Highlights: Safeguarding adults
Published: September 2017
This is a snapshot of safeguarding adults practice and challenges based on SCIE’s work in this area and experience of providing training and consultancy support to care and health providers. It is not a comprehensive review of safeguarding practice, but we hope it provokes further thinking about how to improve safeguarding, and the partnerships that need to develop for that to happen.
Definition of adult safeguarding
It is important to be clear about who the formal adult safeguarding process applies to. The Care Act statutory guidance defines adult safeguarding as:
‘Protecting an adult’s right to live in safety, free from abuse and neglect. It is about people and organisations working together to prevent and stop both the risks and experience of abuse or neglect, while at the same time making sure that the adult’s wellbeing is promoted including, where appropriate, having regard to their views, wishes, feelings and beliefs in deciding on any action. This must recognise that adults sometimes have complex interpersonal relationships and may be ambivalent, unclear or unrealistic about their personal circumstances.’
This definition hints at the challenges of safeguarding, but it is important to be clear about which adults we are discussing. A local authority must act when it has ‘reasonable cause to suspect that an adult in its area (whether or not ordinarily resident there):
- has needs for care and support (whether or not the authority is meeting any of those needs),
- is experiencing, or is at risk of, abuse or neglect, and
- as a result of those needs is unable to protect himself or herself against the abuse or neglect or the risk of it.’ (Care Act 2014, section 42)
So safeguarding is for people who, because of issues such as dementia, learning disability, mental ill-health or substance abuse, have care and support needs that may make them more vulnerable to abuse or neglect.
The Six Principles
First introduced by the Department of Health in 2011, but now embedded in the Care Act, these six principles apply to all health and care settings.
- Empowerment People being supported and encouraged to make their own decisions and informed consent
- Prevention It is better to take action before harm occurs.
- Proportionality The least intrusive response appropriate to the risk presented.
- Protection Support and representation for those in greatest need.
- Partnership Local solutions through services working with their communities. Communities have a part to play in preventing, detecting and reporting neglect and abuse.
Accountability and transparency
in safeguarding practice.
Several themes and messages come up as SCIE engages with the social care, health and related sectors, in relation to safeguarding adults
Safeguarding people who do not have care and support needs Open
Many agencies are facing the challenge of how to support people who are at increased risk of abuse, but who do not have care and support needs. This includes carers, many people who self-neglect, homeless people, and survivors of domestic abuse. Many organisations support people who do not meet the safeguarding criteria, but who may be being abused and are unsure where to go next.
Wherever someone is being harmed, or at risk if harm, there are agencies that can help, even if a formal safeguarding response is not triggered. These include:
- the police
- domestic abuse services
- the National Referral Mechanism for victims of modern slavery
- community and support groups
other social services teams. A local authority has duties to promote an individual’s wellbeing, to prevent or delay care needs from developing, and to assess someone if there are safeguarding concerns and it appears that the person may have care and support needs, even if the person does not want an assessment. All of these may be helpful in a complex situation.
A local authority safeguarding response is not the only, or always the most appropriate, response to keeping people safe.
Section 42 enquiries: challenges Open
Section 42 enquiries are the mechanism by which local authorities respond when adults with care and support needs in their area are harmed or are at risk of harm. In essence, they are the means by which safeguarding gets carried out. However, a number of provider organisations, GPs, and others, have reported that there is inconsistency between local authorities, and between workers in the same authorities, when it comes to carrying out enquiries. Seemingly similar cases will be treated as safeguarding in some areas, but not in others.
SCIE has been told of local authorities, for example, who will only accept a referral after two or more incidents involving a person, and of medication errors being viewed as a safeguarding issue in one local authority, but not in a neighbouring one. This can leave support organisations uncertain how to proceed, and lacking the confidence to challenge local authorities about their decisions. Staff, and safeguarding leads in particular, should be aware of what they are entitled to expect from statutory services.
The Care Act encourages local authorities to ask provider organisations to lead on section 42 enquiries if abuse is alleged to have occurred, for example, in one of their care homes. That level of trust is welcomed by providers, but the potential for a conflict of interests remains a concern. This is particularly so given the time pressures local authorities are under, which might encourage them to ask others to lead an enquiry for resource, rather than practice, reasons. Health and social care providers should be clear with local authorities if they do not feel it is appropriate for them to lead an enquiry.
Support structures and resources Open
Feedback on safeguarding often focuses on problems with resources. One common theme involves difficulties in accessing advocacy support for people entitled to it. Several GPs have suggested a lack of available interpreters can mean they have to rely on family members to interpret for patients, even where there are concerns about the wellbeing of that patient within their family setting.
Provider organisations supporting people at home, sometimes with minimal care packages, have reported concerns that they cannot provide the sort of ongoing, check-in support that might help keep people safe, particularly if people are living slightly chaotic lives. Staff can be left knowing someone they support is vulnerable, but not having the scope to address it as they would wish. Alerting commissioners to the potential impact on a person’s wellbeing can be critical.
Care Quality Commission (CQC) Open
GPs and service providers have mentioned to SCIE that CQC offers helpful guidance and support around safeguarding adults. There are, however, also reports of inconsistent approaches, with different CQC inspectors having a different understanding of what constitutes safe practice, and what should be raised as safeguarding concerns.
There is also a mismatch between the 10 types of abuse set out in the Care Act, and the fact that CQC forms allow for reporting on only six. Service providers should develop good communication links with their inspectors, to discuss and address these issues.
Poor care is sometimes raised with local authorities as a safeguarding alert, when it should in fact be reported to the CQC. The boundary between poor care and abuse or neglect can be fuzzy, but everyone in the sector should be as clear as they can be. They should seek appropriate advice where necessary, about the right reporting routes in various situations.
The Mental Capacity Act (MCA) Open
People with capacity have the right to make decisions that may put themselves at risk. This is a longstanding challenge for safeguarding adults, and a recent overview of Safeguarding Adults Reviews highlights how frequently the MCA is misused in adult safeguarding cases. If someone with mental capacity has declined a safeguarding intervention, there are some grounds on which that can be overridden – for example, if other people are at risk. But the MCA is very clear that everyone with capacity can make their own decisions. This applies even in the important area of keeping safe and feeling in control of one’s life.
Risk-aversion continues to pervade practice. Service providers report that even when they do listen to people who say they want to take risks, family members, commissioners or CQC may challenge the stance they are taking. Providers should ensure they are using the MCA appropriately, and are confident in challenging others to do so.
Another issue is the misuse of Lasting Powers of Attorney (LPA) – for example, where the nominated attorney may be taking financial advantage over someone. Anyone working with someone with an LPA should know what it does and does not cover, and how to raise concerns with the Office of the Public Guardian in those few cases where an attorney may be acting unreasonably.
Making Safeguarding Personal Open
This focuses on the outcomes an individual wants to see from any safeguarding intervention, and includes that person throughout the process. This concept is central to shifting safeguarding practice away from a bureaucratic, process-led approach. Real progress has been reported, but several health and social care staff have said to SCIE that it can remain a challenge to know what outcomes people want, and therefore to really personalise the response. This is especially so with people with advanced dementia or significant learning disabilities, where really close working with the people who know the person best can help.
Working with people who self-neglect has always been complex, requiring skilled and patient interventions. Adding it as a safeguarding category in the Care Act has opened up a new mechanism for supporting people who self-neglect, if they have care and support needs. But differences of approach remain as to when and if, self-neglect should be tackled by adult safeguarding services. This is sometimes exacerbated by shortterm working practices that are ill-suited to patient, ongoing work. Service providers may need to work in close partnership with other agencies to support people well.
Information sharing Open
The Care Act stresses that people being abused, and those making referrals about it to local authority safeguarding teams, should be included and kept informed throughout any safeguarding enquiry. SCIE, however, is still hearing from providers who report that they are not kept informed about who is dealing with a case, and what is happening to it.
Care and health providers’ responsibilities
Providers of health and social care services should ensure they have the key people, relationships, values and systems in place that will help them to keep safe the people they serve. These include:
- Engagement with the Safeguarding Adults Board (SAB)
- Up-to-date, functional policies and procedures
- Clients who understand safeguarding and help shape responses to it
- A safeguarding lead
- A trained workforce – in safeguarding and the MCA
- Information-sharing protocols that support the ‘supply of information’ to the SAB
- Integrated, cooperative working with other parts of the sector
- The scope to engage with, or lead, section 42 enquiries
- Knowledge of when to report concerns, and who to report to
- An emphasis on prevention, information, and advocacy
- A balancing of choice, control and safety – helping you to Make Safeguarding Personal
Case study - Friends of the Elderly
Friends of the Elderly is a charity operating care homes, home care services, day centres, volunteer-led befriending and a grants programme, as well as campaigning to alleviate loneliness and isolation among older people. A CQC inspection on one of its care homes in 2015 delivered an ‘Inadequate’ rating because of safeguarding concerns, and this prompted a wholesale rethink of how the organisation approached safeguarding.
Senior managers met with residents, families and staff, to discuss what had gone wrong, and developed a remediation plan with the local Safeguarding Adults Board (SAB). Commissioning SCIE as consultants to help shape and advise on the work, Friends of the Elderly instituted a number of changes:
- Developed, with input from people who use services, family, and staff members, new policies and procedures for safeguarding, the Mental Capacity Act, and care planning
- Up-to-date, functional policies and procedures
- Established a Concerns Helpline for people who use services, staff and others to report any concerns independently and confidentially. The helpline is hosted by SCIE
- Established an internal safeguarding sub-committee
- Introduced a Quality and Improvement Team to provide central monitoring and support and maintain quality standards
- Introduced a systematic, competency-based approach to training
- Improved internal communications with staff, people who use services and relatives
The end result of these efforts was that, nine months after the ‘Inadequate’ rating, the home was judged to be ‘Good’, and safeguarding practice had improved across the organisation. Even in difficult circumstances, engaging with users and their families, and reviewing practice across the board, can quickly and effectively improve safeguarding outcomes.
Case study - Royal Mencap Society (Mencap)
Mencap is a large national charity providing an extensive range of services to people with learning disabilities and their carers. Supporting so many people with potential vulnerabilities places a great deal of responsibility on Mencap to get safeguarding right.
Over the last three years, Mencap has embarked on a programme of work to make sure its safeguarding structures and systems represent best practice in the sector, including:
- a Safeguarding Panel with clear Terms of Reference. Relevant safeguarding data reports are presented to the Panel. In addition, there is a creative use of more qualitative reports
- an Annual Safeguarding Report
- an overall Quality Framework, including a ‘critical friend’ relationship between Mencap’s provision and quality assurance services
- a Quality and Compliance Committee
- values-based recruitment of staff
- induction programmes emphasising safeguarding as an integral part of practice, rather than a burden and an add-on
- procedures in place and a programme for keeping them updated
- an extensive national training programme
- creative approaches to appraisal that incorporate safeguarding.
Keen to develop further, Mencap commissioned SCIE to review its progress to date, and suggest considerations for future work. These are some of the key suggestions:
- embed the Making Safeguarding Personal initiative further within Mencap
- demonstrate greater involvement of people with learning disabilities in individual safeguarding processes
- continue developing an outcomes focus to safeguarding work
- extend audit methodology to cover wider geographical areas, and a focus on case records, employment practices, and/or thematic approach to learning and development
- consider whether appointing a discrete senior safeguarding lead might help Mencap to continue to improve its safeguarding
- better safeguarding awareness and training for trustees
- further improvements to its Safeguarding Panel.
The work has demonstrated the value of a cycle of improvement and reflection in improving practice in complex areas of work.
On the horizon – a Vulnerable Adults Bill?
Autism Together, the Association for Real Change, and lawyer Alex Ruck-Keene of 39 Essex Chambers have submitted to the Law Commission a proposal for a Vulnerable Adults Bill.
The bill aims to establish a set of principles that would underpin interventions to protect vulnerable people who, although capacitated, are at risk of coercion and duress. the decision whether to proceed with drafting a bill is awaited from the law commission.
Support from SCIE
SCIE provides CPD-accredited safeguarding training, which is tailored to specific audiences. Local authorities, provider organisations, GPs, and national bodies such as the Home Office and the Independent Enquiry into Child Sexual Abuse have all benefitted from our support.
SCIE provides expert safeguarding consultancy. This includes our Learning Together model for conducting Safeguarding Adults Reviews and audits of safeguarding. SCIE also helps to develop or review and improve safeguarding policies and procedures.
SCIE clients include the Church of England, the Chelsea Pensioners, the University of Kent, and large local authority areas such as Manchester and the tri-borough partnership in west London. SCIE also offers a range of MCA training and support.
For more information visit the training and consultancy sections of the SCIE website:
The following is a list of useful resources on safeguarding adults: