What constitutes a safeguarding concern and carrying out safeguarding enquiries FAQs

Given the focus of the two challenges, the spotlight falls on some sectors more than on others. Nevertheless, there is support here for application across all sectors. These questions are presented alongside a summary paper indicating what might help in developing confidence in this area of practice.

Tools offered as support by local safeguarding boards and partners are included as ‘what might help’ within responses to each question. Each is presented because it may help with a particular aspect of the challenges. There is acknowledgement that in all cases, further development is needed. No one tool addresses all the challenges to the complex and longstanding issues. The responses below suggest combining aspects of these tools to generate legally literate and effective partnership responses.  

We suggest that these questions and responses are themselves used as a tool by Safeguarding Adults Boards (SABs) and sector leaders to identify aspects of working with concerns and enquiries where further local development work is needed. They can be used as a basis for local conversations, exploring the issues, setting out achievable and modest changes and actions where it might be possible to see measurable impact.

The flow charts from the frameworks on safeguarding concerns and enquiries are presented in appendix one as a reminder of the messages at the heart of the frameworks. The two frameworks (LGA/ADASS 2019; 2020) can be referred to here. Understanding what constitutes a safeguarding concern and how to support effective outcomes | Local Government Association (Alongside this framework, a frequently raised questions paper was produced following roll out of this framework). Understanding what constitutes a safeguarding concern: FAQs and Making decisions on the duty to carry out Safeguarding Adults enquiries. These frameworks are referred to throughout as the ‘safeguarding concerns and enquiries frameworks (LGA, 2019 and 2020)’.

There are quick guides to understanding what constitutes a safeguarding concern to understanding what constitutes a safeguarding concern on the LGA website. These are a useful tool in considering the questions raised.

This includes responsibilities to make safeguarding personal. The central ethos of the Act is a focus on the wishes and needs of the individual, involving and empowering them within any engagement. ‘Doing with’ rather than ‘doing to’ or ‘doing for.’ This ethos is integrated into guidance and protocols across sectors.

All partners must work within the principles set out in the Care and Support Statutory Guidance (DHSC, 2022) including in making safeguarding personal. (14.13-14.15 of the Guidance).

A cross sector legal framework is provided in the Care Act (2014) for all key organisations and individuals with responsibilities for adult safeguarding and there is a duty to co-operate. This requires the local authority and other parts of the health and care system, as well as other partners, to work together to prevent and address abuse and neglect of those with care and support needs. This is clear in the Act and in the Care and Support Statutory Guidance (DHSC, 2022).

‘The local authority must co-operate with each of its relevant partners [examples are given], and each relevant partner must co-operate with the authority’ (S6 Care Act, 2014).  This includes cooperation to safeguard, ‘protecting adults with needs for care and support who are experiencing, or are at risk of, abuse or neglect’ (S6 (6d) and in S6 (6b) in respect of quality of care and support for adults and carers. Section 7 Care Act (2014) also expects partner agencies to co-operate with the local authority when requested to do so, in relation to adults with care and support needs. (S7 (1) and (3). The partner, this says, must comply or offer written reasons for not doing so. Chapter 15, Care and Support Statutory Guidance (2022) develops understanding of the duties relating to integration, cooperation, and partnership.

Despite these clear messages, there is evidence of uncertainty and lack of clarity about roles and responsibilities.

There are many examples in Safeguarding Adults Reviews (SARs) of a lack of collective responsibility both in raising safeguard concerns and in following them up. For example, a Haringey thematic SAR on issues relating to safeguarding and homelessness (Thematic Safeguarding Adult Review: Homelessness (Haringey SAB, March 2021)) reminded ‘all practitioners and services of their responsibility to refer adult safeguarding concerns and not to rely on others to do so’. A Swindon Safeguarding Partnership SAR (Kieran, 2021) recommended that the partnership ‘seek assurance that decision-making regarding progression from Section 42(1) to Section 42(2) enquiries is sound and fully documented’. A Salford  SAR  (Safeguarding Adult Review: Eric) underlined: ‘When a system comes together, the whole can be greater than the sum of the parts’. There was ‘too much of “that is not our role” or “that is not for our service.” ‘

A conversation in a workshop (LGA, July 2022) expressed uncertainty about whether, on raising a concern with the local authority, it should ‘just be left to the local authority to decide whether there is a safeguarding concern and what needs to happen’. The workshop discussion (LGA, July 2022) explored the need for multiagency engagement in considering the range of options for addressing presenting risks, concluding that far from ‘leaving it to the local authority’, multi-agency engagement is vital. Feedback to referrers is necessary and should be sought if the referrer is not clear whether risks and concerns remain and require support. There is joint accountability.

What can help? Being clear about statutory responsibilities and the range of roles and responsibilities. Reference to sources that underline this partnership responsibility support confidence in asserting its necessity, including:

• the Care Act (2014) and the Care and Support Statutory Guidance (DHSC, 2022). (Direct reference)
• a related government factsheet on Protecting adults from abuse or neglect factsheet  on adult safeguarding which underlines that safeguarding is ‘everyone’s business’. It is not simply for the three statutory partners
• an adult safeguarding toolkit (Adult Safeguarding: A toolkit (BMA includes reference to messages and principles at the heart of the Care Act (2014) and the significance within this of multi-agency effort
• A recent guide from the office of the chief social worker (DHSC, March 2022) reflects a commonly held myth, one that was repeated during workshops (LGA, July 2022). ‘Myth … Once a concern has been raised with the local authority, it is their responsibility to resolve the situation’. ‘Reality … Safeguarding is a collective responsibility working across multiple partners who can help address safeguarding concerns…’
• Forthcoming revision of a cross sector Safeguarding Adults Roles and Responsibilities in health and social care services paper, referenced in 14.72 (Care and Support Statutory Guidance, 2022) can help with this.

This guide (DHSC, March 2022) underlines that ‘It is vital for effective safeguarding that system partners and professionals work with one another to achieve the best outcome for individuals, considering their full set of needs and wishes. System partners may broadly cover different sectors that the individual needs support from such as the police, health, housing, justice, and leisure.’ This report also underlines responsibilities to work together across children and adult services, providing a link to a briefing on transitional safeguarding.

The frameworks are based on the Care Act, 2014 and the Care and Support Statutory Guidance (2022). The safeguarding concerns framework is intended for application across sectors. It ‘proposes a shared, cross sector understanding of what constitutes a safeguarding concern. It promotes across all organisations collective and transparent accountability and responsibility for decisions and actions … Its purpose is to help achieve effective multi-agency outcomes that address risks to wellbeing and safety whether through a safeguarding response or through another pathway.’ (LGA, 2020).

Raising safeguarding concerns and making decisions about these is a multi-agency endeavour. There was therefore significant cross sector consultation and engagement in producing and rolling out the frameworks (including with police, NHSE, CQC, NHS Digital). This is reflected in the concerns framework and in the accompanying FAQ paper. Section 5 of the framework is about supporting decision making in relation to provider concerns in social care and health. Health and CQC colleagues engaged fully with this. Undertakings made in the FAQ paper are a ‘work in progress’.

Whilst the enquiries framework emphasises the local authority duty to make enquiries and to decide whether any action should be taken and by whom, this framework too requires significant involvement across different sectors.

Partners are likely to be involved in a range of ways including in:

• contributing information and advice
• being ‘caused to make enquiries’ by the local authority (14.69 Care and Support Statutory Guidance 2022)
• planning the enquiry
• contributing towards S42 enquiry objectives (or objectives set in pursuing pathways outside of S42 duties)
• making safeguarding personal.

It is important that everyone is clear how the local authority makes decisions about the three statutory criteria in Section 42, Care Act (2014) within the enquiry duty. This transparency in decision making supports conversations and challenge.

Those raising concerns need to be engaged as necessary in achieving outcomes, whether within or outside of safeguarding responses. Knowing about the outcomes achieved and pathways taken to resolve issues and where appropriate contributing to these, is vital both in terms of accountability and also in seeing the point of raising a concern with the local authority and having insight into what works and what doesn’t.

What can help? Multi-agency guidelines prepared by the Gloucestershire SAB are supportive, Safeguarding vs safeguarding. These:

• explore the need for partners to be proactive both where concerns constitute a safeguarding enquiry and where other risks and concerns that are outside of section 42 duties exist
• encourage mutual challenge, including where a safeguarding concern is raised and the local authority decides not to pursue a safeguarding adults enquiry (S42, Care Act, 2014)
• encourage the referrer to ask for an explanation about the decision and to request a review if there is disagreement
• encourage the raising of concerns with the local authority in the way set out in the safeguarding adults concerns framework (LGA, 2020), indicating that taking this approach helps the local authority ‘in the process of gathering information in order to establish that they (the local authority) have ‘reasonable cause to suspect’ that abuse is present’. 

What can help? Local authorities and health providers can benefit from:

• Regular face to face meetings to discuss safeguarding concerns raised in provider Trusts and to consider pragmatic responses that produce effective outcomes and fulfil statutory duties. This happens for example in Surrey where a local authority lead meets with Trust leads weekly. This is valued by both organisations and is working well. In Hertfordshire the local authority safeguarding lead has similar regular meetings with a health trust partner.

• Agreement about routes for escalation. This is included in a Leicester and Leicestershire and Rutland SABs 4.2.1 Guidance for the Oversight Process of S42 Enquiries in NHS Settings.

• The same protocol helps in clarifying the local authority oversight arrangements for safeguarding enquiries where the alleged abuse or neglect occurs in an NHS in-patient setting. The ‘process’ section (4) outlines a system of regular health trust and local authority meetings.

Where a local authority causes a partner to make enquiries (Care and Support statutory Guidance, DHSC, 2022, 14.69), the response must be robust, and assurance given to the local authority about agreed actions… ‘The local authority may well be reassured by the employer’s response so that no further action is required. However, a local authority would have to satisfy itself that an employer’s response has been sufficient to deal with the safeguarding issue and, if not, to undertake any enquiry of its own and any appropriate follow up action.’ The above face to face meetings can support this. They help in jointly agreeing responses and offering assurance to the local authority. In some instances, a joint response from a provider to ‘clusters’ of common concerns can be the subject of these discussions and offer a pragmatic approach. 

The two frameworks (LGA, 2019 and 2020) offer support for a joint approach, mutual challenge and collective learning and development.

It shouldn’t matter where a safeguarding concern comes to light or how it is framed in the first instance. If the concern meets the criteria set out in S42 (1a and b), Care Act (2014), by raising it with the local authority, joint decisions can be made about what needs to happen.

Decisions can be made together about the most effective pathway and the shape of activity necessary to achieve positive outcomes, including prevention.

A safeguarding enquiry is a broad lens, capable of taking in all aspects of the concern and finding what actions are necessary and who might be key in carrying them out.

There is a great deal of activity in adult safeguarding within the range of sectors. There is now a need for strong cross sector leadership (and leadership within sectors) to ‘join the dots’ and to drive shared priorities collectively.

Cross sector reference to the frameworks and the statutory duties that underpin these are sometimes unclear or absent in protocols and frameworks nor are these always supported through integrated training.  A strong message from regional workshops (LGA, July 2022) is that including these cross references would support local development and would support a ‘common language’.

One or two examples are presented here illustrating this need for ‘joining the dots’. These illustrations are from the Care Quality Commission (CQC) and health because the challenges presented by regions (LGA 2022), including that of working with organisational abuse, primarily reflected issues relating to these sectors. There are further examples across all sectors which can be highlighted for sector leaders and SABs.

Recent guidance (CQC, May 2022) aimed at CQC staff on how CQC identifies and responds to closed cultures, has a number of strengths (helping with identifying organisational abuse risk factors, including early warning signs, reflecting human rights and equalities law and making safeguarding personal). It does not however, include advice to raise a concern with the local authority in line with the Care Act (2014) and Care and Support Statutory Guidance (DHSC, 2022) and the concerns and enquiries frameworks (LGA, 2019 and 2020). This is despite its stated purpose including to ‘determine next steps if evidence is uncovered that suggests people are at risk of harm or have experienced harm or abuse’.

The Patient Safety Incident Response Framework (PSIRF, NHSE August 2022), doesn’t make the links across from patient safety incidents to raising safeguarding concerns with the local authority. It is acknowledged that the PSIRF sets out to support system learning and improvement in patient safety rather than to address individual concerns. Nevertheless, making the links explicit between responsibilities in raising safeguarding concerns and improvement at system level is important, especially where organisational abuse is concerned. 

Links between safeguarding and patient safety are highlighted as important in the NHSE safeguarding adults pocket guide: ‘Safeguarding adults is a fundamental part of patient safety and wellbeing and the outcomes expected of the NHS’. The NHS Safeguarding Accountability and Assurance framework (July 2022) draws the attention of system leaders to the new PSIRF which it says may also be activated due to other incident management processes.

Some patient safety issues will constitute a safeguarding concern and perhaps a duty to make safeguarding enquiries and although there are signposts from the PSIRF to other processes outside its scope (such as Human Resources, police, regulatory processes) there is no mention of a safeguarding enquiry as one of these processes. Yet, a safeguarding enquiry, the purpose of which is ‘to decide whether any action should be taken…and, if so, what and by whom’ (Care Act (2014) Section 42(2)), can draw all these processes together to safeguard people.  

The Safeguarding Accountability and Assurance Framework (NHSE, July 2022) sets out roles and responsibilities of providers and commissioners in NHS settings. This includes the NHSE role to ensure that health commissioners work effectively across health and care, encouraging, ‘a culture that supports staff in raising concerns regarding safeguarding issues’. Making more explicit connections to Section 42 (Care Act,2014) safeguarding responsibilities and to the safeguarding concerns and enquiries frameworks will significantly help to achieve this.

What can help?

• Making the connections in practice and in protocols, between quality of care, safety, and safeguarding. For example, making the necessary connections  between the safeguarding concerns and enquiries frameworks (LGA 2019 and 2020)and the recently published NHSE frameworks (July and August 2022).
• Cross sector reference to the safeguarding concerns and enquiries frameworks (LGA, 2019 and 2020). For example, the College of Policing, which sets standards for police forces, recently published an Authorised Professional Practice briefing note (APP) in relation to adults at risk. This includes flow charts, integral to the safeguarding concerns and enquiries frameworks (see appendix 1)  Deciding whether you need to make a safeguarding concern referral and adults at risk. It is acknowledged that there is much to do in rolling out this resource, but this is a starting point.
• Recognising shared core principles across those frameworks and sectors (including transparency, candour, partnership and making safeguarding personal). Making these real in partnership in joining up perspectives.
• Promoting the move away from imposing thresholds (this is signalled in all these frameworks). A proactive approach to engagement across sectors and with people, aimed at ensuring issues are addressed holistically and in a legally literate way.
• Being proactive in ensuring that commissioning assurance plans highlight these connections across Care Act safeguarding duties and linked responsibilities, including patient safety and quality.
• Forthcoming revision of the earlier cross sector Safeguarding Adults Roles and Responsibilities in health and care services paper, referenced in 14.72 (Care and Support Statutory Guidance, 2022) can help with this.

‘There should be a clear understanding between partners at a local level when other agencies such as the local authority, CQC or CCG need to be notified or involved and what role they have. ADASS, CQC, LGA, NPCC (formerly ACPO) and NHS England have jointly produced a high level guide on these roles and responsibilities. The focus should be on promoting the wellbeing of those adults at risk Safeguarding Adults - Roles and Responsibilities’

• Initiatives illustrating multi-agency engagement and tools developed in working with concerns and enquiries (set out in Q2) can help. 

Agreed partnership definitions are essential. Definitions of a safeguarding enquiry and of a concern are offered in the two frameworks published by the LGA in 2019 and 2020.These are reflected in the flow chart in the appendix to this paper.

Collective understanding of what is to be gained through raising a safeguarding concern with the local authority is a vital step in gaining commitment to partnership working within the frameworks (in line with the Care Act (2014) and the Care and Support Statutory Guidance).

This collective understanding of the benefits of raising concerns requires open and honest discussion of barriers to raising safeguarding concerns with the local authority. If there is reluctance to do so, why is this? How can those issues be addressed and benefits for people who may be the subject of safeguarding concerns realised?

It is important for people who may need safeguarding support to understand this too. See for example, Carr, S, Hudson, G., Amson, N., Hisham, I.N., Coldham, T., Gould, D., Hodges, K. and Sweeney, A. (forthcoming), ‘Service users' experiences of social and psychological avoidable harm in mental health social care: Findings of a scoping review’. British Journal of Social Work. This service user informed research shows that service users seemingly do not know about safeguarding concerns as a route to possible support.

Assumptions and mutual blame are among a range of reasons given for not raising a concern with the local authority. Adopting these positions presents barriers to considering the benefits of doing so. But how accurate are those positions?

Participants in conversations (LGA, July 2022) expressed the following positions:

‘We (providers) raise concerns with the local authority, but the local authority doesn’t often pursue these through a statutory safeguarding enquiry’.

‘In any case the local authority doesn’t tell the provider what happens after we raise a concern’.

‘We, the local authority, do not receive many safeguarding concerns from providers in the health sector’.

There needs to be progression from those positions (which are often not backed up with firm evidence) to dialogue and the possibility of progress towards shared understanding and goals. The conversations in the Northeast and the East of England (LGA, July 2022) have demonstrated the need for, and at times the benefit of, such dialogue. Local initiatives, where regular conversations across health providers and the local authority are embedded, demonstrate positive signs that this works (see examples, Question two ‘what helps’):

• Asking questions of the national data and then collecting more information locally, can support better understanding of positions adopted (like those set out above). National data can be used as a ‘can opener’, to show what else needs to be known locally. Bespoke tables were requested from NHS Digital in response to issues raised about organisational abuse during this work: Organisational abuse data for concluded Section 42 enquiries. These are an example of ‘digging deeper’ and importantly such attempts can form the basis of deciding what further local information is needed to inform development. Use the data as a springboard to think about the right way to practice and the right way to record and report. (Note. These bespoke tables can only be produced at regional level which introduces some limitations. Care needs to be taken in drawing conclusions.It’s important to consider the bespoke regional information alongside local authority level data. There is wide variation across local authority areas. The data offered in the bespoke tables is heavily skewed by just a very few outliers.
• An audit approach undertaken by Central London Community Health (CLCH) Trust is a good example of generating local information to inform dialogue and joint understanding. The audit was of safeguarding concerns raised by CLCH staff with local authorities. The aim was to find out about the quality of referrals by CLCH staff as well as outcomes and responses from the local authority. Only 10 per cent to 20 per cent of referrals raised, generated a safeguarding enquiry response led by the local authority. Adult safeguarding leads in the Trust are linking with respective local authority leads to find out what happened to the concerns raised and the rationale. This audit has triggered a review of responses to concerns being raised in one London borough. Further developments will follow. These conversations will support greater clarity going forward.
• The same Trust has also put in place guidance for making referrals to the local authority based on SAFER guidance (based on guidance for safeguarding children). This encourages broad consideration of factors, including insights about the person and their significant other, the context and actions under consideration.
• The safeguarding enquiries framework can support taking these audit findings forward by offering a transparent basis for consideration, discussion and challenge of decisions made.
• The above exercise in CLCH has raised questions both about the need for a clear escalation route where there is disagreement, and about multi-agency accountability for outcomes whether through a section 42 enquiry or through another pathway.  Surrey SAB also has an escalation protocol: Inter–Agency Escalation Policy and Procedure: Resolution of professional disagreements and oversight of risk in work relating to safeguarding adults.

What can help includes understanding and discussing barriers to raising concerns with the local authority and then the significant benefits to be derived from doing so.

Barriers include: 

• uncertainty about what happens when a concern is raised with the local authority
• perceptions or experience of safeguarding responses as a punitive and heavy handed experience
• the patient/service user says they don’t want anything done and there is a lack of confidence in dealing with this conflict
• lack of understanding of legal duties across sectors
• concerns about litigation and or reputation
• internal sector guidance conflicts with the frameworks the Care Act and the Care and Support Statutory Guidance, DHSC, 2022.
• a belief that doing so won’t make any difference.

Conversations need to explore these openly and honestly and to develop mutual understanding and actions.

‘Workers across a wide range of organisations need to be vigilant about adult safeguarding concerns in all walks of life including, amongst others in health and social care, welfare, policing, banking, fire and rescue services and trading standards, leisure services, faith groups, and housing. GPs, in particular, are often well-placed to notice changes in an adult that may indicate they are being abused or neglected. Findings from serious case reviews have sometimes stated that if professionals or other staff had acted upon their concerns or sought more information, then death or serious harm might have been prevented’ (Care and Support Statutory Guidance, DHSC, 2022, 14.36).

Significant benefits to raising concerns with the local authority include:

• avoidance of serious and negative outcomes for people
• helps to put things right alongside people, taking into account their wishes
• supports and gives opportunity for multi-agency assessment of need as well as risk
• helps look at the full range of pathways to support people in reducing risk of abuse and increasing wellbeing
• avoidance of the frustration and risk that results for people where organisations fail to work collectively and engage in ‘passing the buck’ (discussed in a podcast, LGA, 2019 and based on research by Carr, S et al, Health and Social Care in the Community, September 2019).
• helps in revealing patterns, so that underlying causes can be identified, including where others may be put at risk
• informs need for improvement at organisation and system levels
• facilitates early conversations and interventions that prevent escalation of risk
• offers independence and an objective view where an ‘internal view’ may have limitations
• the objectives of a safeguarding enquiry (Care and Support Statutory Guidance, 2022, 14.94) indicate significant benefits. A single agency intervention may well not address all objectives on its own.

Operating within principles of transparency and candour reaps significant benefits across sectors as well as in outcomes for service users and patients. The following offers an evidence base and further insight into one aspect of these benefits. (Appendix two considers further messages from SARs that relate to issues under consideration in this paper).

There are numerous examples in SARs where there are missed opportunities for assessment of care and support needs and where a safeguarding concern being raised and / or an enquiry could have been an opportunity to uncover the need for such an assessment. Raising safeguarding concerns with the local authority can introduce the opportunity to discuss care and support needs. One example relating to facilitating needs assessments is that of the SAR relating to Howard, Isle of Wight (2018). A SAR highlighted as a case study within the safeguarding enquiries framework (LGA, 2019).

A factsheet issued alongside the Care Act (2014) says…   ‘In [some] cases, the risk of abuse may be tackled, but the adult may have other care and support needs which require different services and may lead to a needs assessment or review of an existing care and support plan’.

‘It is important, when considering the management of any intervention or enquiry, to approach reports of incidents or allegations with an open mind. In considering how to respond the following factors need to be considered … [this includes] the adult’s needs for care and support…’ (Care and Support Statutory Guidance (DHSC (2022 14.99))

There is a clear emphasis on this in the Care and Support Statutory Guidance (DHSC, 2022) including in 14.94 (objectives of an enquiry). Also, in 14.99 where the factors to be considered in deciding how to respond, relate largely to considerations where the adult is at the centre. Their wishes, needs, the risk to them (and the risk of that escalating), the impact on them and on their relationships and so on.   

There is a level of agreement that it is important to identify organisational abuse alongside individual concerns not least because ‘repeated safeguarding concerns, particularly if they form a pattern either for the same person or for different people, may be an indication that there are deeper problems in the way that a service operates or is managed. They may also show that interventions are not working, and new approaches may be required’ (ADASS June 2022).

In addition, ‘individual, relatively low-level concerns about quality, may be handled by practitioners or managers in the hope that improvements will be made. It can be difficult to recognise when insufficient improvement is being made and when concerns should be escalated further. This also results in a lack of shared information about quality problems and, as in the Kingswood review, to a disconnect between the number of safeguarding concerns and practitioners’ own knowledge of problems in the service.’ (ADASS 2022)

Organisational abuse is defined as … ‘including neglect and poor care practice within an institution or specific care setting such as a hospital or care home, for example, or in relation to care provided in one’s own home. This may range from one off incidents to on-going ill-treatment. It can be through neglect or poor professional practice as a result of the structure, policies, processes and practices within an organisation’, Care and Support Statutory Guidance (DHSC, 2022,14.17).

Organisational abuse is a possibility in the whole range of provider services. There was some indication at workshops (LGA, July 2022) that it is more often considered in relation to care homes and nursing homes. A strong view was expressed that this should not be the case.

The importance of definition and of indicators of organisational abuse and of applying these, is underlined in seminal SARs such as the one relating to Winterbourne View hospital (South Gloucestershire, 2012) where  …’indicators' highlighting' service' failings' went' largely' unheeded'. This is referenced in a recent publication (LGA, 2022) on discriminatory abuse.

What can help? Early identification of organisational abuse across all sectors can be supported by use of tools and approaches which help in looking beyond single incidents to wider issues, risks and patterns. Examples include:

• To support understanding what constitutes organisational abuse and how to recognise it, Early Indicators of Concern Residential and Nursing Homes for Older People (Marsland P, et al, Centre for Applied Research and Evaluation, University of Hull, October 2012) identified indicators of organisational abuse. These are incorporated in tools by some SABs. For example, in South Gloucestershire these are set out in appendix one of South Gloucestershire organisational abuse procedures (June 2021). This supports objective criteria for evidencing ‘reasonable cause to suspect’ organisational abuse early on. The criteria are set out under four headings:
  • Concerns about management and leadership
  • concerns about staff skills
  • knowledge and practice
  • concerns about adults’ behaviours and wellbeing
  • concerns about the service resisting the involvement of external people and isolating individuals.
• Surrey guidelines for those raising concerns help in deciding whether issues are located in the organisation or the person. This is offered in Making Good Referrals of Adult Safeguarding Concerns in Surrey (appendix C). 
• How CQC identifies and responds to closed cultures (May 2022) is also helpful in this respect.

As a ‘type’ of abuse set out in the Care and Support Statutory Guidance (DHSC, 2022) and in line with that definition, there is a duty to consider organisational abuse as a safeguarding concern and or through a safeguarding enquiry. However, there is evidence including in local and national sector protocols, that organisational abuse is sometimes handled differently to other forms of abuse and neglect and in some cases outside of Section 42, Care Act (2014) responsibilities and duties.

Definitions in some protocols are not entirely reflective of the definition in the Care and Support Statutory Guidance (DHSC 2022). For example, the NHS pocket guide, safeguarding adults (p 8) stops short in its definition of organisational abuse, of the final sentence in the definition in the Guidance (DHSC, 2022). It leaves out the part that states that organisational abuse ‘can be through neglect or poor professional practice as a result of the structure, policies, processes and practices within an organisation’. This may lead to organisational abuse in NHS settings, or identified by NHS staff in other provider organisations, being addressed outside of a safeguarding pathway and outside of S42 Care Act (2014) duties.

It is not uncommon for local authority areas to address organisational abuse under processes that run parallel to the S42 duties. This may be for a range of reasons. Often, for example issues relating to promoting diversity and quality in provision of services, (Section 5 Care Act, 2014) connect closely to S42 duties to safeguard from abuse and neglect. It is not an either / or. If the criteria for a S42 enquiry are met, then this must take place and be recorded and reported as such. The S42 enquiry may, however, take a range of forms, including embracing actions relating to S5 duties.

There is some indication that working within a parallel process, where organisational abuse is suspected (perhaps with a focus on S5 duties), rather than within S42 Care Act safeguarding duties, may be seen as more positively supporting relationships and joint working with providers.

What needs to happen?  Safeguarding needs to develop as the Care Act intended and to be better understood through open partnership conversations, rather than avoided. Undertaking enquiries under S42 Care Act is not optional where the criteria in S42 Care Act (2014) are fulfilled. There is flexibility about how this happens not whether it happens. The individual (s) at risk must be at the centre of joint working. Taking a more open and honest approach across partner organisations can itself strengthen working relationships and understanding.

What needs to happen? Changing the language and approach to safeguarding.

‘Commissioners of care or other professionals should only use safeguarding procedures in a way that reflects the principles … not as a means of intimidating providers or families. Transparency, open-mindedness, and timeliness are important features of fair and effective safeguarding enquiries’ (Care and Support Statutory Guidance 14.73).

The frameworks offer one tool to support the required shift, reinforcing the language and intention of the Care Act. A safeguarding enquiry is simply deciding whether any action should be taken and if so what and by whom, it is not an ‘investigation’. Protocols still include extensive reference to pre Care Act (2014) terminology. Changing this will help.

Safeguarding responses, particularly in provider services are sometimes experienced as a means of apportioning blame, where the local authority ‘investigates’. Instead, there should be dialogue and a joint commitment to improved experiences and outcomes for people. (see for example ‘Making Safeguarding Personal, A Providers Perspective’ in workshop slides from Fidelma Tinneny (LGA March 2019) Making Safeguarding Personal in commissioning one day workshop PART FOUR (local.gov.uk) (presentation two).

What needs to happen? Recording and reporting

The reporting of organisational abuse activity as set out in the SAC is very variable. It is likely that this reflects all of the factors above: a lack of an accepted definition of organisational abuse; a lack of a unified set of objective indicators to support cross sector identification; a range of approaches to considering concerns about provider services and whether these are considered inside or outside of S42 duties; inconsistency (partly arising from the above and linked to limitations of IT systems) in recording and reporting organisational abuse concerns and enquiries; hesitancy about transparency with the local authority and the point of raising a concern with them (as set out in question three).

More accurate reflection of the extent and nature of this type of abuse is needed for governance and other purposes.  Bespoke tables were requested from NHS Digital in response to issues raised about organisational abuse during this work. These     Bespoke tables drawn up by NHS Digital could only be produced at regional level which introduces some limitations. Care needs to be taken in drawing conclusions.   It’s important to consider the bespoke regional information alongside local authority level data.

As a result of wide variation across individual local authority areas, what the bespoke tables reflect is heavily skewed by a very small number of outliers. It may be more useful to look at the numbers reflected rather than the proportions or averages. The data in any case reflects differences in local practice in addressing organisational abuse and in what is recorded and reported. It needs to be used as a springboard to think about the right way to record and report and the right way to practice.

Perhaps this bespoke data illustrates most of all the gaps in what it is possible to draw from the SAC about organisational abuse and therefore what needs to be done locally to plug those gaps. A key issue here is the lack of any detailed information in the SAC at safeguarding concerns stage. This needs currently to be collected locally.

SABs might consider what local information is needed. They might support a better shared understanding of organisational abuse as well as promoting a set of indicators of organisational abuse (such as those set out by South Gloucestershire and based on research evidence) and a methodology (such as that set out by Surrey) to facilitate early identification of organisational abuse across partner organisations. 

Cross sector identification of organisational abuse concerns and raising these as such with the local authority, can support the local authority to report these concerns more accurately in the national SAC data. Typically, IT systems in local authorities need to record and report ‘type of abuse’ at concerns stage for data to reflect this accurately as the concern ad enquiry progress. This would support SAB and cross sector understanding of organisational abuse and support governance. Some local authorities do identify organisational abuse sufficiently early on for this to be recorded and then reported in the SAC data. Others do not. The Surrey guidelines for referrers aims to support both early identification and early recording and reporting. 

Safeguarding adults from abuse and neglect is complex. It is not possible or desirable to produce lists that will say definitively what is or is not abuse or neglect. Commonly agreed definitions as set out in the Care Act, 2014 do help however to provide a basis for conversations with the adult and across sectors. They can support dialogue and confidence about the nature and impact of concerns, both with the adult and across organisations. But definitions can constrain and distract from considering individual circumstances.

This short e-leaning resource, developed by Hampshire, Portsmouth, Southampton and Isle of Wight SABs, can help. It provides a learning opportunity for all organisations across the partnerships to introduce what constitutes a safeguarding concern, including definitions and some key underpinning principles Safeguarding Concerns eLearning, Hampshire Safeguarding Adults Board

The Care and Support Statutory Guidance (DHSC,2022 14.17) urges local authorities not to limit their view of abuse. Abuse and neglect ‘can take many forms and the circumstances of the individual case should always be considered.’ The Care Act (2014) does not define the term, it states only that abuse includes financial abuse.

References to harm in protocols and guidance need to be seen in the context of Section 42, Care Act 2014. This is not just about experience of abuse or neglect but also the risk of it.  Harm need not have been suffered. Too much emphasis on harm can preclude attention to prevention and early intervention.

It is unhelpful to use fixed definitions as a ‘passport’ passing the issue on to the local authority with no view to further involvement or contribution. Consideration of a range of dimensions and pathways requires multi-agency engagement from the start. Important dimensions requiring consideration alongside definitions include:

• the circumstances and context of the concern
• any patterns of similar concerns
• insights about the person and their wishes
• hypotheses about what’s behind the concern
• what’s been done or has been considered in terms of next steps.

This detailed approach supports the referrer and the local authority in thinking about a rationale for what gives them ‘reasonable cause to suspect’ that the criteria in S42 (1a and b) are met. The Surrey guidance helps in this as well as guidelines from the South Gloucestershire SAB

Examples of questions to consider in reaching a hypothesis are set out for a range of common scenarios, including when an individual goes missing from a service, a hospital discharge, a fall and so on. This is an evidence based approach, based on the work of Professor Robert Wachter, author of ‘Understanding Patient Safety (2017).  

Another tool from Surrey assists in deciding on pathways for support. SCC Adult Social Care Level of Need toolkit. It prompts thinking not simply about ‘is this abuse or neglect or not?’ but also about the presenting issue and which pathway might best address it.

This is an approach used across several local authority areas and supports a growing school of thought that introducing ‘thresholds’ (which include lists of scenarios which rule people in or out of safeguarding) is best avoided. This was stated clearly in the two frameworks (LGA, 2019 and 2020). It is counter to personalised practice. Many now consider that such tools must only be a guideline offering ‘for instance’ scenarios and promoting discussion.

Confidence in asserting the need for this more detailed approach to definition can be drawn from the evidence base. The need for such a robust approach is borne out in several SARs.

One of these is a SAR commissioned by Merton SAB in respect of SK.  Here, despite concerns being raised, no safeguarding enquiry was pursued and there were repeated missed opportunities to assess need and risk. The report refers to inflexible thresholds and ‘referral bouncing.’ Decisions were made based on assumptions about a ‘lifestyle choice’ regarding alcohol abuse. Self-neglect issues were not recognised, including in the context of a safeguarding concern.

This SAR and others illustrate practice that excludes certain issues from consideration as a safeguarding concern even though a Section 42 Care Act (2014) enquiry would be both indicated and beneficial. Responses and decisions should be based on individual circumstances. Blanket exclusions of specified circumstances are unhelpful and unlawful. These go against the intentions of the Care Act (2014).

Some protocols specifically exclude from safeguarding support for example, situations where there is alcohol abuse, homelessness, self-neglect, suicide. Each situation must be considered on its merit. The SAR relating to Howard (who was homeless) is highlighted in the safeguarding concerns framework and is a further example. The framework illustrates a responsibility to raise a safeguarding concern in this case.

A range of SARs relating to self-neglect illustrate the same practice of applying a blanket exclusion from a safeguarding concern pathway where self-neglect is an issue. A thematic SAR (Manchester Safeguarding Partnership, June 2021) relating to self-neglect highlights the need for partnership working within safeguarding adults protocols to prevent harm and recommends that Care Act compliance should be reviewed across the partnerships. No safeguarding concerns were raised for example, by any of the hospitals despite multiple admissions of individuals.

One of the prominent features in all of the Manchester cases was that a refusal to engage was seen in simplified terms and a reason for practitioners to withdraw rather than be a risk factor in itself.   

The list of types of abuse presented in the Care and Support Statutory Guidance (DHSC, 2022) is not exhaustive nor can definitions stand alone. The Guidance itself suggests looking at patterns and circumstances in which abuse takes place including in paragraph 14.99 where a focus is required on the impact of abuse or neglect on the individual, on the possibility of escalation of risk to this individual or to wider risks, as well as consideration of the responsibility of the person or organisation that may have caused the abuse or neglect.

Summary of key messages and actions to help with the challenges

Tools and approaches have been identified to support progress and confidence in taking action.

• The Care Act applies across sectors. This is a partnership endeavour.
• Stick to what the Care Act says and the Care and Support Statutory Guidance (DHSC, 2022), not what you think or want it to say.
• Think about making safeguarding personal in all aspects of this. Each question raised includes a making safeguarding personal perspective in the response.
• Develop cross sector relationships and collaboration at all levels through dialogue.
• Talk honestly about why partners are hesitant in raising safeguarding concerns and what is to be gained from doing so. Find pragmatic and workable ways forward together.
• Strengthen and support joint working on safeguarding concerns and enquiries by ensuring there are common messages, consistent with the frameworks, in sectors’ frameworks and protocols.
• Test out assumptions and unpick examples of mutual blaming. Evidence what is really happening and consider how this can be addressed. Use audit, data and conversations to do this.
• Organisational abuse is particularly challenging. Have a particular focus on this. Understand the local issues and questions and see whether something developed elsewhere can help. 
  • Think about what helps in considering where the abuse is located. Is it in the organisation or with the individual or both?
  • Support understanding what organisational abuse is and why it matters that this is a significant focus.
  • Think about the statutory duty in relation to organisational abuse
  • Don’t run parallel processes. Make the connections
  • Consider the information and data that are needed for robust governance.Don’t practice or condone blanket exclusions of circumstances, such as self-neglect, alcohol or substance misuse, homelessness or suicide from safeguarding responses.

• Don’t try to define situations precisely so as to put situations neatly ‘in’ or out’ of safeguarding. Work together to understand individual circumstances and to make decisions. 
• Context and patterns and impact matter alongside definitions in supporting understanding and making decisions.
• Do consider the data and think about what else you need to know. Scrutinise and develop local information and use it as a basis for debate and challenge and to inform next development steps.
• Consider the evidence base that demonstrates the worth of working with the safeguarding concerns and enquiries frameworks. this includes evidence from SARs and research. 

Understanding and making decisions about safeguarding concerns and when a safeguarding enquiry should follow is foundational to effective safeguarding. Flow charts in appendix one are replicated from the safeguarding concerns and enquiries frameworks (LGA, 2019 and 2020)

Appendix two highlights a range of SARs that illustrate the importance of getting this right and establishing greater cross sector confidence in asserting what is right.

Governance through SABs and sector leaders should have a clear focus on this.  

Redbridge SAR summary Mr B SAR and Homelessness HSCWRU report 2019 Kieran SAR Report (Swindon) Haringey thematic SAR on issues relating to safeguarding and homelessness (Haringey SAB, March 2021) A Salford SAB SAR regarding (Eric, 2020)

WSAB Thematic Safeguarding Adults Review Regarding People Who Sleep Rough Lewisham SAB SAR Mia VKPP Learning for the police from Safeguarding Adult Reviews Kirklees SAB Adult N SAR Manchester Safeguarding Partnership- self-neglect thematic Salford SAR Eric

WSSAB - Organisational Learning Review in respect of Kingswood Suffolk SAR Maria Wokingham SAR Adam SIO Guide Investigating Deaths and Serious Harm in Healthcare Settings

Wokingham SAR Adam

SAR relating to Howard, Isle of Wight (2018). SAR commissioned by Merton SAB in respect of SK

SAR in relation to Winterbourne View hospital (South Gloucestershire, 2012) WSSAB - Organisational Learning Review in respect of Kingswood SGSAB SAR Nightingale Learning Brief Suffolk SAR Maria

SAR commissioned by Merton SAB in respect of SK A thematic SAR (Manchester Safeguarding Partnership, June 2021) SAR relating to Howard, Isle of Wight (2018)

Flow charts on making decisions about safeguarding concerns and enquiries from the two frameworks (LGA, 2019 and 2020)

What helps?: These SARs reflect issues explored in the frequently raised questions. They provide an evidence base to support confidence in taking forward significant learning.

This framework from the Bexley Safeguarding Adults Board  helps (section five) with an approach to assurance and embedding learning from SARs.