Safeguarding Adult Reviews provide valuable assurance to the Partnership based on in depth research into an individual safeguarding case. PSAP uses both independently researched and authored investigations and multi-agency learning events to understand the critical issues and areas for improvement in the system.
Commissioning SARs following the death or serious injury of an adult involving abuse or neglect person are reactive activities. Being able to initiate SARs [i.e. Care Act s.44.4 A SAB may arrange for there to be a review of any other case involving an adult in its area with needs for care and support (whether or not the local authority has been meeting any of those needs)] for other reasons can establish a proactive stance, with a preventative focus on the where learning is best placed to improve outcomes:
It allows a pre-emptive approach to tackle practice areas or issues before an incident of harm occurs.
Where a situation or circumstance can provide useful insights into the way organisations are working together to prevent and reduce abuse and neglect of adults.
Explore examples of good practice where this is likely to identify learning that can be applied in future.
The PSAP can take advantage of data from other quality assurance and feedback sources such as partner self-assessment; HMCO Regulation 28 prevention of future deaths reports, audits and complaints. This can inform decision making about the type of circumstance or issue there would be benefit in reviewing. This may include new, complex or repetitive issues, incidents, and areas of practice across a range of agencies. It can also link preventative SAR work into strategic plans, giving the PSAP assurance that reliable functioning of systems are in place rather than post incident review.
Under the Care Act, the PSAP will determine locally the process for undertaking SARs. No one model is prescribed, therefore there is a need to know the choice of options available, and to think about the basis on which to choose. How a review is conducted affects the resulting quality of learning, and whether the process is constructive and educative for those involved.
The choice of approach is therefore significant. More now than before, instead of undertaking the traditional SCR/SAR approach, ‘action learning’ is being adopted. With significant evidence the approach is much more efficient, enhancing:
- partnership working and practitioner development
- mutual recognition of alternative partner perspectives
- collaborative problem solving
Holistic models such as Root Cause Analysis1 (RCA) and SCIE’s Learning Together2, are made up of a variety of smaller, more specific techniques that are helpful at different stages of the investigation and analysis process. Focus in an RCA uses methods and techniques of arranging facts to:
- assist in deciding what additional facts are needed
- establish consistency, validity and logic
- establish sufficient and necessary events for causes
- guide and support inferences and judgements
In the past year the PSAP have used a range of methods or ‘toolbox’3 to provide assurance. Multi-organisational learning events, promoting partnership working, mutual recognition of alternative perspectives and collaborative problem solving, to achieve learning outcomes, for example:
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How do you ensure the person is supported to express their own views and wishes related to the placement and care provided?
Ensure families (where appropriate) are routinely engaged and involved in their relatives lives. The placing commissioner is responsible to establish and maintain this relationship in conjunction with a service provider.
Where a person has a statutory right to representation by an advocate, placing commissioners to ensure this is undertaken.
In other circumstances, ensure non-statutory advocacy representation is available, particularly where families are not involved.
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How do you ensure a person has access to an Independent Mental Health Advocate (IMHA)?
Promote referrals to the IMHA service, with information, advice and support to individuals, families, agencies and organisations.
Where the Mental Health Act is being used to provide care and treatment, ensure a referral has been made for the support of an IMHA.
On discharge from hospital and where a Community Treatment Order (CTO) is in place, ensure a referral to an IMHA service is/has been made as part of the discharge process.
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If necessary, how to safely commission out of area placements?
Association of Directors of Social Services (ADASS) 2016 guidance regarding Out of Area Placements.
Out-of-area safeguarding adults arrangements (PDF)
The recommendations from the Cawston Park SAR.
1Root Cause Analysis (RCA) has been used within health agencies as the method to learn from significant incidents. RCA sets out to find the systemic causes of operational problems. It provides a systematic investigation technique that looks beyond the individuals concerned and seeks to understand the underlying causes and environmental context in which the incident happened.
2SCIE Learning Together (LT) is recognised as one which values practitioner contributions is sympathetic to the context of the case and is experienced as a more transparent process by those involved.
3Results would seem to suggest that accident investigators must have a ‘toolbox’ of approaches available to them, which should be utilised dependently on the type of accident scenario and the particular stage of the accident investigation (Woloshynowych, Rogers et al. 2005).