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Lewisham Safeguarding Adults Board

Concerns Stage 1: Guidance for Making Decisions on Adult Safeguarding Enquiries

1. Purpose of this guidance

This guidance has been developed to assist practitioners in assessing the context, seriousness and level of risk associated with an adult Safeguarding Concern, and in doing so, help with the consistency of decision making used to cause a Safeguarding Enquiry to be conducted. It is primarily for use by lead professionals working in the Local Authority at the point of receiving an adult Safeguarding Concern; although others may also find it helpful to refer to this guidance when responding to a concern of abuse or neglect, and deciding if this should be referred to, the Local Authority. If care providers are using this guidance, it is important to note that all Safeguarding Concerns must be notified to the Local Authority.

The guidance is not intended to replace, but support professional judgement, and links to the section in the London Multi-Agency Safeguarding Policy and Procedures which provides the procedural detail in relation to Safeguarding Enquiries (pages 66-78).

2. Legal definitions

The Care Act 2014 statutory guidance and Section 42 (1) criteria states that the Local Authority must make enquiries, or cause others to do so, if they reasonably have cause to suspect an adult:

a. Has needs for care and support (whether or not the local authority is meeting any of those needs) and;

b. Is experiencing, or at risk of, abuse and neglect; and

c. As a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.

Referring agencies need to use their professional judgement, consider the views of the adult at risk, and where appropriate seek consent for sharing information on a multi-agency basis.

See: Advice for Submitting an Adult Safeguarding Concern.

3. Managing the different levels of harm

In order to manage the large volume of adult Safeguarding Concerns which come under safeguarding adults’ policy and procedures, there is a need to differentiate between those concerns relating to low level harm/risk, and those that are more serious. Whilst it is likely that concerns relating to low level harm/risk will not progress beyond an Initial Enquiry Stage, the concern will be recorded by the Local Authority and proportionate action taken to manage the risks that have been identified. This may include: provision of information or advice; referral to another agency or professional; assessment of care and support needs.

The sharing of low level concerns helps the Local Authority to understand any emerging patterns or trends that may need to be taken into consideration when deciding whether safeguarding adults procedures need to continue.

Local Government Association - Making Safeguarding Personal Toolkit

LGA/ADASS Guidance on What Constitutes a Safeguarding Concern - Sept 2020

4. Using this guidance

The guidance is not designed in a way in which further actions are determined by achieving a score, it is there to provide guidance and key considerations for practitioners who are assessing the context, circumstances, seriousness and impact of the abuse that is occurring, as well as the risk of it recurring.

5. Other Safeguarding Enquiry

Other Safeguarding Enquiries can be used when all of the Section 42 (1) criteria have not been met (see section 2), but the Local Authority still considers it "necessary and proportionate" to conduct a safeguarding enquiry. This could be linked to promoting an individual’s well-being as outlined in Section 1 of the Care Act, or for carers who do not qualify under Section 42. More detail on this subject is provided here (Page 7): ADASS Advice Note   

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Safeguarding Principle - Proportionality

What does this mean for the professionals: A proportionate and least intrusive response is made balanced with the level of risk.

What does this for the Adult: "I am confident the professionals will work in my interest and only get involved as much as needed".

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6. The interface between Section 42 Enquiries and Safeguarding Adults Reviews (SAR)

As a matter of law an enquiry under Section 42 cannot be initiated in relation to an adult who is deceased. However, if the circumstances of the death mean that there are reasons to be concerned about risks to other adults, Section 42 Enquiries may need to be made to decide whether action needs to be taken to protect them. For example, this will often be necessary following a death in an organisational setting where other adults are continuing to receive a service.

Where a Section 42 Enquiry has already commenced and the adult subsequently passes away, then as outlined above, the enquiry may need to be concluded if there are potential ongoing risk to other adults. Otherwise a multi-agency decision involving “interested others”, which could include family members, should be made regarding the enquiry potentially being suspended.

Where a death is suspected to be the result of abuse or neglect and the other SAR criteria are met, a SAR notification should be submitted to enable the Lewisham Safeguarding Adults Board (LSAB) to consider this under Section 44 of the Care Act.

See: How to make a SAR Referral to the Lewisham Safeguarding Adults Board

SAR Notifications must be submitted as soon as possible after the adult’s death. It should be noted that a brief investigation may be necessary to assemble the required information for the LSAB's Case Review Sub-Group to make a recommendation as to whether a SAR should take place. This investigation should aim only to gather sufficient information for that purpose, and should not aim to reach firm conclusions about what happened. This investigation should be recorded as an Other Enquiry.

The Care Act statutory guidance also gives examples of serious abuse or neglect cases where an adult “would have been likely to have died but for an intervention, or has suffered permanent harm or has reduced capacity or quality of life (whether because of physical or psychological effects) as a result of the abuse or neglect”. Under these circumstances, Section 42 Enquiries into what happened to that adult will still need to take place in parallel, to ensure the adult’s immediate safety and the safety of any others who may be at risk, but should be limited to those purposes rather than duplicating more thorough investigations into the history which may take place through a SAR.

The Local Authority (or delegated agency) may need to make initial enquiries to consider whether the conditions for a SAR are met, but should not describe these as Section 42 Enquiries. In these circumstances the meeting should be a Safeguarding Information Sharing meeting and logged onto the case management system as an Other Enquiry. Where the suspected abuse or neglect has taken place in an organisational setting, and there may be potential risks to others, the meeting should be an 'Organisational Safeguarding meeting' and consideration should be given to invoking the Provider Concerns Process.

7. Factors to be considered

Contextual Factors

The following table should be used to consider the context of the Safeguarding Concern alongside the broader issues such as: mental capacity; mental health; physical disability; learning disability; communication issues; possible coercive control and the relationship between the victim and any alleged perpetrator; where the victim lives; who do they rely upon for their care; what is the extent of their circle or network of supportive relationships. 

Table 1: Contextual Factors

1.

The Abusive Act

Less Serious                                           More Serious

Less serious concerns are likely to be dealt with at initial enquiry stage only, whilst the more serious concerns will progress to further stages in the safeguarding adults’ procedures.

2.

Seriousness of Abuse

Less Serious                                           More Serious

Refer to table 2. Look at the relevant categories of abuse and use your knowledge of the case and your professional judgement to gauge the seriousness of the concern.

3.

Pattern of Abuse

Isolated incident

Recent abuse in an ongoing relationship

Repeated abuse

The volume of incidents, Safeguarding Concerns and or Quality Alerts about an individual adult, provider or locality should be carefully considered as part of the wider context of potential abuse, but no benchmark number set to automatically trigger an enquiry.

4.

Impact of Abuse on Victims

No impact

Some impact but not long-lasting

Serious long-lasting impact

Impact of abuse does not necessarily correspond to the extent of the abuse –different people will be affected in different ways. Views of the adult at risk will be important in determining the impact of abuse. Protected Characteristics such as disability should be considered as well as disproportionality.

5.

Impact on Others

 

No one else affected

Others indirectly affected

Others directly affected

Other people may be affected by the abuse of another adult. Are relatives, children or other adults distressed or affected by the abuse?

Are other people intimidated and/or their environment affected?

6.

Intent of Alleged Perpetrator(s)

Unintended/ill-informed

Opportunistic

Deliberate/targeted

Is the act/omission a violent/serious unprofessional response to difficulties in providing care? Is the act/omission planned and deliberately malicious? Is the act a breach of a professional code of conduct?

7.

Illegality of Actions

Bad practice/Not illegal

Criminal act

Serious criminal act

Seek advice from the Police if you are unsure if a crime has been committed. Is the act/omission poor or bad practice (but not illegal) or is it clearly a crime? (* See below)

8.

Risk of Repeated Abuse on the Victim

Unlikely to recur

Possible to recur

Likely to recur

Is the abuse less likely to recur with significant changes e.g. training, supervision, respite, support or very likely even if changes are made and/or more support provided?

9.

Risk of Repeated Abuse on Others

Others not at risk

Possibly at risk

Others at serious risk

Are others (adults and/or children) at risk of being abused: Very unlikely? Less likely if significant changes are made? This perpetrator/setting represents a risk/threat to other adults or children?

*See: London Multi-Agency Safeguarding Policy and Procedures (pages 67-68)

7.2 Types and Level of Abuse

The second table should also be used in conjunction with Table 1. The issues described within the ‘Less Serious’ sections may be notified to the Local Authority, but these are likely to be managed at the Initial Enquiry Stage only, and may not progress to a Safeguarding Enquiry. 

Concerns of a more serious nature should be referred to the Local Authority.

See: Advice for Submitting an Adult Safeguarding Concern

These concerns will receive additional scrutiny and progress further under Safeguarding Adults’ procedures. Where a criminal offence is thought or alleged to have been committed the Police will be contacted. Other emergency services should be contacted as required. 

Table 2: Types and Level of Abuse

 

              Less Serious

More Serious

Discriminatory Abuse

  • Isolated incident of teasing motivated by prejudicial attitudes.
  • Isolated incident of care planning that fails to address an adult’s specific diversity/equality associated needs for a short period.
  • Inequitable access to service provision as a result of a diversity or equality issue. The Protected Characteristics are:

1.      Age

2.      Disability (inc. learning disability)

3.      Gender Reassignment

4.      Marriage and Civil Partnership

5.      Pregnancy and Maternity

6.      Race

7.      Religion or Belief

8.      Sex

9.      Sexual Orientation

  • Recurring failure to meet specific care/support needs associated with diversity or equality.
  • Being refused access to essential services.
  • Denial of civil liberties e.g. voting, making a complaint.
  • Humiliation or threats on a regular basis, recurring taunts.
  • Hate crime which may result in injury/emergency medical treatment/fear for life/attempted murder/honour-based violence.

Domestic Abuse

 

  • Isolated incident of abusive nature.
  • Occasional taunts or verbal outbursts

 

 

  • Inexplicable marking or lesions, cuts or grip marks on a number of occasions.
  • Alleged perpetrator exhibits controlling or coercive behaviour.
  • Limited access to medical and dental care.
  • Accumulations of minor incidents.
  • Frequent verbal/physical outbursts.
  • No access/control over finances.
  • Stalking.
  • Relationship characterised by imbalance of power.
  • Threats to kill, attempts to strangle choke or suffocate.

Also see:

Financial Abuse.

Physical Abuse.

Psychological Abuse. 

Sexual Abuse.

The ‘SafeLives’ Domestic Abuse, Stalking and Honour Based Violence (DASH) Risk Identification Checklist should be used to determine the level of risk in domestic abuse cases and a referral made into MARAC where appropriate.

SafeLives Risk Identification Checklist

Financial or Material Abuse

If any of these elements occur within the context of a family or intimate relationship, then this should be dealt with as Domestic Abuse.  

  • Staff personally benefit from the adult’s funds e.g. accrue ‘reward’ points on their own store loyalty cards when shopping.
  • Money not recorded safely and properly.
  • Adult not routinely involved in decisions about how their money is spent or kept safe – capacity in this respect is not properly considered.
  • Non-payment of care fees not impacting on care.
  • Adult’s monies kept in a joint bank account – unclear arrangements for equitable sharing of interest.
  • Adult denied access to his/her own funds or possessions.
  • Misuse/misappropriation of property or possessions of benefits by a person in a position of trust or control.
  • Personal finance removed from the adult’s control.
  • Ongoing non-payment of care fees putting an adult’s care at risk.
  • Fraud/exploitation relating to benefits, income, property or will.
  • Theft (this may include household items such as food).

Modern Slavery

  • All Safeguarding Concerns about Modern Slavery are deemed to be more serious. (A new Lewisham Modern Slavery Protocol will be published in the early summer of 2021).
  • Limited freedom of movement.
  • Being forced to work for little or no payment.
  • Limited or no access to medical and dental care.
  • Forced marriage.
  • Limited access to food or shelter.
  • Be regularly moved (trafficked) to avoid detection or linked to drug dealing - ‘County Lines’.
  • Removal of passport or ID documents.
  • Sexual exploitation.
  • Starvation.
  • Organ harvesting.
  • No control over movement/imprisonment.
  • No access to appropriate benefits.

Neglect & Acts Of Omission

  • Isolated missed home care visit where no harm occurs.
  • Adult is not assisted with a meal/drink on one occasion and no harm occurs.
  • Adult not bathed as often as would like – possible complaint.
  • Not having access to aids to independence.
  • Inadequacies in care provision that lead to discomfort or inconvenience- no harm occurs e.g. being left wet occasionally.  
  • Recurring missed medication or administration errors that cause no harm.
  • Adult does not receive prescribed medication (missed/wrong dose) on one occasion – no harm occurs.
  • Recurrent missed home care visits where risk of harm escalates, or one missed visit where harm occurs.
  • Hospital discharge without adequate planning and harm occurs.
  • Ongoing lack of care to the extent that health and wellbeing deteriorate significantly e.g. pressure wounds, dehydration, malnutrition, loss of independence/confidence.
  • Failure to arrange access to lifesaving services or medical care.
  • Failure to intervene in dangerous situations where the adult lacks the capacity to assess risk.

Pressure Ulcers: Safeguarding Adults Protocol

Stop the Pressure: NHS Improvement

SEL CCG Guidance on Pressure Ulcer Management

Organisational Abuse

  • Lack of stimulation/ opportunities for adults to engage in social and leisure activities.
  • Adults not given sufficient voice or involvement in the running of the service.
  • Denial of individuality and opportunities for adults to make informed choice and take responsible risks.
  • Care-planning documentation not person-centred.
  • Rigid/inflexible routines.
  • Adult’s dignity is undermined e.g. lack of privacy during support with intimate care needs, sharing under-clothing.
  • Inadequate risk assessment resulting in multiple adult on adult incidents within care setting.
  • Bad/poor practice not being reported and going unchecked.
  • Unsafe and unhygienic living environments.
  • Missed medication round resulting in more than one person not receiving their prescribed medication.
  • Staff misusing their position of power over adults in their care.
  • Over-medication and/or inappropriate restraint used to manage behaviour.
  • Widespread consistent ill-treatment.

Physical Abuse

If any of these elements occur within the context of a family or intimate relationship, then this should be dealt with as Domestic Abuse.  

  • Staff error causing little or no harm e.g. friction mark on skin due to ill-fitting hoist sling.
  • Minor events that still meet criteria
  • for ‘incident reporting’ accidents.
  • Single incident - adult on adult in care setting causing little or no harm.
  • Inexplicable marking found on one occasion.
  • Minor event where adult lacks capacity in keeping themselves safe
  • Recurring missed medication or errors that affect more than one adult and/or result in harm.
  • Incident involving adult on adult in care setting where injury occurs.
  • Deliberate maladministration of medications.
  • Covert administration without proper medical authorisation.
  • Inappropriate restraint.
  • Withholding of food, drinks or aids to independence.
  • Inexplicable fractures/injuries.
  • Multiple (more then 2) adult on adult incidents involving the same adult/s in care setting.
  • Accumulations of minor incidents.
  • Inexplicable marking or lesions, cuts or grip marks on a number of occasions.
  • Assault.
  • Grievous bodily harm/assault with a weapon leading to irreversible damage or death.
  • Pattern of recurring medication errors or an incident of deliberate maladministration that results in ill-health or death.

Psychological Abuse

If any of these elements occur within the context of a family or intimate relationship, then this should be dealt with as Domestic Abuse.  

  • Isolated incident where adult is spoken to in a rude or inappropriate way – respect is undermined but no/little distress caused.
  • Occasional taunts or verbal outburst.
  • Withholding of information to disempower.
  • Treatment or behaviour that undermines dignity and esteem.
  • Denying or failing to recognise adult’s choice or opinion.
  • Coercive or controlling behaviour.
  • Humiliation.
  • Emotional blackmail e.g. threats or abandonment/harm.
  • Frequent and frightening verbal outbursts or harassment.
  • Basic human rights/civil liberties, over-riding advance directive.
  • Prolonged intimidation.
  • Vicious/personalised verbal attacks.

Self-Neglect

  • Hoarding behaviour which doesn’t impact on the health and well-being of the adult or others.
  • Isolated/occasional reports about unkempt personal appearance or property which is out of character or unusual for the adult.
  • Incontinence leading to health concerns.

 

  • Multiple reports of concerns from multiple agencies.
  • Ongoing lack of care or behaviour to the extent that health and wellbeing deteriorate significantly e.g. pressure sores, wounds, dehydration, malnutrition.
  • Behaviour which poses a fire risk to the adult and others.
  • Poor management of finances leading to risks to health, wellbeing or property.
  • Hoarding behaviour impacting on the health and well-being of the individual and/or others.
  • Life in danger if intervention is not made in order to protect the adult.
  • Failure to seek lifesaving services or medical care where required.

LSAB Self-Neglect and Hoarding Multi-Agency Policy, Practice Guidance and Hoarding Toolkit (April 2021)

Sexual Abuse (including sexual exploitation)

If any of these elements occur within the context of a family or intimate relationship, then this should be dealt with as Domestic Abuse.  

  • Isolated incident of teasing or low-level unwanted sexualised attention (verbal) directed at one adult by another whether or not capacity exists.

 

  • Any sexualised touching or isolated or recurring masturbation without consent.
  • Voyeurism without consent
  • Being subject to indecent exposure.
  • Grooming including via the internet and social media.
  • Attempted penetration by any means (whether or not it occurs within a relationship) without consent.
  • Being made to look at pornographic material against will/where consent cannot be given.
  • Female Genital mutilation.
  • Sex in a relationship characterised by authority inequality or exploitation e.g. receiving something in return for carrying out a sexual act.
  • Sex without consent (rape).

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