Croydon review

Conduct a rigorous borough-wide review (through the Croydon Domestic Violence Strategic Group) of the response to domestic violence. This review must address the gap between the strategy and delivery of the strategic aims in the operational practice of partner agencies.

In conjunction with other strategic boards, produce a domestic violence protocol, policy and care pathway. This should include domestic violence enquiry and provision for safeguarding children, adults at risk and vulnerable young people.

Disseminate learning from the two domestic homicide reviews widely across the partnership. This should be in the form of a written briefing to all staff and dissemination sessions and incorporating findings into any domestic violence training that is commissioned and delivered locally.

Commission a borough multi agency domestic violence training programme, which, bearing in mind the findings of this review, should specifically address themes of diversity. This should be done with the support of other strategic boards and take up of training should be audited and monitored by each agency through the Croydon Domestic Violence Strategic Group. It is recommended that the training covers awareness and dynamics of domestic violence, specific skills training on enquiry and completion of MARAC risk assessment, safeguarding responsibilities and referrals pathways.

Examine ways to raise awareness amongst young people of the issue of relationship violence and publicise what support is available.

Consideration must be given (alongside the LSCB and SAB) to include adults within the Croydon MASH process.

Address the issue of having a formal commissioned system in place to provide Appropriate Adult services out of hours.

Through training, ensure that all custody sergeants when granting bail without conditions provide a full rationale around their decision on the subject’s custody record.

Prisoners should be interviewed at the earliest opportunity, and all decisions must be documented in the custody record around not interviewing / rest periods and showing all efforts to contact an Appropriate Adult.

All staff responding to DV incidents to receive mandatory training in the use of the DASH 2009 risk identification, assessment and management tool in order to effectively assess risk.

Implement changes to the current DV guidance to instruct that intelligence enquiries be conducted on suspects and victims MPS wide utilising the MPS systems (Integrated Information Platform, CRIMINT, CRIS, Merlin) and nationally using Police National database.

Ensure Police Merlin reports are completed accurately and are timely expedited to Children’s Social Care.

To address the volume of sharing of information through the Merlin system so that Merlin reports are more focused, specific and relate to the assessment of risk.

Ensure that information and intelligence about risk is always sought between key agencies.

Audit that a rationale for any ‘flags’ on agencies’ case management systems is clearly recorded.

Audit adherence and implementation of policy of conducting Police intelligence checks.

Design a strategy to implement the NICE Guidance (PH 50) on Domestic Violence and Abuse19, ensuring through audit that practice is change and improved.

Improve staff awareness of issues relating to violence and abuse, (primarily against women, as service users and the partners, carers or members of the family of service users) through a dedicated training programme separate from, but based on the Safeguarding Children Strategy. The work to raise awareness must be underpinned by evidence and framed in a way that resonates with different staff groups in SLaM as recommended in ‘Responding to Violence against Women and Children – the Role of the NHS’’.

Update the Trust Policy on Domestic Violence and Partner Abuse (2008) to reflect current best practice and findings from the two domestic homicide reviews conducted in Croydon.

Review the policy and practices around 7 day follow-up email to ensure they meet the requirements of the organisation and comply with national guidance. In the meantime it is recommended that the Assistant Director Patient Safety drafts and distributes a Blue Light Bulletin that clearly states the standard expected for 7 day follow up.

Examine commissioning and delivery of training to support staff in understanding the dynamic of domestic violence in relation to the safeguarding of adults and the role of carers and partners, the risks and needs of those involved.

Examine commissioning and delivery arrangements for the AMHP Service.

Rewrite the multi-agency borough referral pathway agreement to include action taken by agencies and the outcomes of referrals.

Remind crew staff of the safeguarding policy and procedure with specific reference for confirming receipt of all faxed safeguarding referrals and responsibilities for safeguarding children and adults at risk.

Review internal systems of receiving and transmitting safeguarding concerns from crews to the relevant local authority safeguarding teams.

The Joint Strategic Needs Assessment on domestic violence should reference the findings of the two domestic homicide reviews

Work together to help identify funding to commission a pilot borough wide system to improve the response of primary care to patients who are experiencing domestic violence, such as Project IRIS.

Ensure appropriate health engagement in Croydon’s coordinated community response to domestic violence which includes appropriate health representation at the Community Strategic Partnership and Croydon Domestic violence and Sexual Violence Strategy Board.

Identifying and responding to domestic violence and the safeguarding of children and adults, is discussed with General Practitioners (from the GP practices concerned specifically in this review) during appraisal and revalidation.

To write to all Croydon General Practices advising them of the need to ensure that their mandatory safeguarding training (adults and children) for which they are responsible, includes domestic violence information to an appropriate level.

Ensure when appointed that the Lead GP for safeguarding has domestic violence included in their job description.

Consider whether the existing tools for depression screening should include psychological/social aspects on the dynamic of mental health and domestic violence.

Create, disseminate and then regularly review an organisational domestic violence policy and care pathway. This should include: a. Specific reference to the use of the Accident and Emergency prompts for the Emergency Department. b. Routine enquiry policy for health visiting and school nursing services. c. An organisational stance on providing “private time” at the ante natal booking appointment, and then throughout all ante natal care appointments to enable midwives to ask about sensitive issues such as domestic violence.

Embed the use of the Accident and Emergency safeguarding prompts in practice, and seek to include the key questions in the prompts in the new electronic record keeping system (Cerner) to be used by services within CUH from 30 September 2013 onwards.

Review and improve systems of sharing safeguarding concerns between the Emergency Department and other departments with CUH, (including the ward staff).

Work with the Community Safety Partnership to ensure a workforce training programme on domestic violence is delivered (this may be part of the training led by the CSP or separately commissioned).

Develop and distribute a universal resource on the range of help and support available to new parents (this should include a number of issues such as housing, parenting, benefits as well as information on help for victims and perpetrators of domestic violence) to support routine enquiry for domestic violence during ante natal and post natal care.

Reconfirm domestic violence enquiry practices within maternity services and ensure that staff are appropriately trained to ask about domestic violence and respond to a concern or a disclosure from a pregnant woman. This should include approaches for enquiry of pregnant teenagers and also for women who have suffered a miscarriage.

Conduct a system wide review of the processes within Accident and Emergency so that staff are aware of their role and responsibilities in relation to responding to domestic violence and any safeguarding concerns. This should include: a. Mandatory training programme for all Accident and Emergency staff on domestic violence. b. Provision of information on local domestic violence support services and how to refer to them (including the MARAC). c. Ensuring the safeguarding prompts are being used. d. Staff understanding the Domestic Violence pathway. e. Agreeing Accident and Emergency’s staff roles and responsibilities in relation to domestic violence risk assessment and referral to services.

Examine the organisational policy and procedures for the recording of any threats to staff. This should include a refresher for staff and managers and provides management support and a process to ensure that any allegations of crime are reported to Police.

Audit safeguarding children’s training to ensure that domestic violence is appropriately addressed.

Review the Board’s policy on safeguarding children where there is a parent with ill mental health, substance misuse or a learning disability to also include domestic violence.

Highlight and explain widely the ‘think family’ approach so that practitioners, professionals and clinicians understand the concept and their roles and responsibilities regarding safeguarding children.

Provide staff with information on the Toxic Trio to inform their safeguarding practice.

Adopt a new secure email system that provides the authority with a clear audit trail in terms of the time and date it receives Police Merlin Reports.

Consideration to be given to expanding the role and remit of Croydon’s MASH to include vulnerable adults and adult service providers.

The MASH process is developed to ensure robust social care oversight of all Contacts’ that are not progressed to an assessment of the child’s needs by a ‘lead professional’ within the partnership.

Drug services to explore the dynamic of domestic violence when working with individuals who use anabolic steroids.

Review their policy and procedures for identifying and responding to domestic violence and ensure all staff receive appropriate training to support contemporary practice for healthcare practitioners.