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 perspectives and collaborative problem solving.
Nationally, many Safeguarding Adult Boards (SABs) experience frustration that Safeguarding Adult Review (SAR) processes take too long, are too expensive and don’t produce learning that is useful. The SCIE SAR in Rapid Time1 model can provide a process and related tools that support reviews to draw out systems learning to promote practical improvement using a timely and proportionate approach.
The model encourages clarity about the kind of learning needed, so that the review can move from purely describing practice problems to illuminating what lies ‘behind’ those practice problems. Taking a systems approach, the model enables us to understand the social and organisational drivers for current practice problems. The process supports reviews to be turned around more quickly and to provide a shorter more focused final report.
In the past year the PSAP have used a range of methods 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:
| Key question | Learning outcomes |
| How do you monitor local provider services that appear isolated, may have a closed culture, not commissioned locally, not known to safeguarding and known to accept people with complex needs from out of area or funded privately? | Awareness of closed cultures is included in PSAP Adult Safeguarding for Managers training. Plymouth Joint Commissioners utilise the Care Forums to raise awareness of closed cultures. A newly developed Commissioning Intelligence Dashboard monitoring and assuring care homes in the City. CQC’s local monthly quality monitoring meetings offer a forum to share relevant information about services. |
| How do commissioners from out of area safely commission placements in Plymouth? | Once a placement has been agreed upon in principle and the placing Authority has identified a potential provider in Plymouth, they should contact Plymouth City Council, QAIT (Quality, Assurance and Improvement Team) to confirm the intention, potential date and care home. https://www.plymouthonlinedirectory.com/housingandcarehomes/carehomes/outofareaplacements |
| How to better inform and support individuals, families and carers about Safeguarding Adult Reviews and the Coronial process? | Following feedback from families attempting to navigate Adult Safeguarding and Coronial statutory processes, Information sheets have been developed. |
| How can staff, managers and partners access information and guidance regarding self-neglect, hoarding and risk management? | The Adult Safeguarding multi-agency safeguarding manual has been refreshed to reflect current guidance. https://www.plymouth.gov.uk/28-self-neglect-hoarding-and-risk-management-policy-guidance |
| What tools and guidance do staff have to support an effective risk management process? | A revised risk assessment template and guidance has been developed and added to the social care record system. |
1 SCIE SAR’s in Rapid Time - https://www.scie.org.uk/safeguarding/adults/reviews/in-rapid-time