Services

Risk Management: Non-acceptance of referral for perpetrator to same supported housing service when victim is still in residence.

Consider provision of access to Adult Social Care case recording systems to relevant safeguarding experts in the Housing and Communities Service – Directorate. (Better information sharing will enable better practice.)

Line Managers to check case recording accuracy as part of the file audit that is undertaken at each supervision e.g. ensuring correct terminology is used documents named and attached correctly Case closure summary to be written in every case, in line with section 4.1 of “Recording Guidance: Principles and Standards when recording Client and Carer Information”.

Teams to follow the “Recording Guidance: Principles and Standards when recording Client and Carer Information”. If the need is identified as a result of this, practitioners to attend the “Recording Skills and report Writing” training.

Additional clarity to be provided and added to the Bournemouth, Dorset and Poole Multi-Agency Safeguarding Adults Procedures; Safeguarding Strategy Meeting Attendance. To ensure that all invited parties provide information and/or a substitute attendee should they be unable to attend. Review Templates - A mandatory action review mechanism in the review minute template to identify why actions were not completed and how this can be rectified.

Domestic Abuse Awareness and MARAC training is made mandatory for all front line workers within the drug and alcohol workforce.

Review the Treatment System Risk Assessment Process to make sure: identifies risk in relation to domestic abuse, appropriate risk status is identified, tangible, is shared, information is up to date and easily identifiable on HALO – the case management system new/updated risks to other appropriate workers and attach evidence.

Develop a Domestic Abuse Protocol for treatment providers to adhere to that links into Borough Policy and the Pan Dorset Strategy.

Develop a procedure for the drug and alcohol workforce in relation to working with the ‘couples’.

Treatment providers commissioned by the DACT / PHD in Bournemouth to have agency specific Domestic Abuse Policies in place that are understood by the workforce.

Review of the Treatment System involvement with MARAC so a pathway can be developed.

Improve record keeping practice in the following areas: contain more detail, evidence why decisions are made or not, and why appointments are cancelled, notes need improving. with couples, information relevant to both parties must go on both of the parties’ case notes.

Review service provider safeguarding meeting processes: safeguarding sub intervention on HALO. recording information on to HALO from safeguarding meetings. standards of Safeguarding Leads.

Drug and Alcohol Statutory Social Work Team to keep records on HALO when joint working BEAT clients.

Ensure allowance for provision for pets is known to the workforce.

Synopsis of Learning to be Developed and shared with DHC to detail the learning from the DHR.

DHC staff to be supported with the application of the MARM process for people who self-neglect of do not engage with services

Ensure that the requirements of the Mental Capacity Act 2005 are embedded in practice across all agencies, including the appropriate use of advocacy.

Review process to ensure all staff check all records within Locata when dealing with enquiries.

Record keeping training to be introduced to the staff training matrix to ensure accurate and appropriate recording takes place.

Process for people moving on from supported into council stock to include the Housing Officer and floating support worker making contact to establish relationship and ensure joint engagement with new tenant.

Review the process of key information from Locata being transferred to Northgate and EDRMS at the start of a tenancy to provide background knowledge for Housing Officers

Review the Rent Vulnerability Assessment which now takes place for people moving into a tenancy, to ensure it instigates the appropriate action for people who are at risk of falling into rent arrears.

Staff are to be reminded of the importance of recording and to keep all agencies updated of non-engagement and signs of deterioration or withdrawal.