Lewisham Safeguarding Adults Board

Lewisham Adult Safeguarding Pathway

Lewisham Adult Safeguarding Pathway

Lewisham Adult Safeguarding Pathway

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I welcome wholeheartedly the introduction of the Adult Safeguarding Pathway in Lewisham. Safeguarding Adult Reviews in Lewisham and nationally regularly highlight missed opportunities to refer adult Safeguarding Concerns and to conduct adult Safeguarding Enquiries. The Lewisham Pathway provides comprehensive guidance for all those working in and around adult safeguarding. It offers a framework for the prevention of abuse and neglect, including self-neglect, and for protecting individuals who have experienced and or are at risk of abuse and neglect.

The Pathway has been informed by, and indeed references good practice guidance that has been published by the Local Government Association in partnership with the Association of Directors of Social Services. The Lewisham Pathway therefore encapsulates the best evidence available for effective adult safeguarding. Accordingly, I hope that every agency in Lewisham will disseminate the pathway documentation as widely as possible, and add their details to the register so that the Lewisham Safeguarding Adults Board can begin to track implementation.

I would like to thank everyone who has contributed to the development of the Pathway. It forms such an important component of the jigsaw of policies, procedures, practice and services that are designed to keep people safe.

Professor Michael Preston-Shoot                                                                                                                                Independent Chair                                                                                                                                                                  Lewisham Safeguarding Adults Board 

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In this section of the website you will find all the local guidance, tools and forms you need to raise an Adult Safeguarding Concern, and for relevant practitioners to conduct an Adult Safeguarding Enquiry.

This supports each of the four stages outlined in the London Multi-Agency Adult Safeguarding Policy and Procedures.

Concerns Stage 1: Advice for Submitting an Adult Safeguarding Concern 

1. You need to recognise if what you are seeing or hearing is potential abuse or neglect

There are many forms and ways that adult abuse and neglect can occur, so we should not be constrained by definitions and terminologies. Adult abuse is also often complex involving more than one type of abuse occurring at any one time.

However, the most common forms of abuse are:    

Physical Abuse – including assault, hitting, slapping, pushing, misuse of medication, restraint or inappropriate physical sanctions.

Domestic Abuse – including psychological, physical, sexual, financial, emotional abuse; so called ‘honour’ based violence (the definition for Domestic Abuse will change once the Domestic Abuse Act 2021 is implemented). Domestic Abuse and Older People – Information from Safe Lives

Also see this free online training for Female Genital Mutilation and Forced Marriage: Virtual College

Sexual Abuse – including rape, indecent exposure, sexual harassment, inappropriate looking or touching, sexual teasing or innuendo, sexual photography.

Psychological Abuse – including emotional abuse, threats of harm or abandonment, deprivation of contact, humiliation or blaming.

Financial or Material Abuse – including theft, fraud, internet scamming, coercion in relation to an adult’s financial affairs or arrangements.

Modern Slavery – encompasses slavery, human trafficking, forced labour and domestic servitude. (A new Lewisham Modern Slavery Protocol will be published in the early summer of 2021).

Discriminatory Abuse – including forms of harassment, slurs or similar treatment because of race, gender and gender identity, age, disability, sexual orientation or religion.

Organisational Abuse – including neglect and poor care practice within and 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.

Neglect and Acts of Omission – including ignoring medical, emotional or physical care needs, failure to provide access to appropriate health, care and support or educational services, the withholding of the necessities of life, such as medication, adequate nutrition and heating.

Refer to:

Pressure Ulcers: Safeguarding Adults Protocol

Stop the Pressure: NHS Improvement

SEL CCG Guidance on Pressure Ulcer Management

Self-Neglect – this covers a wide range of behaviour neglecting to care for one’s personal hygiene, health or surroundings and includes behaviour such as hoarding. See: LSAB Self-Neglect and Hoarding Multi-Agency Policy, Practice Guidance and Hoarding Toolkit (April 2021)

More detailed information on this subject can be found here: Forms and Signs of Abuse

2. Talk to the adult (unless it is not safe to do so)

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Safeguarding Principle - Protection

What does this means for the professionals: Adults are offered ways to protect themselves, and there is a co-ordinated response to adult safeguarding.

What does this means for the adult: "I am provided with help and support to report abuse. I am supported to take part in the safeguarding process to the extent to which I want and which I am able".

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2.1 If the adult does not wish to report the abuse: Are they in immediate danger or risk of serious harm?

Has a crime been committed? If so, and the adult is in immediate danger or risk of serious harm, then this should be reported to the Police immediately. Help to keep the adult safe until the Police respond. The adult does not need to give their consent under these circumstances due to ‘vital interest’ considerations (immediate danger or risk of serious harm).

How to Report Your Concerns About an Adult

Are others, including children in immediate danger or risk of serious harm? If so, then this should be reported to Police immediately, and consideration also give to reporting this to Children’s Services. Help to keep the child safe until the Police respond. The adult(s) does not need to give their consent under these circumstances due to ‘public interest’ considerations (others, including children are in immediate danger or risk of serious harm). 

How to Report Your Concerns About a Child

Safeguarding and promoting the welfare of children and adults most at risk of abuse and neglect is a shared responsibility. The ‘Think Family’ approach should be used by all practitioners who should consider the needs of the whole family, including young carers, taking into account family circumstances and responsibilities. Existing professional relationships should be viewed as a chance to identify risk, refer to colleagues in other services, and to use targeted support to help prevent problems from escalating and therefore potentially limiting harm. Refer to the: Lewisham Think Family Protocol

2.2 Consider if this matter meets the Section 42 (1) criteria within the Care Act 2014 as a Safeguarding Concern: 

a. do I have reasonable cause to suspect that the adult has needs for care and support; and

b.do I have reasonable cause to suspect that the adult is at risk, or, experiencing abuse or neglect. 

It must be noted that the third criteria (c) under the legal duty for a Section 42 Enquiry (1) is not relevant at the Concern stage: 

c. as a result of those needs is unable to protect himself or herself against the abuse or neglect or the risk of it. 

SCIE: Assessment and Eligibility Outcomes (Care & Support Needs)

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

If this is not a crime and these criteria appear to have been met, then speak to the adult to get their views on the Safeguarding Concern or the incident. It is always best to support the adult in reporting abuse themselves. Find out what they want to happen next. 

If a decision is made not to refer to the Local Authority the individual agency must make a record of the concern and any action taken. Concerns should be recorded in such a way that repeated, low level harm incidents are easily identified and subsequently referred. 

Not referring under safeguarding adults’ procedures does not negate the need to report internally or to regulators/commissioners as required, and if care providers are using this guidance, it is important to note that all Safeguarding Concerns must be notified to the Local Authority. 

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Safeguarding Principle - Empowerment

What does this mean for the professionals: Adults are encouraged to make their own decisions and are provided with information and support.

What does this mean for the adult: "I am consulted about the outcomes I want from the safeguarding process and these directly inform what happens".…………………………………………………………………………………………………………………………...............................

If this criteria does not appear to have been met, but you are unsure, then you must seek further advice including from the Local Authority. How to Report Your Concerns About an Adult

If you are certain that this criteria has not been met, then consider what other pathways, options or services could be used to help support this adult, including providing relevant information? Record your decision-making in relation to this subject in an appropriate manner.

3. Seek the adult’s consent to submit a Safeguarding Concern to the Local Authority

Seek the adult’s consent to submit the Safeguarding Concern and explain this may mean that several agencies may gain access to their personal details:     

  • Read the The Eight Caldicott Principles (updated from seven in December 2020).
  • Does the adult have the mental capacity to consent to the Safeguarding Concern being submitted now?
  • Is there any possibility that the adult has/ is suffering from any type of coercion, control, threat, duress or pressure from another person(s) which may mean they refuse consent?
  • Does mental capacity (including executive capacity) need to be assessed or reviewed? For more information read: Decision Making and Mental Capacity (NICE Guidelines)
  • Give due regard to the adult’s views and wishes, including their desired outcomes, even if Best Interest Decisions have been made linked to the Mental Capacity Act. For more information read: Local Government Association - Making Safeguarding Personal Toolkit including on the six Safeguarding Principles.
  • If the adult does have the mental capacity to consent to the Safeguarding Concern being submitted, but refuses, professionals must be careful that they consider how to keep the adult safe if they continue to submit the concern. This may be particularly relevant in domestic abuse cases. The adult must be informed that a Safeguarding Concern has been submitted, unless it is unsafe or impractical to do so.
  • A Safeguarding Concern can still be submitted without the adult’s consent if ‘vital’ or ‘public’ interest considerations apply (see 2.1 above). For more information read: LGA/ADASS Guidance on What Constitutes a Safeguarding Concern - Sept 2020

4. Gather as much information as possible

Having spoken to the adult (as above) and determined their views, wishes and desired outcomes. Also gather as much information as possible from other relevant sources and documentation:

  • Does anyone else need to be informed or involved, including the nominated safeguarding lead in your agency, before progressing to submitting a Safeguarding Concern?
  • Are there any other internal policy or procedural requirements within your agency?
  • If you unhappy about how your organisation is dealing with a Safeguarding Concern do you know how to escalate this, which could include the use of a Whistleblowing Policy?

Help to keep the adult safe until the Local Authority respond.

Professionals should read the London Multi-Agency Safeguarding Policy and Procedures (pages 61-66) for further information on this subject, using the checklists and good practice guidance that is provided.

5. Submit the Adult Safeguarding Concern 

  • Ensure all of the relevant fields in the Safeguarding Concern Form are fully completed with as much detail as possible, and submitted correctly using the contact details outlined in the link below. The Safeguarding Concern Form is also included on the weblink below.
  • You should receive receipt of this and be kept informed of progress.
  • If you do not receive any feedback on progress you should follow this up with the Local Authority involving your organisational lead if required, and in exceptional circumstances this can also be escalated to the Lewisham Safeguarding Adults Board to consider.

How to Report Your Concerns About an Adult

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).

Enquiry Stage 2: Advice for Conducting an Adult Safeguarding Enquiry

1. The decision-making process

The Multi-Agency Adult Safeguarding Concern Form has been designed to provide all of the detailed and necessary information to allow colleagues in the Local Authority to effectively make a decision on if a Safeguarding Concern needs to progress to a Section 42 (or Other Enquiry) under the Local Authorities duty to do so within the Care Act 2014.

Please also refer to: Guidance for Making Decisions on Adult Safeguarding Enquiries

All of this Safeguarding data will be collated within the Local Authorities case management system (as the lead agency in the Borough) so that there is a central source of information and intelligence, which will allow this to be carefully monitored and assessed.         

2. Enquiry routes

Once a decision is made that a Safeguarding Enquiry must be conducted under the Section 42 duty, the relevant team within the Local Authority will decide who is best placed to conduct this, directing it through one of the four strands (2.1 to 2.4) outlined below. When this is delegated outside of the Local Authority they will still retain the overall responsibility to co-ordinate the enquiry as the lead agency, and as such they will provide the quality assurance and oversight in relation to all Safeguarding Enquiries.

See: S42 Enquiry Report Template (Pdf)    S42 Enquiry Report Template (Word Version)

Professionals should also read the London Multi-Agency Safeguarding Policy and Procedures (pages 66-78) for further information on conducting Adult Safeguarding Enquiries, using the checklists and detailed good practice guidance (target timescales are the bottom of this page). 

2.1 Police investigation

If a Safeguarding Concern has been submitted to the Local Authority and it is identified that an element, or all of this Concern may be linked to criminal activity, then the early involvement of police is essential. Police investigations should be coordinated by the local police MaSH team who may also support other parallel actions or enquiry options, but this should always be police led.   

See pages 67-68 of the London Multi-Agency Safeguarding Policy and Procedures for more information.

2.2 Standard delegation within the London Borough of Lewisham (LBL) Council

All social work staff within LBL can have Safeguarding Enquiries delegated to them, normally through one of the following four main strands:

  1. Neighbourhood Teams 1-4.
  2. Safeguarding and Quality Assurance Team.
  3. Hospital Social Work Team (University Hospital of Lewisham).
  4. Mental Health Social Work Team within South London and Maudsley (SLaM) NHS Trust.

There is a need for supervision and co-ordination of enquiries by Safeguarding Adults Managers (SAMs). 

See pages 57-58 of the London Multi-Agency Safeguarding Policy and Procedures for more information.

2.3 External delegation

Safeguarding Enquiries or elements of them may also be routinely delegated outside of LBL to the following partners:

  1. Lewisham and Greenwich NHS Trust (LGT) Safeguarding Team, who may then sub-delegate across their internal divisions, including to the District Nursing Service.
  2. South London and Maudsley NHS Foundation Trust (SLaM).
  3. South East London (SEL) Clinical Commissioning Group (CCG). 
  4. Care and Nursing Homes.
  5. Home Care Providers.
  6. GP Practices.
  7. Other Service Providers.

See: Causing S.42 Enquiries Letter Template (Word)

SAMs will also need to supervise and co-ordination these enquiries.

2.4 Referrals to Pressure Ulcer Panels (PUPs)

Potential Safeguarding Concerns linked to pressure ulcers can be challenging as it needs to be determined if this has been caused by poor quality care or evidence of neglect or omissions in care provision. This can occur due to other associated factors and may require input from a professional for clinical judgements to be considered:

 The person’s physical and mental health.

  • Multiple co-morbidities.
  • State of overall skin condition of the person.
  • Indicators of neglect of care provision in relation to hygiene and/or repositioning.
  • Evidence of ineffective continence management.
  • Evidence of ineffective nutritional and fluid management.
  • Ineffective Pain management.
  • Evidence of completed and accurate proactive risk and wound assessments and subsequent care planning.
  • Accurate monitoring and recording in all documentation.
  • The views of the service user, family and friends on treatment and care are recorded.
  • Capacity and level of engagement of service users and others.
  • Evidence of appropriate and timely referrals to members of multidisciplinary team
  • Views of others including professionals.

See: SEL CCG Guidance on Pressure Ulcer Management 

While Pressure Ulcers are a risk for people who are frail and not able to move easily, with good management and care these can be prevented. If an adult at risk has a pressure ulcer this should not been as a reason to automatically suspect abuse or neglect, although this should be carefully considered, and a Safeguarding Concern must always be submitted for a stage 3, 4, Unstageable, Deep Tissue Injury and Medical Device pressure ulcers.

If a Safeguarding Concern has been submitted for a pressure ulcer related matter the Local Authority  will pass this case onto the relevant Pressure Ulcer Panel (PUP) to oversee the initial investigation:

  • The Community PUP - overseen by the South East London Clinical Commissioning Group. (Care Home Only)
  • The Acute Trust’s PUP - overseen by Lewisham and Greenwich NHS Trust. (Trust Acute and Community Service)

Health professionals will then inform the safeguarding process by conducting a Pressure Ulcer Synopsis and Root Cause Analysis (RCA) and submit the relevant reports to the appropriate PUP.

If the pressure ulcer amounts to the wilful neglect of an individual who lacks mental capacity, a crime under section 44 of the Mental Capacity Act 2005 may have occurred, and in these instances the police will be informed.

SAM’s should engage with the PUP’s to gain understanding of process and decision making of PUP professionals, alongside assisting to co-ordinate any other elements of the safeguarding enquiry if there is another aspect to this.

The PUP’s will attempt to conclude their investigation within 28 days, but this may not always be possible. Once the PUP’s have decided no further investigation by panel is required, the enquiry is closed to the panel and an action plan process is implemented. The SAM should then co-ordinate any further actions up to the point of the enquiry being closed overall.

3. Professional Curiosity and Critical Evaluation

Professional Curiosity is the capacity and communication skill to explore and understand what is happening within a family (or an organisational setting) rather than making assumptions, accepting things at face value, or allowing your personal values or possible unconscious bias to influence the way that that you see and interpret risk. 

This has been described as the need for practitioners to practice ‘respectful uncertainty’ in applying Critical Evaluation to any information they receive, or ‘thinking the unthinkable’.

Watch this YouTube Video: The journey from reflection towards reflexivity (relevant for all practitioners)

The following factors highlight the need to improve professional curiosity:

  • The views and feelings of some adults can be very difficult to ascertain.
  • Practitioners do not always listen to adults who try to speak on behalf of another adult and who may have important information to contribute.
  • Carers can prevent practitioners from seeing and listening to an adult.
  • Practitioners can be misinformed with stories they want to believe are true.
  • Effective multi-agency work needs to be coordinated.
  • Challenging carers and other professionals requires expertise, confidence, time and a considerable amount of emotional energy.

 The key to effective safeguarding practice is to ask the right questions, including: 

  1. Would I live here, and if not, why not?
  2. Would I be happy with this standard of care for a member of my family?
  3. What does good look like?
  4. Is there anything else going on in this person’s life which might be causing harm, or the potential for adult abuse or neglect?

3.1 Barriers to professional curiosity

It is important to note that when a lack of professional curiosity is cited as a factor in any safeguarding enquiry or review that  this does not automatically mean that blame should be apportioned. It is widely recognised that there are many barriers to being professionally curious, some of which are set out below:

The ‘rule of optimism’.
Risk enablement is about a strengths-based approach, but this does not mean that new or escalating risks should not be treated seriously. The ‘rule of optimism’ is a well-known dynamic in which professionals can tend to rationalise away new or escalating risks despite clear evidence to the contrary.

Accumulating risk – seeing the whole picture.
Reviews repeatedly demonstrate that professionals tend to respond to each situation or new risk discretely, rather than assessing the new information within the context of the whole person, or looking at the cumulative effect of a series of incidents and information.

Normalisation.
This refers to social processes through which ideas and actions come to be seen as 'normal' and become taken-for-granted or 'natural' in everyday life. Because they are seen as ‘normal’ they cease to be questioned and are therefore not recognised as potential risks or assessed as such.

Professional deference.
Workers who have most contact with the individual are in a good position to recognise when the risks to the person are escalating. However, there can be a tendency to defer to the opinion of a ‘higher status’ professional who has limited contact with the person but who views the risk as less significant. Be confident in your own judgement and always outline your observations and concerns to other professionals, be courageous and challenge their opinion of risk if it varies from your own. Escalate ongoing concerns through your manager and by using more formal procedures if necessary.

Confirmation bias.
This is when we look for evidence that supports or confirms our pre-held view, and ignores contrary information that refutes them. It occurs when we filter out potentially useful facts and opinions that don't coincide with our preconceived ideas.

‘Knowing but not knowing’.
This is about having a sense that something is not right but not knowing exactly what, so it is difficult to grasp the problem and take action.

Confidence in managing tension.
Disagreement, disruption and aggression from families or others, can undermine confidence and divert meetings away from topics the practitioner wants to explore and back to the family’s own agenda.

Dealing with uncertainty.
Contested accounts, vague or retracted disclosures, deception and inconclusive medical evidence are common in safeguarding practice. Practitioners are often presented with concerns which are impossible to substantiate. In such situations, ‘there is a temptation to discount concerns that cannot be proved’. A person-centred approach requires practitioners to remain mindful of the original concern and be professionally curious:

  • ‘Unsubstantiated’ concerns and inconclusive medical evidence should not lead to case closure without further assessment.
  • Retracted allegations still need to be investigated wherever possible.
  • The use of risk assessment tools can reduce uncertainty, but they are not a substitute for professional judgement, and results need to be collated with observations and other sources of information.
  • Social care practitioners are responsible for triangulating information such as, seeking independent confirmation of information, and weighing up information from a range of practitioners, particularly when there are differing accounts, and considering different theories/ research to understand the situation.

Other barriers to professional curiosity.
Poor supervision, complexity and pressure of work, changes of case worker leading to repeatedly ‘starting again’ in casework, closing cases too quickly, fixed thinking/preconceived ideas and values, and a lack of openness to new knowledge are also barriers to a professionally curious approach.

3.2 Disguised Compliance

Disguised Compliance involves carers giving the appearance of co-operating with agencies to avoid raising suspicions and allay concerns.

There is a continuum of behaviours from carers on a sliding scale, with full co-operation at one end of the scale, and planned and effective resistance at the other. Showing your best side or ‘saving face’ may be viewed as ‘normal’ behaviour and therefore we can expect a degree of Disguised Compliance in all families; but at its worst superficial cooperation may be to conceal deliberate abuse, and professionals can sometimes delay or avoid interventions due to Disguised Compliance.

The following principles will help front line practitioner’s deal with Disguised Compliance more effectively:

  • Focus on the needs, voice and lived experience of the adult.
  • Avoid being encouraged to focus too extensively on the needs and presentation of the carers, whether aggressive, argumentative or apparently compliant.
  • Think carefully about the engagement of the carers and the impact of this behaviour on the practitioner’s view of risk.
  • Focus on change in the family dynamic and the impact this will have on the life and well-being of the adult. This is a more reliable measure than the agreement of carers in the professionals plan.
  • There is some evidence that an empathetic approach by professionals may result in an increased level of trust and a more open family response leading to greater disclosure by adults.
  • Practitioners need to build close partnership style relationships with families whilst being constantly aware of the adult’s needs and the degree to which they are met.
  • There is no magic way of spotting Disguised Compliance other than the discrepancy between a carer’s account and observations of the needs and account of the adult. The latter must always take precedent.
  • Practitioners should aim to ‘triangulate’ and cross-reference the information they have received to confirm or refute the facts that have been presented.

3.3 Professional Challenge - having different perspectives

Having different professional perspectives within safeguarding practice is a sign of healthy and well-functioning inter-agency partnerships. These differences of opinion are usually resolved by discussion and negotiation between the practitioners concerned, but it is essential that they do not adversely affect outcomes for adults and are resolved in a constructive manner.

If you have a difference of opinion with another practitioner, remember:

  • Professional differences and disagreements can help find better ways to improve outcomes for adults and families.
  • All professionals are responsible for their own actions in relation to case work.
  • Differences and disagreements should be resolved as simply and quickly as possible, in the first instance by individual practitioners and /or their line managers.
  • All practitioners should respect the views of others whatever the level of experience – remember that challenging more senior or experienced practitioners can be hard.
  • Expect to be challenged; working together effectively depends on an open approach and honest relationships between agencies and professionals.
  • Differences are reduced by clarity about roles and responsibilities, the ability to discuss and share problems, and by effectively networking.

3.4 Cultural Competence

Culturally competent safeguarding practice is essential in achieving the right outcomes, and for improving the well-being of adults from Black, Asian and Minority Ethnic (BAME) communities.

Lack of cultural awareness among practitioners can impact on their ability to effectively work with and support adults, and therefore deal with abuse and neglect appropriately. This can also result in poor practice or interventions, which in turn can reduce trust in statutory agencies and create barriers for engagement with and from minority ethnic communities.   

It is important therefore that practitioners are sensitive to differing family patterns and lifestyles that vary across different racial, ethnic and cultural groups. At the same time they must be clear that abuse or neglect cannot be condoned for religious or cultural reasons.

All practitioners working with adults at risk and their carers whose faith, culture, nationality and recent history differs significantly from that of the majority culture, must be professionally curious and take personal responsibility for informing their work with sufficient knowledge (or seeking advice) on the particular culture and/or faith by which the adult and their family or carers live their daily lives.

Practitioners should be curious about situations or information arising in the course of their work, allowing the family to give their account as well as researching such things by discussion with other practitioners, or by researching the evidence base. Examples of this might be around attitudes towards, and acceptance of, services e.g. health and dietary choices.

In some instances reluctance to access support stems from a desire to keep family life private. In many communities there is a prevalent fear that social work practitioners will negatively interfere, and there may be a poor view of support services arising from initial contact through the immigration system, and, for some communities – particularly those with insecure immigration status – an instinctive distrust of the state arising from experiences in their country of origin.

Practitioners must take personal responsibility for utilising specialist services. Knowing about and using services available locally to provide relevant cultural and faith-related input to prevention, support and rehabilitation services for adults (and their family) will help support practice.

This includes:

  • Knowing which agencies are available to access locally (and nationally).
  • Having contact details to hand.
  • Timing requests for expert support and information appropriately to ensure that assessments, care planning and review are sound and holistic.

Often for BAME communities, accessing appropriate services is a consistent barrier to them fully participating in society, increasing their exclusion and potential for victimisation.

4. The Challenge of Engagement and Self-Neglect

Only 5% of Section 42 Enquiries are related to Self-Neglect in Lewisham, but professionals must understand the significance of these complex cases as almost half of all Safeguarding Adults Reviews, and therefore some of the most serious cases of abuse nationally, are related to this subject.

When an adult is self-neglecting, relationship based work becomes crucial and having one worker as a single point of contact may be beneficial.

Using the label “hard to engage” is damaging and may result in other professionals believing there is little point in attempting to do so, and therefore should be avoided (“seldom heard” may be a more appropriate term).

Practitioners should work together if one is struggling to achieve meaningful engagement with the adult, as another may still be able to take the lead on behalf of an Enquiry Officer in managing and monitoring risk.

Practitioners should also consider the following in helping to improve engagement with adults:

  1. Creative, flexible and imaginative ways to communicate with adults, including working with faith, community leaders and non-safeguarding practitioners to achieve the best outcomes.
  2. Producing information in a number of ways to meet individual needs.
  3. Involving family members appropriately to help support adults.
  4. The use of advocacy to engage with adults.
  5. Training staff to enable and improve engagement with adults.

See: LSAB Self-Neglect and Hoarding Multi-Agency Policy, Practice Guidance and Hoarding Toolkit

5. Making Safeguarding Personal during a Safeguarding Enquiry

Making Safeguarding Personal (MSP) is an initiative which aims to develop a person centred and outcomes focus to safeguarding work in supporting people to improve or resolve their circumstances.

 What MSP Seeks to achieve: 

  1. A personalised approach enabling safeguarding to be done with and not to people, using practical methods defined by the adults individual needs rather than those of the organisation.
  2. The outcomes an adult wants, by determining these at the beginning of working with them, and ascertaining if those outcomes were realised at the end.
  3. Improvement to people’s circumstances rather than on ‘investigation and conclusion’.
  4. Utilisation of person-centred practice rather than ‘putting people through a process’.
  5. Good outcomes for people by working with them in a timely way, rather than one constrained by timescales.
  6. Improved practice by supporting a range of methods for staff learning and development.
  7. Learning through sharing good practice.
  8. Further development of recording systems in order to understand what works well.
  9. Broader cultural change and commitment within organisations, to enable practitioners, families, teams and the Lewisham Safeguarding Adults Board to know what difference has been made. 

Also see: Supporting people living with Dementia to be involved in adult Safeguarding Enquiries (March 2021)

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Safeguarding Principle - Empowerment

What does this mean for the professionals: Adults are encouraged to make their own decisions and are provided with support and information.

What does this mean for the adult: "I am consulted about the outcomes I want from the safeguarding process and these directly inform what happens". ……………………………………………………………………………………………………………………………………………

Local Government Association - Making Safeguarding Personal Toolkit

Plan & Review Stage 3: Multi-Agency Adult Safeguarding Planning Meeting Guidance

1. What is the purpose of a Multi-Agency Adult Safeguarding Planning Meeting?

The overarching purpose of a Multi-Agency Adult Safeguarding Planning Meeting is to bring together all of the relevant stakeholders, so that information and intelligence can be shared to determine what the appropriate actions should be to “sufficiently reduce, or remove the risk to the adult” (although it may also be appropriate for this to 'remain' in some circumstances).

This is a shift in terminology and emphasis away from trying to 'substantiate' reports of abuse, which can become combative between professionals and agencies, detracting from the efforts to improve the adult's wellbeing and safety.  

See: Multi-Agency Adult Safeguarding Planning Meeting Form (Word)   Multi-Agency Adult Safeguarding Planning Meeting Form (Pdf)

2. When might a Multi-Agency Adult Safeguarding Planning Meeting be needed?

A Planning Meeting may not be necessary in relation to all Section 42 Safeguarding Enquiries, but the following points should be used to help determine if one is required:

  1. Where the health and safety of the adult is, or maybe compromised, and a detailed (or initial) safeguarding plan is required.
  2. Where there have been previous Safeguarding Concerns and the issues have been repeated, and or, the risks are more acute than previously thought.
  3. Where multiple agencies (including providers) are needed in providing support and or protection, and there is a need to co-ordinate actions.
  4. In organisational or institutional cases where other adults are at risk of abuse or neglect. This may include where issues have affected residents of other Local Authorities.
  5. Where the abuse involved a member of staff/volunteer (position of trust), and this brings into question the safety of other adults, and or the service.
  6. Where there is the potential for parallel or overlapping criminal investigations by Police. In some instances a Planning Meeting may be required at short notice (1 day) following on from the initial Safeguarding Enquiries, if the issues identified place the adult at significant risk of harm, otherwise this should be arranged within 5 working days of a decision being made that one is necessary. With this in mind the following points made under each of the six Safeguarding Principles should be followed to ensure that Planning Meetings are utilised effectively and consistently. The objectives of a Safeguarding Enquiry are laid out on page 70 of the London Multi-Agency Safeguarding Policy and Procedures 

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Safeguarding Principle - Empowerment

What does this mean for the professionals: Adults are encouraged to make their own decisions and are provided with support and information.

What does this mean for the adult: "I am consulted about the outcomes I want from the safeguarding process and these directly inform what happens".……………………………………………………………………………………………………………………………………………

The practitioner who is setting up and chairing a Planning Meeting (see section 3) must ensure that the adult’s views, wishes and opinions are effectively represented, and conduct the meeting in an appropriate manner, using appropriate adaptations if required, allowing for the full participation of the adult and or their representative(s).    

2.1 If the adult does wish to attend the following points must be born in mind:

  • The adult can bring someone to support them at the meeting. This might be a family member, friend or an Advocate (see section 3.2 of the London Multi-Agency Safeguarding Policy and Procedures), and or a legal representative.
  • The meeting is about the adult and their views and wishes. The Chair of the meeting must ensure these are heard and listened to by everyone else.
  • The meeting may need to decide what actions need to be taken, and by who, to make the adult safer and improve their wellbeing. This will be a group decision and the adult’s views will form part of this decision.
  • A Safeguarding Plan may be agreed - this is about how the adult wants to be supported to be safe. Decisions about the adult’s welfare or care will need to be agreed with them.
  • If the adult has been assessed as not having mental capacity to make a particular decision at that time, then it will need to be made in their ‘best interests’, and their views, wishes, feelings and beliefs must still be taken into account. Such decisions must be made in line with the Mental Capacity Act 2005 (Mental capacity should be carefully considered during every safeguarding enquiry- see section 3.1 of the London Multi-Agency Safeguarding Policy and Procedures).

 2.2 If the adult does not wish to attend they may:

  • Give their views in writing, or
  • Ask someone to attend on their behalf, for example an advocate, friend or family member, or
  • Ask the Safeguarding worker or Safeguarding Adults Manager to pass on their views.

 Local Government Association - Making Safeguarding Personal Toolkit  ………………………………………………………………………………………………………………………………………….

Safeguarding Principle - Prevention 

What does this mean for the professionals: Strategies are developed to prevent abuse and neglect that promotes resilience and self-determination.

What does this mean for the adult: "I am provided with easily understood information about what abuse is, how to recognise the signs and what I can do to seek help". ……………………………………………………………………………………………………………………………………………

2.3 The Planning Meeting should consider:

  • The longer-term ongoing support the adult will need.
  • What learning can be shared across agencies to help prevent further re-occurrences. This is also linked to Section 44 of the Care Act 2014 - if the criteria for a Safeguarding Adults Review (SAR) is met.
  • If a referral to the Provider Concerns Process should be made (see sections 5.7 & 5.8 of the London Multi-Agency Safeguarding Policy and Procedures)
  • What training or education is needed to help prevent further re-occurrences of abuse.
  • How information should be recorded and shared in line with the data protection legislation to help prevent further instances of abuse (see section 2.39 of the London Multi-Agency Safeguarding Policy and Procedures

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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 mean for the adult: "I am confident professionals will work in my interest and only get involved as much as needed".

……………………………………………………………………………………………………………………………………………

  • If the abuse or neglect is unintentional and has arisen because an informal carer is struggling to care for another person. An assessment of both the carer and the adult must be considered in relation to wellbeing principles and duties. 

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Safeguarding Principle - Protection 

What does this mean for the professionals: Adults are offered ways to protect themselves, and there is a co-ordinated response to safeguarding.

What does this mean for the adult: "I am provided with help and support to report abuse. I am supported to take part to the extent to which I want and to which I am able". ……………………………………………………………………………………………………………………………………………

  • The details of the Safeguarding Concern and how this places the adult at risk of abuse or neglect.
  • That there is clarity about the type of abuse that has occurred and that this is recorded effectively, considering types of abuse that are particularly under-recorded:
    • Organisational Abuse
    • Discriminatory Abuse
    • Modern Slavery
    • Domestic Abuse.
  • If an enquiry does take place, that an appropriate risk assessment of the available information is conducted that informs decisions regarding how the investigation will be undertaken, by whom, and by when.
  • How a Safeguarding Plan will be delivered to reduce or remove the risk of harm to the adult, and or others.
  • Any potential risks to children and young people (or other adults at risk) and agreement on who will arrange a Child Protection referral, where necessary. Refer to the: Lewisham Think Family Protocol
  • The link with other key processes and procedures e.g. personnel issues (including referrals to the Disclosure and Barring Service or a professional or regulatory body); Police investigations; other regulatory processes such as a NHS Serious Incident, and the link to Pressure Ulcer Panels (see section 6).

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Safeguarding Principle - Partnerships 

What does this mean for the professionals: Local solutions through services working together within their communities.

What does this mean for the adult: "I am confident that information will be appropriately shared in a way that takes into account its personal and sensitive nature. I am confident that agencies will work together to find the most effective responses for my own situation".

……………………………………………………………………………………………………………………...……………………

  • How everyone involved in the enquiry will deliver the actions that are agreed as a result of the investigation in a manner consistent with Making Safeguarding Personal principles (MSP) and that the adult’s views and wishes are achieved as agreed. 

Local Government Association - Making Safeguarding Personal Toolkit

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Safeguarding Principle - Accountability

What does this mean for the professionals: Accountability and transparency in delivering a safeguarding response.

What does this mean for the adult: "I am clear about the roles and responsibilities of all those involved in the solution to the problem".

………………………………………………………………………………………………………………………………………………….

  • That arrangements are in place to give feedback to the person raising the Safeguarding Concern if they are not in attendance at the Planning Meeting.
  • How partners are going to monitor and measure the delivery of the agreed actions with MSP in mind.
  • Issues relating to inequalities and or potential discrimination are identified and taken account of.

3. Who can convene a Multi-Agency Adult Safeguarding Planning Meeting?

An Enquiry Officer or a Safeguarding Adults Manager from the London Borough of Lewisham (LBL) can convene a Multi-Agency Adult Safeguarding Planning Meeting.   

4. Who should attend a Multi-Agency Adult Safeguarding Planning Meeting?

There are a wide range of people who may be required to attend a Planning Meeting, including, but not limited to:

  1. The adult and or their representative (see 2.1).
  2. The Safeguarding Adults Manager or their equivalent.
  3. The Safeguarding Enquiry Officer.
  4. The person who raised the Safeguarding Concern (if they are a professional).
  5. Police manager.
  6. Other criminal justice agencies.
  7. NHS Trust manager and or relevant specialist.
  8. GP
  9. Care Quality Commission.
  10. Care Provider agency manager.
  11. Relevant LBL and or South East London (SEL) Clinical Commissioning Group (CCG) Commissioner.
  12. Quality Assurance or Contracts Officer from LBL and or SEL CCG.
  13. The person/agency alleged to have caused the harm should have been given the opportunity to submit their representations. If this an agency, then a manager not directly involved in providing care in the case may be invited to attend.
  14. Any other relevant agency/service representative as deemed appropriate by the person chairing the meeting.

Whoever attends a Planning Meeting should be of sufficient seniority to make decisions within the meeting concerning the organisation’s role and the resources they may contribute to the agreed Safeguarding Plan.

Planning Meetings should be formally recorded and minutes taken, which should be shared with those attending. This should be completed within 5 working days of the Meeting.

5. Practical arrangements 

Whilst there is a need to formally record the minutes from Planning Meetings, these should be set up as informally and flexibly as possible to meet the requirements of the adult and or their representative(s), whilst also helping ensure that professionals can contribute when these meetings are being set up at relatively short-notice. 

It may be suitable and appropriate to set these meetings up online using video methods, or via telephone, or by being flexible in utilising meeting rooms that are accessible for those involved. Otherwise the chair of the Planning Meeting should consider:   

  1. How to create a comfortable and welcoming environment.
  2. Whether the adult wishes to have a representative(s) with them and whether they will or should have an active or silent role (legal representative). This should be agreed with the adult, their legal representative and the chair ahead of the Planning Meeting.
  3. Any communication requirements or other accessibility issues.
  4. Location of facilities such as refreshments and toilets.
  5. How breaks will be agreed, if needed.
  6. Arrangements should the adult require a break or wish to clarify any points covered in the meeting.
  7. The adult and their representative(s) should not be required to join a room where other attendees have previously gathered, and where possible they should be in the room before other attendees join, having met and had a chance to talk with the chair ahead of the meeting.
  8. Meetings can also be in multiple parts to make them less intimidating (smaller groups) and more manageable for the adult, and include a separate and wider ‘professionals’ meeting.
  9. Where the venue is the adult’s own home, consideration should be given to how their home will be treated with respect, and how to maintain confidentiality if others not attending the meeting may also be present in the home.

See: Multi-Agency Adult Safeguarding Planning Meeting Form (Word)   Multi-Agency Adult Safeguarding Planning Meeting Form (Pdf)

6. How do Planning Meetings link to Pressure Ulcer Panels and the Provider Concerns process?

6.1 Pressure Ulcer Panels 

Any Section 42 Safeguarding Enquiry which has commenced as a result of a pressure ulcer related issue will normally be conducted via one of the two Pressure Ulcer Panels in the Borough of Lewisham, which are both overseen by a senior social work practitioner from within LBL. 

If these are routine cases, then a separate Planning Meeting will not be required, unless one or more of the issues listed in section 2 of this guidance are also present in the case. 

If a Planning Meeting is deemed to be necessary in relation to a pressure ulcer related case, then one should be convened within 5 working days of a decision being made that one is necessary, even if the case has not been brought to a conclusion by the relevant Pressure Ulcer Panel. 

6.2 Provider Concerns 

As described in section 2.3, one outcome from a Planning Meeting might be to make a referral to the Provider Concerns process if the criteria for this has been reached. The Planning Meeting may help to identify signs linked to provider concerns, allowing for early supportive actions to be taken by commissioning authorities in supporting social care providers. A referral for the Provider Concerns Process should be made through the applicable Contracts Officer from LBL and or SEL CCG. 

7. Monitoring and review of Planning Meetings 

The Operational Lead from LBL will provide operational oversight and monitor all activity linked to the Section 42 Enquiry process, including Planning Meetings, in conjunction with the Service Manager with overall responsibility for adult safeguarding within LBL.

The Service Manager within LBL will provide oversight of Planning Meetings, providing quality assurance to the Lewisham Safeguarding Adults Board through ongoing audit and reporting processes.

Plan & Review Stage 3: Multi-Agency Adult Safeguarding Case Conference (MASCC) Guidance

1. What is the purpose of a Multi-Agency Adult Safeguarding Case Conference?

The overarching purpose of a Multi-Agency Adult Safeguarding Case Conference (MASCC) is to bring together all of the relevant stakeholders, so that the Safeguarding Enquiry process can be reviewed, to ensure that the "risk to the adult has been sufficiently reduced, or removed" (although it may also be appropriate for this to 'remain' in some circumstances), before being closed.

This is a shift in terminology and emphasis away from trying to 'substantiate' reports of abuse, which can become combative between professionals and agencies, detracting from the efforts to improve the adult's wellbeing and safety.

See: Multi-Agency Adult Safeguarding Case Conference Meeting Record (Pdf)

Multi-Agency Adult Safeguarding Case Conference Meeting Record (Word)

2. When might a MASCC be needed?

A MASCC will not be necessary in relation to many Section 42 Safeguarding Enquiries, but the following points should be used to help determine if one is required: 

  1. To ensure that in the most complex cases the risk management arrangements that have been put in place are being effective.
  2. Where multiple agencies (including providers) have been involved in offering support and or protection, and ongoing co-ordination is required.
  3. In organisational or institutional cases where other adults may also have also been at risk of abuse or neglect. This may include where issues have affected residents of other Local Authorities.
  4. Where the abuse involved a member of staff/volunteer (position of trust), and this brought into question the safety of other adults, and or the service.
  5. Where there may have been multiple ongoing enquiries by different organisations or other processes, including by Police and the Pressure Ulcer Panels (see section 6).
  6. To consider if other legal or statutory actions or redress are needed. This may include a referral for a Safeguarding Adults Review (SAR - s.44 Care Act 2014).                                                  

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

In some instances a MASCC may be required at short notice following on from an initial Safeguarding Planning Meeting, if the issues identified place the adult at significant risk of harm, otherwise this should be arranged within 10 working days of a decision being made that one is necessary.

See: Multi-Agency Adult Safeguarding Planning Meeting Guidance

With this in mind the following points made under each of the six Safeguarding Principles should be followed to ensure that MASCC’s are utilised effectively and consistently.

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Safeguarding Principle - Empowerment 

What does this mean for the professionals: Adults are encouraged to make their own decisions and are provided with support and information.

What does this means for the adult: "I am consulted about the outcomes I want from the safeguarding process and these directly inform what happens".

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The practitioner who is setting up and chairing a MASCC (see section 3) must ensure that the adult’s views, wishes and opinions are effectively represented, and conduct the meeting in an appropriate manner, using appropriate adaptations if required, allowing for the full participation of the adult and or their representative(s).     

2.1 If the adult does wish to attend the following points must be born in mind:

  • The adult can bring someone to support them at the meeting. This might be a family member, friend or an Advocate (see section 3.2 of the London Multi-Agency Safeguarding Policy and Procedures), and or a legal representative.
  • The meeting is about the adult and their views and wishes. The Chair of the meeting must ensure these are heard and listened to by everyone else.
  • The meeting may need to decide if any additional actions need to take place, and by who, to make the adult safer and improve their wellbeing. This will be a group decision and the adult’s views will form part of this decision.
  • A new Safeguarding Plan may be agreed - this is about how the adult wants to be supported to be safe. Decisions about the adult’s welfare or care will need to be agreed with them.
  • If the adult has been assessed as not having mental capacity to make a particular decision at that time, then it will need to be made in their ‘best interests’, and their views, wishes, feelings and beliefs must still be taken into account. Such decisions must be made in line with the Mental Capacity Act 2005 (Mental capacity should be carefully considered during every safeguarding enquiry- see section 3.1 of the London Multi-Agency Safeguarding Policy and Procedures).

2.2 If the adult does not wish to attend they may:

  • Give their views in writing, or;
  • Ask someone to attend on their behalf, for example an advocate, friend or family member, or;
  • Ask the Safeguarding worker or Safeguarding Adults Manager to pass on their views.

See: Local Government Association - Making Safeguarding Personal Toolkit

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Safeguarding Principle - Prevention 

What does this mean for the professionals: Strategies are developed to prevent abuse and neglect that promotes resilience and self-determination.

What does this mean for the adult: "I am provided with easily understood information about what abuse is, how to recognise the signs and what I can do to seek help".

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2.3 The MASCC should consider:

  • The longer-term health, social care, communication, cultural or other specific needs of the adult at risk.
  • The ongoing support the adult will need.
  • What learning can be shared across agencies to help prevent further re-occurrences (this is also linked to Section 44 of the Care Act 2014 - if the criteria is met).
  • What training or education is also needed to help prevent further re-occurrences of abuse.
  • How information should be recorded and shared in line with the data protection legislation to help prevent further instances of abuse (see section 2.39 of the London Multi-Agency Safeguarding Policy and Procedures).

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Safeguarding Principle - Proportionality  

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

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

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Safeguarding Principle - Protection

What does this mean for the professionals: Adults are offered ways to protect themselves, and there is a co-ordinated response to adult safeguarding.  

What does this mean for the adult: "I am provided with help and support to report abuse. I am supported to take part in the safeguarding process to the extent to which I want and to which I am able".

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  • Any potential risks to children and young people (or other adults at risk) and agreement on who will arrange a Child Protection referral, where necessary (if this hasn’t already been actioned and is applicable).
  • How actions that may be needed to further reduce the future risk of harm to the adult, and or others, will be delivered.
  • Ensure there is clarity about the type of abuse that has occurred and that this is recorded effectively, considering types of abuse that are particularly under-recorded:
    • Organisational Abuse
    • Discriminatory Abuse
    • Modern Slavery
    • Domestic Abuse.
  • The link with other key processes and procedures e.g. personnel issues (including referrals to the Disclosure and Barring Service or a professional or regulatory body); Police investigations; other regulatory processes such as a NHS Serious Incident, and the link to Pressure Ulcer Panels (see section 6).

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Safeguarding Principle - Partnerships 

What does this mean for the professionals: Local Solutions through services working together within their communities.

What does this mean for the adult: "I am confident that information will be appropriately shared in a way that takes into account its personal and sensitive nature. I am confident that agencies will work together to find the most effective responses for my own situation".

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Safeguarding Principle - Accountability

What does this means for the professionals: Accountability and transparency in delivering a safeguarding response.

What does this mean for the adult: "I am clear about the roles and responsibilities in all those involved in the solution to the problem".

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  • That arrangements are in place to feedback the conclusion of the Case Conference and any other relevant information to those who need to be advised and are not in attendance.
  • Where other processes, such as a complaints procedures have been suspended pending the outcome of the enquiry, that these are subsequently resumed.

3. Who can convene a MASCC?

    An Operational Lead/Manager within the London Borough of Lewisham (LBL) can convene a MASCC, or a Service Manager within LBL for more complex or serious cases.  

    Operational leads should seek advice from their senior colleagues if they are in doubt about convening a MASCC.

    4. Who should attend a MASCC?

    There are a wide range of people who may be required to attend a MASCC, including, but not limited to:

    1. The adult and or their representative (see 2.1).
    2. The Safeguarding Adults Manager (SAM) or their equivalent.
    3. The Safeguarding Enquiry Officer.
    4. Police manager.
    5. Other criminal justice agencies.
    6. NHS Trust manager and or relevant specialist.
    7. GP
    8. Care Quality Commission.
    9. Care Provider agency manager.
    10. Relevant LBL and or South East London (SEL) Clinical Commissioning Group (CCG) Commissioner.
    11. Quality Assurance or Contracts Officer from LBL and or SEL CCG.
    12. The person/agency alleged to have caused the harm should have been given the opportunity to submit their representations. If this is an agency, then a manager not directly involved in providing care in the case may be invited to attend.

    MASCC’s should be formally recorded and minutes taken, which should be shared with those attending. This should be completed within 10 working days of the Case Conference.

    5. Practical arrangements

    Whilst there is a need to formally record the minutes from MASCC’s, these Case Conferences should be set up as informally and flexibly as possible to meet the requirements of the adult and or their representative(s), whilst also helping ensure that professionals can contribute when these meetings are being set up at relatively short-notice.

    It may be suitable and appropriate to set these Case Conferences up online using video methods, or via telephone, or by being flexible in utilising meeting rooms that are accessible for those involved.

    Otherwise the chair of the MASCC should consider:   

    1. How to create a comfortable and welcoming environment.
    2. Whether the adult wishes to have a representative(s) with them and whether they will or should have an active or silent role (legal representative). This should be agreed with the adult, their legal representative and the chair ahead of the Conference.
    3. Any communication requirements or other accessibility issues.
    4. Location of facilities such as refreshments and toilets.
    5. How breaks will be agreed, if needed.
    6. Arrangements should the adult require a break or wish to clarify any points covered in the Case Conference.
    7. The adult and their representative(s) should not be required to join a room where other attendees have previously gathered, and where possible they should be in the room before other attendees join, having met and had a chance to talk with the chair ahead of the meeting.
    8. Meetings can also be in multiple parts to make them less intimidating (smaller groups) and more manageable for the adult, and include a separate and wider ‘professionals’ meeting.
    9. Where the venue is the adult’s own home, consideration should be given to how their home will be treated with respect, and how to maintain confidentiality if others not attending the Conference may also be present in the home.

    See: Multi-Agency Adult Safeguarding Case Conference Meeting Record (Pdf)

    Multi-Agency Adult Safeguarding Case Conference Meeting Record (Word)

    6. How do MASCC’s link to Pressure Ulcer Panels and the Provider Concerns process?

        6.1 Pressure Ulcer Panels

        Any Section 42 Safeguarding Enquiry which has commenced as a result of a pressure ulcer related issue will normally be conducted via one of the two Pressure Ulcer Panels in the Borough of Lewisham, which are both overseen by a senior social work practitioner from within LBL.

        If these are routine cases, then a MASCC will not be required, unless one or more of the issues listed in section 2 of this guidance are present in the case.

        If a MASCC is deemed to be necessary in relation to a pressure ulcer related case, then a MASCC should be convened within 10 working days of a decision being made that one is necessary, even if the case has not been brought to a conclusion by the relevant Pressure Ulcer Panel.

        6.2 Provider Concerns   

        As described in section 2, one outcome from a MASCC might be to make a referral to the Provider Concerns process if the criteria for this has been reached (see sections 5.7 & 5.8 of the London Multi-Agency Safeguarding Policy and Procedures). The MASCC may help to identify signs linked to provider concerns, allowing for early supportive actions to be taken by commissioning authorities in supporting social care providers. A referral for the Provider Concerns Process should be made through the applicable Contracts Officer from LBL and or SEL CCG.

        7. Monitoring and review of MASSC’s

        The Operational Lead for LBL will provide operational oversight and monitor all activity linked to the Section 42 Enquiry process, including MASCC’s, in conjunction with the Service Manager with overall responsibility for adult safeguarding within LBL.

        The Service Manager within LBL will provide oversight of MASCC’s (including chairing more complex Case Conferences as required), providing quality assurance to the Lewisham Safeguarding Adults Board through ongoing audit and reporting processes.

        Closing the Enquiry Stage 4

        A Safeguarding Concern/Enquiry can be closed at any of the previous three stages of the procedure.

        However, the following points should be used as a checklist to ensure the procedure has been closed effectively and appropriately:

        • Anyone involved in the Safeguarding Concern/Enquiry should be advised on how and who to contact if there are further concerns about the adult at risk.
        • There should be agreement on how any further concerns will be followed up.
        • It is good practice where a care management assessment, Care Programme Approach (CPA), reassessment of care and support, health review, placement review or any other pre-booked review is due to take place following the safeguarding enquiry, for a standard check to be made that there has been no reoccurrence of concerns.
        • Closure records should note the reason for this decision and the views of the adult at risk to the proposed closure. The SAM responsible should ensure that all actions have been taken, building in any personalised actions:
          • Agreements with the adult at risk to closure.
          • Referral for assessment and support.
          • Advice and information provided.
          • All organisations involved in the enquiry updated and informed.
          • Feedback has been provided to the referrer (this is very important).
          • Action taken with the person alleged to have caused harm.
          • Action taken to support other service users.
          • Referral to children and young people made (if necessary).
          • Outcomes noted and evaluated by adult at risk.
          • Consideration for a Safeguarding Adults Review (SAR).
          • Any lessons to be learnt.

        The adult safeguarding process may be closed but other processes may continue, for example, a disciplinary or professional body investigation. These processes may take some time. Consideration may need to be given to the impact of these on the adult and how this will be monitored. Where there are outstanding criminal investigations and pending court actions, the adult safeguarding process can also be closed providing that the adult is safeguarded.

        All closures no matter at what stage are subject to an evaluation of outcomes by the adult at risk. If the adult at risk disagrees with the decision to close safeguarding down their reasons should be fully explored and alternatives offered.

        At the close of each enquiry there should be evidence of:

        1. Enhanced safeguarding practice ensuring that people have an opportunity to discuss the outcomes they wanted at the start of safeguarding activity.
        2. Follow-up discussions with adults at risk at the end of safeguarding activity to see to what extent their desired outcomes have been met.
        3. Recording the results in an anonymised way by fully completing all data recording requirements so this can be used to inform practice, and provide the necessary performance monitoring information for the Lewisham Safeguarding Adults Board.

        Adult Safeguarding Pathway Resources

        Adult Safeguarding Posters - See it, Report it!

        Adult Safeguarding Leaflet:

        Single Agency Policy and Procedures Template (for use by any agency)

        Adult Safeguarding Pathway Forms and Templates

        Prevention

        We can all help to prevent adult abuse and neglect by supporting the delivery of these key objectives:

        1. Improve Public Awareness

        This can be achieved by helping to support awareness building campaigns and by signposting adults to appropriate sources of information. One easy way to do this is by following @lewisham_sab on Twitter and supporting the campaigns we deliver.

        2. Identify Adults who May be at Increased Risk

        There are many factors which might increase the risks of adult abuse and neglect including: older age; physical, mental, sensory, learning or cognitive illness or disability; and having to rely on others for health and social care support.

        3. Identifying & Responding Effectively to Abuse

        Organisations and individuals working to improve their understanding and early identification of the different types of adult abuse, so that an effective response can be achieved in conjunction with the adults views and wishes.

        4. Consistent & Widespread Application of Policies & Procedures

        It is important for organisations delivering services to adults to have appropriate policies and procedures which are developed in line with guidance from the Lewisham Safeguarding Adults Board, and embedded into the practice of all professionals. See: Pathway Resources

        5. Focus on Equality & Narrowing Inequality

        Adults from financially deprived backgrounds are more likely to become an identifiedvictim of adult abuse and neglect, and  it is less likely that an adult from some ethnic minority communities will be engaged with statutory services in Lewisham. All professionals can help to improve reporting and equal access to protective services.

        6. Help Adults to Protect Themselves

        Every organisation delivering services to adults at risk of abuse and neglect can identify ways in which they can help to inform, and support adults in protecting themselves from abuse.

        7. Provide Information, Advice & Advocacy

        Individual organisations will know the communication needs of their client groups, and as such are best placed to provide bespoke adult safeguarding information in the most appropriate formats, methods and languages. See: Pathway Resources

        8. Provide Access to Training & Education

        Organisations have a responsibility to provide access to up to date and relevant adult safeguarding training for their staff and volunteers, and additional support for the person (s) responsible for leading on this subject within that agency.

        9. Support Broader Wellbeing Strategies

        There is a clearly established link between the prevention of adult abuse and broader health and wellbeing strategies, including the reduction of social isolation and loneliness. Organisations can help to engage adults in these type of strategies, which will also indirectly help to prevent adult abuse.

        Please let us know if you have any thoughts or ideas in relation to prevention.

        Adult Safeguarding Network: Register of Agencies - Your Feedback - Good Practice Library

        Please get in touch and let us know if your agency has connected to this Pathway through your agencies policy and procedures, and by signposting staff/volunteers to these webpages.

        If you also have any feedback on the Pathway, or want to generally share good practice including anonymised case examples of how you have helped to support adults in achieving positive outcomes, then please let us know and we will share and promote this via this webpage if this is suitable: LSAB@lewisham.gov.uk

        Agencies connected to this Pathway

        1. London Borough of Lewisham

         

         

         

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