These questions and responses are intended for use alongside the framework itself to support anyone involved in safeguarding adults from abuse.
This page considers frequently asked questions (FAQs) raised during webinar sessions (December 2020 to March 2021, LGA ADASS), the subject of which was the suggested multi-agency framework to support understanding what constitutes a safeguarding concern (LGA/ADASS, 2020). This is referred to as ‘the concerns framework’ throughout.
An intention to review (in 2021) is included in the concerns framework. Until then, this FAQ serves to clarify areas of uncertainty and those which merit emphasising. The review will build on this.
These questions and responses are intended for use alongside the framework itself to support anyone involved in safeguarding adults from abuse. The questions reflect challenges highlighted across all sectors at webinars. The responses help in considering how any presenting risk can be addressed, whether within or outside safeguarding adults processes. All organisations working with adults, as well as those who may be in need of care and support, their families, carers, and communities, need a common understanding of the circumstances that should lead to raising a safeguarding concern to the local authority, and support and reassurance too about the circumstances where other actions, outside of safeguarding processes, may be required.
These questions alongside the framework itself form a basis for local discussion towards achieving that common understanding.
1. Who is this framework for?
The concerns framework is for everyone across all organisations, including the public. The aim is to support frontline practice in all organisations by providing a consistent framework for decision-making.
It is not solely local authority focused. All organisations working with adults need a common understanding of the circumstances that should lead to raising a safeguarding concern to adult social care in the local authority and the circumstances where other actions, outside of safeguarding processes, may be required.
The concerns framework sits alongside a framework for making decisions about the local authority duty to make statutory safeguarding enquiries. (Referred to throughout this paper as the enquiries framework). The enquiries framework has more of a local authority focus (because this decision about carrying out an enquiry is a local authority duty). However, it is helpful for everyone to understand the decision-making process at enquiries stage too (Making decisions on the duty to carry out Safeguarding Adults enquiries).
2. Why is a shared understanding of safeguarding concerns important? What benefits does this bring?
The following were all significant for those who took part in the webinars (December 2020/March 2021)
- I feel more confident in my decision and in having conversations
- I have a basis on which I can challenge others where there is a difference of opinion
- It provides a basis for conversations where there is uncertainty
- I can explain better to the adult or their families, what a safeguarding concern is and how to report for themselves
- This will mean that risks to wellbeing and safety will be addressed, whether as a safeguarding concern, or outside of safeguarding responses, by jointly agreeing alternative pathways for support
- This provides a clear understanding for the local authority of what to report as a safeguarding concern in the Safeguarding Adults Collection (SAC)
- It offers a more consistent approach to how organisations respond to concerns by providing greater clarity for people raising a concern about what they should consider & greater clarity for local authorities on what (initial) action they should take when a concern is raised.
Comments on this during webinars included: ‘[When raising safeguarding concerns] this almost always seemed to result in being told it wasn't safeguarding, with no trail of how decisions were made. This [framework] makes it much clearer what the common understanding should be’.
Comments from webinars (set out in italics) relating to questions raised in this FAQ paper are from webinars commissioned by LGA during the period December 2020-March 2021 in relation to the safeguarding concerns framework.
3. What are the criteria suggested in the concerns framework for defining a safeguarding adults concern?
The framework suggests that a safeguarding concern will be identified where there is reasonable cause to suspect that an adult who has care and support needs, is at risk of or experiencing abuse and neglect.
The criteria are derived from Section 42, Care Act, 2014. The criteria suggested in the framework for determining that a safeguarding concern should be identified are set out in S42(1a and b). That is, do I have reasonable cause to suspect that the adult has care and support needs? (Whether or not those needs are being met). S42 (1a), and do I have reasonable cause to suspect that the adult is experiencing, or at risk of, abuse or neglect? S42(1b). If these are met, then the framework suggests a safeguarding concern be raised with the local authority.
These two clearly defined criteria lend transparency and accountability to decision-making. The framework encourages conversations, both between people in referring agencies, between those who refer a concern and those in the local authority who receive the concern referral, to enable informed decisions about the range of pathways for addressing risk and/or support needs, rather than simply defaulting to raising a safeguarding concern or missing situations involving risk that require a response of some kind.
It must be noted that an individual does not have to be eligible for care and support under the Care and Support (Eligibility Criteria) Regulations for a safeguarding concern to be raised or for the local authority S42 duty to apply.
Sometimes, on specialist areas of practice, such as where there are issues relating to pressure ulcers, specialist advice/decision-making protocols are available. For example, national guidance on pressure areas. Local safeguarding concerns protocols will indicate where these should be referred to.
4. Question: Why doesn’t the framework, as part of defining a concern make reference to S42(1c), Care Act 2014
The framework notes that the Care and Support Statutory Guidance in 14.17 applies to local authorities (14.17 Local authorities should not limit their view of what constitutes abuse or neglect, as they can take many forms and the circumstances of the individual case should always be considered; although the criteria at paragraph 14.2 will need to be met before the issue is considered as a safeguarding concern). The concerns framework is multi-agency. It offers a rationale for differentiating between a concern and an enquiry so that early intervention and prevention as part of adult safeguarding is recognised and progressed by everyone at all stages in a timely way in practice and reflected in recording and reporting.
The framework makes the point that making judgements about this third criteria in Section 42(1c), Care Act 2014 (which is, that as a result of those needs [the adult] is unable to protect himself or herself against the abuse or neglect or the risk of it) can be complex and may take time. This may not become apparent until some way in to working with an individual. This is often only understood once the local authority and others undertake further information gathering under the S42(1) duty, as described in the Care and Support Statutory Guidance (DHSC 2020) 14.92.
The local authority may later decide against further pursuing an issue as a safeguarding concern. However, at the stage of a concern being raised, because S42(1) (a and b) are met it will be recorded and reported as such.
Adult safeguarding responsibility is much broader than simply those situations that progress to a safeguarding enquiry. There is a shared responsibility across organisations to address risks to wellbeing and safety, whether through safeguarding responses or through alternative support pathways. Early raising of concerns with the local authority enables conversations to explore these wider responsibilities. The framework encourages a focus on the continuum of safeguarding activity towards supporting better outcomes for everyone. (The following diagram is also repeated in an appendix for easier reading).
The adult safeguarding continuum, safeguarding concerns, safeguarding enquiries and other pathways
Universal: social and welfare services provided to all adults who have support needs, who have apparent need for care and support and can obtain advice and information from public, private, voluntary and faith sector organisations.
Adults who are at risk or experiencing abuse
Targeted services: signpost the adult in need of support to universal and targeted services. Local authorities do have duties to establish, provide and maintain a service, providing adults with information and advice which will prevent, delay, or reduce the need for care and support (Care Act, 2014, S2, S4).
Safeguarding concerns: Where there is reasonable cause to suspect that the following criteria is met; the adult has needs for care and support and is experiencing, or is at risk of, abuse or neglect (S42) (1) (a) and (b). Follow your local authority referral pathway for raising safeguarding concerns.
Examples of universal and targeted services include police, victim support, fire and rescue services, domestic abuse outreach services, accident and emergency departments, GPs, housing support, homelessness services, trading standards, faith organisations.
Adult in need of a safeguarding response
Safeguarding concerns will be assessed by the local authority to determine if there is reasonable cause to suspect that the three statutory criteria (S42) (1) (a), (b) and (c) are met and if met they will make whatever enquiries it thinks necessary, in partnership with the adult and partner agencies to decide whether any action should be taken. If the S42 criteria is not met the local authority will advise on other more appropriate pathways to follow.
The Care and Support Statutory Guidance (DHSC, 2020) 14.6 includes a reminder that local authority statutory adult safeguarding duties ‘apply equally to those adults with needs for care and support regardless of whether those needs are being met, regardless of whether the adult lacks mental capacity or not, and regardless of setting other than prisons and approved premises where prison governors and [Her Majesties Prison and Probation Service] respectively have responsibility. However, senior representatives of those services may sit on the Safeguarding Adults Board and play an important role in the strategic development of adult safeguarding locally. Additionally, they may ask for advice from the local authority when faced with a safeguarding issue that they are finding particularly challenging’.
Comments on this during webinars included…
Those of us from a local authority drift to three [statutory] criteria and miss the point that this is what those other than local authority staff should use to help them decide to make referrals."
5. What are the core ingredients that should form the basis of my decision-making in relation to safeguarding concerns? How can I apply these? Where can I find case studies that illustrate applying these?
The core messages in the framework are set out under four headings. These ingredients should be at the heart of all decision-making:
- Legal literacy and shared values and principles (Principles referred to include: Human Rights Act (1998) principles; the six statutory principles for safeguarding adults, alongside Making Safeguarding Personal (Care and Support Statutory Guidance, 2020 14.13-14.15) and the five core principles of the Mental Capacity Act, 2005. (see section 3 of this framework and appendix 2) derived from the statutory framework, including that the person concerned should be central to decision-making. The outcomes they want to achieve and how these may be accomplished. This is at the heart of Making Safeguarding Personal (Making Safeguarding Personal, see Care and Support Statutory Guidance, 2020 14.14-14.15).
- Working collectively; including consistency in defining, referring, and responding to safeguarding concerns
- A focus on prevention and early intervention. Understanding that a safeguarding concern is not the only route through which a multi-agency approach to identifying and managing risk to wellbeing and safety can be facilitated. Information gathering across organisations may lead to an alternative decision and pathway
- Acknowledgement of the importance of recording and reporting for evidencing of defensible decision-making; using national and local data and information to ask questions about and to develop effectiveness of decision-making and practice across all organisations.
These support effective practice. Application of these is explored in detail in section three and in case studies in appendix 3 of the framework.
A case study about Howard is set out at the end of section two of the framework. It reflects how these core ingredients can support effective practice. The SAR upon which this is based illustrates what can happen if these messages do not inform practice. Further case studies are offered in appendix three.
The framework suggests that these core messages help in empowering people to make decisions in every situation, and this is more helpful than solely offering examples against which staff need to ‘match’ the situation they are working with. ‘Scaffolding’ for decisions is the aim, rather than ‘thresholds’ that can lock people out of safeguarding processes without applying this personalised, partnership approach.
Comments from webinars included: ‘The ‘threshold’ for mental health safeguarding is often much higher … perhaps the framework helps in offering core considerations and criteria on which to objectively base decisions in relation to individual circumstances and in challenging decision-making and practice which is flawed on the basis of the legal and other literacies’.
‘In my authority we have recently had a matrix which can be used to decide if something is safeguarding. My worry about this is some professionals may have limited training/experience and this matrix might prevent alerts or concerns being made?’
6. Might the approach set out in the concerns framework open the floodgates so that local authorities become saturated with referrals of safeguarding concerns?
It might, initially. However, this is a consistent framework for everyone, offering support so that staff are empowered and developed to make informed decisions. This can have a longer-term impact so that the local authority ultimately receives a greater proportion of appropriate referrals. In the long run, this approach can establish confidence and empower everyone to raise appropriate concerns. It helps prevent situations that need a response from slipping through the net. It encourages practice which does not routinely default to raising a safeguarding concern.
Arrangements at the ‘front door’ are important. Potential for appropriate referrals will increase and other pathways can be identified through conversations early on if an effective ‘front door’ system is in place.
Strong partnership working bringing together knowledge and experience of the range of alternative pathways will be significant in further development of this framework both strategically and at the front line. A Multi-Agency Safeguarding Hub (MASH) can help.
Developments across organisations and sectors will help. For example, the Care Quality Commission (CQC) has advised that further clarity will be offered in its forthcoming revised guidance on statutory notifications. Regulated services are responsible for reporting incidents that indicate abuse or neglect. The revised guidance will assist providers in determining what is and is not ‘safeguarding’. This forthcoming guidance will have a focus on providers assessing risk and facilitating understanding of the range of pathways available for addressing identified risk. That guidance and this safeguarding concerns framework should be mutually supportive and help front line staff.
A forthcoming toolkit for police colleagues, to be published by the College of Policing, will promote the approach set out in the safeguarding concerns framework (including the flow chart for supporting decisions on what constitutes a concern). This will support local conversations with police colleagues about when to raise a concern with the local authority.
Comments on this during webinars included: ‘I raised a concern but didn’t get any feedback…So I’ll just raise everything because I’m not sure and I don’t want to be blamed for not doing so…’
‘In my region MASH provide "consultations" - you present the scenario/concern, and they will advise. This is really helpful...’
7. What should be reported as a safeguarding concern in the SAC and when? What are the benefits of approaching SAC reporting like this?
This framework suggests that where anyone raising a safeguarding concern with the local authority has determined that there is reasonable cause to suspect that S42(1a and b), Care Act, 2014, are met and where the local authority has checked that this has been determined, a safeguarding concern will be reported in the SAC.
This approach means that early intervention and prevention responses are acknowledged and valued in the SAC as part of safeguarding responses. The SAC data will reflect the broad range of activity within the scope of safeguarding responsibilities, including work across partner organisations that presents at the ‘front door’ of the local authority.
There need only be ‘reasonable cause to suspect…’ that S42 (1a and b) are met at this stage. The local authority will simply ask the question ‘has the referrer considered and determined that S42 (1a and b) are met?’ (rather than engaging in ‘evidence checking’). Then record that this is met and how met. If so, the local authority will report this in the SAC (Discussion in the webinars and debate at the NHS digital SAC working group suggests that when the concerns framework is reviewed the extent of this ‘checking’ by the local authority that the criteria in S42(1a and b) have been determined by the referrer is clarified as above. This to include at the top of the flow chart on page 38, where this might reflect that the referrer has determined the criteria are met and the LA has checked that the referrer did so. In addition, in core message 15 of the framework the suggestion that a ‘clear case’ be set out by the referrer be amended to checking that the criteria have been determined by the referrer.)
This determination of S42 (1a and b) being met will usually be before information gathering under s42 (1) progresses beyond initial stages and before all three criteria for the S42 duty can be understood and applied in deciding about how to proceed.
The decision at the ‘front door’ of the local authority needs to drive the recording and reporting of safeguarding concerns. The reporting decision shouldn’t wait until the situation progresses for example to a safeguarding team. Where this happens, whole swathes of concerns are ‘missed’ from the SAC data. A whole aspect of early intervention and prevention activity may be lost/ not ‘counted’.
Reporting of the determination that a safeguarding concern has been raised with the local authority should happen, whether or not it is later decided to pursue the issues raised through a different care and support pathway. That the activity is reported in the SAC early on reflects and values the broad range of activity that is in the early prevention and early intervention space. Hitherto this has been ‘hidden’ in local data.
An analogy of a bus journey may help. You can get on the ‘safeguarding bus’ at the start of the journey if there is reasonable cause to suspect that those two criteria (S42(1a and b)) are met. Then, if a little down the route it turns out that this isn’t a safeguarding concern after all, you can get off the bus and take a different route. However, in broad terms significant work in the early intervention/prevention space may have taken place. By reporting the safeguarding concern in the SAC this will be acknowledged as safeguarding activity.
NHS Digital intends to work with local authority colleagues on the SAC Working Group to adapt the guidance it issues to local authorities in relation to the SAC data (during the first half of 2021) to include this information and definition. This will recognise that this suggested concerns framework has not yet been adopted by all local authority areas. There will be space in the SAC return for the local authority to tell NHS Digital if a different approach has been followed and how it is different.
Both national and local data and information should contribute to a focus on the quality of decision-making. Using all that information to understand effectiveness of outcomes whether or not the presenting issues are identified as safeguarding concerns. It will be helpful for example for local information and data gathering to support understanding of whether a marked difference emerges between how those raising concerns and how the local authority defines a safeguarding concern and if so, to put local learning and development on this issue in place. Robust recording of decisions will facilitate developing practice through local case file audit.
Clear recording (feeding into local data and information) of issues that ultimately are not pursued in a single instance as a safeguarding concern, facilitates identification of cumulative patterns that may later require a safeguarding response.
This approach means that the number of safeguarding concerns is most unlikely to match the number of safeguarding enquiries triggered within the S42 duty. The concerns framework and the enquiries framework (Making decisions on the duty to carry out Safeguarding Adults enquiries) together therefore remove the emphasis there has been on ‘conversion rates’ (concerns to enquiries) as a performance indicator. The two have different definitions as set out in the two frameworks. A safeguarding concern (where Section 42 (1a and b) are met) may be pursued through a range of pathways. Only when all three of the criteria in Section 42, Care Act, 2014 are met will it be pursued through instigating a statutory safeguarding enquiry. A safeguarding concern that does not meet all 3 criteria (S42(2) Care Act, 2014), can be pursued through any of a range of alternative pathways (see response to question 12 in this FAQ paper), thus the individual’s safety and wellbeing is still supported.
8. Does the framework emphasise the significance of Making Safeguarding Personal, along with other core principles?
Yes. The framework underlines the importance of application of fundamental principles right from the start of recognising issues that might constitute safeguarding concerns. There must be a focus on the person and their wishes. This should include offering the support of a suitable person or advocate in decision-making where the adult has ‘substantial difficulty’ in being involved. This requirement is clearly set out in the Care Act, 2014 and in the Care and Support Statutory Guidance, 2020, Paragraphs 14.54 and chapter 7).
Making safeguarding personal is highlighted throughout the concerns framework and its appendices including in the core messages on page eight, the flow chart on page seven and in appendix two to the framework. Application of core principles is demonstrated in case studies included in appendix three and, particularly in the Julie case study. Principles include human rights principles, the wellbeing principle, making safeguarding personal, core statutory safeguarding principles, Mental Capacity Act principles, and the need for legal literacy are underlined throughout.
This making safeguarding personal response includes the need for conversations to establish a person’s views and wishes about the presenting issues, how these can be addressed and what outcome the person wants to achieve. This includes considering whether the adult needs support to do this, for example through an advocate.
The six statutory safeguarding principles are set out in the Care and Support Statutory Guidance (DHSC, 2020) 14.13. In 14.92 this statutory guidance adds two more principles ‘for local decision-making processes.’ These are i) recognition of the part that communities play in safeguarding adults from abuse and ii) a principle of offering feedback wherever possible. In 14.92 these two principles sit alongside the six statutory safeguarding principles  and are significant in the context of practice in relation to safeguarding concerns.
Prevention: it is better to take action before harm occurs
Proportionate: 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 delivering safeguarding feedback whenever possible (Care and Support Statutory Guidance, 2020, 14.92)
Comment from webinars included: ‘Making Safeguarding Personal should apply from the very first point of identifying a concern, including as part of raising a concern. This should include discussion about outcomes and consent’.
9. Do I need to seek the consent of the adult before raising a safeguarding concern? What if the adult is not consenting?
Yes. However, where an adult does not wish an adult safeguarding concern to be raised, raising a concern may still be justified, for example where there is a vital risk to the person or others; where there is a public interest consideration or issue, or where a best interest decision needs to be made (where the adult lacks capacity to make the decision). It is important to record the rationale for decision-making on this issue. Support with decision-making should be offered where the person has ‘substantial difficulty’ in being involved . Advocacy may be offered in this context. If this is declined or as part of advocacy support a conversation about risk may be needed.
Making Safeguarding Personal does not mean ‘walking away’ if a person declines safeguarding support and/or a S42 enquiry. That is not the end of the matter (This and other key messages for MSP are set out in Myths and realities about Making Safeguarding Personal). Empowerment must be balanced for example, with a duty of care and the principles of the Human Rights Act (1998) and of the Mental Capacity Act (2005). The need for balance on this issue is illustrated elsewhere within the Care Act (2014), in section 11, where it is explicit that although the local authority duty to carry out a needs assessment (S9) may be removed if the adult does not consent, this does not apply where the adult is experiencing or at risk of abuse or neglect. S11(2)(b)’.
Section 11 Care Act (2014) sets out circumstances where, even in the face of a refusal of assessment by the adult, there is a continuing duty under S9 Care Act (2014). This enables practitioners to pro-actively work together to understand a person’s care and support needs and how this might impact on their ability to protect themselves. This is potentially helpful if a person is experiencing or at risk of abuse or neglect but refuses a needs assessment. The individual should be kept informed and as involved as possible. This ability to carry out a S9 assessment (which the person cannot decline where S11(2)(b) applies) may support a ‘way in’ for offering support and for identifying need and risk alongside the person.
At the core of the Care Act 2014 is the wellbeing principle and helping people to achieve the outcomes that matter to them in their life. The local authority must promote wellbeing in carrying out any of its duties. Part of promoting wellbeing is promoting protection from abuse and neglect (See 1.1-1.6 Care and Support Statutory Guidance, 2020).
The case study about Howard at the end of section two of the concerns framework illustrates practice in the face of refusal of an assessment and the significance of making safeguarding personal in practice responses: ‘Howard must be involved in discussion and decision-making but … his declining of an assessment of needs and/or a safeguarding assessment must not be the end of the matter (S11, Care Act (2014)). The risk to him is perceived by a number of professionals to be significant. Consideration should be given to ways in which the risk … could be managed or mitigated. Conversations with him should seek to understand the underlying reasons for this refusal and ways that these might be addressed’.
A comment from a webinar drew attention to: ‘The …local authority's dual role in regard to adult safeguarding - S42 Care Act (multi-agency leadership role) and S9 and s11(2)(b) Care Act (assessment of a person with care and support needs at risk of abuse or neglect). S11(2)(b) explicitly rules out the need for consent. If that were better understood, it would help reduce the angst over the issue of consent’.
10. Are there circumstances in which risk of suicide should be identified as a safeguarding concern? Are these considerations linked to decisions about self-neglect and safeguarding?
Yes, there are circumstances in which risk of suicide will be identified as a safeguarding concern. Responses should be person centred, engaging with individual circumstances, and including the reasons for the suicidal ideation and the presenting risks. Blanket policies ruling out a safeguarding concerns pathway for addressing situations involving risk of suicide are not appropriate.
Suicide is at one end of a continuum of self-harm, however self-harm and self-neglect are not the same. Determining whether self-harm, suicide and/or self-neglect (in individual circumstances) might constitute a safeguarding concern will be supported by using the core messages set out in the safeguarding concerns framework for decision-making.
Where there is risk of suicide the core messages in the safeguarding concerns framework apply. The need to make safeguarding personal is highlighted throughout the safeguarding concerns framework including in core message four. The response should include conversations with the individual to establish their views and wishes. What is the nature of the presenting issues? What is at the heart of these from the perspective of the individual? Have they given consent for you to discuss the situation with others? If not, why not? Have you involved anybody else, do you need to seek help for the person? Have you discussed this with the adult? (see question 9 in this FAQ paper on ‘consent’).
Self-harm including attempted suicide and suicide is often a way of dealing with difficult feelings and memories or overwhelming situations and experiences. Support is available for anyone who self-harms and thinks about self-harming. Safety of the person is paramount and in a mental health crisis or emergency, call a mental health crisis line or 999.
The Care and Support Statutory Guidance (DHSC, 2020,14.16) is clear that the list of types of abuse/neglect in the Guidance is not exhaustive and in 14.17 that ‘local authorities should not limit their view of what constitutes abuse or neglect, as they can take many forms and the circumstances of the individual case should always be considered’. There is a strong implication here that the answer to this question about risk of suicide and whether this might constitute a safeguarding concern should not be the subject of a ‘blanket’ decision by any organisation but decided on each individual set of circumstances.
Consideration of Section 42(1a) may follow and be part of the conversation with the adult. Is there reasonable cause to suspect that this adult has needs for care and support (Help in defining ‘need for care and support’ is set out in section three of the safeguarding concerns framework on pages 18/19.). If there is uncertainty about this, the concerns framework suggests a conversation within or outside of your organisation. Then consideration of Section 42 (1b) may follow; is there reasonable cause to suspect that the adult is experiencing, or is at risk of, abuse or neglect? (see categories of abuse set out in 14.16-17 of the Care and Support Statutory Guidance (DHSC, 2020). Is abuse or neglect or the risk of it a factor in these circumstances? It may be that the individual discloses the root causes of suicidal thoughts as related to abuse or neglect. See for example the circumstances of Ms W set out in 14.164 of the Care and Support Statutory Guidance (DHSC, 2020).
It may be concluded based on using the above ‘scaffolding for decision-making, that support through the route of a safeguarding concern is indicated because there is reasonable cause to suspect that the individual has need for care and support and because conversations have uncovered reasonable cause to suspect abuse and/or neglect as a factor in suicidal thoughts/threats.
If a safeguarding concern is not determined as the most appropriate route, then another pathway for support for the adult will be indicated. Conversations with the adult and others will help in deciding how best to offer support and reduce the risk of harm. This may for example be through therapeutic support, a safety plan, robust partnership working. It may be that intervention through carrying out duties under the Mental Health Act are required. The level of risk should be identified and addressed.
It may be that the situation is believed initially not to constitute a safeguarding concern, but later new information indicates that it does. This should be monitored and there should be a preparedness to change approach where necessary in the light of new information.
Self-harm and self-neglect are not the same, although there may be some overlap. What drives people to hurt themselves may also drive them to deprive themselves of the basic care and comfort they need in order to thrive.
Self- neglect is considered as a ‘type’ of abuse in the Care and Support Statutory Guidance (DHSC, 2020, 14.17) ‘This covers a wide range of behaviour neglecting to care for one’s personal hygiene, health or surroundings and includes behaviour such as hoarding’. This Statutory Guidance says that in respect of self-neglect, assessment as to whether or not a safeguarding enquiry (S42(2), Care Act 2014 is prompted ‘should be made on a case-by-case basis.’ The same is true in determining whether such a situation should be considered a safeguarding concern. The safeguarding concerns framework suggests that where there is reasonable cause to suspect the individual has care and support needs and may be at risk of experiencing abuse then all agencies have a responsibility to consider raising a safeguarding concern with the local authority.
Self-harm is not considered explicitly in 14.17 Care and support Statutory Guidance (DHSC, 2020).
Comments from webinars drew attention to these issues:
‘A key thing I took away was that self-harm isn't classed as self-neglect and this has been difficult in our area’.
‘The usefulness of this approach of…’practical 'unpicking' of the case studies with regards to what is self-neglect, mental health and acts of omission’.
‘Suicide, or threats of suicide may often be tied into many other complex issues, which can be connected back to self-neglect. I think this needs to be carefully considered in relation to the debate on safeguarding concerns. The s.44 criteria for SARs specifically highlights this subject.’
11. What does the framework say about consideration of raising a safeguarding concern in respect of a patient of a health provider service? How might this issue be progressed and clarified?
Section two of the framework suggests that in all situations the core ingredients for practice are applied in deciding whether circumstances constitute an adult safeguarding concern. (See question and response five above). There is some way to go in achieving greater clarity on this issue and aspects of the challenge are set out in section five of the concerns framework.
NHSE anticipates that further progress in achieving this clarity can take place in the context of the move to integration and collaboration that is at the heart of Integrated Care Systems (ICSs). This provides a catalyst for change. The mandate for scrutiny has been with CCGs. From April 2021 this may rest with the ICS. These bodies will seek assurance that transparency and partnership are hallmarks of addressing incidents that might constitute a safeguarding concern. The concerns framework makes some suggestions for supporting good practice in section five and some of these are set out here.
There are recurrent questions as to what constitutes a quality issue, a patient safety issue, an issue about access to services or a safeguarding concern. In workshops that formed a basis for the concerns framework, there were examples given of protocols and practice in Health Trusts that actively encourage outward reporting to the local authority. However, there was wide variation of opinion about what constitutes an issue, a safeguarding concern, and a serious incident.
Development of guidance around a more uniform understanding of safeguarding concerns and the implications for health provider trusts raising these externally with the local authority under the leadership of NHS England and NHS Improvement (NHSEI) is likely to be through the influence of the extensive NHS safeguarding Adults from Abuse Network (SAAN). Discussions in SANN have already begun about bringing greater clarity through local development and then using this to influence and underpin revision of the NHSE Safeguarding Accountability Framework (SAAF) before September 2021. This is significant and welcome work as currently there is a lack of clarity in NHS guidance and frameworks which do not always foreground safeguarding as an option.
The concerns framework draws attention to existing guidance from NHSE and suggests the following can help in the meantime:
- That ICSs (formerly CCGs) seek assurance from NHS Provider Trusts that transparency and partnership are hallmarks of addressing incidents that might constitute a safeguarding concern and report on this to SABs
- That NHSE develops future guidance on unified definitions through its Safeguarding Accountability Framework, sharing exemplars of unified approaches to definitions to support best practice in the meantime
- That SABs seek assurance on the interface between the NHS Serious Incident Process and local safeguarding procedures. This can make use of available data, including data from local and national NHS reporting systems, and may require a memorandum of understanding. The NHS Serious Incident Framework, NHSE (2015) already specifies that: ‘The interface between the serious incident process and local safeguarding procedures must … be articulated in the local multiagency safeguarding policies and protocols… [That] Health providers and commissioners must liaise regularly with the local authority safeguarding lead to ensure that there is a coherent multiagency approach to investigating and responding to safeguarding concerns, which is agreed by relevant partners. Partners should develop a memorandum of understanding to support partnership working wherever possible’
Some SABs require Health Provider Trusts to share data on the number of Serious Incidents and safeguarding incidents addressed in house. This can then be compared to local data on, for example, the number of safeguarding concerns referred by health provider Trusts to the local authority and the number of statutory safeguarding adults enquiries relating to these settings. This provides a basis on which to understand and develop local practice. The same core messages for making decisions about safeguarding adults concerns should apply in health provider settings as elsewhere and this is an area on which SABs can seek assurance.
12. If it is decided that the presenting issues do not meet the criteria in S42(1 a and b) for a safeguarding concern what other pathways can be considered for addressing risk and needs for support? How does the framework help with this?
The framework’s core messages are important as a foundation for decision-making here. Partnership working and a focus on identifying and mitigating risk will be important alongside legal literacy, making safeguarding personal, applying the range of core principles and a collective acceptance of responsibility for prevention and early intervention.
Case studies in appendix three and four offer frameworks for practice drawing on these core ingredients. Many organisations support people who do not meet the s42(1) criteria, but who may be being abused and are unsure where to go next. Organisations talking to one another and understanding each other’s roles will help find the best support pathway.
Other alternative pathways where the adult’s situation does not fulfil the criteria in both S42(1a and b) include (not an exhaustive list):
- Referral for a S9 Care Act assessment which should have a focus on the individual’s wellbeing (including protection from abuse and neglect)
- Referral for a S10 Care Act (2014) carer assessment (Support in making decisions about unpaid carers and safeguarding is set out in section 3, pages 19/20 of the safeguarding concerns framework including reference to paragraphs 14.45-50 of the Care and Support Statutory Guidance, 2020 and in particular 14.46)
- Referral for advocacy support (A statutory requirement as set out in S67 and S68 Care Act (2014)) to support decision-making and involvement.
- Multiagency risk assessment conference (MARAC; domestic abuse)
- Multi agency public protection arrangements (MAPPA; designed to protect the public, including victims of crime, from serious harm by sexual or violent and other dangerous offenders)
- A contract monitoring or commissioning response to issues in a health or care provider setting
- A specific pathway to resolve issues regarding care, including clinical care, for example in relation to pressure ulcer care
- A regulatory response
- Review of a person’s care and support or health care plan.
Where S42 (1a and b) are met then these responses could also form part of a safeguarding adults plan and response or later, part of a safeguarding enquiry.
Some local authority areas have frameworks for multi-agency meetings, panels, or forums. Sometimes called VARM (vulnerable adult risk meetings) or MARM (multi-agency risk management meetings). These do not rely on adult safeguarding services to initiate actions or convene meetings. For example, see appendix 4 to the safeguarding concerns framework, Bournemouth, Christchurch & Poole, and Dorset MARM framework.
Important within both the concerns framework and the enquiries framework is the principle that there is no hierarchy of responses. Whether a situation is identified as a safeguarding concern or as meriting a statutory enquiry or as requiring another response, including perhaps one of the above, the aim is to find a person centred and partnership approach to managing risk effectively.
Comments from webinars included: ‘Cambridgeshire SAB are doing some work on pathways for vulnerable people who do not meet the criteria for an adult at risk.’
13. Is the framework just another term for a non-statutory or ‘other’ enquiry?
No. ‘Other enquiries’ is a voluntary element in the SAC and the term refers to those [enquiries] where the adult did not meet all of the Section 42 (1) criteria, but the local authority considered it necessary and proportionate to have a safeguarding enquiry (Safeguarding Adults, England, 2018-19 Experimental statistics). It could be any of the three criteria that are not met. (‘Other enquiries’ are considered in the safeguarding enquiries framework).
‘Other enquiry is not a term used in the Care Act 2014 or in the Care and Support Statutory Guidance (DHSC, 2020). This is explained in the NHS Digital information relating to the SAC and in the safeguarding enquiries framework (LGA/ADASS, 2019).
A safeguarding concern, on the other hand will always meet the criteria in S42 (1a and b) and then a decision will be made by the local authority as to whether S42 (1c) is met in which case a statutory safeguarding enquiry will take place. Or an alternative pathway for response and support may be indicated.
NHS Digital and the SAC working group (A national group representative of regions and a range of safeguarding roles in local authorities) are in the early stages of considering how the SAC data might support capturing concerns that do not progress to a S42(2) statutory enquiry and the various practice routes that might be taken, rather than just capturing this narrower subset (currently called ‘other enquiries’).
14. How can the framework support SABs? What can SABs do to support putting the framework into practice?
The framework can support the role of the SAB in clarifying the circumstances that should be raised with the local authority by partner organisations and in clarifying the reporting arrangements that should reflect this activity. This can then assist both SAB assurance and its targeting of support activity.
SABs are ideally placed to support putting this framework into practice. This framework is a multi-agency framework that needs partnership support to work well and consistently in practice. The contribution of all SABs in implementing the framework would support the consistency that is needed to avoid a national ‘patchwork of practice’ and of reported data.
Putting the framework into practice has the potential to enable the SAB to better understand whether decisions about raising of safeguarding of concerns with the local authority are consistent and effective in supporting positive outcomes for people in a broad range of safeguarding responsibilities, including in prevention and early intervention. The SAB will need to generate and analyse local information to support the SAC data in seeking assurance on this.
Some commentators have drawn general conclusions from published data about the extent to which people are protected (A Patchwork of Practice). Public perceptions are influenced by such analyses. Engaging with this concerns framework can support SAB responses to the drawing of such conclusions. The SAB will want to understand the nature of concerns raised and the extent to which they are raised with the local authority, and the effectiveness with which any risk in those situations is addressed either through being identified as a safeguarding concern or through other pathways for early intervention and prevention.
The role of SABs in assurance and as a source of advice and assistance is set out in 14.133-14.161 of the Care and Support Statutory Guidance (DHSC, 2020) where the responsibilities set out include reference to:
- Clarity about what types of circumstances should be raised with the local authority
- Evidencing and analysis of what lies behind local data and information to inform improvement and development at strategic and practice levels (including via audits)
- Prevention as a core responsibility of a SAB including commissioners, providers, and the regulator, acting to address poor quality care and identifying where this may amount to abuse/neglect
- Cooperation and collaboration across the partnership … balancing confidentiality and the ‘need to know’
The framework has a focus on all these areas of responsibility.
Examples offered at webinars of SAB action in relation to the concerns framework include:
- Surrey SAB… has set up a task and finish group to look at what needs to be done to implement the framework locally.
- Herefordshire SAB is encouraging people to attend development sessions and will be supporting the framework. Forms are being revised to support the decision-making framework.
- Lewisham is revising and reviewing the adult safeguarding pathway and producing guidance, training, and support to help with decision-making.
- Newcastle is suggesting an alteration to how the related performance information is captured. The SAB has plans and a process in place t- agree an approach to the framework and its implementation. A regional picture is being established about approaches to implementation.
- Gateshead is revising its multiagency policy in line with the framework.
- Hampshire, Portsmouth, Southampton, and the Isle of Wight have published local guidance alongside this national framework and multiagency workshops are planned. At Hampshire MASH level it is being shared with individual providers to support decision-making about referring. The MASH process and safeguarding referral form will require review.
Comments from webinars included:
As part of SAB chairs network, was involved in original patchwork of practice discussions which ultimately led to this work, seems a shame the guidance is so optional given collective support for its value at the start of the journey?"
I think the framework needs to be applied consistently across the country with some sort of endorsement or directive, otherwise we will still be in the same position as we were when the Patchwork of Practice was written."