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Lewisham Safeguarding Adults Board

Enquiry Stage 2: Advice for Conducting an Adult Safeguarding Enquiry

1. The decision-making process

The Multi-Agency Adult Safeguarding Concern Form has been designed to provide all of the detailed and necessary information to allow colleagues in the Local Authority to effectively make a decision on if a Safeguarding Concern needs to progress to a Section 42 (or Other Enquiry) under the Local Authorities duty to do so within the Care Act 2014.

Please also refer to: Guidance for Making Decisions on Adult Safeguarding Enquiries

All of this Safeguarding data will be collated within the Local Authorities case management system (as the lead agency in the Borough) so that there is a central source of information and intelligence, which will allow this to be carefully monitored and assessed.         

2. Enquiry routes

Once a decision is made that a Safeguarding Enquiry must be conducted under the Section 42 duty, the relevant team within the Local Authority will decide who is best placed to conduct this, directing it through one of the four strands (2.1 to 2.4) outlined below. When this is delegated outside of the Local Authority they will still retain the overall responsibility to co-ordinate the enquiry as the lead agency, and as such they will provide the quality assurance and oversight in relation to all Safeguarding Enquiries.

See: S42 Enquiry Report Template (Pdf)    S42 Enquiry Report Template (Word Version)

Professionals should also read the London Multi-Agency Safeguarding Policy and Procedures (pages 66-78) for further information on conducting Adult Safeguarding Enquiries, using the checklists and detailed good practice guidance (target timescales are the bottom of this page). 

2.1 Police investigation

If a Safeguarding Concern has been submitted to the Local Authority and it is identified that an element, or all of this Concern may be linked to criminal activity, then the early involvement of police is essential. Police investigations should be coordinated by the local police MaSH team who may also support other parallel actions or enquiry options, but this should always be police led.   

See pages 67-68 of the London Multi-Agency Safeguarding Policy and Procedures for more information.

2.2 Standard delegation within the London Borough of Lewisham (LBL) Council

All social work staff within LBL can have Safeguarding Enquiries delegated to them, normally through one of the following four main strands:

  1. Neighbourhood Teams 1-4.
  2. Safeguarding and Quality Assurance Team.
  3. Hospital Social Work Team (University Hospital of Lewisham).
  4. Mental Health Social Work Team within South London and Maudsley (SLaM) NHS Trust.

There is a need for supervision and co-ordination of enquiries by Safeguarding Adults Managers (SAMs). 

See pages 57-58 of the London Multi-Agency Safeguarding Policy and Procedures for more information.

2.3 External delegation

Safeguarding Enquiries or elements of them may also be routinely delegated outside of LBL to the following partners:

  1. Lewisham and Greenwich NHS Trust (LGT) Safeguarding Team, who may then sub-delegate across their internal divisions, including to the District Nursing Service.
  2. South London and Maudsley NHS Foundation Trust (SLaM).
  3. South East London (SEL) Clinical Commissioning Group (CCG). 
  4. Care and Nursing Homes.
  5. Home Care Providers.
  6. GP Practices.
  7. Other Service Providers.

See: Causing S.42 Enquiries Letter Template (Word)

SAMs will also need to supervise and co-ordination these enquiries.

2.4 Referrals to Pressure Ulcer Panels (PUPs)

Potential Safeguarding Concerns linked to pressure ulcers can be challenging as it needs to be determined if this has been caused by poor quality care or evidence of neglect or omissions in care provision. This can occur due to other associated factors and may require input from a professional for clinical judgements to be considered:

 The person’s physical and mental health.

  • Multiple co-morbidities.
  • State of overall skin condition of the person.
  • Indicators of neglect of care provision in relation to hygiene and/or repositioning.
  • Evidence of ineffective continence management.
  • Evidence of ineffective nutritional and fluid management.
  • Ineffective Pain management.
  • Evidence of completed and accurate proactive risk and wound assessments and subsequent care planning.
  • Accurate monitoring and recording in all documentation.
  • The views of the service user, family and friends on treatment and care are recorded.
  • Capacity and level of engagement of service users and others.
  • Evidence of appropriate and timely referrals to members of multidisciplinary team
  • Views of others including professionals.

See: SEL CCG Guidance on Pressure Ulcer Management 

While Pressure Ulcers are a risk for people who are frail and not able to move easily, with good management and care these can be prevented. If an adult at risk has a pressure ulcer this should not been as a reason to automatically suspect abuse or neglect, although this should be carefully considered, and a Safeguarding Concern must always be submitted for a stage 3, 4, Unstageable, Deep Tissue Injury and Medical Device pressure ulcers.

If a Safeguarding Concern has been submitted for a pressure ulcer related matter the Local Authority  will pass this case onto the relevant Pressure Ulcer Panel (PUP) to oversee the initial investigation:

  • The Community PUP - overseen by the South East London Clinical Commissioning Group. (Care Home Only)
  • The Acute Trust’s PUP - overseen by Lewisham and Greenwich NHS Trust. (Trust Acute and Community Service)

Health professionals will then inform the safeguarding process by conducting a Pressure Ulcer Synopsis and Root Cause Analysis (RCA) and submit the relevant reports to the appropriate PUP.

If the pressure ulcer amounts to the wilful neglect of an individual who lacks mental capacity, a crime under section 44 of the Mental Capacity Act 2005 may have occurred, and in these instances the police will be informed.

SAM’s should engage with the PUP’s to gain understanding of process and decision making of PUP professionals, alongside assisting to co-ordinate any other elements of the safeguarding enquiry if there is another aspect to this.

The PUP’s will attempt to conclude their investigation within 28 days, but this may not always be possible. Once the PUP’s have decided no further investigation by panel is required, the enquiry is closed to the panel and an action plan process is implemented. The SAM should then co-ordinate any further actions up to the point of the enquiry being closed overall.

3. Professional Curiosity and Critical Evaluation

Professional Curiosity is the capacity and communication skill to explore and understand what is happening within a family (or an organisational setting) rather than making assumptions or accepting things at face value.

This has been described as the need for practitioners to practice ‘respectful uncertainty’ in applying Critical Evaluation to any information they receive, or ‘thinking the unthinkable’.

Watch this YouTube Video: The journey from reflection towards reflexivity (relevant for all practitioners)

The following factors highlight the need to improve professional curiosity:

  • The views and feelings of some adults can be very difficult to ascertain.
  • Practitioners do not always listen to adults who try to speak on behalf of another adult and who may have important information to contribute.
  • Carers can prevent practitioners from seeing and listening to an adult.
  • Practitioners can be misinformed with stories they want to believe are true.
  • Effective multi-agency work needs to be coordinated.
  • Challenging carers and other professionals requires expertise, confidence, time and a considerable amount of emotional energy.

 The key to effective safeguarding practice is to ask the right questions, including: 

  1. Would I live here, and if not, why not?
  2. Would I be happy with this standard of care for a member of my family?
  3. What does good look like?
  4. Is there anything else going on in this person’s life which might be causing harm, or the potential for adult abuse or neglect?

3.1 Disguised Compliance

Disguised Compliance involves carers giving the appearance of co-operating with agencies to avoid raising suspicions and allay concerns.

There is a continuum of behaviours from carers on a sliding scale, with full co-operation at one end of the scale, and planned and effective resistance at the other. Showing your best side or ‘saving face’ may be viewed as ‘normal’ behaviour and therefore we can expect a degree of Disguised Compliance in all families; but at its worst superficial cooperation may be to conceal deliberate abuse, and professionals can sometimes delay or avoid interventions due to Disguised Compliance.

The following principles will help front line practitioner’s deal with Disguised Compliance more effectively:

  • Focus on the needs, voice and lived experience of the adult.
  • Avoid being encouraged to focus too extensively on the needs and presentation of the carers, whether aggressive, argumentative or apparently compliant.
  • Think carefully about the engagement of the carers and the impact of this behaviour on the practitioner’s view of risk.
  • Focus on change in the family dynamic and the impact this will have on the life and well-being of the adult. This is a more reliable measure than the agreement of carers in the professionals plan.
  • There is some evidence that an empathetic approach by professionals may result in an increased level of trust and a more open family response leading to greater disclosure by adults.
  • Practitioners need to build close partnership style relationships with families whilst being constantly aware of the adult’s needs and the degree to which they are met.
  • There is no magic way of spotting Disguised Compliance other than the discrepancy between a carer’s account and observations of the needs and account of the adult. The latter must always take precedent.
  • Practitioners should aim to ‘triangulate’ and cross-reference the information they have received to confirm or refute the facts that have been presented.

3.2 Professional Challenge - having different perspectives

Having different professional perspectives within safeguarding practice is a sign of healthy and well-functioning inter-agency partnerships. These differences of opinion are usually resolved by discussion and negotiation between the practitioners concerned, but it is essential that they do not adversely affect outcomes for adults and are resolved in a constructive manner.

If you have a difference of opinion with another practitioner, remember:

  • Professional differences and disagreements can help find better ways to improve outcomes for adults and families.
  • All professionals are responsible for their own actions in relation to case work.
  • Differences and disagreements should be resolved as simply and quickly as possible, in the first instance by individual practitioners and /or their line managers.
  • All practitioners should respect the views of others whatever the level of experience – remember that challenging more senior or experienced practitioners can be hard.
  • Expect to be challenged; working together effectively depends on an open approach and honest relationships between agencies and professionals.
  • Differences are reduced by clarity about roles and responsibilities, the ability to discuss and share problems, and by effectively networking.

3.3 Cultural Competence

Culturally competent safeguarding practice is essential in achieving the right outcomes, and for improving the well-being of adults from Black, Asian and Minority Ethnic (BAME) communities.

Lack of cultural awareness among practitioners can impact on their ability to effectively work with and support adults, and therefore deal with abuse and neglect appropriately. This can also result in poor practice or interventions, which in turn can reduce trust in statutory agencies and create barriers for engagement with and from minority ethnic communities.   

It is important therefore that practitioners are sensitive to differing family patterns and lifestyles that vary across different racial, ethnic and cultural groups. At the same time they must be clear that abuse or neglect cannot be condoned for religious or cultural reasons.

All practitioners working with adults at risk and their carers whose faith, culture, nationality and recent history differs significantly from that of the majority culture, must be professionally curious and take personal responsibility for informing their work with sufficient knowledge (or seeking advice) on the particular culture and/or faith by which the adult and their family or carers live their daily lives.

Practitioners should be curious about situations or information arising in the course of their work, allowing the family to give their account as well as researching such things by discussion with other practitioners, or by researching the evidence base. Examples of this might be around attitudes towards, and acceptance of, services e.g. health and dietary choices.

In some instances reluctance to access support stems from a desire to keep family life private. In many communities there is a prevalent fear that social work practitioners will negatively interfere, and there may be a poor view of support services arising from initial contact through the immigration system, and, for some communities – particularly those with insecure immigration status – an instinctive distrust of the state arising from experiences in their country of origin.

Practitioners must take personal responsibility for utilising specialist services. Knowing about and using services available locally to provide relevant cultural and faith-related input to prevention, support and rehabilitation services for adults (and their family) will help support practice.

This includes:

  • Knowing which agencies are available to access locally (and nationally).
  • Having contact details to hand.
  • Timing requests for expert support and information appropriately to ensure that assessments, care planning and review are sound and holistic.

Often for BAME communities, accessing appropriate services is a consistent barrier to them fully participating in society, increasing their exclusion and potential for victimisation.

4. The Challenge of Engagement and Self-Neglect

Only 5% of Section 42 Enquiries are related to Self-Neglect in Lewisham, but professionals must understand the significance of these complex cases as almost half of all Safeguarding Adults Reviews, and therefore some of the most serious cases of abuse nationally, are related to this subject.

When an adult is self-neglecting, relationship based work becomes crucial and having one worker as a single point of contact may be beneficial.

Using the label “hard to engage” is damaging and may result in other professionals believing there is little point in attempting to do so, and therefore should be avoided (“seldom heard” may be a more appropriate term).

Practitioners should work together if one is struggling to achieve meaningful engagement with the adult, as another may still be able to take the lead on behalf of an Enquiry Officer in managing and monitoring risk.

Practitioners should also consider the following in helping to improve engagement with adults:

  1. Creative, flexible and imaginative ways to communicate with adults, including working with faith, community leaders and non-safeguarding practitioners to achieve the best outcomes.
  2. Producing information in a number of ways to meet individual needs.
  3. Involving family members appropriately to help support adults.
  4. The use of advocacy to engage with adults.
  5. Training staff to enable and improve engagement with adults.

See: LSAB Self-Neglect and Hoarding Multi-Agency Policy, Practice Guidance and Hoarding Toolkit (to be published in Mid-April).

5. Making Safeguarding Personal during a Safeguarding Enquiry

Making Safeguarding Personal (MSP) is an initiative which aims to develop a person centred and outcomes focus to safeguarding work in supporting people to improve or resolve their circumstances.

 What MSP Seeks to achieve: 

  1. A personalised approach enabling safeguarding to be done with and not to people, using practical methods defined by the adults individual needs rather than those of the organisation.
  2. The outcomes an adult wants, by determining these at the beginning of working with them, and ascertaining if those outcomes were realised at the end.
  3. Improvement to people’s circumstances rather than on ‘investigation and conclusion’.
  4. Utilisation of person-centred practice rather than ‘putting people through a process’.
  5. Good outcomes for people by working with them in a timely way, rather than one constrained by timescales.
  6. Improved practice by supporting a range of methods for staff learning and development.
  7. Learning through sharing good practice.
  8. Further development of recording systems in order to understand what works well.
  9. Broader cultural change and commitment within organisations, to enable practitioners, families, teams and the Lewisham Safeguarding Adults Board to know what difference has been made. 

Also see: Supporting people living with Dementia to be involved in adult Safeguarding Enquiries (March 2021)

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Safeguarding Principle - Empowerment

What does this mean for the professionals: Adults are encouraged to make their own decisions and are provided with support and information.

What does this mean for the adult: "I am consulted about the outcomes I want from the safeguarding process and these directly inform what happens". ……………………………………………………………………………………………………………………………………………

Local Government Association - Making Safeguarding Personal Toolkit

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