Cheltenham review

Ensure the review into Gloucestershire’s collective response to individuals experiencing multiple disadvantages considers the findings from this review. This will ensure that the countywide response to ‘complex needs’ considers the specific needs of victims of domestic abuse and supports future victim engagement in services/increased safety

Ensure agencies are aware of the need to address immediate physical (shelter, food, clothing, emergency health care, sleep etc) needs (that may be caused by DA) first in complex cases to support victim engagement

A small working group drawn from multi-agency partners, in conjunction with the Safeguarding Adults Board Workforce Development sub-group, be formed to review both the content and delivery of existing Mental Capacity Act Training, and Domestic Abuse training ensuring sufficient emphasis is given to the impact on decision-making capacity of long-term substance misuse, domestic abuse, and/or coercion and control.

Multi-agency partners to review the Mandatory, or other status of such training to respective areas of the workforce involved in assessing and supporting people’s decision-making.

Ensure agencies are aware of the immediate safety measures that should be considered when responding to victims of domestic abuse to ensure safety planning is not delayed or linked to ongoing victim engagement

For the Safeguarding adults board to ensure the findings from this review are considered alongside the 5 women SAR to ensure a joined up approach to the learning around ‘ensuring agencies can respond effectively at the point when someone is ready to accept support’ and the need to act fast in these situations to safeguard vulnerable people.

When agencies contact the police regarding safe and well checks, where possible, the information should be relayed directly (phone/face to face) in order to convey the risk associated with the individuals it concerns. This will support police in ensuring Safe and well checks are conducted appropriately and victims are safeguarded.

Domestic abuse training should explore the impact of domestic abuse on the person’s ability to maintain self-care independently and how this area of a person’s life may be used as a means to isolate them from an otherwise supportive network.

When engaging with people who have complex needs and where domestic abuse may be known or suspected, all professionals should exercise professional curiosity when exploring with the person their ability to self-care and/or the appropriateness of their support network in relation to any arising needs for care and support.

HM Prison Service to review its policies and practice around communications from prison in cases of domestic abuse to ensure the ongoing safeguarding of victims.

All agencies to ensure DA training is clear on how professional should respond to immediate and long term risk; recognising the opportunity of perpetrator incarceration in engaging and safeguarding victims in the long term.

All NHS Integrated Care Boards to provide a solution for how domestic abuse risks presented to and by a patient are documented within clinical records, so that NHS staff do not inadvertently increase their patient’s risk of harm from or to others

NHS Gloucestershire Safeguarding teams to look to a solution for how risks relating to domestic abuse are consistently recorded across health partners.

The domestic abuse partnership board to review DA training and to consider opportunities to commission countywide training via Lot 5 of the DA Framework to ensure a consistent approach to DA Training for the county that is sustainable in upskilling all professionals in identifying and responding to DA. Training should ensure the inclusion of a specific DA perpetrators module to ensure all professionals understand how to identify perpetrators of DA and respond effectively to manage their behaviour and hold them to account.

For CBH staff in key supportive roles to receive training in relation to mental Capacity, the Mental Capacity Act and how assessments are carried out. In order to increase their understanding and allow them to fully engage in professional discussion with partner agencies, and also to confidently challenge a decision if the need to do so arises.

When working with people at risk of domestic abuse, practitioners regularly review the input of informal support to ensure appropriate support remains available.

Customer Service Officers ensure that all suitable referrals are passed to the Locality team for assessment.

Customer Service Officers inform professionals when they have not been able to complete an agreed action, and that action remains outstanding and not closed unless the professional advises to do so.

Where individuals are reluctant to engage with Registered Social Workers specifically, alternative social care practitioners may provide support to the individual under the direction of an appropriately qualified lead worker.

ASC workers to clearly record the purpose and anticipated content of ongoing welfare telephone calls and/or visits and where for any reason the welfare check is not undertaken, this is immediately escalated to the line manager for discussion and agreement on next steps. ASC workers may wish to agree in advance relevant “code words” to be used by the individual to alert the worker to perceived risk/threat and agreed actions that will follow in these circumstances; this will be clearly recorded on the person’s record.

When working with individuals who may be at risk of abuse or neglect, practitioners remain professionally curious ensuring all appropriate methods of communication are utilized.

Multi-agency reviews to be requested by ASC if situation escalates/changes.

ASC practitioners remain aware of the principles of Making Safeguarding Personal in conjunction with the statutory requirements of s11 Care Act 2014 “Refusal of Assessment” and document where this has been considered

For ASC practitioners to clearly document that they have considered the impact of domestic abuse on the person’s ability to make decisions with capacity free of coercion or controlling behaviours.

Make efforts to ensure continuity of care with a “usual GP” for patients who are known to be vulnerable.

Make every contact count - using opportunity for conversations about domestic abuse and exploring options and choice. Make efforts to seek consent to liaise with and involve family members if considered safe and potentially helpful to do so.

Development of a ‘notice, ask, refer’ reminder card for staff is being progressed by the Domestic Abuse Lead in the Trust.

GHCNHST level 2 manadatory safeguarding training has been based around a family where domestic abuse impacts on each family member from a baby to an older adult with care and suport needs. Includes reference to alcohol misuse and MAPPA.

The Gloucestershire Probation Delivery Unit Quality Improvement Plan is revised to include learning from this DHR. The Probation Service aim is to deliver excellent services. We are working to improve the quality of work in domestic abuse cases: sentence management; assessments and reports.

Improve access to information about domestic abuse call outs to inform assessment.

Recognising the care and support needs of those addicted to alcohol and the likely self-neglect as a consequence of this. There were a number of missed opportunities for SWASFT crews to raise safeguarding alerts for self-neglect to Adult Social Care.