We have recently supported a number of related projects. During our work, we pulled together research to present to strategic leads and commissioners about inequalities in mental health support, this includes:

1. As of June 2023, 143,119 people were waiting for an autism assessment in England, new NHS data has revealed. This is a 47% increase in the number of people waiting in just one year.
2. 79% of autistic adults will experience poor mental health with 50% of autistic adults experiencing depression.
3. In total 2,035 autistic people and people with learning disabilities are in inpatient mental health hospitals in England.
4. 1,310 (64%) of these people are autistic.
5. There are 215 under 18s in inpatient units that are autistic or have a learning disability. Of these, 93% are autistic.

There has long been a call for change, including discussion of Mental Health Act Reform, but without a shift in the way we currently approach mental health support, for autistic people and people with learning disabilities, that it is unlikely to achieve the changes that campaigners, organisations and individuals are asking for.

A movement in mental health approaches: Intersectionality

With evidence also of racial and ethnic inequalities in mental health and some discussion on late diagnosis, and mis-diagnosis before diagnosing autism in women and girls, I have considered the need to look at mental health, autism and learning disabilities through the lens of intersectionality, looking at the experience of autistic people and people with learning disabilities, in recognition of the potential multitude of additional inequalities faced by this group.

Research in Practice describes intersectionality as a framework for examining, deconstructing and challenging the idea that parts of a person’s identity are experienced as discrete categories.

Through this lens, I have considered the need to look at identity, how and when people seek autism diagnosis, and how health and social care support can work together, to support individuals who are asking for ‘mental health support’. With complex legal frameworks at play, including the Mental Health Act, Mental Capacity Act, Care Act, The National Health Service Act, Human Rights Act and many others, I am currently working on supporting organisations to understand how a person may present as needing support from the mental health system, how this translates into commissioning needs, now and for the future, and how the current system can align to offer support within current approaches, while we await the wider reform that is in discussion.

I have plenty more to learn, more evidence to gather and more importantly, more people to work with, who are directly impacted by the current mental health, health and social care, system.

With many organisations sharing research and guidance on good practice, I hope to continue to support organisations to embed these, with additional demographic and intersectional considerations each area will undoubtedly require.

If you would like to get in contact to discuss how we can support your organisation please email us: info@scie.org.uk

Despite the Care Act’s impact, there’s a palpable sense that the transformation of services is still ongoing. Implementation of its provisions has been challenging and incomplete, leaving many ambitions unrealised. Today, the reality for many seeking to access social care services is one of frustration and inequality.

A major challenge has been funding, which has not kept up with demand for social care. Over the years, local authorities’ budgets have been squeezed, piling pressure on an overstretched social care system. With rising costs of care, fewer people now receive state funded support for their care needs.

The workforce remains unstable, with higher turnover than other industries. Morale among social care professionals has fallen as they find themselves with more work to do, but with less time and resources. In some cases, tasks like providing accessible information and carrying out care assessments have been reduced to mere signposting.

Despite these challenges and ongoing pressures, there has been a longstanding lack of appetite by the main political parties to address the root causes, particularly how care is funded. For people to experience the quality of what they need and deserve, we must also change the way social care is organised, including exploring the potential for new service models and the role of innovation.

Recent calls for revisiting the balance of responsibilities between individuals and the state open the door to reshaping the narrative about care work to reflect its skilled nature and its value to society.

With emerging policies, innovations, and campaigns, there’s hope for a fairer and more equitable social care system. As we look ahead, the Act’s core principles remain our guiding star at SCIE, driving our commitment to improving social care for all.

Resources

What good looks like (local.gov.uk)

NHS England » Brick by brick

NHS England » Joint guiding principles for integrated care systems – learning disability and autism

National strategy for autistic children, young people and adults: 2021 to 2026 – GOV.UK (www.gov.uk)

Building the right support for people with a learning disability and autistic people – GOV.UK (www.gov.uk)

NHS England » Meeting the needs of autistic adults in mental health services

Learning from Lives and Deaths – people with a learning disability and autistic people (LeDeR) – King’s College London (kcl.ac.uk)

NHS England » Culture of care standards for mental health inpatient services

The transformation of social care

Looking back, there is no doubt that the Care Act 2014 has been transformational. For the first time, there was an improved focus on people’s wellbeing and independence. This meant shifting from a service-led system to enabling individuals to have choice and control over the care and support they needed. The role of unpaid carers was also acknowledged by the Care Act with a new statutory requirement for local authorities to assess and meet their wellbeing needs, too.

The adoption of co-production principles and practices in social care is another of the key changes we have seen. The Care Act 2014 was the first piece of legislation to include the concept of co-production, emphasising the importance of placing people at the heart of their care and involving them in the design and delivery of services.

Over the years, we have seen the value of co-production increasingly recognised and good practice adopted, most recently in the Government’s 2021 Adult Social Reform White Paper. The regulation of social care has evolved to include people’s experiences, in the form of “I” and “We” statements, in the evaluation of care quality and safety. Co-production also underpins and informs all our work at SCIE, enabling us to spread best practices across the sector.

The challenges ahead

Despite the Care Act’s impact, there’s a palpable sense that the transformation of services is still ongoing. Implementation of its provisions has been challenging and incomplete, leaving many ambitions unrealised. Today, the reality for many seeking to access social care services is one of frustration and inequality.

A major challenge has been funding, which has not kept up with demand for social care. Over the years, local authorities’ budgets have been squeezed, piling pressure on an overstretched social care system. With rising costs of care, fewer people now receive state funded support for their care needs.

The workforce remains unstable, with higher turnover than other industries. Morale among social care professionals has fallen as they find themselves with more work to do, but with less time and resources. In some cases, tasks like providing accessible information and carrying out care assessments have been reduced to mere signposting.

Despite these challenges and ongoing pressures, there has been a longstanding lack of appetite by the main political parties to address the root causes, particularly how care is funded. For people to experience the quality of what they need and deserve, we must also change the way social care is organised, including exploring the potential for new service models and the role of innovation.

Recent calls for revisiting the balance of responsibilities between individuals and the state open the door to reshaping the narrative about care work to reflect its skilled nature and its value to society.

With emerging policies, innovations, and campaigns, there’s hope for a fairer and more equitable social care system. As we look ahead, the Act’s core principles remain our guiding star at SCIE, driving our commitment to improving social care for all.

I was interviewed by Kate during the process of making her documentaries and she told me that the cost of her late husband’s basic care needs was nearly £4,000 per week. Kate earns a good salary, yet how can she, let alone anyone else, afford that week in, week out for who knows how many months or years?

The social care sector needs a shake-up. We have an amazing workforce, but they are underpaid and overstretched. We rely heavily on unpaid carers, but sadly, they often do not get the recognition or support they deserve. It’s easy to forget that many will also be working full- or part-time to earn the money needed for some form of professional care for their loved one. They may also, like Kate, be raising children. It’s an exhausting and impossible task.

I am thankful, at least, that the Government’s Accelerating Reform Fund (ARF) – an initiative to encourage and grow innovation within the social care sector, for which SCIE is providing hands-on support – is recognising the crucial need to transform adult social care and provide much-needed support to unpaid carers.

Of the 122 projects registered across all 42 integrated care systems (ICS) for ARF support, about 7 in 10 have an element focusing on unpaid carers. This is at least one project within each of the 149 local authorities in England that has received funding. These include:

• A project in Coventry and Warwickshire to expand a digital self-help tool that will enable carers to identify local support and access bespoke information to support their own wellbeing
• Connecting hospitality, tourism and leisure businesses with unpaid carers in West Yorkshire so they can donate holidays and experiences to carers as a way to recognise their invaluable contribution to society
• Scaling up approaches for identifying unpaid carers in south-west London, such as through hospital discharge programmes, and referring them to carers networks

I am excited by the scope and potential promise of each project funded by the ARF so far. At SCIE, we are working alongside all local authorities involved to share knowledge, insights and best practice so that we develop these projects and learn how to successfully to scale them up to a national level.

Collaboration and innovation are key to changing the future of social care, and I hope that this is a first step to easing the financial, physical and emotional burden that so many unpaid carers experience as they do their best to care for the people they love.

• Kate Garraway documentary highlights urgent need for social care improvements, says SCIE
• £20 million boost for adult social care innovation announced

Colleagues from Luton’s safeguarding teams helped us work through the legal and practical issues that could impact decisions on the frontline on how to respond to a potential safeguarding case, and we role-played being a member of the multidisciplinary adult safeguarding hub (e.g. the police, community nurse, family member, etc.), as part of our safeguarding training.

This case study work shone a light on the complexities of safeguarding on the frontline in a local authority, and how the response to each case must be very nuanced, ensuring personal wishes are respected. Decisions are rarely being black or white, yet they have a direct impact on individuals who may often require a range of help. Practitioners also stressed that trust and support from their local leadership is essential to their everyday work so they can be confident in their sensible judgment and collaborative decisions.

What struck me was not only our local authority colleagues’ expertise and dedication, but also their willingness to openly share their experiences and engage with us about their concerns, the intricacies of their jobs, and what elements they would like to change if possible.

From our point of view, discussing matters with local experts, also helped us to understand how important it is that national safeguarding legislation and guidance can be translated locally and the importance that what we do, enables local experts to provide the best possible support to people who are vulnerable.

My colleagues and I wish to thank SCIE and Luton Borough Council for making this event such an informative and engaging day, whilst also challenging us on how the department can help to further improve safeguarding both nationally and locally.

• SCIE safeguarding resources and support

The programme set out the impact that a care home owner seemingly focused on profit margins, has on the staff he employs and the residents. Through restrictive contracts, the apparent ignoring of understaffing concerns, and a closed culture, we see how residents are harmed through neglect (multiple safeguarding alerts, missed medication, poor manual handling practice etc). The closed culture developed by the owner made it that much harder for management and staff to whistleblow.

There is sadly a continuity in the themes and messages drawn from other investigations into residential settings including Whorlton Hall (an independent registered hospital supporting autistic people or people with a learning disability), This was also subject to a BBC Panorama undercover investigation which exposed abuse and poor care. Our safeguarding adult review, commissioned by Durham Safeguarding Adults Partnership, detailed a number of findings which were discussed by the Coalition for Change including:

• failing to listen to and act on concerns raised by individuals and families;
• regulation and commissioning failing to recognise or respond effectively to the warning signs of abusive cultures becoming established;
• weaknesses in short-term commissioning with no effective means of assessing the quality of care or outcomes being delivered at many high cost placements
• challenges in the system’s ability to hold the directors and shareholders of care organisations to account.

At Addison Court, we saw how overseas staff were taken advantage of therefore becoming part of the closed culture, we know open cultures are ones where organisations involve and listen to, residents and relatives. They are transparent in their practice and raise concerns with the commissioners and relevant health organisation. They invest in, and ensure staff are trained and supported to provide good care in line with what is expected, and staff are given information about external support agencies to contact for advice and guidance. In such settings residents and staff thrive.

At a time when a number of care providers are relying on overseas staff, it is vital that there is clear guidance on how such staff are recruited. Allied to that it is important that consideration is given not just to the standard induction training and support that would be provided to local staff, but also what is needed in terms of supporting staff to understand expectations, the different statutory and regulatory frameworks and the code of conduct under the respective professional body.

We know there are a number of care providers who focus on providing good person-centred care. They will own up to mistakes and learn from them. Evidence, including from the Care Quality Commission, shows that good leadership and a strong culture that values and listens to staff, and gives them time to listen to and work with residents, are essential to deliver better and safer care. Every care home needs to review their safeguarding practice on a regular basis, and we urge them to seek help when they need.

We at the Social Care Institute for Excellence are here to help any care home or provider requiring support to improve in this area, and we urge all support organisations to help shine a light on the need for open, not closed, cultures..

• SCIE safeguarding resources and support

1. Risk assessment and information sharing

Risk factors for sexual abuse within the older population include being a woman, increasing age and having limited mental capacity. For people with learning disabilities women are again at higher risk, as are those with a more severe cognitive impairment and those living in services as opposed to living with a family. Across both groups perpetrators of sexual incidents are considerably more likely to be men, and more likely to be another person receiving a service.

The reviews found gaps in the initial assessment at the point of admission to a care home. Initial assessments frequently focused only on needs and not risks, which meant that staff had limited knowledge of the risks someone might pose to others.

This was especially true when the new resident was self-funding their placement with no input from social services. Social workers tend to carry out more robust assessments and often have more detailed history surrounding the person.

Even when social services were involved and risks were known, if the person was moving from one local authority area to another there was often no system for passing on crucial information.

Key information held by families as well as statutory agencies and outgoing care providers wasn’t shared in many of the cases looked at, making it difficult for new providers to make informed decisions about the level of risk and how to manage it. Instead various agencies and individuals had pieces of information that if brought together might have highlighted patterns of escalating behaviour that needed to be addressed urgently.

Even when risk was identified SARs found there was often no local multi-agency forum to consider those risks, and what action could be taken to reduce them.

When an incident had occurred, local authority safeguarding teams usually relied exclusively on the care provider to take full responsibility and come up with the answers. Not all care providers are equipped to do this in high-risk situations, and most will need help from specialist health services to provide wrap-around support and robust risk management strategies.

Safeguarding teams also tended to focus largely on the victim when making enquiries not the perpetrator, possibly leading to an incomplete picture and an unbalanced response to risk management.

Failing to share information, to collaborate with other providers and to properly assess makes it difficult to manage risk across a whole care setting population.

The Care Quality Commission (CQC, 2020) identified the need for risk assessment that takes account of the needs of those already living in a residential setting when considering new residents.

2. Language and misconceptions

An overwhelming finding was the use of inappropriate language to describe sexual assaults, particularly in relation to older people. It was common for assaults to be described as ‘disinhibited behaviour’ or ‘sexually inappropriate’, often attributed to dementia. Researchers found staff often had difficulty accepting that sexual assaults could happen at all, believing incidents must be rare, and often disbelieving victims when it did arise, particularly those with a diagnosis of dementia. Some researchers found that the emotional responses of victims following an assault could in fact mirror symptoms of cognitive impairment.

Misconceptions and the use of inappropriate language minimises the seriousness of the assault and often leads to inadequate responses that leave harmful behaviour unchecked. Non-consensual sexual activity is a serious sexual assault, it is a crime, and it should be recorded and responded to as such by all providers and agencies.

SCIE’s engagement with safeguarding adults boards (SABs) and police forces has also identified two wider points about the involvement of the police. The first is a general reluctance to involve the police. The second, a reluctance to pursue a prosecution because of challenges around gaining evidence, or the vulnerability of the perpetrator (as was the case in some of the SARs we looked at).

3. Policies, guidance, and staff training

Another common theme was the lack of sexual safety policies, processes, and guidance for staff, not only to help them recognise serious sexual assault but to prevent it. In the cases reviewed there were often predictors of dangerous behaviour that if know about or responded to earlier might have prevented subsequent harm. In one case sexual assaults perpetrated against care staff were dismissed when they should have been seen as significant, and a possible precursor for assaults against victims unable to protect themselves. In another, clearly delusional beliefs and fixations displayed by the perpetrator toward the victim were not taken seriously. In a third case the absence of a shared understanding of the significance of historical sexual incidents and a proper process for careful handover at the point of transition, left young people at risk.

Most commentators concluded there would be benefit in the introduction of suitable sexual safety policies, guidance, and quality standards to promote best practice, instil confidence in staff, and provide a framework for staff training.

Any guidance should be linked to the Mental Capacity Act 2005 to help staff understand:

• That in the absence of capacity to decide about taking part in sexual activity, the activity is non-consensual and is an assault
• Even when a person is believed to have capacity providers and agencies cannot rely solely on the person themselves to manage their own potentially harmful behaviour.

Training for staff not only needs to equip them to recognise sexual abuse but also to see sexual safety in its broadest sense, including environmental/cultural sources of vulnerability (e.g. the impact of having a care population with a wide range of needs, the layout of a building and staffs views on relationships), as well as issues such as self-empowerment. Training needs to be supported by the provision of appropriate assessment and risk assessment tools alongside detailed guidance.

This might be an area for local SABs and/or commissioning teams to get involved with, as having a shared and consistent local approach will help to avoid some of the challenges around information sharing, multi-agency responses, and different interpretations of risk.

4. Staffing

The final key theme to emerge was the significance of low staffing levels and high staff turnover. Good risk assessment and risk management requires close observation and consistent practice if sexual abuse is to be prevented. Staff require training, guidance and time and space to practice and reflect. Staff shortages leave gaps and high staff turnover dilutes skills and knowledge. Even in the statutory

sector reviewers found that pressures of work fostered a culture of ‘assess and forget’ rather than ongoing enquiry when risks were known.

Although perpetrators are much more likely to be other users of services some abusers are paid employees or visiting workers, and the review highlighted the risks associated with the loss of legacy data concerning previous allegations against members of staff due to systems changes. It also identified significant risks linked to the employment of family members working together in the same service, creating the potential for collusion with abusers and the dismissal of allegations.

Finally, the findings questioned the effectiveness of the processes followed by providers and safeguarding teams when the Crown Prosecution Service (CPS) decides not to charge a person (be it a member of staff or another user of the service), when they believe there is insufficient evidence to convict. One SAR reviewed involved a care assistant ultimately convicted of sexually assaulting 3 women with learning disabilities, who had been the subject of similar allegations twice before but reinstated following the CPS decision with no apparent follow-up safeguarding action.

Employers and safeguarding teams work to a different threshold than the police when an allegation is made, one where the likelihood of an incident having occurred is assessed ‘on the balance of probability’. In the absence of a multi-agency assessment of this probability the right actions may not be taken, and the risk of harm will remain.

Conclusion

Although we will never be able to eliminate the risk of sexual abuse entirely, SCIE’s research and review of a small sample of relevant SARs showed numerous missed opportunities to minimise it. It also showed common systems failures that leave people with care and support needs and staff unsupported and exposed.

The themes identified resonate with broader issues around effective safeguarding practice beyond sexual abuse. By ensuring staff are supported through up-to-date training, and policies and guidance that are regularly reviewed, care providers can improve the quality of care that residents receive and help to reduce the risk residents face from sexual or other forms of harm within a care setting.

Podcast: Sexual assaults in care homes

SCIE safeguarding resources and support

I think I speak for many in children’s social care when I say that this endeavour was enthusiastically welcomed for many reasons, not least of which is the fact that it moves from a victim blaming focus towards a more systemic understanding of the problem of criminally exploited children, young people and their families.

I also feel that data never actually tells a story, we have to read data in combination with our own experience and context. Asking a series of questions to understand what the data could mean. So what has the Home Office said?

• SCIE’s safeguarding resources

The figures show that since the County Lines Programme launched in 2019:

• 3,588 county lines have been closed
• 10,209 people have been arrested
• 5,727 individuals have been referred by police to safeguarding.

These sound like huge numbers and my first response was delight. What an enormous number of children made safer, what an important amount of control smashed, what a lot of people prevented from harming others.

Then I tried to stop and think a little more. Over ten thousand lines closed. The detail provided by the Home Office suggests that this combines two categories of lines. Phone lines disconnected (type 2) and phone lines reviewed and showed not to be usable for drug trafficking (type 1.) So, we would need to understand a little bit more to know what this data means. And does the public understand a line closure to mean a literal phone line, or would we have the greater expectation that a line closure really means the network disrupted and disbanded. The channel for harm taken away.

Similarly, the relationship to the numbers interested me. For each line closed, we have 2 (and a bit) people arrested. For each line closed we have 1 (not quite 2) people referred by the police to safeguarding.

Is this the right balance? Should each line closed result in multiple arrests, the whole network facing prosecution? Or do, in fact, the arrests show the extent of the impact that our work to prevent child criminal exploitation is achieving? How do we show the level of disruption? How do we measure childhood safety?

These figures do not tell the whole story, data needs narrative and we need to know whether we are making it so that exploitation is reducing. Is our community becoming safer? Will fewer people lose out? The only way we will get to this is a fully systemic response. And this is where SCIE comes in. SCIE seeks to support change, and this means focussing on people’s stories. We need to hear the voices of people to accompany this data to make sure we know what really counts. To find out more about SCIE’s support to safeguarding everywhere.