SafeguardingMATTERSIssue 21

JAN 2020

Learning and Development to Build Confidence in PracticeThe information in this edition is drawn from, Serious Case Reviews (SCR), Safeguarding Adult Reviews (SAR) and Multi-Agency Audits, this includes cases completed and early learning from others.

Contact usLeicestershire and Rutland Safeguarding Children Partnership and Safeguarding Adults Board The Safeguarding Boards Business Office, Room 100, County Hall, Glenfield, Leicestershire, LE3 8RA. Telephone: 0116 305 7130 Email: SBBO@leics.gov.uk

Why we do reviews?Why do the Leicestershire and Rutland Safeguarding Children Partnership (LRSCP)and Leicester Leicestershire and Rutland Safeguarding Adult Boards (LLRSAB) undertake Reviews? The prime purpose of any review is for agencies and individuals to identify ways that professionals and organisations can improve the way they work together both individually and collectively to safeguard and promote the welfare of the child or adult. It is important that good practice is recognised as well as areas for improvement. They do not review how someone died or was seriously harmed, or who is culpable.

Reviews are often run alongside other processes for example, Coroners Inquests and Criminal investigations.

Continued on the next page....

DEFENSIBLE DECISION MAKING

SafeguardingAdults Board

SafeguardingAdults Board

SafeguardingAdults Board

Reviews and audits take place within a wider culture of practitioner learning and development. It is important that staff have regular opportunities to reflect on their own practice and that of their colleagues, and to learn from effective safeguarding work.

CONTENTSp2 Undertaking A Review

p3 Review Methodologies

p5 Reviewing and updating procedures

p6 Learning and Development Practice and Materials

p7 The Leicestershire& Rutland Safeguarding Children Partnership is here!

Children who go missing

p8 7 Minute Briefings and 7 Minute Briefing Action Plan

ACCURATE RECORDING

Local Children Safeguarding Practice Reviews (LCSPR)

A Child Safeguarding Practice Review (previously known as a Serious Case Review (SCR)) is undertaken when a child dies, or the child has been seriously harmed and there is cause for concern as to the way organisations worked together. The purpose of a child safeguarding practice review is for agencies and individuals to learn lessons that improve the way in which they work, both individually and collectively, to safeguard and promote the welfare of children

The trigger for this is a notifiable incident –

There is a Duty on local authorities to notify incidents to the Child Safeguarding Practice Review Panel (this is a National Panel). Working Together 2018 states that a local authority in England knows or suspects that a child has been abused or neglected, the local authority must notify the Child Safeguarding Practice Review Panel if

• the child dies or is seriously harmed in the local authority’s area, or

• while normally resident in the local authority’s area, the child dies or is seriously harmed outside England.

Working Together 2018

Safeguarding Adult Reviews (SAR)

Under Section 44 of the 2014 Care Act, Safeguarding Adults Boards (SABs) are responsible for Safeguarding Adults Reviews (SARs)

Safeguarding Adults Boards (SABs) must arrange a SAR when an adult in its area dies as a result of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked more effectively to protect the adult.

SABs must also arrange a SAR if an adult in its area has not died, but the SAB knows or suspects that the adult has experienced serious abuse or neglect. In the context of SARs, something can be considered serious abuse or neglect where, for example the individual 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. SABs are free to arrange for a SAR in any other situations involving an adult in its area with needs for care and support.

Domestic Homicide Reviews DHR

Since 13 April 2011 there has been a statutory requirement for local areas to conduct a DHR following a domestic homicide that meets the criteria.

A Domestic Homicide Review (DHR) is a multi-agency review of the circumstances in which the death of a person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect by a person to whom they were related or with whom they were, or had been, in an intimate personal relationship, or a member of the same household as themselves.

Undertaking A ReviewA primary concern when deciding how a review is undertaken is that it will promote effective learning and improvement. A review can provide a useful insight into the way organisations are working together to prevent and reduce abuse including highlighting good practice.

All reviews will:

ask agencies to share information on the contact they have had with a child/young person/adult

• look for the voice of the child/young person/adult

• analyse information

• identify learning

• make recommendations

• share learning

Contents

2 Safeguarding MATTERS

Review Methodologies (not an exhaustive list)

Traditional model

Typical features include:

• appointment of a panel, including chair (usually independent) and core membership which determines terms of reference and oversees process

• independent report author

• combined chronology of events (see below)

• involved agencies produce Individual Management Reports, often known as IMRs (see below), outlining

• involvement and key issues

• overview report with analysis, lessons learned and recommendations

• relevant agencies produce action plans in response to the lessons learned

• formal reporting to the commissioning board and monitoring implementation across

• partnerships

Root Cause Analysis (RCA)

RCA is a technique which can be used to uncover the underlying causes of an incident. It looks beyond the individuals concerned and seeks to understand the underlying causes and environmental context in which the incident happened. It is designed to identify the sequence of events working back from the incident itself and identifies a range of factors which contributed to the incident.

This allows the real causes and contributory factors to be identified so that the relevant organisations can learn and put remedial actions in place.

Action Learning Approach

This option is characterised by reflective/action learning approaches, which identify both areas of good practice and those for improvement and do not apportion blame. This is achieved via close collaborative partnership working, including those involved at the time, in the joint identification and deconstruction of the serious incident(s), its context and recommended developments.

The broad methodology is:

• scoping of review/terms of reference: identification of key agencies/personnel, roles;

• timeframes:(completion, span of person’s history); specific areas of focus/exploration

• appointment of facilitator and overview report author

• production/review of relevant evidence, the presiding procedural guidance, via

• chronology, summary of events and key issues from designated agencies

• material circulated to attendees of learning event; anticipated attendees to include: The Safeguarding Partners, frontline staff/line managers, agency report authors; other co-opted experts (where identified); facilitator and/or overview report author

• learning event(s) to consider: what happened and why, areas of good practice, areas

• for improvement and lessons learned

• consolidation into an overview report, with: analysis of key issues, lessons and recommendations

• event to consider first draft of the overview report and action plan

• final overview report presented to the Safeguarding Partners

• agree dissemination of learning, monitoring of implementation

• follow up event to consider action plan recommendations

• ongoing monitoring via the Safeguarding Partners.

RECOGNISING ABUSE

3 Safeguarding MATTERS

Contents

Further variance

There is integral flexibility within this option as to the scale. Further, the exact nature can be adapted, dependent upon the individual circumstances, case complexity and requirements and preferences of the commissioning agency. For instance, the involvement of external agency/consultancy can vary from not at all to a full role in documents review, staff interviews and report production.

Multi-Agency Practice Learning Review

This approach is suitable where several organisations have been involved in a case and it has been determined that there is the potential for learning and/or a need to refine or introduce policies and procedures to improve how they can work together in the future, to minimise a repeat of the incident concerned.

The methodology should be proportionate to the incident, however would normally involve the compilation of a multi-agency chronology, which is used to highlight critical areas for further examination within a facilitated workshop. The review should make best use of all available evidence including any single agency investigation reports and /or safeguarding investigations in order to maximise learning and reduce administrative burden. Normally a suitably qualified chair from the Safeguarding Partners would lead and facilitate the review and a report author commissioned from within the Safeguarding Partners who is suitably independent to the case produce a summary report and action plan.

Key priorities are ensuring the participation of all organisations in the coordination of information, participation in the workshop and in implementing the action plan.

Individual Management Reviews (IMR)

IMR’s are a means of enabling organisations to reflect and critically analyse their involvement, to identify good practice and areas where systems, processes, or individual and organisational practice could be enhanced. They are key learning tools used in many reviews and can be used in a multi or single agency environment.

It is important that individuals who are asked to undertake IMRs have the relevant skills and sufficient independence from the case being reviewed. IMRs must be signed off by the Chief Officer of each organisation

Multi Agency Chronolgy

Chronologies are important tools particularly when combined across organisations. This enables a group of organisations to identify gaps in specific areas such as communication, decision making and risk assessment.

Many of the methodologies outlined utilise chronologies within them, however they can be used in isolation to achieve an overview of a case fairly simply, which can assist in assuring or developing multi agency working.

In this approach each agency produces a single chronology of involvement over the period that has been agreed as relevant to the investigation or review. They may also be asked to provide chronologies relating to more than one person of interest in the case.

The chronologies are then combined using a ‘chronolator’ This enables the review to determine whether there appears to be points for further investigation or potential for learning; or where this is the case, more detailed examination and discussion in a facilitated multi-agency workshop.

Any identified learning points should be noted and translated into actions which are shared with the Safeguarding Partners and implemented.

Case Audit

This method brings together managers and/or practitioners to consider significant events within a case and analyse together what went well and what could have been done differently.

Its focus is on learning which can lead to future improvements and it results in an action plan with recommendations for learning and development.

The child, young person, adult or family are not involved however the findings may instigate further review or investigation which should involve them.

MAKING SAFEGUARDING PERSONAL

4 Safeguarding MATTERS

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VOICE OF THE ADULT

Contents

In response to Audit and Reviews the following things have happened: Reviewing and updating proceduresAll staff should ensure they are signed up for automatic updates on the following these links

www.llradultsafeguarding.co.uk/home/register/

https://llrscb.proceduresonline.com/chapters/register_updates.html

ChildrenManagement of Marks of Concern in Pre-Mobile Babies and Non-Independently Mobile Children

Concealed Pregnancies

Safeguarding Disabled Children

Thresholds for Access to Services: For Children and Families in Leicester, Leicestershire & Rutland

AdultsSafeguarding Adults Thresholds Guidance

Vulnerable Adult Risk Management (VARM) VARM is a framework to facilitate working effectively with adults who have capacity, are at risk due to self-neglect, non- engagement and where that risk may lead to ‘significant harm or death’ This process should not affect an individual’s human rights but seeks to ensure that the relevant agencies exercise their duty of care in a robust manner and as far as is reasonable and proportionate.

The following Chapters have been updated:

Have you signed up to the safeguarding procedures updates?

???????

VOICE OF THE CHILD

Needs and Risks

Unive

rsal and targeted

TIER 1Universal

If unsureconsult

Requiring universalservices - children with no additional need

Requiring earlyintervention - children with someadditional needs

Requiring targetedand enhanced support -children with multipleneeds becoming morecomplex

Requiring acute/statutoryintervention - childrenwith complex and/oracute needs

TIER 3Targeted

TIER 2Additional

TIER4Specialist

5 Safeguarding MATTERS

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Learning and Development Practice and MaterialsAvailable to download online

Was not heard The ‘Was Not Heard’ film came about as a result of identifying that the voice of the child is not always heard or listened to. This was particularly evident on the case of Joe’ who in spite of him telling people what was wrong in his life on a number of occasions no action was taken.

Under Article 12 of the UN Convention on the Rights of the Child it states that children have a right to an opinion and for that to be heard and taken seriously in all matters affecting them.

This film is to make staff aware that they have duty to respond to the voice of the child and also to support that voice in being heard. It also shows that children communicate not just through their voice but through their actions and their silence.

The film was based around a script developed by local young people

We suggest that the film be used in training where appropriate and ask the following questions

So, what exactly are the barriers to hearing children’s voices in your practice?

What can we do better to include and consider the views and lived experiences of the children and young people we work with?

Trilogy of Risk

This simple pack contains a poster, a leaflet, a PowerPoint and video introduction.

These can be used by managers and trainers to raise awareness and share key messages.

http://lrsb.org.uk/trilogy-of-risk

Thresholds PowerPoint The Thresholds Guidance:

• Assists the local authorities in making consistent decision around potential safeguarding referrals (in consultation with their manager)

• Enables agencies to understand how these decisions are made.

• Aids defensible decision making-helps define where a safeguarding enquiry is required and also where alternative routes could be used to address any risks

http://lrsb.org.uk/sab-trainers-network

VARM PowerPoint The VARM Guidance

The VARM is a framework to facilitate working effectively with adults who have capacity, are at risk due to self-neglect, non-engagement and where that risk may lead to ‘significant harm or death

http://lrsb.org.uk/sab-trainers-network

Know it a Alcohol/drug misuse a Domestic abuse a Mental ill-health

Share it• Do not be afraid to ask for advice – it is okay not to know all the answers• Seek advice and support from your manager/supervisor• Contact other practitioners involved with family members• Consider a referral to social care/early help• Signpost/refer to specialist services if appropriate

Remember• If you see something, do something• Know your organisation’s procedures• Write down your concerns• Be persistent – check the progress of your concerns• Check: is anyone else working with or worried about this family or individuals?• Trust is key – vulnerable people need to feel safe, respected and listened to

Spot it• Trust your instincts• Ask open questions and listen • Be curious: things are not always as they first appear• People may minimise and deny their difficulties• Where one risk factor is identified, always look for others• Gather other relevant information, for example children in family, adults with additional needs, financial and social factors• Look for evidence of other forms of abuse

If any of these are present:• Risks of harm and impact could be higher for children and vulnerable adults• Ability to parent/care could be lower

Who to contact

Safeguarding adults: llradultsafeguarding.co.ukSafeguarding children: llrscb.proceduresonline.com

Trilogy of Risk

If there is an immediate or urgent risk, take action

!

Trilogy of Risk

Know it a Alcohol/drug misuse

a Domestic abuse

a Mental ill-health

If any of these are present:

• Risk of harm and impact could be higher

for children and vulnerable adults

• Ability to parent/care could be lower

Safeguarding adults: llradultsafeguarding.co.ukSafeguarding children:

llrscb.proceduresonline.com

Who to contact

If there is an immediate or urgent

risk, take action

!

Contents

The Leicestershire & Rutland Safeguarding Children Partnership is here!The partnership oversees organisations working together to safeguard children with a focus on reviewing, learning and improving practice in safeguarding children from neglect and abuse.

A critical part of any audit is to capture any learning which supports improvement in practice that strengthens our safeguarding of children and young people

The aim of the Children who go Missing audit was to: Understand from a multi-agency perspective the child/young persons’ experience as a ‘missing child’, this included:

• Compliance with and consistent application of the LLR LSCB Multi-Agency Safeguarding Children procedures

• Quality of referrals

• Application of thresholds to services

• Identification and response to a missing child

Agencies were asked to audit them themselves, recording findings on an audit tool which was designed in consultation with multiple partner agencies.

It replaced the Local Safeguarding Children Board on 29th September in line with changes in legislation and Government Guidance - Working Together 2018. Local Authorities, Police and Clinical Commissioning Groups are now all jointly and equally responsible for safeguarding children – however safeguarding children is still everyone’s business, and all who work with children have a role to play in how we work together to safeguard them.

During the first six months of operation the partnership will be revising and developing its approaches to performance and quality assurance of safeguarding practice and to improving engagement with agencies across the two Counties that work with children.

The other initial change of note is that Serious Case Reviews

have been replaced by Child Safeguarding Practice Reviews. These are clearly focussed on learning to improve practice and can be carried out in the most appropriate way to support learning to be gained and improvements made as quickly as possible. In some cases of national interest or importance these reviews may be part of a wider national review.

Current Serious Case Reviews will continue. They will either be completed by the end of March 2020 or handed over to the Safeguarding Children Partnership.

Publicity and awareness materials that reference the LSCB will remain valid to the end of March 2020, but by then will be replaced by updated partnership versions.

You can find out more on the Safeguarding Partnerships website: www.lrsb.org.uk

LSCB Multi-Agency Audit 2018-19, Children who go Missing

Contents

7 Cases - Summary of findings

What worked well What worked not so well What we need to do more of

4 of the 7 cases had evidence of a comprehensive assessment being undertaken and risk was appropriately identified and managed.

Good evidence, in most of the cases, that referrals were completed and responded to in an appropriate and timely way. A good starting point helps decision making

Evidence of better outcomes where the appropriate direct work and effective engagement supported and developed positive relationships

Where recording was comprehensive, and child focused evidence supports planning and decision making

Good exploration of family/safety network and developed which was then utilised to safeguard the child and offer support.

In some cases, good information sharing and effective communication between agencies was significant in ensuring the safeguarding of the children.

The voice of the child was evident in 4/7 cases and this was identified as being considered within the assessment.

Risks identified in 2 cases – these was escalated for an operational review

In 3 cases there were no chronologies and or genograms on the children’s files.

Lack of good and clear supervision and management oversight in all but one case

Some cases raised concerns regarding robustness of assessments and plans not SMART and therefore the outcome and impact was difficult to measure.

Two young people moved into supported accommodation without effective assessments, plans and safety goals which subsequently increased the risk of harm.

One case identified that practitioners missed opportunities to recognise the cultural differences & needs of the young person.

Poor information sharing:

Some agencies not made aware of the missing episodes and risks concerning CSE and CE that were escalating

Dealing with a young person in isolation and recording non-engagement when they did not attend appointments

Making and receiving good quality referrals (Look at Thresholds and MARF guidance)

Building good family/safety networks

Comprehensive, and child focused recording

Knowing what ‘risky’ looks like and how risk is increased when combined with other factors e.g. Trilogy of Risk

Use Chronologies and Genograms – they help planning and can tell the child’s ‘story’

SMART Plans

Provide Good Supervision and Management Oversight

Request supervision and Management Oversight

Find out what therapeutic and support services are available for example Turning Point and make referrals

Recognise cultural aspects of the family and needs of the young person

Share relevant information to:

• Avoid silo working

• Understand the risk

• Avoid misunderstandings.

7 Minute Briefings and 7 Minute Briefing Action Plan With increasing pressures and demands on time, it can be hard to find the time for learning and development. Learning for seven minutes is manageable in most services, and learning is more memorable as it is simple and not clouded by other issues and pressures.

Clearly such short briefings will not have all the answers, but it is hoped that they will act as a catalyst to help teams and their managers to discuss and reflect on their practice and systems.

Each 7-minute briefing may vary slightly in its style, but the important thing is that you use them to generate discussion on the learning themes/key messages in a way that is relevant and accessible to your service, team and workers.

All of the cases are based on real people and events, but we have changed names, ages and family compositions.

We would encourage you not just to focus on those briefings relevant to the age group you support but to expand your knowledge base of other areas.

We encourage all agencies to record or evidence how they have used our 7-minute briefings on the 7-Minute Briefing Action Plan Template provided at the end.

8 Safeguarding MATTERS

Contents

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02Grace

1 month Children’s Review 7 Minute Briefing

01 BackgroundGrace aged 1 month was taken to the Paediatric Emergency Department presenting with swelling of the lower part of the left leg and facial bruising. The child was later identified as having sustained fractures to the left leg and left wrist, 3 fractured ribs and bruising to the face and neck. Her parents offered no explanation of how these injuries occurred.

02 Safeguarding ConcernsTrilogy of risk (alcohol and domestic abuse and mental health issues)

Baby’s father had epilepsy, short term memory loss and anger management issues attributed to Shaken Baby Syndrome

Household Debt

04 Findings SummaryGood Practice

It is recognised that multi-agency meetings took place and the baby’s parents were visible to services and received intensive support.

Practitioners raised their concerns and made appropriate referrals to Children’s Social Care (CSC).

There is some evidence good record keeping

LLRSCB Babies and bruising policy (published in 2016 and refreshed 2019) requires practitioners to notify CSC about mark/bruises to a pre-mobile baby/child

05 Reviewing your PracticeIn your assessment of Parenting Capacity have you considered the physical and mental health of the parents?

Are the parents in receipt of any specialist health support?

Is constant crying impacting on parenting?

Are parents responding appropriately the child’s needs?

How are you considered how the child is communicating their needs? What are the physical or behavioural indicators?

06 Reviewing your PracticeIs their clarity regarding parenting capacity – What needs to change?

Have goals been set? /What are the timescales?

What are the indictors for improvement?

Is supervision addressing the success of safety

03 Key Learning ThemesTrilogy of Risk -There was a lack of recognition of domestic abuse and the seriousness of this in the context of Pregnancy

Head Injury - Long-term impact in adulthood (parenting capacity) of being a shaken baby / having suffered a head injury as a child

Voice of the Child – Lack of recognition that the persistent crying together with poor parental response could be a safeguarding risk and the child’s lived experience poor

Parenting Capacity Assessments – Need to be dynamic with clear expectations including pre-birth assessments

07 Action – To raise awarenessTrilogy of Risk Resources http://lrsb.org.uk/trilogy-of-risk

1.3.10 Management of Marks of Concern in Pre-Mobile Babies and Non-Independently Mobile Children.

https://llrscb.proceduresonline.com/p_pre_mobile_babies.html?zoom_highlight=bruising

Voice of the Child http://lrsb.org.uk/voice-of-the-child-voc

Coping with a Crying Baby Safeguarding Matters Issue 20 July 19

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01 BackgroundJoe aged six sustained a head injury and a fractured foot. Joe was known to Children’s Social Care. Prior to the incident, Joe was twice the subject of Child Protection Plans due to Neglect and the Risk of Sexual and Emotional Abuse.

It was known that Joe’s mother had been a Looked After Child (LAC) from when she was six years old. She became a Looked after Child due to the abuse she received from her own mother.

02 Safeguarding ConcernsMum had post-natal depression and had difficulties in managing a crying baby. She managed Joe by using physical abuse. Her own low self-esteem made her believe she was a bad mother.

She attended several parenting classes but found it difficult to empathise and show any warmth in her parenting of Joe. She believed her baby cried on purpose and overtly admitted hitting her baby but with a lack of remorse, minimising and denying her own actions.

04 Progress• Work is underway with UHL Midwifery (MW) and

LPT Health Visitors (HV) to ensure that GP records are checked during the antenatal period to identify if the mother or father was previously a looked after child. This information will be identified by the ‘Leaving Care Health Summary’, a comprehensive summary of the young person’s health and social care.

• A copy of the ‘Summary’ is given to the young person and also stored in the GP and Social Care records. This information will contribute towards the MW/HV assessment of any additional support the parent(s) may require to adequately parent their child.

05 Progress• A ‘Voice of the child’ film called ‘Was not Heard’ is

being produced across LLR to promote the views of children and young people who have a right under article 12 to have their voice heard and listened to.

• Large-scale learning events are taking place relating to children with disabilities include specific focussed work on hearing the voice of children, in the context of children with disabilities

06 Progress• A survey on blockages in multi-agency working

was carried out in 2017 and 2018 and Findings reported to LLR LSCB Procedures Group and into Heads of Service for front door services in City and Leicestershire County.

03 Key Learning Themes• The Parenting Capacity of Adults who were

previously Looked After Children (LAC).

• Practitioners failed to recognise the voice of the child (including the verbal and non-verbal voice of the child) and understand the child’s lived experiences and long-term impact of abuse.

• Lack of appropriate response to physical abuse.

• The need for good quality supervision and exploration of professional challenge.

07 ProgressCSC has been focussed on a range of developments and actions in relation to practice. The CSC improvement plan has encompassed the development of practice standards for assessments which have been developed as part of the Growing Quality in CSC framework. The standards, which have been introduced to all workers, set out clear expectations of good quality assessments across all service areas and include:

• Robust management oversight of all work allocated including a plan of actions. • All assessments are to be completed using minimum standards. All assessments have management oversight

‘Joe’ Aged 6

Alternative Case Review 7 Minute Briefing

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01 BackgroundColin was a young man who had learning difficulties and some physical impairments. He was resident in supported living accommodation and had previously been in foster care. Colin moved to supported living in order to develop his independence, but this did not happen effectively, and information showed that he had less independence than when he was being fostered. There were also misunderstandings around the Mental Capacity Act and whether Colin had capacity to make decisions. Colin began to assert his independence and there was an increase in disruptive behaviour as well as Colin placing himself in risky situations with a new group of friends. He was murdered by peers.

02 Safeguarding Concerns• Escalation of disruptive and violent behaviour

• Requesting increased sums of money and losing possessions

• Staying out all night with friends who were not known to the support workers

• Having been the victim of an assault

04 Findings Summary• There should have been greater emphasis on preparatory

work to develop Colin’s independence in the community and effectively manage risks. This work should have commenced from early in his placement, rather than waiting until shortly before Colin started asserting his right to go into the community without supervision.

• Care and support staff working in accommodation-based services for people with learning disabilities should:

o Have at least a basic understanding of the Mental Capacity Act and Deprivation of Liberty as they apply to their resident group

o Know which residents are / are not subject to DoL

o For residents with such capacity, have strategies and skills to support residents to evaluate and manage potential risks arising from decisions to go out unaccompanied

05 Findings Summary• When a provider of accommodation and support services makes a specific

request for a care plan review, there is a responsibility on Adult Social Care managers and commissioners to urgently and positively respond to that request

• With the consent of the adult in question, consideration should always be given to inviting family members to attend review and planning meetings and generally to have an active input into these processes. This should happen on a pro-active basis

• If there is evidence of a pattern of violent incidents involving people with care and support needs (as perpetrators and / or victims) in a supported living or care home environment, this should be considered as a potential safeguarding issue

06 Multi-Agency Recommendations OverviewChildren’s and Adults’ Services, including social care and health services, should jointly review transition pathway processes

The SAB should ensure that learning from this SAR is shared as widely as possible.

03 Key Learning Themes• Transitional planning and risk management

• Staff knowledge of MCA and DoLS

• Care Plan Reviews

• Involving families in review processes, support planning and risk assessment and management

• Violent incidents in care and support settings

• Inter-agency communications and professional challenge

• Inter-agency communications, care plan reviews and contingency planning

07 Changes Resulting from the Review• Multi agency risk assessments have been updated

to support agencies in improving the quality of assessment of risk in a range of circumstances.

• Frontline police officers and staff received training to improve communication with individuals with learning disabilities and autism. Communication guides published.

• Transitions pathways have been reviewed – new Leicester City local authority strategy published

• Learning shared with local authority, police and health staff for practice improvement

Colin 23 Safeguarding Adult

Review 7 Minute Briefing

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01 BackgroundAlison died aged 32, she lived alone, her daughter aged 7 lived with extended family. Alison had a long history of alcohol misuse and mental health issues. Alison and her family were supported by several services. (Mental Health, Children and Adult Social Care, Police, GP, Substance misuse service, Domestic Abuse services). Alison’s drinking impacted on her capacity to parent, her relationships with family, friends, neighbours and engagement with agencies. Alison had periods when her drinking was more manageable and her outlook more positive.

02 Safeguarding ConcernsAlcohol misuse

Domestic Abuse

Inconsistent engagement with support services

04 Findings SummaryThe coordination of support services to A was compromised by the number of individuals, agencies and forums involved with her or monitoring her situation, lack of linkage, terminology purpose of meeting action review

Responses to changes in A’s situation and behaviour were made to the ‘presenting issues’ rather than to a holistic and multi-agency assessment of her social and health care needs, situation and desired outcomes.

05 Findings SummaryChildren’s Services and Adult Social Care to review established processes and procedures where adults with social and health care needs have children who are receiving services from Children’s Services

A met the criteria for inclusion in the Care Programme Approach, but care and support was not managed under this framework which would have enabled the coordination of the services offered/provided to her.

Clarity needed on the purpose/actions and review process of Multi agency meetings

06 Reviewing your own Practice/cases Is Self-Neglect an issue?

Have I looked beyond the presenting issues?

What other agencies are involved?

I am clear what the plans are?

I have been invited to a multi-agency meeting, am I clear what the purpose is ? Section 42 Strategy , VARM, JAG etc

Are there any children involved?

03 Key Learning ThemesAssessments need to demonstrate ‘professional curiosity’ in looking beyond the ‘presenting issues’

Self-Neglect – Consider the use of the Vulnerable Adults Risk Management (VARM) process when the service user has Mental Capacity, refuses services but at risk of significant harm

Mental Capacity (MCA) – Consider application of the MCA where capacity may be compromised by substance misuse

Care Programme Approach would have offered a pathway for planning and review

07 Raising your Awareness All information is found http://www.llradultsafeguarding.co.uk/

Mental Capacity Act

Application of the Vulnerable Adults Risk Management (VARM)

Self-Neglect

Children’s Safeguarding Procedures

Alison 32 Safeguarding Adult

Review 7 Minute Briefing

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01 BackgroundBert, who was in his mid-60s, experienced an acute mental health crisis one weekend. The Police were called and remained with him whilst a Mental Health Act assessment was being arranged. There was significant delay in convening the assessment due to the capacity of the assessment team. Once they arrived, there was confusion about whether a bed was available for Bert, which prevented the assessment being concluded, and the team took the decision to leave Bert in his home whilst a bed was being sourced, believing that he would not leave. A warrant was to be obtained to take Bert from his home once the Court opened in the morning. Bert subsequently left his property and died in a traffic accident.

02 Safeguarding Concerns• Delays in convening the Mental Health Act assessment

• Miscommunication about bed availability

• Some tension between the professionals involved with Bert

• Implications for Bert’s safety of being left alone

04 Findings Summary• Limited Approved Mental Health (AMHP)

Professional and on-call Drs to carry out MHA assessments out of hours

• Reduced availability of crisis services such as the Mental Health Triage Car out of hours

• Stretched police resources

• Lack of a bed manager out of hours to coordinate beds

• Mis-communication surrounding bed availability and the need to continue sourcing a bed

• Lack of clarity in the communication between police, AMHPs and Drs regarding actual risks; roles and responsibilities in managing those risks

05 Findings Summary• Confused communication surrounding whether the Mental

Health Act assessment had concluded or whether a new assessment was required

• Need for joint response to provide interim care while awaiting admission

• Poor system to access to AMHP out of hours; limitations of managerial support

• Lack of resilient systems to coordinate beds

• Limitations of policies and protocols to support joint working

06 Multi-Agency Recommendations Overview• Learning from this review should be used

to inform the strategic work of the agencies involved (for Local Authority, Health, Clinical Commissioning Group)

• Access to acute mental health inpatient beds (for Health, Clinical Commissioning Group and Local Authority) to be examined

• Agencies contributing to this SAR should consider what additional training and guidance is indicated from the learning

03 Key Learning Themes• Mental Health crisis care availability

• Bed availability and management

• Availability of interim care arrangements to manage risk where admission is necessary, but no bed is available

• Risk assessment and management

07 Changes Resulting from the Review• Training provided by AMHP team leader to duty

managers

• Updated guidance delivered to AMHPs for when a bed is not available

• De-escalation and resilience training delivered to AMHPs

• Improved bed management system implemented by Health

• Strategic oversight route for mental health issues

Bert, 67 Adults Review

7 Minute Briefing

01 03

0407

0506

02

02 Safeguarding ConcernsDehydration as a contributing factor in Annie’s death

Management of End of Life Care

Poor communication between: Staff and Annie, Home Manager and GP, Family and GP

Application of the Mental Capacity Act MCA) Principles

04 Findings SummarySpeech and Language Therapy (SALT)

The Care Home could have referred for an assessment and did not need to wait for the GP to do it. SALT is not just about swallowing but exploring methods of communication.

How did Annie communicate her wants/needs and distress?

05 Reviewing your practiceHave methods of communication been established with the resident?

Are Care Plans up to date and understood?

Are End of Life plans in place ( if appropriate) and clearly communicated to care staff and family.

06 Reviewing your practiceHas decision making followed the Principles of the Mental Capacity Act?

03 Findings SummaryApplication of the MCA and its Principles

There was no evidence of any efforts to establish communication with Annie (MCA principles)

Best Interest Assessment decisions appear to have been taken by family and GP without using an independent person to represent Annie’s views in line with practice and procedure

Role of Family

GP relied solely on the opinions of the family to inform the decision making

Care Planning including End of Life

There appears to be lack of clarity as to whether the patient had a ‘end of life’ plan, it is not clear when or how this decision was made, no record of any discussion re end of life.

Artificial Nutrition and Hydration (ANH) and PEG

Lack of understanding of ANH in end of life care. Confusion regarding whether the PEG was working and no recourse to expert opinion. The lack of fluids surpassed the length of time one would normally expect for someone nearing the end of life.

07 ActionsEnsure staff are familiar with Artificial Nutrition and Hydration (ANH) guidance https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/treatment-and-care-towards-the-end-of-life/about-this-guidance

Ensure staff are aware of the role of her Speech and Language Therapy (SALT) service

Ensure appropriate training is undertaken on the application of the Mental Capacity relevant to role

Annie, 92 Safeguarding Adults

Review 7 Minute Briefing

01 BackgroundAnnie aged 92 had Alzheimer’s, a history of heart disease and had been in receipt of care at home including respite. A stroke in 2016 had resulted in left side paralysis, speech and swallowing difficulties.

Annie had been a business woman, a mother to two adult children, a grandma and great grandma.

Annie was admitted to a Nursing home via hospital. A Percutaneous Endoscopic Gastrostomy (PEG) in her stomach allowed for nutrition via a tube.

Annie died 2 weeks later due to several complications related to her stroke, however she was also dehydrated. A palliative care expert said ‘The care given in this case did not meet the required level’

7 Minute Briefing Action Plan

Title of 7 Minute briefing

Name of organisation Team Manager

Name of section and team Contact Details

Identify the learning or recommendations that are relevant to your team and your team’s discussion on those points

1

2

3

Please ensure that you keep a copy of this discussion and plan for your records

Action Plan

What actions have been agreed to improve practice?

What needs to happen? Who will do it? By When? How will you know when this has been done?

How will you know if it has worked?

Please ensure that you keep a copy of this discussion and plan for your records