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Briefing for practitioners: Second National Analysis of Safeguarding Adult Reviews

This briefing is of particular relevance to the work of practitioners and others who have frontline contact with individuals. It aims to support their best practice in direct work and to promote the achievement of positive outcomes.


It also provides evidence to support best practice in how services work together to prevent and safeguard people from abuse and neglect (including self-neglect) and how organisations and Safeguarding Adults Boards can support practitioners through the challenging complexity of adult safeguarding practice. It is therefore of particular relevance to the work of practitioners and others who have frontline contact with individuals. It aims to support their best practice in direct work and to promote the achievement of positive outcomes.

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), Safeguarding Adults Boards (SABs) must carry out a Safeguarding Adults Review (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. The SAB may also (section 44(4)) undertake a SAR in any other case concerning an adult with care and support needs. The purpose of all reviews is to identify learning that can drive change to prevent harm occurring in future similar circumstances.

SABs are free to employ whatever methodology they choose to carry out a SAR, but statutory guidance requires the involvement of practitioners and of the individual (if surviving) and their family members where possible. Practitioners may be invited to a learning event to share their experiences of working with the individual concerned or with others in similar circumstances. Practitioner perspectives are vital to ensuring the review incorporates practitioners’ lived experience of adult safeguarding practice.

Key messages

What were the key findings of the second national analysis of SARs?

This study analysed the findings of 652 SARs completed over the 4-year period, drawing out common learning themes. The analysis showed self-neglect to be the type of abuse most commonly reviewed, featuring in 60 per cent of reviews, 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, reported nationally through NHS Digital and locally in Safeguarding Adults Boards’ annual reports, 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.

Shortcomings in practice have an immediate and direct impact upon the individual, and there is important learning for practitioners to apply to their own direct work. It is also the case that features in the other domains – for example, resources and time pressures, information-sharing, case coordination, availability of guidance and aspects of the national legal and policy context – can impact on direct practice. It is important that practitioners are alert to this and escalate concerns about ways in which their own effectiveness may be compromised.

What were the findings about direct practice?

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/perseverance of involvement, and attention to health needs, each noted in around 22 per cent of cases. Observed less frequently but nonetheless present in a small number of cases were good attention to mental capacity (11 per cent), use of a ‘think family’ approach (8 per cent), use of advocacy (7 per cent), legal literacy (6 per cent), understanding of personal history (4 per cent), work with unpaid carers (4 per cent) and hospital discharge (4 per cent). Very occasional positive mention was made of recording (3 per cent), transition planning (3 per cent), use of professional curiosity (3 per cent) and attention to protected characteristics (1 per cent).

The most commonly noted practice shortcomings were poor risk assessment/risk management (noted in 82 per cent of cases), shortcomings in mental capacity assessment (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 needs (43 per cent), mental health needs (41 per cent) and physical health (37 per cent). An absence of professional curiosity (44 per cent) meant that circumstances were sometimes taken at face value rather than explored in detail. Other commonly found shortcomings included absence of legal literacy (40 per cent), superficial acceptance of individuals’ apparent reluctance to engage (38 per cent), absence of a ‘think family’ approach (37 per cent). Poor recording, poor attention to unpaid carers, lack of understanding of personal history, absence of trauma-informed practice, shortcomings in hospital discharge and poor attention to living conditions were each found in around a quarter of cases. Observed less frequently but nonetheless having a negative impact were a lack of perseverance (21 per cent), poor access to advocacy (21 per cent), lack of attention to substance use (20 per cent), poor transition planning (15 per cent), poor attention to protected characteristics (12 per cent) and absence of relationship-based practice (10 per cent).

Key messages:

  • Explicit and comprehensive risk assessment is an essential component of practice, as is a focus on proportionate risk management.
  • It is vital that practitioners pay close attention to mental capacity, carrying out capacity assessments where indicated, particularly where an individual consistently disregards high levels of risk to themselves or others, and where there might be concern about executive function, for example as a result of the impact of acquired brain injury or prolonged alcohol dependency. The potential impact of impaired executive brain function on decision-making must be considered.
  • The multitude of potential pitfalls in adult safeguarding, illustrated by the wide range of shortcomings set out above, means that practitioners must be competent and confident across a wide range of knowledge and skills. SARs also commented positively on the personal qualities that practitioners brought to their work. Compassion, kindness, care, empathy and sensitivity were all noted as good practice, along with commitment, dedication, professionalism, skill and diligence.
  • It is important continuously to reflect on the demands that safeguarding practice makes on practitioners and to identify how continuing professional development can support knowledge and skill development and the ability to use personal qualities in professional practice.

What were the findings on the wider systemic 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 information-sharing and an absence of case coordination present in almost three-quarters of cases. Shortcomings in use of the Care Act 2014 section 42 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 were lack of management oversight, poor provision or use of policies and procedures, and pressures on staffing and workloads, each 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, sometimes 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, risk and mental capacity.

Factors such as poor case coordination and information-sharing, pressures on staffing and workloads, availability of commissioned resources, and absence of management scrutiny, training and guidance, compromise the effectiveness of safeguarding. They have a direct influence on how practitioners in any one agency approach their work with an individual. Practitioners’ awareness of these systemic factors can assist them to take appropriate actions, for example to contribute actively to interagency coordination and information-sharing, and to escalate difficulties to the appropriate level in the safeguarding system.

Learning and applying lessons

When a SAR has taken place in their locality, practitioners can expect to see the learning being disseminated by the SAB and by their own employer. SAR reports and associated documents such as executive summaries and practitioner briefings provide significant learning and make an important contribution to practice development initiatives and to continuing professional development. Practitioners have a professional responsibility to highlight where learning has resulted in practice improvement and service development, and where obstacles or barriers remain. Practitioners should make active use of the learning from SARs, using team meetings, supervision sessions and other opportunities for reflection to discuss findings and their implications for practice.

It is important that practitioners learn the lessons from Safeguarding Adults Reviews, both in their own locality and elsewhere, and draw on this developing evidence base to inform their own practice.

Next steps

What happens next?

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, such as hate crime, modern slavery, sexual exploitation or self-neglect, and about abuse that happens in settings such as care homes.

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

  • Changes to law and national policy guidance;
  • Strengthening the pathway for escalating concerns to central government departments, for example about gaps in services and the impact on services of public sector austerity;
  • Improved understanding of what effective safeguarding looks like;
  • Improvements to the way Safeguarding Adult Reviews are carried out;
  • Improvements to the use of the web-based library of Safeguarding Adult Reviews1 so that they can be easily found and used for learning;
  • Better reporting of abuse or neglect and the reasons why it may have happened.

As a frontline practitioner, you are in a position that has huge potential to make a difference to the outcomes of safeguarding for the individuals with whom you work. Awareness of the most frequent pitfalls in direct practice can guide the enhancement of your own practice and enable you to contribute to overall service improvement.

The full second national analysis report has been published by the Local Government Association. Other short briefings are also available, presenting summary information for senior leaders, SAB chairs and business managers, SAR authors, elected members 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.