Analysis of Safeguarding Adult Reviews: April 2017 - March 2019

Analysis of Safeguarding Adult Reviews: April 2017 - March 2019 COVER
This report was commissioned by CHIP − the sector-led Care and Health Improvement Programme, co-produced and delivered by the Local Government Association and the Association of Directors of Adult Social Services in England.




Introduction

This page is the executive summary of a report commissioned by CHIP − the sector-led Care and Health Improvement Programme, co-produced and delivered by the Local Government Association and the Association of Directors of Adult Social Services in England. You can download the full report below

This first national analysis of Safeguarding Adult Reviews (SARs) in England was funded by the Care and Health Improvement Programme, supported by the Local Government Association (LGA) and the Association of Directors of Adult Social Services (ADASS). Its purpose was to identify priorities for sector-led improvement. This summary identifies the headline findings and provides an outline of the 11 sections of the main report, to which readers can turn for further detail. Building on published regional thematic reviews and analyses focusing on specific types of abuse and neglect, the analysis fills a significant gap in the knowledge base about adult safeguarding across all types of abuse and neglect.

Methodology

Material for analysis was collected from Safeguarding Adult Boards (SABs), 98 per cent of which (129/132) responded to requests for published and unpublished reviews completed between 1 April 2017 and 31 March 2019. This material was triangulated with SARs available in the national repository held by the Social Care Institute for Excellence, and from SAB and other web sites. In total 231 SARs are included in the analysis [1]. A data collection framework tool [2] was used to gather structured and unstructured data, which were subject to quantitative [3] and qualitative thematic analysis [4].

Footnotes

1. Representing the work of 103 SABs. 22% of SABs (29/132) did not complete a SAR during this period.
2. Managed using Smart Survey.
3.Using the R programming language and Microsoft Excel.
4. In the main report the quantitative analysis is presented both nationally and by region.

 

SAB governance of SAR decision-making

Findings relating to SABs’ management of the complete SAR process were compared and contrasted with their powers and duties codified in Section 44, Care Act 2014 and amplified in statutory guidance [5]. Findings were also analysed against the standards outlined in quality markers [6]. The result is a set of key questions to guide SABs and SAR authors in their decision-making from referral through commissioning, choice of methodology and approach to family involvement, to quality assurance, publication, action on recommendations and reporting.

Footnotes

5. Department of Health and Social Care (2020) ‘Care and Support Statutory Guidance: Issued under the Care Act 2014’. London: The Stationery Office.
6. Social Care Institute for Excellence and Research in Practice for Adults (2018) ‘Safeguarding Adult Review Quality Markers Checklist’. London: SCIE.

Key questions for SABS and SAR authors

  • Has decision-making about SAR referrals clearly distinguished between mandatory and discretionary reviews?
  • How timely has decision-making been regarding responses to referrals?
  • What types of abuse and/or neglect are the main and secondary focus in each SAR?
  • What methodology has been chosen and why?
  • What methods for gathering and exploring information have been chosen and why?
  • What positive and negative reasons for delay have impacted on the SAR process?
  • Have services and agencies cooperated as required? [7]
  • What approach has been taken to involvement of the person and their family?
  • Do annual reports provide information about SARs in progress and completed, their findings and the actions taken in response to those findings, as required in statute?
  • How has SAR quality been assured?
  • How has the SAB captured the outcomes of action taken to implement SAR recommendations?
  • Have the reasons for decisions at all stages of the SAR process been recorded?

Footnotes

7. Section 44(5) Care Act 2014.

 

Types of abuse and neglect

The 231 reviews in the sample investigated a range of types of abuse and neglect, sometimes including multiple types per case [8], the most common being self-neglect.

Types of abuse and neglect

Type of abuse/neglect

SARs n

Per cent [9]

Type of abuse/neglect

SARs n

Per cent

Self-neglect

 104

45%

Sexual abuse

 12

 5%

Neglect/omission

85

37%

Sexual exploitation

  5

 2%

Physical abuse

45

19%

Modern slavery

  2

 1%

Organisational abuse

33

14%

Discriminatory abuse

  2

 1%

Financial abuse

30

13%

Other

11

5%

Domestic abuse

22

10%

Not specified

 29

13%

Psychological abuse

 19

 8%

 

 

 

Percentages have been rounded to the nearest whole number.

Modern slavery, sexual abuse, and sexual exploitation occurred more prevalently in younger people, whereas neglect and abuse by omission occurred more in those who were older. Psychological/emotional abuse and modern slavery were more prevalent for females, whereas financial, physical abuse and self-neglect were slightly more prevalent for males.

No direct correlations were found between the types of abuse and neglect that become the focus of SARs and those referred for adult safeguarding enquiries [10], but there were regional variations in the prevalence of section 42 enquiries and the prevalence of SARs. Some types of abuse and neglect were positively associated with one another. For example, domestic, financial, physical and emotional abuse consistently occur together. Conversely, some types of abuse, such as self-neglect and neglect/omission, appeared unrelated to all other types.

Footnotes

8. The total is therefore higher than the number of SARs.
9. Percentages have been rounded to the nearest whole number.
10. Section 42 Care Act 2014.

Cases

There were 263 people whose experiences were reviewed in the SARs [11, 12], 81 per cent of whom had died, a finding in line with previous thematic reviews [13]. There were slightly more men (129) than women (109), with regional variations. The average age was 55, varying significantly by region. Comparison with Section 42 data showed that the people featured in SARs were more likely to be younger and male, whereas those for whom Section 42 enquiries took place were older and female. 

Few SARs provided information about, or analysed, the impact of sexuality and ethnicity. 

A range of health concerns were reported, the most common being mental health and chronic physical conditions. There was complex interplay between physical comorbidities and between physical and mental ill-health, sometimes related to significant life events. The most common living situations were living alone (36 per cent) and in group care (33 per cent); the most common location for the abuse/neglect was the person’s own home (48 per cent) [14], followed by residential/nursing care (18 per cent). The most common perpetrator of abuse was ‘self’ (48 per cent) , followed by care providers (30 per cent). Noteworthy here, because of Government criticism [15] that SARs have paid too little attention to the deaths of people sleeping on the streets, was the inclusion in the sample of 25 cases (11 per cent) where adults were or had been homeless. 

In relation to whether criminal prosecutions had been pursued, in the majority of cases (54 per cent) they had not, and a further 29 per cent of the reports did not specify. However, in 37 cases (16.2 per cent) prosecution had concluded, with custodial sentence being the most common outcome, and in a further four cases no conclusion had yet been reached. The theme of imprecision was noted again, with reports omitting details of outcomes or of the reasons for investigations being discontinued, but the analysis also highlights the importance of collaboration between those investigating abuse and neglect to ensure a clear focus on how to achieve best evidence.

Footnotes

11. Some SARs considered the circumstances of more than one individual.
12. 129 men, 109 women, 1 transgender, 24 other/not stated.
13. For example, Braye, S. and Preston-Shoot, M. (2017) ‘Learning from SARs: A Report for the London Safeguarding Adults Board’. London: ADASS.
14. Due to the high proportion of self-neglect cases in the analysis.
15. GOV.UK: The Rough Sleeping strategy

Themes and recommendations

This section of the main report presents quantitative data on SARs’ observations on good and poor practice and the recommendations they make for service improvement [16]. These are categorised across four domains: direct practice with the individual, interagency working, organisational features, and SAB governance, with each domain containing a number of themes. Extracts from the tables are given below to show, for each domain, the most prominent good practice and poor practice themes, and the number of mentions each received [17,18].

Direct work

Top good practice themes

n

Top poor practice themes

n

Top recommendation themes

n

Responding to health

56

Mental capacity

138

Risk assessment

72

Personalisation

53

Risk assessment

134

Mental capacity

64

Continuity

37

Safeguarding

115

Working with caregivers

62

Care/support

36

Working with carers

111

Care/support

56

Safeguarding

32

Care/support

110

Personalisation

47

Mental capacity

32

Responding to health

99

Responding to health

45

 

Interagency working

Top good practice themes

n

Top poor practice themes

n

Top recommendation themes

 n

Information-sharing

53

Case coordination

168

Case coordination

126

Case coordination

45

Information-sharing

162

Information-sharing

96

Safeguarding

37

Safeguarding

115

Safeguarding

76

Legal literacy

5

Procedures

53

Procedures

54

Record sharing

3

Legal literacy

44

Record sharing

27

 

Organisational features

Top good practice themes

n

Top poor practice themes

n

Top recommendation themes

n

Management scrutiny

10

Staffing/workloads

64

Training

90

Commissioning

6

Management scrutiny

63

Commissioning

65

Specialist advice

4

Training

54

Quality assurance

48

Staff support

4

Resources

49

Policy/procedures

42

Quality assurance

4

Commissioning

49

Records/recording

38

 

SAB governance

Top good practice themes

n

Top poor practice themes

n

Top recommendation themes

n

SAR management

3

Self-neglect policy

15

Learning dissemination

75

SAB procedures

2

Escalation policy

14

Quality assurance

50

Learning dissemination

1

Risk policy

9

Training

39

Membership

1

SAR management

9

Self-neglect policy

34

Training

1

M/capacity policy

8

Other procedures

33

 

Three further sections of the main report, namely Good Practice, Poor Practice, and Recommendations, provide the findings of the qualitative thematic analysis across the four domains to accompany the quantitative analysis above, drawing on examples and evidence from specific SARs. The concerns that are highlighted across the four domains, and the recommendations made in response, are not new and have been raised in previous thematic reviews [19]. The findings pose two questions for SABs, their partners and SAR authors, namely:

  • Are we making sufficient use of the available evidence from SARs and from research when analysing the facilitators that enhance and the barriers that impede good practice?
  • Are we learning what still needs to be achieved locally and nationally to provide the best context for preventing and protecting individuals from different types of abuse and neglect?

These questions can inform debate within and between SABs, regionally and nationally, on what makes adult safeguarding so challenging and change so apparently difficult to achieve, with the outcomes informing strategic business plans.

There was a trend towards all recommendations being addressed to the SAB, giving it the responsibility for determining which (combination of) agencies should lead on implementing particular findings. The theme of imprecision was noticeable here. In 10 SARs recommendations were directed to ‘partner agencies’ without specifying which services were included in this phrase. There were also occasions when recommendations were directed to “health”. It is more helpful for SABs when SAR authors are clear about which agencies they believe should lead on implementing particular recommendations.

The recommendations concerned with direct practice were analysed partly through the lens of the six adult safeguarding principles outlined in the statutory guidance. The recommendations directed specifically at SABs were analysed through the lens of the roles and responsibilities for Boards, articulated in the same statutory guidance. The SAR process does not end, however, with the recommendations. Some SARs explicitly acknowledged this by listing the changes that had already been made to local policies, procedures and practices as a result of emergent learning from the review process. Annual reports should be capturing improvements and enhancements arising from SAR outcomes. When further cases of types of abuse and neglect are referred for review, these present an opportunity to review what changes have been achieved and what further work remains to be done.

Footnotes

16. The data is also available by region.
17. Note that SARs can make recommendations relating to one domain based on practice identified in another (for example poor practice in direct work can result in an organisational recommendation).
18. The main report shows the full range of different themes within each domain.
19. For example, see Braye, S., Orr, D. and Preston-Shoot, M. (2015) ‘Learning lessons about self-neglect? An analysis of serious case reviews.’ ‘Journal of Adult Protection’, 17, 1, 3-18.

Conclusions and reflections

The concluding reflection in the main report signposts further actions that would sustain the work begun in this national analysis. It highlights again the importance of analysing cases through the lens of an available evidence-base, this time drawing on ‘seminal’ reviews to pose and begin to answer the question of what else adult safeguarding needs to learn, for example about hate crime, organisational abuse or self-neglect, when creating a national and local context in which best practice can thrive. However, it is important to remember that SARs also commented on good practice and to recognise that much adult safeguarding practice is unheralded, person-centred and committed to empowerment, prevention and protection. This analysis took place during the COVID-19 pandemic which, in many respects, has shown the very best of health and social care staff, emergency services and other practitioners on whom people at risk of abuse, neglect and significant harm rely.

Sector-led improvement priorities

The findings of this analysis give rise to priorities for sector-led improvement. They are clustered below within five main categories. The priorities are numbered as in the main report, for ease of cross reference. Some should already be standard good practice but require reinforcement. Others will require additional resources [22].

SAB practice on the commissioning and conduct of SARs (priorities 2, 4, 5, 6, 7, 8, 10, 14, 18, 20)

2: SABs should review their record-keeping to ensure that completed SARs remain in the collective memory, available as a baseline for measuring subsequent change.
4: The SAR quality markers should be reviewed and completed, informed by the findings of this national analysis. After dissemination of the revised quality markers, SABs should be asked to report on how they have been used to enhance the SAR process.
5: SABs should be asked to provide reassurance that partner agencies understand the relevant legislation regarding referral and commissioning of SARs.
6: Regional and national SAB networks to review approaches to the interpretation and application of section 44 Care Act 2014 in decision-making about SAR referrals.
7: SABs should review their governance procedures for SARs and ensure that referrals and decision-making are timely, with meeting minutes and reviews clearly noting the reasons for positive or negative delay.
8: SABs must ensure that SARs identify the types of abuse and neglect within cases being reviewed.
10: SARs should give a full account and offer a reflective analysis of the methodology used. The quality markers should be revised to emphasise the importance of methodological rigour.
15: SAB should review their reporting of SARs in annual reports to ensure compliance with the requirements of statutory guidance and the imperatives that learning is embedded, and the impact and outcomes of reviews evaluated.
18: SABs should review their approach to ensuring the quality of reports.
20: Terms of reference for all SARs must include consideration of how race, culture, ethnicity and other protected characteristics as codified by the Equality Act 2010 may have impacted on case management.

Supporting sector-wide learning from SARs (priorities 1, 3, 11, 13, 19, 29)

1: The future of the national library of SARs should be secured, with SABs committed to depositing completed reviews therein, and technology developed to enable searching by types of abuse and neglect.
3: SABs should adopt the data collection tool to collate learning from future SARs.
11: Regional and national networks provide a space where SABs can discuss learning regarding a proportional and change-oriented approach to cases involving types of abuse and neglect that have previously featured in local reviews.
13: Regional and national networks provide a space where SABs can discuss and disseminate learning from experiences of individuals’ and families’ involvement in SARs.
19: Sector-led improvement to engage with SABs to capture the impact of review activity.
29: SABs locally, regionally and nationally should be leading a continuing conversation that seeks to address the questions that arise out of the poor practice reported by SARs.

Support for adult safeguarding practice improvement  (priorities 16, 17, 21, 22, 23, 24, 25, 26) [23]

16: The national SAB network should engage with national bodies responsible for services whose roles include adult safeguarding to reinforce agency and service compliance with their duties to cooperate and share information.
17: Further work should take place on the interface between s.42 and s.44 Care Act 2014: (a) to inform understanding of routes that provide best learning where people have survived abuse and neglect, and (b) to inform initiatives to strengthen practice in the category of abuse and neglect most prevalent in s.44 statistics (ie self-neglect).
21: Consideration should be given to the dissemination of briefings on good practice regarding all forms of abuse and neglect but especially those newly highlighted by the Care Act 2014 within adult safeguarding, such as domestic abuse, modern slavery and discriminatory abuse (hate and mate crime).
22: Briefings should be published for practitioners and managers on the implications for best practice in adult safeguarding of the requirements of the Equality Act 2010.
23: In light of the reported poor practice in direct work with adults at risk, SABs should review (in local, regional and national discussion) how they seek assurance on practice standards and contribute to improvement, working to the priorities in the main report. 
24: In light of the reported poor interagency working, SABs should review (in local, regional and national discussion) how they seek assurance on standards of interagency practice and contribute to improvement, working to the priorities in the main report.
25: In light of the reported concerns about how organisations support safeguarding practice, SABs should review (in local, regional and national discussion) how they seek assurance on organisational systems, culture and resources, and contribute to improvement across their partnership, working to the priorities set out in the main report.
26: In light of the consistency of recommendations in SARs across all four domains of analysis, which replicate those made in earlier reviews, SABs should review (in local, regional and national discussion) how they seek assurance on practice standards and contribute to service and policy improvement and enhancement across their partnerships.

Revision to national policy/guidance (priorities 9, 14, 27)

9: In light of the findings from this national analysis, the statutory definitions of types of abuse and neglect should be revisited and, if necessary, revised to ensure that they fully capture the developing understanding of the contexts in which adult safeguarding concerns and risks emerge.
14: Statutory guidance should be revised to indicate when the SAR process commences. 
27: SABs, regionally and nationally, should discuss the role of SARs in sharing learning with central government departments and national regulatory bodies, and holding them to account when findings require a response that is beyond the scope of local SABs.

Further research to inform sector-led improvement initiatives (priorities 12, 28)

12: Comparative research should be commissioned to highlight the effectiveness of different review methodologies. 
28: Projects should be commissioned to develop the evidence-base for good practice with respect to preventing, and protecting people from, particular types of abuse and neglect, working to the priorities set out in the main report.

Footnotes

22. The report’s authors believe that improvement priorities that are new resource-dependent are: 1, 4, 12, 17, 19, 21, 22 and 28. 
23. Drawing also on the roles of designated named professionals in healthcare and safeguarding leads such as Principal Social Workers in councils, as set out chapter 14 of the statutory guidance.