Standard 2: Policy, Procedures and Guidelines

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Good policies, procedures and guidelines are necessary to ensure statutory requirements are met and a good standard of care is delivered.

Following robust policies and procedures will ensure that:

  • People are empowered and supported to make their own decisions.
  • Staff are preventing harm rather than responding to issues after they have occurred.
  • Staff and using the least restrictive intervention that is appropriate to the risk.
  • Those in the greatest need are protected and supported.
  • Staff work in partnership in the local community and have a role in preventing, detecting and reporting any neglect or abuse.
  • There is transparency and accountability in safeguarding practice.

Care homes, supported living providers and domiciliary care providers will ensure all staff are aware of the safeguarding adults and children policy and any relevant guidance or procedures to ensure they deliver a good standard of care.

Some of the specific policies include:

  • Chaperone Policy
    • applicable to children and adults.
  • Consent to Treatment Policy
    • applicable to children and adults.
    • must make explicit reference to MCA and Gillick competence /Fraser guidelines.
  • Deprivation of Liberty Safeguards (DoLS) 2009
    • ensures that staff adhere to legislation and any updated guidance.
  • Domestic Abuse Policy
  • Domestic Abuse Workforce Policy
  • Fall Management Policy/Protocol
    • to include a supporting risk assessment, personalised care plan and least restrictive option. The falls policy will include guidance on which falls constitute a safeguarding concern.
  • Medication Administration Policy
    • includes covert administration and best interest decision making processes.
  • Nutrition and Hydration Policy
    • includes a recommended assessment tool, covering a risk of choking and best interest decision making processes.
  • Policy in relation to Severance Agreements
    • makes it explicit that no payments will be made to encourage staff to withhold any concerns about care quality and patient safety.
  • Prevent Policy
  • Record Keeping Policy
    • outlines the minimum national standards in relation to accurate and safe record keeping.
  • Restriction/Restraint Policy
    • compliant with the Mental Capacity Act (MCA) covering the use of all forms of restraint. The restraint policy must include children and rapid tranquilisation as appropriate.
  • Safeguarding Policy
    • Reflects the Children Act 2004 and the Care Act 2014, and is compliant with the SSCP Safeguarding Children Procedures, SSAB Safeguarding Adults Procedures and includes specific information on Child Sexual Exploitation (CSE), Missing, Exploited and Trafficked, Female Genital Mutilation (FGM), Prevent, Looked after Children and Modern Day Slavery.
  • Safeguarding Supervision Policy
    • sets out the requirements of the workforce in relation to the requirement for supervision for staff working directly with children and adults.
    • clearly outlines the process for enabling all staff who work directly with families, including those in adult services, to access supervision and also the level and frequency of supervision provided to all staff including the Named Professionals and Safeguarding Leads
  • Safer Recruitment Policy
    • including DBS checks for staff and volunteers working with children and adults
  • Serious Incident Policy
  • Whistle Blowing Policy
    • reflects the Public Interest Disclosure Act 2012 and covers arrangements for staff to express concerns both within the organisation or to external agencies.
    • the provider will ensure that appropriate, relevant, accessible information is available at all times in all areas to staff, users and carers and the wider public in relation to whistleblowing.
    • the information will inform the public how to report concerns or allegations. This will include information for staff within the organisation.

2a. Do you have a Safeguarding Adults Policy?

You may find it useful to consider the following when writing or reviewing your policy:

  • Does the policy explain how to identify, respond to and manage any safeguarding concerns?
  • Does it involve residents and their families and carers in designing and reviewing these arrangements.?
  • Is it clear how to report suspected abuse or neglect?
  • Does it reflect the principles of working together/joint working?

2b. Do you have a safeguarding policy written in a format that is accessible to those using the service and meets their communication needs?

Good practice suggestions:

  • Is the policy clearly written, taking the Accessible Information Standard into account?
  • Think about where it is to be located so that everyone (staff, residents, visitors) can easily read it.

 

2c. Is your safeguarding policy easy for those using the service, staff, visitors and other service providers to access?

For good accessibility, consider the following:

  • Where is it displayed?
  • What format it is in?
  • When / how often it is reviewed?
  • How is it promoted or shared?

2d. Does your safeguarding adult policy refer to Think Family and the safeguarding of children?

The Family Resilience/Think Family model is the approach to safeguarding in Surrey. It promotes the importance of a whole-family approach and recognises providing early help is more effective in promoting the welfare of children than reacting later.

For more information visit:

2e. Do you have a Mental Capacity Act and Deprivation of Liberty Safeguards Policy?

The Mental Capacity Act 2005 is concerned with the human rights of individuals aged 16 and over whose decision-making capacity is impaired. The core principles of mental capacity legislation and the legal framework within which professionals operate are highlighted:

  • protecting the rights of individuals
  • promoting dignity and respect of the person, their beliefs, values and wishes
  • promoting person-centred care and supportive decision-making which ensure that decisions made are in the best interests of individuals at that time.
  • a presumption of capacity

All care providers should have an MCA Deprivation of Liberty Safeguards (DoLS) policy and all health and social care professionals should be aware of their roles in respect to mental capacity, particularly for end-of-life care and advanced decision making.

More information is available in Standard 10: Mental Capacity Act (MCA) Policy and Deprivation of Liberty Safeguards.

2f. Do you have a Domestic Abuse Workforce Policy?

We would hope employers would be committed to develop a workplace culture in which there is zero tolerance of abuse and where support is offered to staff who are affected by domestic abuse.

Employers owe a duty of care to employees and have a legal responsibility to promote a safe and effective work environment.

Employers should consider:

  • Introducing an internal workforce policy about how you will support staff affected by domestic abuse and raise awareness of domestic abuse and the specialist support services available across Surrey with your managers and workforce.
  • Having information available about:
    • The Contact the Everyone's Business Advice Line run by Hestia, as a resource for employers to advise them on how to approach disclosures of domestic abuse by their employees. Call 07770 480 437 or 0203 879 3695 or email Adviceline.EB@hestia.org
    • White Ribbon UK who have resources and information including how to be an ambassador.

An example of a Domestic Abuse Workforce Policy can be found on the Healthy Surrey website: Domestic abuse in the workplace - Healthy Surrey

2g. Do you have a Whistleblowing Policy?

Whistleblowing is raising a concern about something happening in the service which could harm those who live or work there.

A good whistleblowing policy supports the workforce to feel confident and supported to report safeguarding concerns internally, as a first step. The policy should support staff to understand how to report through other routes if they either feel unable to challenge or if they receive an unsatisfactory response and clearly explain how to report a concern, who to contact and how to do so.

Attention should be given to helping staff understand what information/facts are needed to help the investigation. Consideration could also be given to periodically discussing the policy within team meetings to ensure that volunteers and new staff are aware of it.

Whistleblowing for employees: What is a whistleblower - GOV.UK (www.gov.uk)

Your whistleblowing policy should include:

  • An explanation of what whistleblowing is, particularly in relation to the organisation
  • A clear explanation of the organisation’s procedures for handling whistleblowing, which can be communicated through training.
  • A commitment to training workers at all levels of the organisation in relation to whistleblowing law and the organisation’s policy
  • A commitment to treat all disclosures consistently and fairly
  • A commitment to take all reasonable steps to maintain the confidentiality of the whistle blower where it is requested (unless required by law to break that confidentiality)
  • Clarification that any so-called ‘gagging clauses’ in settlement agreements do not prevent workers from making disclosures in the public interest.
  • An idea about what feedback a whistle blower might receive.
  • An explanation that anonymous whistle blowers will not ordinarily be able to receive feedback and that any action taken to look into a disclosure could be limited.
  • Anonymous whistle blowers may seek feedback through a telephone appointment or by using an anonymised email address.
  • A commitment to emphasise in a whistleblowing policy that victimisation of a whistle blower is not acceptable. Any instances of victimisation will be taken seriously and managed appropriately.
  • An idea of the time frame for handling any disclosures raised.
  • An idea of the time frame for handling any disclosures raised.
  • Clarification that the whistle blower does not need to provide evidence for the employer to look into the concerns raised.
  • The process must also specify who people can contact and how (for example, local authority and Care Quality Commission). For more information, see the Care Quality Commission guidance on whistleblowing.
  • Information about blowing the whistle to the relevant prescribed person(s).

Remember that:

  • Whistle blowers are protected by law and must not be victimised.
  • Staff and volunteers may be afraid of what might happen if they Whistle blow. This can stop them from identifying and reporting abuse and neglect.

2h. Do you have a Safe Recruitment Policy?

All care providers must operate a robust recruitment procedure undertaking any relevant checks. It is the provider’s responsibility to ensure that they only employ fit and proper staff who are able to provide care and treatment appropriate to their role. 

CQC highlight two fit and proper tests that are separated within the health and Social Care Regulations.

  1. Regulation 19 – the requirement for the fit and proper person test for persons employed
  2. Regulation 5 – the requirement for director to be fit and proper persons

Resources

Safeguarding children, young people, and adults at risk in the NHS.

More information is available in Standard 8 Safer recruitment and retention of staff.

2i. Do you have a Complaints Policy?

When you receive a complaint into your service it is important to adhere to your in-house policies although it is essential that you consider if the content of the complaint constitutes an allegation of abuse or neglect towards any resident.

Remember for a safeguarding referral to be required under the Care Act 2014, the person has to meet the usual three criteria:

  • having care and support needs
  • experiencing (or being at risk of) abuse or neglect.
  • being unable to protect themselves because of those needs.

Equally it is important that individuals feel safe and comfortable to challenge poor practice standard of care. Anyone should feel confident to raise a complaint without fear of reprisal.

You must reassure them that they will receive help and support in taking their concern forward.  They should also be advised that they can nominate an advocate or representative to speak and act on their behalf if they wish. If an adult has no appropriate person to support them, and has substantial difficulty in being involved, they must be informed of their right to an independent advocate.

Creating an open and honest culture encourages individuals to raise concerns. It is essential to ensure their voice is heard.

2j. Do you have a Safeguarding Supervision Policy?

Everyone should have an opportunity to have reflective supervision to support staff to understand how to identify and respond to potential harm and neglect in your service, as well as having the opportunity to learn from their experiences. This should be a safe space for staff to feel comfortable to challenge poor practice, raise concerns and feel supported through the process. We are aware that there is a potential for under reporting safeguarding concerns by staff who are afraid that this will affect their jobs. Creating an open and trusting culture is paramount.

NICE guidance safeguarding in care homes looks at line management and supervision responsibilities.

More information is available in Standard 4: Safeguarding supervision.