Domesti

c Violence Community Audit

A Report on the Introduction of Routine

Enquiry into Domestic Violence in

Manchester NHS

April 2006

Domestic Violence Community Audit

Researchers and Authors:

Maria Kovacs

Pauline Omoboye

Caroline Taylor

Abbey Brown

Louise Murray – MMU Tutor

Acknowledgements:

Thank you to Anne, Kay and Shakeela for your contributions.

Staff and volunteers at the Pankhurst for always making us feel so welcome.

Women’s Aid Outreach workers for supporting women to take part.

Alison Surtees, Creative Industry in Salford, for the advice and training on

cameras.

MMU’s Community Audit and Evaluation Centre and the Home Office Active

Learning for Active Citizenship program.

The NHS Domestic Violence Project: Caroline for your enthusiastic support

and Abbey for all your work.

Thank you to all staff who agreed to take part in the community audit.

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Contents

Acknowledgements Page 2

Summary of Findings Page 4

Summary of Recommendations Page 5

Introduction & Project Outline Page 6

Background and Definitions: Domestic Violence and Health in Manchester Page 8

Domestic Violence Community Audit - Methodology Page 11

Findings Page 15

Recommendations Page 25

A Checklist Poster for Health Settings Page 30

Appendices Page 31

All poems copyright to Pauline Omoboye:

Peoples Choice Page 7Beating The Door Page 14At Your Service Page 29

Summary of Findings

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The introduction of routine enquiry of women’s experiences of domestic violence is a key challenge facing the NHS. The Community Audit group is clear that such a significant change will not be achieved overnight or without a certain amount of challenge and discomfort. These findings may make challenging reading for some. Government focus on health professional’s new duties to assist women experiencing domestic violence has already resulted in some important changes in Manchester. More remains to be achieved, however, if this change is to be significant and sustained.

The community audit looked at the environment supporting routine enquiry in 6 key Manchester NHS health settings. This environment should both support professionals to make routine enquiry and enable women to disclose domestic violence and gain access to appropriate advice, information and support. Key findings were that:

Staff interviewed were generally very sympathetic to the need to respond appropriately to women experiencing domestic violence. However, there was a lack of awareness of how to do this effectively in most (not all) settings.

There was limited and sometimes confused knowledge of the main domestic violence advice, advocacy and support services in Manchester. Worryingly, there appears to be very few referrals to these services.

Participation in domestic violence training was limited in most settings. Most settings displayed posters in public areas promoting domestic

violence services. However, one key setting had no domestic violence information at all in public areas.

Leaflets or cards, which patients might take away with them, were not available in half the settings public areas and not at all in more discrete areas such as toilets.

Systems for updating literature were generally reactive and lacked priority. More could be done to support staff responsible for updating posters and leaflets.

No specific domestic violence information was available in community languages in any setting.

In certain settings the safety of minority ethnic women may well be being compromised by the practice of using relatives/friends to interpret.

Generally staff demonstrated a high level of awareness of the importance of confidentiality, their professional responsibilities and agreed practices to support patient confidentiality. Good practice has been developed in the management of patient files to assure confidentiality and safety. However, certain practices that could undermine patient safety and confidentiality were evident in some settings.

Findings in full are available on pages 15 to 23.

Summary of Recommendations

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If routine enquiry is to be a significant intervention supporting the improved health of women and children Manchester more will need to be done. These recommendations are offered as an approach, which might assist this. Recommendations are made in direct response to the findings of the community audit and appear in full at the end of this report.

Key recommendations include:

Basic domestic violence awareness and annual refresher training should be mandatory for all staff and should equip them to respond appropriately and supportively to patients.

All staff need greater awareness of the key Manchester domestic violence advice, advocacy and support services available to support their interventions. In particular all staff should be aware of the NHS Domestic Violence Advice, Advocacy and Support Service.

There should be a clear expectation that NHS services make referrals to domestic violence advice, advocacy and support services. The number of referrals made in each setting should be monitored through the Manchester NHS Domestic Violence Project.

Staff awareness of the dangers of using friends or relatives to interpret needs to be raised and unsafe practices need to be challenged.

Services should review their systems for updating domestic violence literature, taking account of the limitations and opportunities offered by the environment. A lead information contact should be identified.

The Manchester NHS Domestic Violence Project should develop a proactive information order system to support the lead information contact in all NHS settings.

Safety audits should be conducted which include the review of key practices to ensure that patient confidentiality and safety is maintained.

Adult patients should be informed that they would normally be seen individually and professionals conducting consultations should routinely offer these on an individual basis.

More consideration should be given to the needs of children when supporting a woman who raises the issue of domestic violence.

Introduction and Project Outline

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IntroductionIn September 2005 a group of 6 women volunteers started work on a participatory research project focussing on Domestic Violence. Women in this group had all used and/or volunteered in Domestic Violence Services and came together to use their experiences to help facilitate change through an action research project. Manchester Metropolitan University Community Audit and Evaluation Centre (CAEC) and the Manchester NHS Domestic Violence Project worked in partnership to support this group.

This research focuses on the implementation of routine enquiry of women’s experiences of domestic violence with specific attention given to the environmental context needed to support this significant change. The background to the project, including further information on CAEC and the NHS Domestic Violence Project, Domestic Violence and Health in Manchester is presented below. This is followed by a more detailed examination of the Community Audit Methodology.

Community AuditCommunity Audit is a University accredited course developed for students studying for a professional qualification in Youth and Community Work. Manchester Metropolitan University’s Community Audit and Evaluation Centre received Home Office funding to develop Community Audit as part of the Active Learning through Active Citizenship (ALAC) Greater Manchester Hub. A number of community groups have used Community Audit to consider the needs of their community and/or evaluate how well these are being met through services or projects. The course approach values informal education and critical dialogue with high levels of community participation. In this group the research was community lead, all women having experiences of both domestic violence and health services. Community Audit fully considers barriers to participation and prioritises inclusivity and a partnership approach alongside consideration of a range of research methods and methodology.

Manchester NHS Domestic Violence ProjectHealth Services have both duties and opportunities to address Domestic Violence. In Manchester the NHS Domestic Violence Project takes the lead in developing policy, strategy, minimum standards, commissioning appropriate services and promoting best practice. This work is guided and supported by a steering group, whose members are representatives from all Manchester Trusts and specialist health areas. This work also needs to be informed by service users who have experienced domestic violence thereby contributing to the Trusts’ Patient and Public Involvement Strategies. The Community Audit approach is one concrete way in which user involvement will support change within the NHS, ensuring that service development is open to the scrutiny of and informed by service users.

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Peoples Choice

Throughout this course I want to get a clear meaningThe full pictureThe truth And clear factsI want to highlight a subject that mattersI want to strengthen, understand and combat

I want to listen to voices of importanceWork in partnership, challenge and resistAchieve results, review services, be empoweredWork on an inexhaustible list

I want to make a difference to my local communityLook at policies, practice, guidelines and moreLook at values, shape our future, have an impactBe more effective than ever before

With our group I want to show the importanceOf working together as a team with an aimShow how with equality, diversity and co-operationCollective confidence can enhance our game

I want to show our ability, give social justiceWith support, stimulation and expertiseAnd our commitment and richness of experienceThrough this audit will highlight these needs

And we will know when we’ve reached what we’ve aimed forBecause the evidence will be clear for all to seeIn a video, book or a documentAnd we can stand tall and say change came through me!

Pauline OmoboyeNovember 2005

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Background and Definitions: Domestic Violence and Health in Manchester

The Department of Health defines ‘Domestic Violence’ as:“ Physical violence, sexual violence, emotional and psychological abuse, and financial abuse. It therefore describes a continuum of behaviour ranging from verbal abuse, through threats and intimidation, manipulative behaviour, physical and sexual assault, to rape and even homicide. The purpose of this behaviour is to enable the perpetrator to exercise power and control over the victim. The vast majority of such violence, and the most severe and chronic incidents, are perpetrated by men against women and their children.”

In Manchester, it is estimated that 40,005 women (aged over 19) will experience domestic violence in their lifetime and that 17,780 of these will experience domestic violence on an annual basis. The health impact of Domestic Violence is broad ranging and severe, including both short and longer-term effects on physical and mental health. Research identifying these health impacts is well summarised in recent Government publications1.

Physical health effects include: Injuries as a result of assault – domestic violence is the leading

cause of injury for women aged 14-44 Chronic physical health problems 15 times more likely to abuse alcohol 9 times more likely to abuse drugs Loss of hearing, vision and physical disfigurement

Mental health effects include: Higher rates of depression, anxiety, self harm 3 times more likely to attempt suicide 4 times increased risk of post-traumatic stress disorder

Pregnancy: 23% of women are at risk of domestic violence during pregnancy 37% of women physically assaulted are assaulted for the first time

during pregnancy 2 times more likely to experience miscarriage Increased rates of unintended pregnancies and terminations

Every week in the UK two women are killed by current or former partners2. Domestic Violence accounts for one quarter of all violent crime3and as such is a major strategic issue to be tackled by Crime and Disorder Partnerships. Primary Care Trusts became responsible authorities within these Partnerships on 30th April 2004.

1 Tackling domestic violence: exploring the health service contribution, Home Office 20042 Living without Fear: An integrated approach to tacking violence against women, Home Office & Cabinet Office 1999, p73 The 1998 British Crime Survey: England and Wales, Home Office, 1998, Table A2.3

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All children/young people living in a violent household will be psychologically and emotionally damaged by this witness experience, although their responses to these experiences will vary. In addition, the perpetrator directly abuses 50-70% of children living with an abused mother. Research also indicates long-term consequences for children’s well being. 4

With current prevalence rates, it is estimated that 13,159 of Manchester’s girls and young women currently aged under 19 will go on to experience domestic violence as adults. 6,007 of these will experience this violence on an annual basis.

The total cost to Manchester of domestic violence is £117,129,760 a year, including a cost of £7,149,991 to health services.5

Government has identified that the health service is:“uniquely placed to change public attitudes to domestic violence, and ensure that women experiencing domestic violence can access services to help them change their situation.”6

Health care professionals are more likely than any others to be approached by, or be in touch with, abused women and children. This puts Health services in the unique position of being able to access a broad and representative range of women and children experiencing domestic violence.

Additionally, consultation with abused women and children has indicated that they would trust and disclose to a health care professional if they were encouraged and supported to do so. This is not current practice. Government has indicated clear expectations that NHS services are modernised to address domestic violence. This is in line with broader requirements within the NHS Plan to ‘redesign the NHS around the needs of the patient’7. Addressing domestic violence contributes to one of the core functions of Primary Care Trusts in tackling health inequalities.

Domestic violence is the largest single reason for homeless presentations from families and single women in Manchester. In 2004-05 this accounted for 28% of families presenting as homeless (496 families) 27% of single women (267 women) and 0.9% of single men (28 men). Objective 5 of Manchester City Council’s Homelessness Strategy, (required under the Homelessness Act 2002) commits the authority to reducing the number of homeless presentations and representations: “ By working in a holistic way, and adopting a multi-agency approach with people we rehouse, we should reduce repeat presentations by addressing the reasons for people becoming homeless.” 8

4 Mental Health Services for Children Who Witness Domestic Violence, McAllister Groves, B., Boston, http://www.athealth.com/Practtioner/ceduc/dv_children.html5 All Manchester prevalence and cost statistics from Manchester NHS Citywide Domestic Violence Project Spring Newsletter, March 20056 Tackling Domestic Violence: the role of health professionals, Home Office 20047 Cited in South Manchester PCT Patient and Public Involvement Strategy, March 2004, pg 78 http://www.manchester.gov.uk/housing/strategy/homeless/homestrat/objct5.htm

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Addressing domestic violence as a significant underlying cause of homelessness in Manchester is therefore embedded in Manchester’s Homelessness Strategy.

Health Services are required to introduce routine enquiry of domestic violence for all women using maternity services in 2008. Additionally, it is expected that good practice will promote the use of routine enquiry for all women across all health settings.

The Home Office defines routine enquiry as:“Asking all women who are using the service direct questions about their experiences, if any, of domestic violence regardless of whether there are signs of abuse or whether violence is suspected”9

The introduction of routine enquiry is a key challenge, requiring change on many levels within the NHS.

Domestic Violence Community Audit - Methodology

A group of 6 women volunteers met in September 2005, responding to an invitation to work on a participatory research project focussed on Domestic

9 Tackling Domestic Violence: the role of health professionals, Home Office 2004, pg 4

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Violence. Women in this group had all been involved with Domestic Violence services as service users and/or volunteers. The group agreed that their project would aim to assist the change needed to implement routine enquiry, drawing on their experiences to inform the research from a ‘service user’ perspective. All women in the group identified a key motivation for their involvement as wanting to support change that tackled domestic violence and gave women access to support and choices. In agreement with the Manchester NHS Domestic Violence Project Manager, Caroline Rowsell, the focus of the project was to consider the environmental context, which will support the introduction of routine enquiry.

The group identified that the environment, that is, setting and surroundings, included consideration of:

The physical environment and its impact on staff and patients Information and resources available to staff and patients Communication and contact between staff and patients Working practices in the particular environment

The purpose of the environmental observation was to consider: How the setting supports health professionals to routinely enquire into

women’s experiences of domestic violence How the setting supports women to disclose domestic violence and

gain access to appropriate advice, information and support

The group took part in the MMU Community Audit program (see Appendix 1):“We met to discuss what a community audit actually is and how best to carry out the research. This was done by looking at what women believe provides a good service (see opposite) and what provides a poor service. After several meetings where the group looked at several research methods, and discussed the advantages and disadvantages of each method, it was decided that it was best to incorporate a couple of different research methods to best evaluate the information that was available and required.”

The group selected 2 methods: observation of the setting, accompanied by a series of semi-structured interviews with a range of staff to ensure their perspectives and experiences were valued and included in the research. “The interview was complied to look at the policies and procedures of the different organisations where we carried out the research. This was achieved by asking the set interview questions to members of staff within that particular health setting…where time and circumstance allowed, the interview was normally carried out with the practice manager and also with a member of reception staff. The interviews were carried out in this manner to enable discrepancies to be easily identified. Also, when read in conjunction with the observation charts, it was easy to identify the theoretical practice from the reality of the actual service being delivered”

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An

observation grid was devised to ensure

reliability of the observation i.e. that it produced similar results under constant conditions on all occasions and was not dependent on the subjective judgement of an

individual observer.

The validity of

the chosen

research

methods i.e.

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whether they measured what they were supposed to measure, was considered. Minimum Standards adopted by Manchester Health Trusts on Domestic Violence include a standard on creating a supportive environment for disclosure. Both the observation grid and interview schedule were developed against the requirements for this standard.

The group worked in teams visiting a range of health settings during February and March 2006. These included:

2 GP practices with differing ward profiles An NHS Walk-In Centre 1 accident and emergency department 1 dental setting 1 hospital maternity service

Each research team used the same combination of methods: an observation grid and semi-structured interviews (see appendix 2). In addition researchers filmed their initial evaluations of each setting.

The group considered ethics in the research, agreeing the need to fully involve staff and to be sensitive to any personal experiences of Domestic Violence sitting alongside their professional responsibilities. Staff involvement in the research was offered on the basis of confidentiality and anonymity. Permission was sought in advance and at each setting. The observation grid and interview schedule were piloted and revised before proceeding with the remainder of the research.

Notes from each interview and completed observation grids were used to provide data for analysis. The group met twice to consider this data and agree on findings for each setting and the project as a whole. The group then drafted recommendations following discussion of the key findings.

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Beating The Door

Another violent pounding

At my front door

Another dishevelled body

Collapses on my floor

Another weepin’ baby

Confused and distressed

Another disturbing chapter

In this written text

Another badly beaten body

Clothes in shreds

Another beating undeserved

Deep gashes to her head

Another scar upon her body

An even deeper one in her mind

Another case of vicious violence

Of the most degrading kind

Another silent crime unreported

Kept locked up inside

Another unrecorded incident

Too ashamed to confide

Another sleepless night

And the fear or more

Until the next innocent victim

Comes knocking at my door

Pauline Omoboye

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Findings

These findings are presented against the requirements of the Manchester NHS Trusts Domestic Violence Minimum Standard 2: creating a supportive environment for disclosure. They combine findings from both observation (O) and interview (I) methods, highlighting any discrepancies. Results are combined for all 6 settings.

Good practice points, which the communityaudit group consider might be adapted toother settings, are highlighted.

Requirement 2a part 1: all health settings promote the message that domestic violence is not acceptable

Evidence sought from the Community Audit against this requirement: Posters, leaflets and other literature informing patients and staff of

domestic violence advice, advocacy and support services and campaigns are readily available (Observation: O)

There is a mechanism in place to ensure literature & posters are up to date (Interview: I)

Findings 5 of the 6 settings had posters displayed, just 50% had both posters

and leaflets on display 1 key setting had no literature on display in public areas to

promote domestic violence services4 services had developed their own patient information systems, dependent on the physical limitations and technological opportunities of the setting. These included information on domestic violence services: - Information folder in reception area with details on a range of issues and contact details of support/advice services- Separate room for leaflets and information- Access to touch screen computer with a link to End the Fear website (touch screen computers were available to patients in the main reception area)- A5 sheet with list of key service numbers for patients to take away (this setting had extremely limited space)

Practice Managers and lead/ senior nurses were most commonly cited as taking responsibility for updating literature and posters. As noted

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above this has mixed success. Staff identified a key barrier being the level of busy routine and consequent lack of priority given to proactively updating literature.

ConclusionMost services displayed information in public areas promoting domestic violence services. However, stocks of leaflets, which patients might take away with them, were only available in 50% of settings. One key setting had no domestic violence information at all in public areas although it had an effective information system for staff. Systems for updating literature were generally reactive and lacked priority. More could be done to support staff responsible for updating posters and leaflets.

Requirement 2a part 2: the patient will be dealt with appropriately if they raise the issue of domestic violence

Evidence sought from the Community Audit against this requirement: Scenario question (I):” What would happen if a woman and her 2

children entered your health care setting saying that her violent partner was following her? How would you ensure the safety of the woman, her children, staff and other patients?”

Staff are trained in domestic violence awareness and child protection (I)

There is access to private space that is comfortable (O) There is a play area for children (O)

Findings

In one setting 80% of the staff team were reported as having taken part in recent domestic violence awareness training. Both members of staff interviewed in this setting had a good knowledge of domestic violence advice and support services and made referrals to these services. This setting also provided the most considered and complete response to the scenario question taking into account safety & advice needs, assuming responsibility to both call the police and make a referral to the domestic violence advice service, offering the health setting as a meeting place.

This setting also gave a real example of an appropriate response:

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A patient came into the setting very distressed, told the receptionist of domestic violence and then quickly fled. The receptionist was able to follow the woman to give her a leaflet about the Domestic Violence Advice Service. A referral was made and a private space provided for the meeting with the Domestic Violence Advice Worker.

This response highlights the importance of basic domestic violence awareness, including knowledge of relevant services, in the whole staff team.

Initial child protection training and refresher courses were widely reported for all staff.

Participation in domestic violence awareness training was, by contrast, variable and generally much more limited. In 2 settings there was no knowledge of staff taking part in domestic violence awareness training. In another 2 settings there was an information link with a lead professional responsible for domestic violence, which was offered as an alternative to up to date training for all staff. In the remaining setting team leaders and the patient services manager had taken part in training currently and in the past.

Most responses to the patient scenario question were inadequate. All settings considered security and immediate safety and had systems in place to assist with these. Only 2 of the 6 settings considered referral to a domestic violence advice service. Only 1 setting reported that they would automatically call the police, another would encourage the woman to do so. None of the responses mentioned the specific needs of the children. Most responses did however consider the need for private space to respond. One setting was even able to offer a ‘safe room’ with an access code for entry, a drinks machine and telephone.

All but one setting had access to private, comfortable space. For one setting this was not possible except in private consultation rooms, which were used by consultants.

Only 2 settings had a play area for children, neither of these was supervised. Provision of toys in other settings was basic or non-existant.

ConclusionParticipation in domestic violence training for the whole staff team supports an appropriate and adequate response to patients who raise the issue of domestic violence. Most services had not given adequate consideration to how they might respond supportively to patients experiencing domestic violence. In some settings where there is a lead professional for domestic violence there is a tendency to rely on this person to provide basic as opposed to expert knowledge. All staff members should have basic domestic violence awareness training, which should enable them to consider an appropriate response for their role and equip them with the relevant knowledge.

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One service was limited in responding to patients by the lack of private space accessible to any staff member. Renegotiating access arrangements to space normally reserved for senior clinical staff would help provide a more appropriate patient response. More consideration might be given to the needs of children in reception areas.

Requirement 2a part 3: accessible literature (including how to access support services) is provided in a way that is easy for patients to access discreetly

Evidence sought from the Community Audit against this requirement: Posters are on display and leaflets or cards are available in the toilets

(0) The service information/welcome pack includes information on

domestic violence services & the Domestic Violence Helpline telephone number (O)

Domestic violence literature is available in community languages (O)

Findings 4 of the 6 settings had posters or cards displayed in the women’s

toilets. This needed to be extended to the disabled accessible toilet and mother and baby facility in one setting.

2 settings had no discrete information available at all. None of the settings had leaflets or cards available in toilets for patients

to take away discreetly. None of the 4 services, which had a service information/welcome pack,

had information on domestic violence in this. None of the settings had domestic violence literature available in

community languages. However, all Central Manchester and Manchester Children’s University Hospitals NHS Trust leaflets had information on link workers in 8 community languages.

ConclusionMost services displayed information in discrete areas (e.g. toilets) on domestic violence services. However, leaflets or cards, which patients might take away with them, were not available in these areas. No specific domestic violence information was available in community languages in any setting. None of the services had yet taken the opportunity of providing basic information on domestic violence services (e.g. DV Helpline telephone number) in their service welcome pack.

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Requirement 2b: Safety audits should be carried out on health settings and work stations to ensure that service user safety and confidentiality can be assured

Evidence sought from the Community Audit against this requirement: The environment is child friendly (O) Signs are displayed informing patients that aggressive behaviour will

not be tolerated (O) Information is not given out to friends/relatives at reception/on the

phone (O & I) Computer screens are not visible to anyone other than the user (O) Patient names are not called out over a tannoy or shown on screens (0

& I) Conversations cannot be overheard at reception or in the consultation

rooms (O) There is an active suggestions/comments and complaints procedure

(O) The service confidentiality policy is displayed (O) Patient files are managed to ensure confidentiality (I)

Findings In all 6 settings staff demonstrated a good level of awareness of the

importance of confidentiality, their professional responsibilities and agreed practices to support patient confidentiality.

At interview all staff were clear that information was not given out to friends or relatives without the permission of the patient. In one setting however, it appeared to be accepted practice for husbands to be given results for women who did not speak English. Although flags were in place for sensitive information, in practice this could prove difficult if this permission was sought through these same related interpreters. (See 2e below)

A number of systems were in place to ensure patient confidentiality in computer records including the use of flags, passwords and medical abbreviations. Flags were used to highlight a confidentiality clause i.e. where patients had requested restricted access to information.

Where routine enquiry had been implemented the setting had developed a clear recording system to flag up both that domestic violence had been discussed and where patients had disclosed domestic violence.

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There may be a policy practice gap on confidentiality. In one setting staff were overheard giving information out about a patient. Computer screens were generally visible in 3 of the settings.

Some settings faced particular environmental challenges. One service had open plan reception facilities with no attached private space. Patients would be given forms to fill in to ensure some confidentiality but where they needed assistance with form filling, confidentiality was in practice compromised. This service is awaiting new facilities. In another setting conversations could be overheard from the consultation rooms. Again this service is awaiting new facilities.

Hand held notes are in use for specific purposes in a number of settings e.g. for x-ray, maternity notes, wound care. Some consideration had been given to the security of this information e.g. use of envelopes. However, in at least one setting further thought needed to be given to the management of these files. In this setting some patient notes were normally held in an unsupervised slot outside rooms and were potentially vulnerable.

3 settings did not use a tannoy system. For the remaining 3 it was not considered practical to not call patient names out over the tannoy. If, however, patients requested it would be arranged for a member of staff to come and collect them.

In 4 settings signs were displayed informing patients that aggressive behaviour would not be tolerated.

5 of the 6 settings had a sign welcoming suggestions, comments and complaints. Only 1 service had leaflets on display informing patients of the complaints/suggestion procedure. In 2 settings patients were expected to ask for these from reception/practice manager. One setting had 2 suggestions boxes in the main reception area.

2 settings had leaflets explaining the service confidentiality policy. One setting had a poster with a service confidentiality statement. The remaining 3 settings had no information regarding patient confidentiality on display.

The safety of children needed to be given more thought in 2 settings. One service had 2 unguarded heaters. Another service had an unprotected plug socket next to the play area.

ConclusionGenerally staff demonstrated a high level of awareness of the importance of confidentiality, their professional responsibilities and agreed practices to support patient confidentiality. Good practice has been developed in the management of patient files to assure confidentiality and safety. Two settings faced environmental challenges, which compromised patient confidentiality – both these services were awaiting new facilities.

Certain practices that could undermine patient safety and confidentiality were evident in some settings. Staff need to be aware of the visibility of computer screens to patients and be clear on the restriction of information to patients’

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relatives except where explicit consent has been given. The practice of using friends or relatives as interpreters needs to be revised (see 2e below). The safety of the environment for children needs to be thoroughly considered in all settings. The vulnerability of hand held notes, particularly those on display in unsupervised settings needs to be addressed.

Service confidentiality policies could be more proactively promoted in some settings, as could suggestions and complaints procedures.

Requirement 2c: Systems should be in place to ensure that patients are aware that consultations, wherever possible, will take place on an individual basis

Evidence sought from the Community Audit against this requirement: Patients are informed that they will be seen individually in the service

leaflet/information pack, by signs on display, by the receptionist. (O & I) The reception area and separate private space are accessible for

disabled patients (O) All pregnant women are offered individual consultations (I)

Findings None of the settings informed patients that they would be seen

individually by use of methods such as signs on display, in the service leaflet/information pack.

Only 1 setting reported informing patients at reception that they could be seen individually.

Patients were not normally seen individually. 1 setting considered it difficult to see patients individually and would need to be ‘alerted to a problem’. Another setting would see patients individually if they ‘suspect domestic violence’. One other setting reported that individual consultations were at the discretion of the consultant and practice varied on this.

2 services exclusively relied on midwives to see pregnant women individually

1 of the 6 settings had limited accessibility for mobility impaired patients. Another setting had locked gates impeding access to the disabled ramp.

Most settings had developed strategies for seeing patients individually e.g. to conduct particular medical procedures, where they felt this was needed.

Conclusion

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More could be done to inform patients that they can be seen individually. There is too much reliance on being alerted to or recognising a ‘problem’ before patients are offered an individual consultation. There appears to be a culture in some settings that couples would normally be seen together.

Not all settings are fully accessible for disabled patients.

Pregnant women are offered individual consultations through midwives. The responsibility of other medical professionals towards routine enquiry of pregnant women is not clear.

Requirement 2d: If there are suspicions of domestic violence then it is preferable for a female patient to be seen by a female member of staff

Evidence sought from the Community Audit against this requirement: There is a female member of staff trained and available to talk with

women patients about domestic violence (I) Staff time is made available to patients who raise the issue of domestic

violence (I) Staff are aware of advice, advocacy and support services for women

experiencing domestic violence and make referrals to them (I)

Findings 3 of the 6 settings reported that no female member of staff was trained

and available to talk with women about domestic violence. Of the 3 remaining settings: in the first 80% of staff were trained; in the

second there was a specialist; in the third the NHS Domestic Violence Advice and Advocacy Service would be used.

3 services responded positively that they would offer ‘ however long it took’ to patients who raised the issue of domestic violence.

There was generally a limited (and in some cases confused) awareness of advice support and advocacy services for women experiencing domestic violence.

Only 2 settings mentioned the NHS Domestic Violence Project and Advice and Advocacy Service available through this.

Perhaps unsurprisingly then, only one setting reported having actually made a referral to any domestic violence advice, advocacy or support service.

Conclusion

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Staff are generally sympathetic to the need to put aside time for women patients experiencing domestic violence. However, there was a lack of awareness of how to do this effectively in most settings. The NHS Domestic Violence Advocacy and Support Service was only cited as a resource for 2 of the 6 settings. There was limited and sometimes confused knowledge of the other main domestic violence advice advocacy and support services in Manchester. Worryingly, there appears to be very few referrals to these services.

Requirement 2e: All health settings should ensure that appropriate interpreters are made available (in most circumstances it is not acceptable to use friends, relatives or children)

Evidence sought from the Community Audit against this requirement: Posters are displayed in community languages advertising interpreter

services (O) Interpreters, where needed, are made available to patients as part of

routine practice (I) The service has a strategy to offer an interpreter to a woman patient

whose friends/relatives might normally interpret for her (I)

Findings None of the settings displayed posters advertising interpreter services

in community languages.

All Central Manchester and Manchester Children’s University Hospitals NHS Trust leaflets had information on link workers in 8 community languages.

One setting asks if an interpreter is needed in every letter that is sent out to patients.

All settings had good knowledge of and access to interpreter services

One setting owned a clear practice of using relatives to interpret (‘relatives are so helpful in translating’); one other setting considered that the use of the patient’s daughter would be acceptable. In a third

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setting the professional interviewed highlighted that guidelines were that no family member should interpret but acknowledged that in practice where a consultant agreed to this it was very difficult to challenge.

Only one setting clearly stated that they would not use a friend/relative to interpret.

ConclusionThe safety of minority ethnic women may well be being compromised by the practice of using relatives/friends to interpret. More needs to be done to raise awareness amongst staff of the dangers inherent in this approach and to advertise to patients the interpreting services available.

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Recommendations

Requirement 2a part 1: all health settings promote the message that domestic violence is not acceptable

1. Services should review their systems for updating domestic

violence literature in public areas, taking account of the limitations

and opportunities offered by the environment. A lead information

contact should be identified.

2. The Manchester NHS Domestic Violence Project should develop a

proactive information order system to support the lead information

contact in all NHS settings.

3. Information technology such as screen savers on touch screen

computers in public areas and messages on electronic welcome

screens should be used to promote knowledge of routine enquiry

and to publicise the NHS DV Project End the Fear website.

Requirement 2a part 2: the patient will be dealt with appropriately if they raise the issue of domestic violence

4. Basic domestic violence awareness and annual refresher training

should be mandatory for all staff and should equip them to respond

appropriately and supportively to patients.

5. There should be a clear expectation on all staff to have basic

domestic violence knowledge. Staff should have the opportunity

through training to explore likely scenarios for their work setting and

to consider the appropriate response for their role.

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6. Specialists and leads in domestic violence should be viewed as

expert support in order to (rather than as a reason not to) develop

broader, whole service responses.

7. Services limited in responding to patients by the lack of private

space accessible to any staff member will want to negotiate access

to space normally reserved for senior clinical staff.

8. More consideration should be given to the needs of children e.g.

play equipment in reception areas, when supporting a woman who

raises the issue of domestic violence.

Requirement 2a part 3: accessible literature (including how to access support services) is provided in a way that is easy for patients to access discreetly

9. The Manchester NHS Domestic Violence Project should identify the

relevant community language profiles with the lead information

contact in each setting and, where possible, provide appropriate

literature.

10.Services should consider the inclusion of information on domestic

violence services in their next service information/welcome pack.

Maternity services should make this a priority.

11.Leaflets/cards, which patients can take away discretely, should be

constantly available in areas such as toilets and private consultation

rooms.

Requirement 2b: Safety audits should be carried out on health settings and work stations to ensure that service user safety and confidentiality can be assured

12. Safety audits should be conducted which include the review of key

practices to ensure that:

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a. Computer screens are not visible to anyone other than the

user

b. The environment is safe for children

c. Hand held notes are not vulnerable

d. Friends/relatives are not used as interpreters

e. Information is not given to patient’s relatives except where

explicit consent has been given. It is not safe practice for

this consent to be sought or given through relatives/friends

acting as interpreters.

f. Staff are aware of the risk of being overheard when giving

out patient information

13. Service confidentiality policies could be more proactively promoted

in some settings, as could suggestions and complaints procedures.

Requirement 2c: Systems should be in place to ensure that patients are aware that consultations, wherever possible, will take place on an individual basis

14. Adult patients should be informed that they would normally be seen

individually. The service information pack, signs in reception and

the receptionist can all assist with this.

15. Professionals conducting consultations should routinely offer these

on an individual basis.

16. Settings need to be aware of their access arrangements for

disabled patients and the need to make ‘reasonable adjustments’.

17. All health professionals need to be aware of the opportunity they

have to assist with routine enquiry even where it is not legally

required of them. This is considered good practice by the

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Department of Health and could make a significant difference to

women experiencing domestic violence.

Requirement 2d: If there are suspicions of domestic violence then it is preferable for a female patient to be seen by a female member of staff

18. Sufficient female staff need to be trained in each NHS setting to

ensure patients have appropriate initial support on domestic

violence issues.

19. All staff need greater awareness of the key Manchester domestic

violence advice, advocacy and support services available to support

their interventions. In particular all staff should be aware of the

NHS Domestic Violence Advice, Advocacy and Support Service.

20. There should be a clear expectation that NHS services make

referrals to domestic violence advice, advocacy and support

services. The number of referrals made in each setting should be

monitored through the Manchester NHS Domestic Violence Project.

Requirement 2e: All health settings should ensure that appropriate interpreters are made available (in most circumstances it is not acceptable to use friends, relatives or children)

21.Staff awareness of the dangers of using friends or relatives to

interpret needs to be raised and unsafe practices need to be

challenged.

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22. Interpreting services should be advertised to patients in all letters

sent out, in service leaflets and posters in reception areas.

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At Your Service

I remember it like it was yesterdayThe sun shone in the clear blue skyAnd everything carried on as usualWhile deep inside I wanted to hide

It took me ages to pluck up the courageIn fact it was weeks before I picked up the phoneWhere at the end of the line was a friendly voiceAnd for that moment I was no longer alone

There was a rhythm in her voice that spelt comfortI could almost picture her smileAnd not once did she question my honestyOr shrug me off, to put my name on file

She just listened and listened and heard meNo interruptions just acknowledgement she could hearAnd it’s something I will always rememberBecause for once it dispelled all my fear

It was remarkable, an experience to treasureMeasured by the emotions I feltAnd not by the violence I sufferedOr by the scarring from the buckle of a belt

In it’s place was a service that offeredT.L.C. as it’s middle nameA voice that gave me a free lessonWith something positive and a direction to aim

I’m so happy that my friend had informed meOf this service for all those in needIt was a step up the ladder of life changesA realisation, and I’d just sown the seed

Now in it’s place is a woman of substanceA presence with style, full of graceAnd I stand tall with an air of defianceNot just another slap in the face

Pauline OmoboyeOctober 2005

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In Manchester this year, 18,000 women will experience domestic violence.

How will you help?

Do you:1. Display up to date posters about Domestic Violence?2. Have leaflets or cards that patients can take away

discreetly?3. Have information about Domestic Violence in all your

communities’ languages?4. Have a safe, accessible and private space where a

patient can talk confidentially?5. Ensure that you see patients individually?6. Ensure that patients who need interpreters are not

asked to talk through friends or family members?7. Take part in domestic violence training?8. Ensure children’s needs are considered?9. Ensure that you protect patient confidentiality?10. Refer women to domestic violence advice, advocacy and support services?

Routine Enquiry – women want to be asked!To find out more visit www.endthefear.co.uk

Appendix 1: DV Community Audit Program

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Agree ground rules and additional content of course

Reading list and course plan

MMU student registration and campus tour

What is community?

Community: an overview of the theory

Community and domestic violence

Consultation, participation and involvement

Community participation and empowerment: putting theory into

practice

Phases of Community Audit process

Barriers to participation – experiences and theory. What does

this mean for the Audit process

Research and evaluation – your experiences

Ethics in research – methodology

Research methods

Agree research focus and method and timescale

Develop research tools

Conduct Pilot

Conduct community audit research

Analysis and evaluation of findings

Presentation of findings: report and tools and dissemination

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Appendix 2: Interview Schedule

Health setting ………………………………………

Date of interview ………………………………………

Name of interviewee ………………………………………

Job title of interviewee ………………………………………

1) If I came in as a patient here what kind of services would you offer me?

2) One of the key issues for patients experiencing domestic violence is that confidentiality is assured. Please could you summarise your:

a) confidentiality policy and your

b) information sharing policy

3) Who has access to patient files?

4) Are there any circumstances where notes are hand held by the patient or their partner or carer?

IF YES - What arrangements are there for ensuring sensitive information is kept confidential?

5) Is there the opportunity not to have names called out over the tannoy?

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6) What are the procedures to ensure confidentiality over the telephone?

7) What training on domestic violence awareness and child protection have you and members of your team taken part in over the last 12 months?

(2b)

8) Is there a female member of staff trained and available to talk with women patients about domestic violence?

(2d)

9) How much time could you make available for a patient who raises the issue of domestic violence

(2a+2d)

10) What would happen if a woman and her 2 children entered your health care setting saying that her violent partner was following her? How would you ensure the safety of the woman, her children, staff and other patients?

(2a+2b)

11) Are interpreters made available to patients? (2e)

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12) How would you offer an interpreter to a woman patient whose family/partner might normally interpret for her?

(2e)

13) What systems do you have in place to ensure that consultations with patients can take place on an individual basis?

How are women made aware of this?(2c)

When patients are not seen individually, how is confidentiality assured to them?

14) In 2008 it will be a statutory requirement to routinely enquire about domestic violence to pregnant women. How would you ensure that a pregnant woman is offered an individual consultation?

(2c)

15) Are you aware of any advice, advocacy or support services that you might

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refer women who are experiencing domestic violence to?Which ones? (2d)

Have you ever referred a patient to them?

16) Who ensures that you have up to date literature and posters?

How well do you think this works? (2a)

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Appendix 3: Observation Grid

Community Audit Course

In partnership with Manchester Metropolitan University and Manchester NHS Citywide Domestic Violence Project

Setting ………………………………………………………………………

Observer ………………………………………………………………………

Date …………………..

Time started …………………..

Time finished …………………..

Please tick all appropriate boxes

Requirement Evidence Yes No Comments

2a) Part 1

Promote the message thatdomestic violence is not acceptable

-Posters

- Leaflets

- Other literature

Specify which:

- End the fear posters

- End the fear leaflets

- End the fear cards

- Women’s Aid leaflets/Discus

- Manchester rape crisis leaflets

- St Mary’s Sexual Assault Centre

-

-

0 Less than 10 More than 10

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Please tick all appropriate boxes

Requirement Evidence Yes No Comments

2a) Part 2

The patient will be dealt with appropriately ifthey raise the issue ofdomestic violence

Access to private space that is comfortable

There is a play area

Supervised child care facilities are offered – confirmed by member of staff

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Please tick all appropriate boxes

Requirement Evidence Yes No Comments

2a) Part 3

Accessible literature isprovided on domesticviolence support and advice services. This iseasy for patients toaccess discreetly

In the toilets there are domestic violence:- Posters

- Leaflets

- Cards

The service information pack includes:- Domestic violence services

- Domestic violence helpline number

Domestic violence literature is available in other languages

There is an information welcome pack available to patients

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Please tick all appropriate boxes

Requirement Evidence Yes No Comments

2b) Part 1

Safety audits are carriedout in health settingsand work stations

The environment is child friendly Are there any hazards? Is there security?

Information is given out about patients to friends relatives:

- at reception

- on the phone

Signs are displayed informing patients that aggressive behaviour will not be tolerated

Suggestions, comments, complaints procedure:

-sign welcoming

-leaflets available

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Please tick all appropriate boxes

Requirement Evidence Yes No Comments

2b) Part 2

Service user safety and confidentiality isassured

The confidentiality policy is on display

Conversations can be overheard at:

- Reception

- Consultation rooms

Patients names are called out over the tannoy system or are shown on a screen

Computer screens are visible to anyone other than the user

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Please tick all appropriate boxes

Requirement Evidence Yes No Comments

2c)

Systems are in place to ensure that consultationscan take place on an individualbasis

The service leaflet/ information pack informs patients that they will be seen individually

There are signs up about seeing patients individually

The receptionist tells patients that they can be seen individually

The reception area is accessible

There is an accessible private space

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Please tick all appropriate boxes

Requirement Evidence Yes No Comments

2e)

Appropriate interpretersare made available

Posters are displayed in community languages advertising that interpreter services are available on request

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