Briefing for senior leaders and SAB members: Second National Analysis of Safeguarding Adult Reviews

This briefing summarises the key findings from the second national (England) study ‘Analysis of Safeguarding Adult Reviews April 2019 – March 2023’. This study builds on learning from the first national analysis of SARs completed over a two-year period, April 2017 - March 2019, which considered learning from 231 reviews. In this second analysis, all 136 SABs responded with details of SARs completed in the four-year period, enabling 652 reviews to be included. Some SARs feature more than one individual; in total the circumstances of 861 people were considered.

The briefing aims to support senior leaders to demonstrate leadership in service improvement and practice development, based on the learning from Safeguarding Adult Reviews (SARs), and to ensure compliance with statutory duties. Senior leaders will also in many cases represent their agency on the Safeguarding Adults Board (SAB) and in that capacity will contribute to the effective functioning of the SAB, the achievement of its objectives and its specific role in undertaking SARs.

The analysis and this briefing were commissioned by the Local Government Association (LGA) and the Association of Directors of Adult Social Services (ADASS) as Partners in Care and Health (PCH), supporting councils to improve the way they deliver adult social care and public health service.

What is a Safeguarding Adult Review?

Under the Care Act 2014, sections 44 (1-3), SABs must carry out a SAR when an adult with care and support needs has died or suffered serious harm, and it is suspected or known that the cause was neglect or abuse (including self-neglect) and there is concern about how agencies worked together to protect the adult from harm. The purpose is to identify learning that can drive change to prevent harm occurring in future similar circumstances. The SAB may also (section 44(4)) undertake a discretionary SAR in any other case concerning an adult with care and support needs. Thus all reviews, whether mandatory or discretionary, are statutory. This mandate does not appear to be consistently understood by all SAB partners or SAR authors.

This second national analysis showed self-neglect to be the type of abuse most commonly reviewed, featuring in 60 per cent of reviews (an increase from 45 per cent in the first national analysis). It was followed by neglect/omission (46 per cent), domestic abuse (16 per cent), physical abuse (14 per cent) and financial abuse (13 per cent). This differs from the pattern of safeguarding enquiry activity under section 42 of the Care Act 2014, in which neglect/acts of omission normally feature most frequently, followed by physical abuse, financial/material abuse and psychological abuse.

The learning that emerged from the analysis is spread across five domains of adult safeguarding: direct work with the individual(s) concerned; interagency collaboration; organisational features within the agencies involved; SAB governance; and the national legal, policy and financial context.

Key message: Shortcomings in direct work have an immediate impact upon individuals, and there is important learning for senior leaders about enabling and sustaining best practice. Features in the other domains – resources and time pressures, information-sharing, case coordination, poor guidance and aspects of the national legal and policy context – also impact on direct practice. Senior leaders should be alert to this and address concerns when the effectiveness of direct safeguarding practice is being compromised by features in this wider safeguarding system.

Content and Processes of SARs

Care Act 2014 statutory guidance, which must be followed unless there are good reasons to justify departure from it, specifies requirements to which SABs must give and record due regard. It is the SAB itself that determines whether a review is commissioned. Ideally, reviews should be completed within six months, although parallel processes, such as criminal investigations or Coroner inquests, may lengthen the timescale. It is clear that exceptional operational service demands during the Covid-19 pandemic also resulted in slower reviewing processes. SABs are free to determine the review methodology and the means by which information is collected and analysed, but practitioners should be involved, along with family members, and the individual where they are still alive.

Administrative law requires that decision-making should be lawful, reasonable and rational. Decision-making should be timely once individuals and agencies involved have been consulted and all relevant information considered. Reasons for decisions should be recorded. Decision-making can be challenged in the High Court by way of judicial review or investigated by the Local Government and Social Care Ombudsman. This applies to public authorities of all kinds, and to SABs and their SAR processes.

The analysis identifies inconsistencies and omissions in SAR processes, decision-making and quality. For example, some reports did not adequately record the types of abuse and neglect experienced by the individuals involved and did not consider their protected characteristics under the Equality Act 2010. Some reports lacked clarity about the legal mandate for the SAR, the way in which it had been conducted, or how individuals / families had been involved. In some cases there had been difficulties arising with the quality and timeliness of information provided by agencies to enable the SAB to complete its statutory duty and to comply with statutory guidance.

Wider implications

The analysis identifies a significant gap in SAR findings about the national legal, policy and financial context. While SARs often referred to the national context of the Covid-19 pandemic, beyond this only a minority highlighted the local impact of the national context or made recommendations at this level. The National Network for SAB Chairs has an agreed escalation protocol with the Department of Health and Social Care, enabling matters of national importance to be raised.

Quality standards

Quality Markers outline national standards for the commissioning, conduct and management of SARS, and for the dissemination of learning to stimulate practice and service improvement. It remains unclear from SAR reports what impact these standards have had on the SAR process. The quality of reports is also variable. Not all reports refer to the review’s terms of reference. There is variable use of research relevant to the type of abuse and neglect that the case involves, and limited reference to other SARs conducted locally, regionally or nationally. Lessons are, therefore, being constantly learned anew rather than a best practice evidence-base being drawn upon to identify where practice and service shortfalls need to be remedied.

Practice improvement

Detailed analysis of learning was completed on 229 of the 652 SARs. There was a focus on both good practice and practice shortcomings, with the latter much more prevalent. Particular emphasis was given to key areas of policy interest: safe care at home, denied or difficult access (powers of entry), organisational abuse, homelessness, transitional safeguarding and substance misuse.

The most commonly noted good practice related to risk assessment and management (in 31 per cent of cases) and applying the principles of Making Safeguarding Personal (29 per cent). Also commended were recognition of abuse or neglect (including self-neglect), continuity of involvement, and attention to health needs, each noted in around 22 per cent of cases.

The most commonly noted practice shortcomings were poor risk assessment/risk management (in 82 per cent of cases), shortcomings in mental capacity assessments (58 per cent), and lack of recognition of abuse/neglect (56 per cent). Also frequently highlighted were shortcomings in making safeguarding personal (50 per cent), absence of professional curiosity (44 per cent) and attention to people’s care and support, physical and mental health needs, each noted in around 40 per cent of cases. An absence of professional curiosity meant that circumstances were sometimes taken at face value rather than explored in detail. Other highlighted shortcomings included absence of legal literacy, superficial acceptance of individuals’ apparent reluctance to engage, assumptions about ‘lifestyle choice’, poor recognition of the impact of trauma and poor attention to people’s living conditions.

Key Messages: It is important that learning about direct practice reaches those practising at the front-line, and that practitioner learning is supported through training and workforce development initiatives. Where SAR learning results in renewed focus on specific aspects of practice, senior leaders must ensure that their agency’s workplace environment and culture are receptive to the development of best practice, and that workforce skills and knowledge can have the desired impact on practice.

What were the findings on the wider organisational and interagency factors that impact upon direct practice?

While good interagency practice was noted in around a fifth of cases, shortcomings were more widely noted, with poor case coordination and information-sharing present in almost three-quarters of cases. Shortcomings in use of the Care Act 2014 s42 safeguarding provision, and of multi-agency (risk management) meetings were each noted in around 38 per cent of cases. Also regularly featured were concerns about the quality of recording, how agencies understood their roles and responsibilities, and how services communicated across local authority and other boundaries.

The most frequently mentioned organisational features that impacted on practice were poor management oversight, poor use of policies and procedures, and pressures on staffing and workloads, present in over a quarter of cases. Failure to provide training and concerns about commissioning practice, including quality assurance of provider services and communication about ‘out of authority’ placements, were also noted, along with an absence of suitable, often specialist, resources.

In terms of Safeguarding Adults Board governance, a few reports noted an absence of relevant guidance; examples included lack of policies on self-neglect, escalation, allegations regarding people in positions of trust, risk and mental capacity.

Key Messages: Clearly these organisational and interagency factors have a direct influence on how practitioners approach their work with an individual and can compromise the effectiveness of safeguarding. Senior leaders must ensure that the negative impact of organisational and interagency features is minimised and that organisational barriers to best practice are removed.

Learning and applying lessons

Statutory guidance outlines expectations on the reporting and use of SAR findings. SARs do not have to be published but SAB annual reports must provide details of SARs in progress and the findings and recommendations of completed reviews. They must specify what has already been done to improve and enhance services and practice as a result of SAR findings and recommendations, and what remains to be achieved. Subsequent annual reports should update on the outcomes that have been achieved.

Key message: It is important that senior leaders contribute to ensuring that SAB annual reports comply with the SAR reporting requirements in the statutory guidance, including providing evidence of improvements that have resulted from actions taken as a result of SAR learning.

This research helps us to understand how safeguarding can be more effective. It also shows that everyone needs to learn more about some forms of abuse and neglect - hate crime, modern slavery, sexual exploitation or self-neglect - and about abuse that happens in settings such as care homes. It also shows how SARs can be improved to ensure that clear lessons are learnt when tragedies happen.

The report sets out 31 priorities for sector-led improvements in adult safeguarding. They include:

• Changes to law and national policy guidance;
• Strengthening pathways for escalating concerns to central government;
• Improved understanding of what effective safeguarding looks like;
• Improvements to the way Safeguarding Adult Reviews are carried out;
• Improvements to use of the web-based library of Safeguarding Adult Reviews²;
• Better reporting of abuse or neglect and the reasons why it may have happened.

Concluding key message

The full second national analysis report has been published by the Local Government Association. Other short briefings are also available, presenting summary information for practitioners, elected members, SAB chairs and business managers, SAR authors and individuals/families experiencing safeguarding intervention.

This work is part of ongoing work led by the Association of Directors of Adult Social Care and the Local Government Association providing resources for councils and their partners’ roles and responsibilities in keeping people safe.Find out more about safeguarding resources.