SCOTTISH EXECUTIVE

Protecting Children: A Shared Responsibility

Chapter 5: PROVISION OF HEALTH SERVICES

This chapter

Outlines the roles and responsibilities of Health Boards and NHS Trusts in Child Protection.
Presents a Health Boardspecification for a child protection service.
Suggests ways of implementing the specification at Trust level.
Identifies the core responsibilities of clinical managers in the community and those of managers in Accident and Emergency Departments.
Highlights policy and legislation in areas of staff selection, supervision and support, education and training of staff.
Addresses research and audit.

When preparing plans for the management and delivery of local health care services, the Priorities and Planning Guidance is the framework to enable the NHSiS to focus on the most important national priorities. The context for this Guidance has been set by the Government White Papers Designed to Care : Renewing the NHS in Scotland (1997) and Towards a Healthier Scotland (1999) and the Comprehensive Spending Review. Against a backdrop of significant constitutional, organisational and service change, the agenda for the coming years emphasises the need to implement existing strategic plans which will deliver improved services to the patient and put in place measures which will ensure the performance of the NHSiS continues to improve in terms of quality, effectiveness and efficiency.

The Government has placed an important focus on improving the health and tackling inequalities of children and young people and this child protection guidance should be part of that attention given to developing services for the young. Health Boards, NHS Trusts and other agencies are required to work together in an open and collaborative manner to produce a Health Improvement Programme (HIP) for the population of each Health Board area. The process should be developed to ensure that the HIPs are collectively owned and seen as the authoritative reference point for local health care systems. Children's Services Plans are the framework by which health and local authorities plan and deliver child health services, of which child protection is an integral part.

The HIP should build on existing strategies, produce a clear plan, demonstrate the multi-professional and multi-agency approach, recognise service developments and recognise the role of patients and local health councils. Each programme should identify measures, which include protection and safeguarding of the public health, the development of health promotion, and therefore child protection will be included. In addition the HIP will make clear reference to, and be supported by, strategies for human resources, estates, information management and technology and finance.

The principal agenda for the Trusts will be the implementation of the relevant Health Improvement Programmes and this will be supported by the production of a Trust Implementation Plan (TIP), which should involve clinicians, primary care practitioners and the Trust team. The plans must be agreed by the host Health Board to ensure they support the delivery of the Health Improvement Programme and that resource and finance assumptions are consistent. NHS Trusts have an explicit responsibility for the quality of care provided to their patients, and this accountability will be discharged utilising the clinical governance framework: clinical governance being defined as the corporate accountability for clinical performance. Child protection will be included within this framework.

Responsibilities of Health Boards and NHS Trusts

Each Health Board should have a Commissioner with a responsibility for planning and commissioning child health related services, which should include a comprehensive, cohesive and effective child protection service.

Each Trust should identify a doctor and a nurse with responsibilities for liaison between health services including hospital and community services and establish links with Local Medical Committees and other appropriate committees involving individual practitioners, in accordance with the local Child Protection Guidelines.

The responsibilities of the Health Board include:

commissioning an effective and comprehensive child protection service.
ensuring that sufficient resources are available and that expert medical and nursing advice on child protection cases is made available to colleagues and other agencies when required.
ensuring that there is a strategic workforce plan to provide therapists to support and treat children, in line with the Acute Services Review recommendations.
taking a strategic lead for health and inter-agency child protection matters and co-operating with other agencies in planning, commissioning and monitoring services and undertaking the timeous review of inter-agency guidelines.
ensuring appropriate managerial and clinical representation on the local Child Protection Committee(s).
ensuring that the child protection service is consistent with the Health Improvement Programme for Children, Trust Implementation Plans and Local Authority Children's Services Plans.
ensuring that the Health Board Commissioner responsible for Children's Services works with other Health Boards to ensure that the Health Board meets the obligations under the Children (Scotland) Act 1995 and works towards a consistent approach to good practice across Scotland.

The Health BoardSpecification for a Child Protection Service should include:

a policy and framework to develop a comprehensive approach to the prevention of child abuse.
the identification in all Trusts of a Senior Nurse or Doctor with responsibility for ensuring that there are appropriate guidelines and procedures in place and that the Trust and its staff comply with local child protection/child protection committee procedures.
the identification of a Senior Nurse and Lead Clinician within Trusts with paediatric services with experience and training in child protection to ensure that there are appropriate guidelines and procedures in place and to ensure that the Trust and its staff comply with local child protection committee procedures.
the introduction of a formal programme of training in child protection for all staff whose work brings them specifically into contact with children.
the availability of programmes of training on child protection issues for all staff and these should be included in their general induction programmes.
the identification of resources to ensure that inter-agency training programmes are in place.
the establishment of a system of clinical supervision and support for all staff dealing with child abuse cases and a system of peer review.
establishing a system for ensuring that all newly appointed staff with considerable access to children are checked against policerecords.
ensuring the validation of professional qualifications with the appropriate professional body.
the establishment of clear lines of responsibility and communication between other agencies, Trusts and the Health Boards.
the promulgation of detailed guidance for the organisation of the health service to deal with suspected child abuse including modes of access to health professionals on call 24 hours a day, facilities available, inter-agency working arrangements and access to appropriately trained police surgeons.
the introduction of a specific mechanism by which health carers may gain access to appropriate legal advice on child protection issues through the Central Legal Office.
the establishment of an explicit mechanism to access advice from the appropriate lead commissioner at the Health Board.
the establishment of a mechanism to cascade information to professions supplementary to medicine, as well as doctors and nurses.
the implementation of a policy on record-keeping which states the purpose and format staff should use when recording information about patients, parents or carers.
the establishment of guidelines and use of standard proformas to ensure the speedy transfer of the relevant records when the child and/or the family move in or out of the agency area, or information about missing families.
the establishment of a mechanism by which a current list of Keepers of the Child Protection Register in Scotland is regularly disseminated to clinical managers and mechanisms are in place to identify at risk children as they utilise child health services.
the promulgation of policies and guidelines for consent and confidentiality issues concerned with child protection.
the promulgation of detailed guidance for the examination of children suspected of being abused including advice on the nature of the examination, the method of recording, appropriate facilities and equipment and arrangements for joint forensic examination where appropriate.
the establishment of a comprehensive system for the follow-up of children suspected and proven to have been abused, including the identification and the provision of appropriate treatment as required by the appropriate clinician.
the commissioning of services for the provision of therapy, counselling and support for children and families where abuse has occurred or where continuing support is needed, ensuring that adequate resources have been allocated.
the implementation of a system to monitor a child protection element of child health service provision to include:
a Trust annual review of all staff whose work involves child protection cases
an audit of inter-agency services
a mechanism for professional practice accountability for all staff.

Trust Responsibilities and Roles of their Staff in Child Protection

The Trust is responsible for the implementation of the specification.

In line with the Health Improvement Programmes and Trust Implementation Plans, the Trust needs to ensure that a framework exists within which practitioners have the skills and appropriate knowledge to fulfil their responsibilities to protect children. Trusts should ensure that:

in areas where children are cared for, a pro-active approach to protecting children and responding appropriately to instances of suspected or actual child abuse and neglect is the norm. Child protection may be only a small part of a practitioner's work, but it requires an informed awareness of known indicators as well as detailed knowledge of the local policies and guidelines/procedures of the Child Protection Committee and those of the Trust.
there is effective leadership and clinical supervision in place which is underpinned with current knowledge and practice in the prevention, identification, assessment and management of child protection. All staff should recognise personal limits of experience and knowledge and not feel inhibited in seeking advice from the Senior Nurse/Lead Clinician Child Protection.
staff are informed about changes affecting practice and of any additional resources required to fulfil the Trust's responsibilities towards protecting children.
staff who are likely to come in contact with children or with families with children during their work have access to, and receive, appropriate child protection training, updating and clinical supervision.
after completing the induction programme all staff understand the Trust's child protection policies, procedures and guidelines.
the continuing training needs of practitioners are assessed and the workforce remains informed, knowledgeable, competent and performs to a high standard.
effective communication systems between operational managers and practitioners and between the Senior Nurse/Lead Clinician Child Protection, other disciplines and units are in place. This is to ensure that a regular update about workload and staffing, emergencies, individual cases and changes in procedures is provided for the various units. The operation of the system should be evaluated and reviewed at regular intervals with the Senior Nurse and/or Lead Clinician Child Protection.
where a case conference is called, relevant information from health services is collated, the Trust is appropriately represented and a system for continuing care and review is in place.
systems are set up for formal notification of case conferences and formal notice of non-attendance when staff do not attend, together with a copy of any report sent in due to absence, while ensuring prompt receipt of minutes from the case conference.
where parent held child health records are in use, consideration should be given to the method of keeping parallel records in situations where there are concerns about abuse and/or neglect.
to avoid loss of early information from notes, cases are regularly reviewed with staff to ensure that all information about the child or family is considered where children are suspected of having been abused or neglected.
there is an agreed system for the timely transfer of health records about a child where there are child protection concerns.
assistance is given in the preparation of inter-agency case reviewreports whenever a case involves an incident leading to a death of a child where abuse is confirmed or suspected, or a child protection issue is likely to be of major public or professional concern.
the Trust should ensure that all policies are monitored and clinical practice audited.

The Responsibilities of the Clinical Manager* in the Community

The core responsibilities of the Clinical Manager based in the community are outlined below and these also relate to the specialist clinical managers identified later.

Clinical Managers based in the community should:

set up a communication system with appropriate health personnel, social work and education departments, Children's Reporter and voluntary organisations about current concerns as well as particular cases. Effective liaison between staff and those of other agencies should be demonstrated.
regularly review caseloads and monitor those records where children are suspected of having been abused or neglected and, with the practitioner ensure that all the information about the family and child is reviewed.
be informed about missing families or 'no access' visits, where there is a concern about a family or a child whose name is on the Child Protection Register. On receipt of the information, the manager is responsible for instituting the procedures of the NHS Trust without delay and ensuring that the Keeper of the Child Protection Register is informed if the child is not found in their Health Board area.
ensure that the system for hand-over from the midwife to health visitor and health visitor to school nurse is effective.
ensure staff have adequate legal advice when required to appear as witnesses in court or to submit statements or other medical reports for the court.
assist in determining the priorities of individual workers, recognising the time necessary for undertaking intensive work with families.
ensure that appropriate systems of record keeping and reporting are established.
give professional advice and information to other health professionals and agencies about the specific role of the health visitor in child abuse cases, and emphasise the importance of prevention, detection and ongoing support.
ensure health visitors have up-to-date knowledge and training in post-natal depression and its early recognition and are aware of the difficulties caused by the condition for bonding between mother and baby, as well as making sure that appropriate referral for treatment mechanisms are in place.

The Clinical Manager for School Nurses

In addition to the core responsibilities, the clinical manager for school nurses should ensure that:

there is a reliable system of hand-over from the health visitor to the school nurse.
school nurses are aware of both the child protection procedures of the local authority and the local CPC guidelines.
there is a system for informing the school nurse about all the children in her schools who are on the Child Protection Register and that nursing records are maintained, with the information contained in these being accessible only to those with the proper authority.
the manager is informed at the earliest opportunity when a school nurse is aware of, or has become involved in, a case of suspected or known child abuse. The manager will wish to discuss the child and family with her in the light of the information that the school has provided and consider what further action should be taken.
there is an effective system in place so that the school nurse can monitor and support these children, keep accurate records and offer reports as necessary.
other professionals and agencies clearly understand the role of the school nurse with school age children.
liaison takes place, as appropriate, with the local authority education, social work services and police.

The Senior Midwife

The Senior Midwife, who is usually the equivalent to the Clinical Manager, should in addition to the core responsibilities already identified, ensure that:

there is an effective communication system between midwives and other practitioners.
there is an agreed arrangement for hand-over between midwives and health visitors, ensuring the name and telephone number are exchanged within the first week after the birth.
there is an early response to information of a pregnancy in a family where there has been an identified concern for the unborn child and other children, which may require a re-ordering of caseloads or redeployment of midwifery staff.
parents with special needs, including learning disabilities, have their needs met, are supported and are referred where necessary to the appropriate source of support to enable the child to have appropriate care.

The Responsibilities of The Clinical Manager in Accident and Emergency Departments

The clinical manager should ensure that:

the agreed procedures and guidelines are easily available and staff are familiar with them.

there is always a clinical manager available to give advice and support to staff, particularly where there is a difference of opinion with other professionals or conflict with parents/carers.
the agreed procedures for obtaining advice from the paediatric unit, whenever children who are suspected of child abuse are brought to the department, are followed.
staff are aware of the potential risk to children, in situations where their mothers present to Accident and Emergency Departments, following injuries from domestic violence.
there is access to all child protection registers and staff are familiar with the procedure for making enquiries of them. Consideration should be given to 'flagging' notes to highlight cases of risk. Staff should know how to obtain advice from the social work department at all times, and know how to contact the duty social worker.
arrangements are in place to notify the health visitor or school nurse of all visits made by children up to the age of 16 years to the Accident and Emergency department.
there are recording and reporting systems of all cases of suspected or actual child abuse admitted to the department and that there is a system for reviewing these records in place.

Staff Selection, Supervision and Support

Employers, and others, who recruit paid or unpaid staff or volunteers who have substantial unsupervised access to children must check applicants' previous employment history and take up references before any appointment. Employers should explore with applicants any gaps in employment history. They should supervise new staff carefully to monitor their relationship with children and so reduce the likelihood of child abuse. Health services must request information from the Scottish Criminal Records Office as to whether prospective recruits who will have access to children have any criminal convictions. This also applies to staff when they move to new posts which give them access to children. The arrangements for disclosure of criminal convictions for statutory bodies are set out in NHS Circular No. 1989(GEN)22. The Government has extended access to information about criminal convictions to voluntary child care organisations and the arrangements will be extended further when the provision of Part V of the Police Act 1997 come into force. This will, in due course, be subject to separate guidance.

Education and Training for Health Staff

All NHS Trust staff, who are likely to come into professional contact with children or with their families, should have access to and receive appropriate training, updating and clinical supervision. Access to training, relevant to the level of responsibility and involvement of the professional, in child protection work should be provided through pre and post-registrationeducation and training and within induction courses. The respective clinician and senior nurse for child protection and the clinical managers are responsible for ensuring that they and their staff have an appropriate knowledge base and skills (see Annex E). This will be achieved through training, case review and clinical supervision.

All medical staff require training in the identification of children who may have been abused or neglected and in the implementation of the local child protection guidelines. Formal and informal undergraduate and postgraduate training should be available and include some components of inter-agency collaboration.

Paediatricians and police surgeons who are likely to be involved in specialist examinations of children suspected of abuse or neglect require further training in clinical skills, including video-colposcopy, report writing and court processes. Access to regular Continuing Medical Education to update and maintain these skills is essential. National agreement on core skills and experience leading to a process of accreditation is recommended.

All specialist paediatricians and police surgeons undertaking joint paediatric/forensic examinations require regular peer review, both locally and nationally. Informal opportunities to seek advice and support from peers in the management of complex and difficult cases should also be available. (See Section under Chapter 8)

The Child Protection Committee has responsibilities for identifying inter-agency training needs and taking a lead role in developing and promoting inter-disciplinary training programmes.

Education and training enables policy makers and practitioners to evaluate the developing body of knowledge from research and implement relevant changes to practice. The content of education and training programmes on child protection for all health staff is contained in Annex E.

Research and Audit

Local and national research studies and audit projects are required to evaluate and monitor practice to inform both future service development and the maintenance of good clinical practice.

The diagrams overleaf offer flowcharts to highlight the processes involved when there are suspicions that a child has been abused or neglected.

*The term "Clinical Manager" is used in this document, but it is recognised that Trusts are changing their structures and this term may be obsolete. It is however necessary for each Trust to identify a person of equivalent status who will be responsible for fulfilling the identified tasks.

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