1. What is Frailty?

The term frailty or ‘being frail’ is often used to describe older people.

People who are frail often have reduced muscle strength and so get more tired easily (fatigue). They may find it much harder to recover from health issues such as a urinary tract infection or leg ulcers.

Frailty describes a person’s overall stamina and how this relates to their chance of recovering quickly from health problems. Approximately 10% of people aged over 65 are frail. In those aged 85 and over, this increases to 25-50% (Age UK).

People living with frailty may or may not have other major health conditions. Being frail can be seen as a fairly ‘minor’ health problem, but in reality it can have a severe and long term impact on a person’s physical and mental health and wellbeing.

2. Frailty and General Health

There are a number of health conditions that are associated with being  frail. Where staff from different organisations are working with a person, their carers and family, the overall aim should be that the person’s frailty does not result in poorer health outcomes for them (see Promoting Wellbeing and Preventing, Delaying or Reducing Needs chapters). It is important that a well-planned, joined-up care package is in place to prevent problems arising in the first place and provide a rapid, specialist response if their situation changes.

Where frailty is a concern, the following should be assessed and monitored on an ongoing basis as part of the person’s care and support plan (see Care and Support Planning chapter):

  • general health;
  • malnutrition and dehydration;
  • bladder and bowel problems;
  • dementia;
  • delirium (confusion);
  • mental health;
  • risk of falls.

2.1 General health

As people age their health needs change, but there are practical steps people can take at any age to improve their health and reduce their risk of frailty.

All aspects of a person’s health should be addressed as part of their general health needs. These include:

  • looking after their eyes;
  • looking after their mouth and teeth;
  • keeping active;
  • getting the right medicines;
  • getting vaccinations;
  • preventing falls;
  • looking after their hearing;
  • eating and drinking well;
  • looking after their bladder and bowels;
  • keeping mentally healthy;
  • keeping their brain active.

There are other issues that affect a person’s general health, including:

  • keeping warm;
  • making sure their home environment is safe;
  • preparing for winter as well as for heatwaves;
  • caring and looking after themself.

Information about all of these issues can be found in A Practical Guide to Healthy Ageing (NHS and Age UK). 

2.2 Malnutrition and dehydration

Having a balanced diet and sufficient (non-alcoholic) fluids are essential to keep well. This is particularly important for someone living with frailty.

Malnutrition affects approximately 1 in 10 older people and is a risk factor for becoming frail. It is a serious condition where a person’s diet does not have the right amount of nutrients. This could be due to not getting enough nutrients (undernutrition) or getting more than is needed (overnutrition). Both these factors can contribute to health conditions. Nutrients are important to maintain physical health and promote healing after injury or illness.

People who are malnourished are more likely to visit their GP, have hospital admissions and take longer to recover from illness or operations. If an older person loses weight, whilst it could be due to health conditions, it may also be a result of being malnourished.

Older people are also more at risk of dehydration, where the body loses more fluid than it is taking in. Symptoms of dehydration include:

  • feeling thirsty;
  • having dark yellow and strong-smelling urine;
  • feeling dizzy or lightheaded;
  • feeling tired;
  • having a dry mouth, lips and eyes;
  • not passing much urine – fewer than four times a day.

Dehydration is one of the most common reasons why an older person is admitted to hospital. It is also associated with increased risk of urinary tract infections, falls and pressure ulcers.

If it is suspected that a person who is frail is malnourished or dehydrated, with their permission (or their relevant person) their GP should be informed as soon as possible.

If the person is likely to become malnourished or dehydrated, ensuring sufficient intake of nutrition and fluids should be included in their care and support plan including working with the person to ensure they have food and drink that they like and can tolerate.

2.3 Falls

Falls can be common in older people and can result in serious health issues. Once someone has experienced a fall, particularly if it has resulted in a significant injury, it can be a main cause of loss of independence and even eventually going into long-term care. After a person has had a fall, the fear of falling again can result in a loss of confidence and self-esteem which can lead to them becoming increasingly inactive, this in turn leads to a loss of strength and a greater risk of further falls.

Working with someone to prevent them falling or from having further falls can include a number of simple practical measures such as:

  • making simple changes to their home;
  • ensuring they have the right medication;
  • ensuring they have the right prescription glasses; and
  • doing regular exercises to improve their strength and balance.

See Falls Prevention (NHS)

2.4 Bladder and bowel problems

Urinary and bowel incontinence and constipation are very common, particularly in older people. However, embarrassment and stigma about these issues mean people often delay seeking help and support. These conditions in older people are often poorly managed and can cause them a lot of distress. Not enough of an appropriate diet and fluids can also impact on a person’s bowel and urinary problems.

If there are concerns that a person who is frail is suffering incontinence or constipation, they – or their relevant person – should be supported to speak to their GP.

For further information about these issues, visit the websites below:

Urinary incontinence – NHS

Bowel incontinence – NHS

Constipation – NHS

2.5 Dementia

More than 850,000 people in the UK are estimated to be living with dementia. People who are living with frailty and who also have dementia are at increased risk of poor health as a result of not being able to care for themselves adequately, particularly if they are living alone.

For further information see Dementia: Practice Guidance chapter.

2.6 Delirium

Delirium is an episode of acute confusion. It can often be mistaken for dementia, but it is often preventable and treatable. Older people are more at risk of developing delirium and it can be quite common (particularly for those who have cognitive impairment, severe illness or have broken their hip or have a urinary tract infection for example).

Older people with delirium may have longer stays in hospital, have an increased risk of complications such as falls, accidents or pressure ulcers and be more likely to be admitted into long-term care. There is also a high mortality rate associated with delirium. It is therefore very important to recognise and treat delirium as early as possible, to avoid these complications.

For further information please see these websites:

Confusion (NHS) Sudden confusion (delirium)

Delirium – sudden confusion (Dementia UK)

2.7 Mental health problems

Mental health problems such as depression and anxiety can be quite common for older people, and can have a major impact on their quality of life. Mental health problems in older adults may not be reported and so often go undetected and are therefore under-treated.

Where an adult who is living with frailty is suspected of having mental ill health issues, they may be supported to speak to their GP or other relevant agencies.

See also Your mind matters (Age UK)

 3. Related Issues

3.1 Loneliness and social isolation

Many elderly people suffer from loneliness. This can have a serious effect on their mental and physical health and wellbeing.

Loneliness and social isolation can have additional negative impact on someone who is already living with frailty. There are different ways that loneliness can be addressed, depending on the needs, wishes and interests of the person. Discussions should take place with them to see what local services are available to support them to feel less lonely and isolated.

For further information see Elderly Loneliness (Age UK)

3.2 Physical activity

The benefits of physical activity for older adults is well evidenced, with multiple health benefits including promoting general health, improving cognitive function, lowering the risk of falls and reducing the likelihood of developing some long-term conditions and diseases.

Depending on the needs, wishes, interests and physical ability of the person living with frailty, there will be different options and organisations for them if they want to get involved in activities in their local area.

See also Being Active as you get Older (Age UK)

3.3 Safeguarding

People who are frail may experience, or be at risk of, abuse or neglect. This may be a result of their frailty or in combination with other mental or physical health conditions. They may be directly targeted by perpetrators who perceive them to be vulnerable or suffer unintentional abuse. Abuse may be committed by people they know such as family, friends or carers or by strangers.

People living with frailty may experience health and social care services that are not suited to their individual needs. They can also be vulnerable to receiving poor quality healthcare and services. In such circumstances they or their relevant person should be supported to make a complaint, as appropriate, to ensure that they receive the care and support to which they are entitled. This may need to involve the local authority and / or the Care Quality Commission if there are safeguarding concerns related to a service provider. For further information see Safeguarding Enquiries Process Section.

3.4 Supporting people at the end of life

Advanced care planning is key to ensuring a person who is frail receives good, personalised care at the end of their life. People should be encouraged to have proactive discussions about their wishes for care at the end of life as early as possible and their wishes recorded. These discussions should include advance decisions to refuse treatment and do not attempt resuscitation decisions.

See the chapter on Planning Ahead for Health and Social Care Decisions.

4. Living with Frailty

People living with frailty can be supported to live as full a life as they wish and are able, although this may mean they need to adapt how they live their life and find new ways to manage daily tasks and activities. This may apply to their family and friends too.

If someone is living with frailty, it does not mean they lack mental capacity (see Mental Capacity chapter) or cannot lead a full and independent life. Just because a person is frail does not mean that they cannot make decisions about their daily life or wider issues such as finances and where they live for example. They may need some practical support to put those decisions into practice however, where they may have physical difficulties for example in achieving those goals.

Frailty can deeply challenge a person’s sense of themself as well as change how they are perceived and treated by others, including health and care professionals. Ensuring they receive person centred care and their wishes and desires are listened to and acted upon wherever possible therefore, is key to their sense of self-esteem and ongoing enjoyment of life.

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Please note: If the issue concerns an NHS contracted service or care provision this will be dealt with by the defined NHS quality assurance process. Assurances and updates will be fed back into intelligence sharing meetings.

RELEVANT INFORMATION

Deciding if You need to Raise a Safeguarding Concern to the Local Authority (Flowchart)

Stage 1: Decision Making Process to Initiate the Managing Safeguarding Concerns at an Organisational Level Procedure

1.1 Collating inter-agency intelligence.

1.2 Multi-agency information and concerns raised via a number of methods and sources:

  • local authority led multi-agency intelligence meetings;
  • concerns raised from partner organisations;
  • consistent number of S42(1) related to the same service provider;
  • consistent Health Safeguarding Datix related to the same service provider;
  • quality of Consideration Logs.

Organisational concerns of a significant or critical nature should progress to a recommendation to DASS to invoke the Managing Safeguarding Concerns at an Organisational Level procedure.

1.3 When there is a body of information or sufficient risk to indicate proactive steps are required these will need to be considered against the Safeguarding Adults Thresholds Guidance Tool, notwithstanding any immediate risks being managed. A formal multi-agency meeting will be held to consider all information and intelligence to support the group in making a recommendation on action to take to the DASS.

This and subsequent meetings will be minuted to demonstrate the evidence and the level of concern to the DASS prior to initial decision making.

Note: Those that are of low concern will be dealt through other channels e.g. multi-agency intelligence meetings / agencies internal processes such as quality assurance / contract monitoring arrangements.

1.4 Recommendation made to Director of Adult Services (DASS)

1.5 DASS / Deputy to make decision and appoint a Lead Officer with immediate effect of agreeing the recommendation.

1.6 Role of Lead Officer: The Lead Officer will work with the Adult Safeguarding Coordinator to ensure a multi-agency Organisational Safeguarding Concerns Meeting is convened within appropriate timescales and involves all relevant agencies. The Lead Officer role includes ensuring timescales and targets are set, work is progressed according to plan, evidence is collated and there is effective document control.

The Lead Officer will be responsible for alerting the Organisational Safeguarding Enquiries Group, through the Chair, of any new risks / risks to achieving targets and plans and will take a key role in the Communication Strategy. In addition, where applicable, they may oversee the fact-finding process and / or organise people engagement to gain views and desired outcomes

1.7 Inform the organisation within one working day of the decision to enter the Managing Safeguarding Enquiries at an organisational level process. Any exceptional circumstances (for example police / coroner involvement etc) should be discussed with Lead Officer / DASS.

Stage 2: Initial Organisational Safeguarding Enquiries Fact Finding Meeting (Pre-meet) Organisation Joins Second Section

Look at Presenting Evidence / Immediate Risk Mitigation

2.1 Organisational Safeguarding Concerns Meeting organised within five working days of the DASS agreement to proceed. To include all relevant partners including the organisation to share information in order to assess risk / identify gaps in the information which is essential for providing assurance of the level of care and dignity provided:

First part of meeting to:

  • identify and clarify the totality of the level of concerns and any presenting risks from a multi partner perspective;
  • consider the scale and impact of any immediate risk management plans which have been implemented;
  • if appropriate, consider the organisations initial response;
  • if appropriate, consider latest CQC or quality monitoring reports.

Second part of the meeting to:

  • provide evidence and rational for the Safeguarding Enquiries on an organisational level process;
  • listen to the views of the organisation in question;
  • agree safeguarding planning; to consider and agree type of enquiries / leads /  timescales;
  • determine future risk management strategy and draw up quality assurance* and Communication Strategy** ;
  • consider protective actions for those currently in receipt of care and/or services from the organisation to be assured that acceptable levels of care / service are being received. If self-funding applies the locality in which organisation is based is responsible for offering reviews to those self-funding;
  • identify and agree on the quality assurance factors including how outcomes will be measured;
  • identify the outcomes of the process.

* Quality Assurance Strategy: It is important that the outcomes the person, families or friends want to see within the service provision are determined and every effort to achieve these outcomes; this may involve, for example, including changes suggested into the service improvement plan. For this reason, it is important a meeting is arranged early on in the process to identify these outcomes and quality assurance of evidence is benchmarked as to whether they meet this.

**Communication Strategy: outlines how, when and who information will be provided to and from to ensure all information is processed and acted upon to safeguard -people.

Stage 3: Findings Meeting

3.1 Findings Meeting organised no longer than 14 working days of the initial Managing Safeguarding Enquiries at an organisational level meeting. The purpose of the meeting is to:

  • assess and agree the findings from ‘fact finding’ enquiries;
  • draw up issues for a service improvement plan;
  • update the risk management plan and agree any further safeguarding measures;
  • consider actions to monitor the safety of people and agree triggers to escalate risk, whilst improvements are being made;
  • consider commissioning intentions;
  • preserve information that may be helpful to police investigations.

3.2 The organisation is expected to develop the Improvement Plan within 48 hours of this meeting.

3.3 The Improvement Plan should be shared with the Lead Officer and DASS and once finalised disseminated to applicable multi-agency partners by the Safeguarding Coordinator ahead of any future meetings.

Project Management Meetings

3.4 The Lead Officer will meet with the organisation throughout this stage of the process. The frequency of meetings should be agreed in advance and based on needs, but a general guide is weekly in the beginning to support the organisation with the embedding of change and to assure the immediate improvement of high-risk needs.

3.5 These meetings present an opportunity to review in depth the Organisation Improvement Plan, highlighting areas of high risk for focus. The Organisation Improvement Plan is key in this process, as it sets out clearly the expectation in respect to areas for improvement, timescales and the measurement of evidence required which will be quality assured.

3.6 Organisation Improvement Plans allow the Organisational Concerns Group and organisation to have oversight of the areas which are progressing and those still requiring completion.

3.7 The Organisational Concerns Meetings also provide an opportunity for the organisation to identify areas they feel improvements have been made or request for additional support. As an example, the Organisational Concerns Group may be able to assist with identifying trainers, examples of best practice recording tools or specialist services the organisation can link to for ongoing service support.

3.8 As change continues to be embedded, the frequency of the Organisational Concerns Group Meetings / Visits can be reduced.

3.9 The Lead Officer should provide feedback to the Chair on progress with the Organisational Improvement Plan, which will be shared with the Organisational Concerns Group via update meetings.

Stage 4: Update Meetings

4.1 Update Organisational Concerns Meetings will be held as and when required but are likely in response to areas of risk not being managed or corrected by the organisation. As risks are brought to the attention of the chair and the Organisational Concerns Group, update meetings are held in response to bring together senior level resources and expertise from across the partnership which can assist in resolving barriers.

4.2 Update Organisational Concerns Meetings will consider risk which will address the probability of risk and the likely impact of risk on the safety of people who use the services of the organisation. The meeting will consider if is it unsafe for people to continue to receive a service from the organisation; furthermore the meeting will also consider the risks of moving people to an alternative provision.

4.3 In cases where it has been assessed that the risk of continuing placements or allowing residents to stay in a placement are too high, consideration should be made as to suspension of placement and / or removal of residents.

Stage 5: Quality Assurance

5.1 Quality assurance of the improvements and their sustainability will be undertaken throughout the Managing Safeguarding Enquiries at an organisational level process. Feedback from people who have used a service and their carers will act as control measures to assess whether there has been noted difference in the organisations service delivery. An organisation will seek feedback from family and friends that the service has improved, these will be collated and included within the quality assurance strategy.

5.2 This process may be useful for planned quality assurance activities which are above and beyond those being undertaken throughout the process i.e. support from local Healthwatch or a degree of independent scrutiny as an activity.

Stage 6: Closing the Organisational Safeguarding Concerns Process

6.1 The final meeting considers the current level of risk, the sustainability of changes and feedback from people who use services and their relatives / friends.

6.2 Feedback obtained from the Quality Assurance Strategy will evidence whether the level of improvement and change that has taken place. These quality assurance activities may include, for example:

  • validation of organisation improvement plan by social care or health professional;
  • feedback from people who use services from the organisation, family and friends;
  • review by third party, such as partner Local Authority.

6.3 Upon an agreed from the Managing Safeguarding Enquiries at an Organisational Level Group decision that satisfactory improvements that are sustainable has been achieved, the Managing Safeguarding Enquiries at an Organisational Level Group responsibility will come to an end and the relevant parties, including the organisation, will be formally notified by the Chair within 24 hours of the meeting.

Organisation Learning

6.4 The Managing Safeguarding Enquiries at an Organisational Level Group may consider whether an organisational Learning Meeting is required. If this is agreed, the Lead Officer will convene a Learning Meeting, which the organisation will also be invited to.

6.5 The aim of the meeting is to establish what went well and what could be helpful to inform any future project and what might have been done differently.

6.6 Organisational learning identified through people who use services, families or their friends should be included, linking in to how outcomes they identified could be achieved and can be shared with other organisations to improve the prevention of abuse and quality of services.

6.7 Any lessons learnt can be fed into the safeguarding multi-agency training offer, commissioning cycle, improve the safeguarding adults’ function and raise awareness with other staff members. Any changes made to practice, improving the quality and safety for people who use organisations, can be disseminated within organisations bearing in mind the need for confidentiality.

Review

6.8 Contract monitoring review by the commissioning body is required in order to ensure that the improvements have been sustained. This should take place within three months of the initial submission of the Improvement Plan and be supported by evidence generated in the Project Management Meetings.

Appendices

1. Initial Organisation Concerns Meeting Agenda

Click here to view Initial Organisation Concerns Meeting Agenda

2. Initial Organisation Safeguarding Concerns Meeting Agenda with Guidance

Click here to view Initial Organisation Safeguarding Concerns Meeting Agenda with Guidance

3. Organisation Safeguarding Concerns Meeting Agenda

Click here to view Organisation Safeguarding Concerns Meeting Agenda

4. Managing Safeguarding Concerns at an Organisational Level Meeting Agenda with Guidance

Click here to view Managing Safeguarding Concerns at an Organisational Level Meeting Agenda with Guidance

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 1. Introduction

Autistic adults may have been diagnosed as a child, or when they are older. Some may not have been diagnosed at all; this may be because they do not realise they are autistic, have not have wanted support or have not felt able to speak to anyone about it.

Many people learn to cope with autism in their own way, although this may not be easy. They may be married or living with a partner, have families and successful careers. Others may be socially isolated, especially if they find it difficult to spend time with family or make friends.

This chapter is a summary of some of the main issues that staff need to consider when working with an autistic adult, to help ensure their needs and wishes are identified and taken into account and adjustments are made as required so they can participate fully in decision making. It also provides additional references and website links.

2. What is Autism?

Autism affects how people communicate and interact with the world.

The cause of autism is unknown, or if in fact if there is a definite cause. More than one in 100 people are autistic, and there are around 700,000 autistic adults and children in the UK (National Autistic Society). Whilst people from all nationalities, cultural, religious and social groups and be autistic, more males are diagnosed than females, but this may be a result of under-diagnosis in females.

Autism is not an illness or disease; it cannot be ‘cured’. It is a lifelong condition, and some people feel that being autistic is an important part of their identity. Autism  may not be visible and therefore can be easily missed  (see Working with Adults with Hidden Disabilities chapter).

All autistic people can learn and develop. Getting the right support and understanding makes a huge difference to autistic people.

3. The Autism Spectrum

See also What is Autism? (National Autistic Society)

Autism is a spectrum condition; there is a wide variation in the type and severity of symptoms that people can experience. All autistic people share are affected in different ways.

‘Autism spectrum disorder’ (ASD) or, more simply, autism is the commonly used term.

Autistic people may:

  • find it hard to communicate and interact with other people;
  • find it hard to understand how other people think or feel, and find it how to say how they feel themselves;
  • find it hard to make friends or prefer to be on their own;
  • seem blunt, rude or not interested in others without meaning to;
  • be highly focused on interests or hobbies;
  • be over or under sensitive to light, sound ,taste or touch, finding them stressful or uncomfortable;
  • get very anxious or upset which can lead to meltdowns or shutdowns;
  • take longer to understand information;
  • do or think the same things over and over and feel very anxious if their routine changes, resulting in repetitive and restrictive behaviour.

Autism is not a learning disability, and autistic people can have any level of intelligence. However, autistic people may have other conditions (see Section 4, Other Conditions), which will mean they need different levels of support.

4. Other Conditions

Other conditions that can also affect autistic adults include:

  • Attention deficit hyperactivity disorder (ADHD);
  • dyslexia and dyspraxia;
  • problems sleeping (insomnia);
  • mental health problems;
  • learning disabilities;
  • epilepsy;
  • problems with joints and other parts of the body, including:
  • flexible or painful joints;
  • skin that stretches or bruises easily;
  • diarrhoea or constipation.

For more information on these conditions see Other Conditions that affect Autistic People (NHS)

5. Assessment and Diagnosis

If someone thinks they may be autistic and wants to speak to someone about it, they should make an appointment to see their GP. If you think an adult you are supporting may be autistic, the National Autistic Society has advice on how to discuss this with them (see Broaching the Subject).

They may be referred to a specialist for an autism assessment (see What happens during an Autism Assessment, NHS).

An autism diagnosis can be a daunting time, and may come as a shock, but for others it is a relief to find out why they think, feel and act the way they do.

Autism is not a medical condition that can be treated or cured, but following assessment, autistic people can benefit can access appropriate support and interventions, and adjustments can be made to help them stay well and have a good quality of life.

See also Newly Diagnosed: Things to Help (NHS)

Assessments and care and support plans should be reviewed and revised if it is felt that a person’s condition, or related conditions, are either deteriorating or improving. In addition, under the Equality Act 2010, services should make changes to the way they are delivered to ensure they are accessible to autistic people and people with other disabilities. The changes are called ‘reasonable adjustments’. Autistic people should always be asked if they require reasonable adjustments, and details of these should be clearly recorded and referred to each time the person accesses the service. Reasonable adjustments should be reviewed to ensure they continue to reflect a person’s circumstances.

6. Working with Autistic Adults

Autistic people can live a full life; it does not have to stop anyone having a good life. Like everyone else, autistic people have some things they are good at as well as things they find more of a challenge. A strengths-based assessment (see Section 5, Assessment and Diagnosis) should reveal these and be included in the person’s care and support plan, alongside any ‘reasonable adjustments’ to the way services will be delivered.

Everyone is different, but there are some common characteristics that staff should consider when communicating and working with an autistic person.

  • Personalisation: Make sure the person is at the heat of all decision making, work with them to identify their unique abilities and challenges, and then work alongside them to achieve their (self) identified needs;
  • Communication: Staff should remember that the person may find it difficult to communicate and interact with other people. Staff should understand that what the person says and how they say it may well be a feature of their condition. They should give the person time to communicate and be calm and considered in their communication with them.
  • Understanding: The adult may find it difficult to understand how other people think or feel, therefore staff should remember that they may not be deliberately unfeeling or uncaring, but they are not able consider other people in the way that others do.
  • Suitable environment: Staff should ensure that any meeting or intervention with an autistic person does not take place in a noisy or over-stimulating environment. If they meet the person outside the workplace, they should find out from them what type of place they like to go, that is manageable for them and does not cause them additional stress.
  • Anxiety: Autistic people can get anxious or stressed about unfamiliar situations and social events. Staff should take this into consideration when working with someone and plan interventions or meetings accordingly.
  • Presenting information:  Autistic people may take longer to understand information that is presented to them. Staff should give them additional time to process information and provide it in easy read formats or give other assistance where required. They should also check with the person that they have understood what is being communicated, both at the time and also check their understanding again at later dates.
  • Take time: Autistic people may do or think the same things over and over again. Staff should bear this in mind when working with autistic people, and build additional time into their meetings and visits so that the person does not feel pressured to be quicker than is comfortable for them. Attempts to rush them may result in them feeling stressed which in turn may negatively impact on other behaviours.
  • Training: Training is important, as it helps to ensure that staff have the right skills and knowledge to be able to provide safe, compassionate, and informed care to autistic people. The Health and Care Act 2022 introduced a requirement for regulated service providers to ensure that their staff receive training on learning disability and autism which is appropriate to their role. The Oliver McGowan mandatory training on learning disability and autism is the government’s preferred and recommended training for staff to undertake. The training is delivered in two parts: Tier 1 is for people who require general awareness of the support autistic people and people with a learning disability may need, and Tier 2 is for people who provide care and support to autistic people or people with a learning disability. Both tiers begin with an e-learning session. Employers are responsible for ensuring their staff have the appropriate training for their role, and will advise staff on whether they should complete Tier 1 or Tier 2.

7. Further Information

7.1 National organisations and sources

National organisations that provide detailed or further information include:

Social media pages dedicated to issues affecting autistic people include

Facebook:

Twitter:

Forums and communities:

7.2 Local support

Support services in a person’s local area should include:

  • local support groups (this information should be available from the local autism assessment service);
  • the local authority who may carry out a needs assessment with the person;
  • the local authority’s information and advice service;
  • at college or work – speak to student support services or the human resources department about reasonable adjustments which can be made;
  • search for local groups using:
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1. Introduction

It is essential that workers in adult social care and partner agencies who are working with adults with care and support needs, consider and include the needs of all family members when carrying out assessments and developing plans.

There are four steps to the Whole-Family Approach:

  • Step one: Think family;
  • Step two: Get the whole picture;
  • Step three: Make a plan that works for everyone;
  • Step four: Check it is working for the whole family.

This chapter is taken from The Care Act and Whole-Family Approaches (Local Government Association et al) and provides guidance about using the Whole-Family Approach in daily practice. Whilst it is written for local authority workers, it is appropriate to everyone working with an adult receiving care and support services and their families.

2. Step 1: Think Family – Early Intervention and Prevention

Under the Care Act 2014, a whole council, whole-family approach which organises services and support around the adult and their family must be taken. It also means that everyone working with the adult and their family must think about the needs of each member of the family, including any children.

The principle of wellbeing is at the heart of this approach (see Promoting Wellbeing chapter). A vital part of an adult’s wellbeing is the situation they live in, who they live with and their family relationships. It is important to achieve a balance between their wellbeing and that of any family or friends caring for them.

A whole-family approach to promoting wellbeing and preventing need for care and support may include helping the adult and their family to think about what changes may happen in the future, and to plan for these, for example when the adult needs more care or if a carer becomes unwell for example (see Reducing, Preventing or Delaying Needs chapter).

The needs of young carers, for example a teenager who has to look after their disabled mother, are included in both the Care Act 2014 and in the Children and Families Act 2014. This is to make sure all workers involved take a whole-family approach to assessing and supporting the adult and the young carer and delivers support in a coordinated, organised way. See Annex A of The Care Act and Whole-Family Approaches (Local Government Association et al).

In an organisation that thinks family:

  • There should be senior leadership commitment to a whole-family approach with protocols in place so that services can be coordinated.
  • Staff training ensures the skills and referral arrangements are in place so that service protocols are operating ‘on the ground’.
  • Family-related questions are embedded in processes at first contact and subsequently, such as:
    • Who else lives in your house?
    • Who helps with your support and who else is important in your life?
    • Is there anyone that you provide support or care for?
    • Is there a child in the family (including stepchildren, children of partners or extended family)
    • Does any parent need support in their parenting role?
  • There is an active approach to establishing if there are any significant potential changes in families’ lives and working with them to plan for these.
  • Families and carers are an integral part of the design, delivery and evaluation of services and support. (Adapted from the LGA guidance, p. 3)

3. Step Two: Get the Whole Picture – Whole Family Assessment

Getting the whole picture means seeing each person as an individual, as well as recognising the part they play in their family and community. Everyone has something to contribute to addressing the adult’s needs. The Whole-Family Approach builds on everyone’s strengths and develops their resilience. It also promotes working together with carers as partners, as well as the adult and other members of the family and friends where appropriate.

Understanding the needs of the whole family and getting them to think about the outcomes they want to achieve individually, as well as a family is vital. It means the worker can then provide the right guidance, information and services.

Assessment is an important part of the process for everyone. During the assessment, the worker can give guidance and information to help the family understand the situation, their needs and strengths. This can help to reduce or delay any increase in the adult’s needs and make sure that they have support when they need it. The aim of assessment is to get a full picture of the person and their needs and goals, so any carers must be consulted. Carers are recognised in the Care Act, in the same way as those they care for.

In an organisation that gets the whole picture:

  • Information on the assessments and care plans that family members are receiving from other organisations is routinely identified and shared between partner agencies as appropriate. Where possible and appropriate, assessments are coordinated or combined.
  • Proportionate assessments are undertaken in a way that is most appropriate to each family.
  • People providing care and support are identified and involved in assessments to provide their expertise and knowledge and views of what works and what does not.
  • Risks to carers of sustaining their caring role are always considered.
  • Carers’ willingness to continue caring is always established.
  • Where they wish to have one, carers are provided with an assessment carried out by their local council. In such circumstances, the council will consider the carers’ eligibility for support in their own right.
  • In all instances, even when a person can achieve an outcome independently, consideration is given to any impact on others and whether they might be adversely impacting on the health or safety of others, particularly family members and children.
  • At assessment, all of a person’s needs are identified regardless of whether they are being met by any carer.
  • Consideration of the ability to maintain family or other significant relationships, including with any children, and the impact on the adult’s wellbeing of these not being maintained is always considered. This applies to both the person in need of care and support and their carer.
  • When a child may be a young carer, consideration is always given as to whether to undertake a young carer’s needs assessment under section 17 of the Children Act 1989.
  • Assessments of an adult identify any potential child in need who does not have any caring responsibilities. (Adapted from the LGA guidance p. 4)

Where an assessment does identify a potential child in need, the worker should contact their line manager to discuss the situation and a referral should be made to children’s services as appropriate (see South Tyneside Safeguarding Children procedures).

4. Step Three: Make a Plan that Works for Everyone – Developing Plans

When councils and other agencies adopt a whole-family approach to developing care and support plans, this can help to achieve the best outcomes for the whole family. Sometimes, however, a plan can have a negative impact on other members of the family, particularly carers. This is something which must be considered when plans are reviewed.

A whole family approach can also make better use of resources. Sometimes plans are needed for more than one member of the family and from different organisations, for example the Care Programme Approach if mental health services are involved. Plans should not be developed in isolation from one another but should be developed together. If everyone involved agrees, including the practitioners, plans for different family members can be combined to form a single plan in which there may be parts for individual family members as well as the family as a whole. This can be particularly important in making sure that everyone’s wellbeing is being considered and it can also be helpful in addressing any areas of conflict that arise and agreeing a way forward so that everyone achieves what they need, as far as possible.

In an organisation that makes plans that work for everyone:

  • Planning takes into account the wellbeing of all the family and the impact of any services and support on other family members. This includes identifying and responding to situations such as mutual caring, and carers living at a distance or outside of the local area.
  • Planning always involves carers, and consideration is given to the involvement of other family members.
  • Planning considers how carers can be supported to look after their own health and have a life alongside caring.
  • Plans include consideration of support to ensure a carer is able to fulfil any parenting role.
  • Consideration is given to how a person’s circle of support can be developed, where this might benefit them.
  • Plans from different organisations for any family members are identified and consideration given as to whether these can be aligned, coordinated or integrated into a single plan (where all involved agree).
  • Where plans are integrated, a lead organisation is identified to undertake monitoring and assurance. It must be clear when the plan will be reviewed and by whom. (Adapted from the LGA guidance p. 5)

5. Step Four: Check it is Working for the Whole Family – Review of Plans

As with assessment and care planning, wherever possible a whole-family approach to reviews should be taken. It should concentrate on the results that are being achieved by the adult and their family. Workers should consider giving others permission to conduct the review; this could be the person themselves, a carer or someone else.

Workers need to oversee the process and sign off all reviews. Sometimes a ‘light touch’ approach can be helpful in the early stages, which might include a telephone call or asking the adult or another family member to carry out a self-review to check that things are working as intended. Whatever approach is used, it should always include consider any impact of the plan on other family members.

Where the review identifies things that have changed, the plan may need to be updated to include these. Again the adult, their carer and anyone else they want included should be involved. The whole-family approach should make sure that everyone’s needs and wellbeing are considered (including any children), that there are no consequences for anyone that had not been seen in advance and that everyone agrees with the plan.

In an organisation that knows its approach is working for the whole family:

  • The impact of the plan and results being achieved are reviewed in relation to both the individual and the whole family. This includes consideration of any unintended consequences for other members of the family.
  • Consideration is given to any changes that can be made to maximise the benefit to the whole family.
  • Carers’ (including young carers’) needs are routinely reviewed and the support they are willing and able to provide, as well as the outcomes they want to achieve, is re-established.
  • Any anticipated changes in the family that may impact on needs and support are identified and considered in any revised plan.
  • The plan is checked to see that it is providing adequate support to ensure children are not expected to offer inappropriate or excessive levels of care. (Adapted from the LGA guidance p. 6)

6. Tools to use with the Whole-Family Approach

Annex C of The Care Act and Whole-Family Approaches (Local Government Association et al) 

includes some practical tools for working with families which can be adapted and developed for local use. These include:

  • questions to consider including in conversations at initial contact, assessment and care planning stages;
  • whole-family care planning discussion questions;
  • a genogram
  • how to identify support networks;
  • an emergency crisis plan.

Annex D also provides a checklist of key practice points.

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RELEVANT INFORMATION

Northumbria Missing Adults Protocol– Guidance for police and partner agency staff about the joint response to adults at risk of or who have gone missing.

Hospitals Missing Adult Patient Protocol – Outlines the role of Northumbria Police in assisting NHS Trusts to locate and ensure the wellbeing of patients who have been declared missing and there is a genuine concern for their safety.

Herbert Protocol – A national scheme introduced by the police in partnership with other agencies which encourages carers and family members to record useful information, which could be used in the event of a vulnerable person with Alzheimer’s or dementia going missing.

Philomena Protocol – An initiative that helps locate and safely return a young person who is a looked after child (in care) as quickly as possible when they are missing (see also Transition to Adult Care and Support chapter).

Winnie Protocol – A Northumbria Police and Northumberland, Tyne and Wear Safeguarding Adult Boards scheme to encourage carers and professionals to record useful information which could be used in the event of an adult going missing. It is differs from the Herbert Protocol as this can be completed for any adult who goes missing.

Northumbria Police Hostel Policy – This policy explains the process Northumbria Police will use to assess the most appropriate course of action when a person is reported missing from a hostel.  It explains the 8 criteria which will be used to determine whether or not the incident should be closed.

See also Missing Persons, Northumbria Police

November 2023: A link to the updated Northumbria Missing Adults Protocol was added.

 

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This information is relevant to all those working with adults with care and support needs. It outlines different types of hidden disabilities and how staff should be aware of and respond to such issues.

SOUTH TYNESIDE SPECIFIC INFORMATION

Safeguarding: Keeping you Safe from Abuse and Neglect (Easy Read Leaflet)

RELEVANT CHAPTERS

Equality, Diversity and Human Rights in a Safeguarding Context

Mental Capacity

RELEVANT INFORMATION

Councils need to check how they help People with Hidden Disabilities (Local Government and Social Care Ombudsman)

September 2022: Section 2.2, Developmental / neurodevelopmental disabilities and Section 7, Training and Awareness have been revised. Section 6, Hidden Disabilities Sunflower Lanyard is new.

1. Introduction

Not all disabilities can be seen from a person’s outward appearance. Hidden disabilities are sometimes also called invisible disabilities and include, for example, mental and physical health problems and developmental disabilities.

Following an investigation of three complaints against London Councils, the Local Government and Social Care Ombudsman recommended that local authorities should check their procedures to avoid disadvantaging people with hidden disabilities.  This advice also applies to all organisations working with adults with care and support needs.

In each of the cases investigated by Ombudsman, the found that the local authorities did not do enough to help people with hidden disabilities to use their services. This included not making reasonable adjustments to help a woman with autism to repay overpaid housing benefit, and not helping a man with severe dyslexia to deal with parking tickets and permits.

2. Types of Hidden Disability

Whilst there is now a better understanding of some of the conditions that constitute hidden disabilities, it is vital that all interactions with adults, including assessments, are conducted with hidden disabilities in mind. This is to ensure all relevant care and support issues affecting the adult are identified, to ensure they receive the appropriate services relevant to their individual needs. This process is vital to ensure that people with hidden disabilities are not discriminated against, as a result of their disability being missed or reasonable adjustments not being made.

The lists below are not exhaustive; there will be other physical and mental health problems and other conditions that result in hidden disabilities.

2.1 Mental health

For many adults who suffer with mental health problems, their issues may not be immediately obvious and can be misunderstood. Without good working relationships and without a member of staff undertaking a comprehensive assessment with the adult, key aspects of the care and support that they require may be missed and their problems, therefore, could be compounded. Such issues may include depression, stress, bipolar disorder, psychotic and neurotic thought processes and suicidal thoughts.

2.2 Developmental / neurodevelopmental disabilities

Other conditions which can be hidden include:

  • Dyslexia (development of literacy and language related skills affected);
  • Dyspraxia (perception, language and thought processes affected);
  • Attention Deficit Hyperactivity Disorder – ADHD (inattentiveness and hyperactivity-impulsivity);
  • autistic spectrum disorder  / ASD (communication, interaction and relationships with others can be affected).

Adults with such conditions often develop ways of coping which may make it difficult for staff to identify them as disabled. Even when someone can function well in many situations, this does not mean they are not disabled.

Issues to be aware of include:

  • communication issues (verbal and non-verbal);
  • understanding instructions;
  • the speed at which they process things; and
  • interpretation of social situations.

Some of these conditions may also co-exist with other hidden disabilities.

See Autism UK: What is Autism and Related Conditions for more information.

The Autism Act 2009 came into force in January 2010. Under the Act the Government has to publish and keep under review an Autism Strategy, as well as guidance for implementing the strategy which requires local authorities and NHS bodies to act (see Adult Autism Strategy: Supporting its Use; Department of Health and Social Care) and National Strategy for Autistic Children, Young People and Adults: 2021 to 2026 (Department of Health and Social Care and Department for Education).

2.3 Physical health issues

Not all physical health problems are clearly visible. There are many conditions which can be hidden to include hearing and sight impairments, chronic fatigue syndrome / myalgic encephalomyelitis (ME), chronic pain and chronic illnesses such as fibromyalgia, epilepsy, diabetes, kidney failure and sleep disorders.

Such conditions should also be taken into consideration as a hidden disability.

2.4 Other issues for consideration

2.4.1 Mental capacity

See also Mental Capacity chapter

Adult social care staff and other staff working with adults should be particularly mindful in considering mental capacity issues for adults with hidden disabilities when:

  • assessing needs and make care planning decisions;
  • conducting safeguarding enquiries;
  • when there is a dispute over ordinary residence.

2.4.2 Human rights

See also Equality, Diversity and Human Rights in a Safeguarding Context chapter

Article 3 of the Human Rights Act 1998 imposes a duty to take reasonable steps to provide effective protection to children and other vulnerable persons whom the state knows or ought reasonably to know, are being subject to inhuman or degrading treatment (see also Z v United Kingdom Application No 29392/95, (2001) CCLR 310, ECHR).

3. Equality Act 2010

See also Equality, Diversity and Human Rights in a Safeguarding Context chapter

It is essential that people with hidden disabilities are not either directly or indirectly discriminated against, that is they should have the same level of assessment, care and support planning, care and support services and other opportunities as those who do not have a disability.

“The Equality Act 2010 requires councils to anticipate the needs of people who may need to access their services. This means when councils are alerted to the fact someone might need to be treated in a different way, they should ask that person what adjustments are needed, and consider whether these are reasonable…. We recognise the significant challenges faced by public service providers in adapting their processes to the needs of people who may require adjustments, particularly where the services have been automated. But this is a duty councils must meet and needs they must anticipate.” Local Government and Social Care Ombudsman

4. Working with Adults who may have Hidden Disabilities

Staff working with adults should be aware that they, or their carer, may have hidden disabilities, particularly those who are having contact with the service for the first time. It is important to not make quick judgments about a person based on initial communication.

Where there are communication issues or other factors are present that are not otherwise easily explained, staff should consider whether hidden disability / disabilities may be the cause and carry out further investigations as appropriate.

When a hidden disability is discussed with an adult and / or their carer, the member of staff should record both the discussion and the hidden disability in the adult’s case records (see Case Recording chapter). Where the adult already has a care and support plan, this may mean a review is required and adjustments to the plan may be required to respond to the newly disclosed / diagnosed disability which may change the person’s eligible care needs within the care and support plan.

5. Blue Badge Scheme

The Blue Badge scheme has been extended to include people with hidden disabilities, such as autism and mental health conditions, for example.

The criteria have been extended so that people are eligible who:

  • cannot undertake a journey without there being a risk of serious harm to their health or safety or that of any other person;
  • cannot undertake a journey without it causing them very considerable psychological distress;
  • have very considerable difficulty when walking (both the physical act and experience of walking).

This is particularly important for adults who find leaving their house a challenge. This may involve detailed preparations and sometimes overwhelming anxiety about plans going wrong or not being able to find parking spaces. Some autistic people might be unaware of road safety issues or become overwhelmed by busy or loud environments.

For further information see: Running a Blue Badge parking scheme: Guidance for local authorities (UK Government)  and Blue Badge Scheme (South Tyneside Council)

6. Hidden Disabilities Sunflower Lanyard

This is a symbol a person can wear if they have a hidden disability, or on behalf of somebody that does. For example, parents or carers may choose to wear lanyards for the people they support.

A lanyard helps to inform others, health professionals and members of staff in public places, that the person wearing it or someone with them has a hidden disability – this includes autism, chronic pain, dementia, hearing impairment.

Hidden disabilities that are eligible for sunflower lanyard include:

  • a learning disability;
  • sensory loss, including difficulty seeing or hearing;
  • dementia including Alzheimer’s disease;
  • autism;
  • anxiety or any other mental health condition;
  • a physical disability that may not be obvious.

See The Hidden Disabilities Sunflower Lanyard scheme.

7. Training and Awareness

Local authorities and other service providers should ensure they have a disability policy, ensure that staff are aware of hidden disabilities and know how to respond appropriately.  It should be addressed as part of general equal opportunities training.

Other associated training to consider include:

  • autism awareness;
  • disability awareness;
  • mental health awareness.

See NHS Learning Disability Employment Programme.

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RELEVANT CHAPTERS

Managing Risk

RELEVANT INFORMATION

Work Related Violence (Health and Safety Executive) 

This chapter was added to the APPP in January 2020.

1. Introduction

Harassment and violence towards staff can have a direct effect on their health and safety. It can also affect standards of work, performance, confidence, morale of all staff.

Staff in roles most at risk are those who:

  • give a service;
  • are carers;
  • in education;
  • involved in cash transactions;
  • make deliveries / collections;
  • exhibit controlling behaviour towards others;
  • represent authority.

Those committing acts of harassment and / or violence to staff maybe adults with care and support needs, their family or friends or other members of the public. A person who commits such acts may be subject to a police investigation and criminal prosecution or other organisational sanctions, such as loss of service.

Managers and staff have a responsibility to abide by the policies and procedures of the service to:

  • limit incidents of harassment and violence;
  • respond to them appropriately;
  • protect themselves and their colleagues;
  • reporting the incident to the police with a view to prosecution where appropriate.

2. What is Violence and Harassment?

2.1 Violence

Violence to staff is defined abuse, threats or assaults in circumstances relating to their work. This includes:

  • verbal abuse;
  • offensive language;
  • discriminatory or derogatory remarks, for example those which are racist, sexist or homophobic in nature;
  • obscene gestures;
  • threatening behaviour;
  • stalking;
  • physical attacks;
  • spitting; and
  • throwing objects.

2.2 Harassment

Harassment is when a person causes alarm or distress to a member of staff; this can result in the victim being put in fear of violence. It can include repeated attempts to communicate with the member of staff, which are clearly unwanted and contact them in a way that the perpetrator expects to cause them distress or fear.

3. Assessing Risk from Violence and Aggression

The main factors that can create risk are:

  • mental health disorders;
  • impatience;
  • frustration;
  • anxiety;
  • resentment;
  • drink and / or drugs;
  • inherent aggression.

3.1 Violence risk assessments: staff responsibilities

Every adult who has a history of aggression / violence must have a care and support plan risk assessment. This should identify the risks and states the actions to be taken to minimise these risks. This should include family or friends who have such a known history, even if the adult themselves does not present a risk.

Information should be shared with other concerned organisations.

Systems in place to flag high risk cases should be activated.

Risk assessments should be regularly reviewed, care plans updated and actions taken to minimise risks.

Senior managers should be informed of risks and decisions documented and signed on case files.

3.2 Violence risk assessments: managers responsibilities

When carrying out a potential violence risk assessment, the following factors should be considered.

In the workplace:

  • work activities;
  • working conditions;
  • design of the work activities and surrounding environment;
  • frequency of situations that present a risk of workplace violence;
  • severity of the potential consequences to the member of staff who may be exposed to a risk;
  • information on workplace violence based on historical evidence and accurate information;
  • measures already in place to prevent workplace violence.

The wider working environment:

  • description of the department or area the manager or supervisor is in charge of;
  • history of violence in the department / service area;
  • activities in the department / service area that could expose workers to violence;
  • circumstances that might increase the risk of violence in the department / service area;
  • measures in place to address violence and the resources needed to implement them.

3.3 Recording

See Case Recording chapter

It is crucial for the safety and wellbeing of staff, adults and the protection of the organisation and wider community that risk assessments are fully documented. This includes clearly documented management oversight and decision making.

4. Management Responsibilities

Managers must assess the risk of both physical and non-physical assault to staff and take appropriate action to deal with it.

These steps may include:

  • providing suitable training and information;
  • improving the design of the working environment (such as physical security measures);
  • making changes to aspects of staff roles;
  • following the escalation policy of the organisation including reporting high risk cases of potential risk of violence and all incidents of actual physical and non-physical assault so that preventative action can be taken to ensure it is not repeated.

This will also help managers to check for patterns and so help predict the types of incidents that could occur.

Findings from all risk assessments should be communicated to all staff as appropriate, and arrangements need to be put in place to monitor and review such assessments.

Mechanisms should be in place to share learning with staff and across the service.

4.1 Staff support

Depending on the seriousness of the incident, staff who have been the victim of harassment and / or violence should receive robust support from managers and the organisation’s human resources department as appropriate.

This may include:

  • debriefing by the line manager, as soon as possible following the incident;
  • supervision with the line manager for a more indepth examination of the incident and any learning points that arise or further discussion with other colleagues including senior managers;
  • team discussion regarding the incident where appropriate to share learning and any change in practice required;
  • referral for counselling for the member of staff, where required;
  • support for the member of staff and the line manager, as required, in the case of any ongoing police investigation and subsequent prosecution or other internal organisational sanctions taken against the person perpetrating the harassment or violence.

Managers should also ensure that where the perpetrator is an adult who still uses the service, that steps are taken to discuss the situation with them, their behaviour, how they could have responded differently and referral to other agencies for support / interventions regarding behaviour management as appropriate.

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SOUTH TYNESIDE SPECIFIC INFORMATION

South Tyneside Housing Strategies 

RELEVANT INFORMATION

Integrated Health and Social Care for People Experiencing Homelessness (NICE)

Housing LIN (Learning and Improvement Network)

Homelessness: duty to refer – for NHS staff (Department of Health and Social Care)

Capacity and Housing Issues (39 Essex Chambers)

September 2022: This chapter has been updated to include reference to a new category of primary need which was introduced in the Domestic Abuse Act 2021.

1. Introduction

The relationship between local housing and adult and social care departments can be complex because there are often legal and practical difficulties arising from circumstances where vulnerable adults and families fall below or between two legal frameworks. Their needs may not be sufficient to qualify them under the Care Act 2014 (CA) but they may also not meet the criteria for a positive housing decision because they do not have sufficient vulnerability to be assessed as being in ‘priority need’ (see Section 4.2.2, Section 189: Priority Need).

The CA allows the local authority to provide any type of accommodation which may be called ‘ordinary accommodation’, that is “accommodation in a care home or in premises of another type” where they would receive care and support services relevant for their assessed needs.

From an adult social care perspective, the local authority must not meet a person’s care and support needs by taking any action which is required – either by itself or another local authority – under the Housing Act 1996 (HA) or other housing related legislation. A local authority can provide ordinary accommodation under the CA when they are not under a duty to provide that person with accommodation under the HA.

Once the local authority has assessed an applicant’s needs as satisfying the relevant criteria, it must provide accommodation on a continuing basis so long as the need of the applicant remains as the same as originally assessed.

A local authority from an adult social care perspective may provide ordinary accommodation, and any other service within reason, to an adult whom it assesses as needing care and support under the CA; whether or not the local authority uses that power is for it to decide.

See also Appendix 1: Further Information.

2. South Tyneside Homelessness Service

Click on the link to view Homelessness: South Tyneside Homes

3. Safeguarding Concerns

Adults who are homeless may be vulnerable to abuse, whether they are rough sleeping, sofa surfing or in temporary accommodation. For example their lack of stable accommodation can leave them vulnerable to physical, emotional or sexual abuse, criminal exploitation and their possessions vulnerable to theft.

Staff who work with adults who are homeless should be aware of the increased possibility of safeguarding issues, be able to recognise the signs of potential abuse and to take action if they suspect that someone is being abused (see Stage 1: Concerns chapter).

4. Homelessness Legislation

4.1 Housing Act 1996

The main legislation that addresses local authority duties in relation to people who are homeless is the Housing Act 1996. This states the legal requirements that underpin local authority action to prevent homelessness and provide assistance to people who are threatened with homelessness or who are homeless.

In 2002, the legislation was amended through:

  • the Homelessness Act 2002 which means each local housing authority has a duty to undertake a review of homelessness and to develop and implement an effective strategy to deal with homelessness in consultation with both Social Services and other organisations; and
  • the Homelessness (Priority Need for Accommodation) (England) Order 2002 which extended the class of persons with a priority need for accommodation to six additional categories:
  • 16-17 years old;
  • 18-20 care leavers ;
  • vulnerable care leavers;
  • former members of the armed forces;
  • vulnerable former prisoners;
  • persons fleeing violence.

These were introduced to ensure a more strategic approach to tackling and preventing homelessness and to strengthen the assistance available to people who are homeless or threatened with homelessness by extending the priority need categories.

The Domestic Abuse Act 2021 further added to the categories of priority need by extending these to include people who are made homeless as a result of domestic abuse.

4.2 Homelessness Reduction Act 2017

The Homelessness Reduction Act 2017 (HRA) amended the Housing Act 1996.

One of the aims of the HRA is to ensure that all eligible households who are homeless or threatened with homelessness receive genuine and effective advice and assistance to help them secure accommodation. The HRA aims to widen access to homelessness advice and prevention services for all households who are experiencing homelessness or who are at risk of losing their home. It introduced a statutory duty to carry out assessments on all applicants, as well as duties to prevent and relieve homelessness in all cases.

Key sections in the Act are outlined below.

4.2.1 Section 179: Expanded the general duty to provide advice

Local housing authorities have a duty to ensure that advice and information on homelessness prevention and on how people can access help and support when homeless is made available free of charge. The HRA specifies the types of information that have to be made available and requires that advice and information be tailored to meet the needs of the following specific groups:

  1. people released from prison or youth detention accommodation;
  2. care leavers;
  3. former members of the regular armed forces;
  4. victims of domestic abuse;
  5. people leaving hospital;
  6. people living with a mental illness or impairment; and,
  7. any other group that the authority identify as being at particular risk of homelessness in their area.

The local authority can provide this advice themselves or arrange for other agencies to do it on their behalf.

4.2.2 Section 189: Priority Need

A person who is homeless and who approaches the local authority for assistance (known as an eligible applicant) has to fall into one of the priority need categories in order for the local authority to have a duty to obtain temporary accommodation for them. The following people have a priority need for accommodation:

  1. a pregnant woman or a person with whom she resides or might reasonably be expected to reside;
  2. a person with whom dependent children reside or might reasonably be expected to reside;
  3. a person who is homeless or threatened with homelessness as a result of an emergency such as flood, fire or other disaster;
  4. homeless 16 and 17 year olds;
  5. care leavers aged 18, 19 and 20;
  6. a person who is vulnerable as a result of old age, mental illness or handicap or physical disability or other special reason, or with whom such a person resides or might reasonably be expected to reside;
  7. people who are vulnerable as a result of time spent in care, the armed forces, prison or custody;
  8. people who are vulnerable because they have fled their home because of violence;
  9. A person who is homeless as a result of being a victim of domestic abuse. There is no requirement that the person must have ceased to occupy the accommodation for this category of priority need to apply. A person is considered homeless if accommodation is unreasonable to continue to occupy because it is probable that this will lead to domestic abuse against them or someone in the household.

The term ‘vulnerable’ is not defined in the legislation, but the Homelessness Code of Guidance (para 8.16) contains guidance and case law has considered how to define and interpret ‘vulnerable for example, Hotak v Southwark LBC; Kanu v Southwark LBC; Johnson v Solihull MBC [2015] UKSC 30. The Supreme Court judgment decided in these cases a homeless person is in priority need if they are vulnerable compared to the average person, not the average homeless person (Johnson vulnerability).

The test involves comparing the ability of the applicant to deal with the effects of being homeless with the ability of a hypothetical ordinary person to deal with the same situation. In order to be deemed vulnerable, the applicant must be:

  1. significantly more vulnerable than an ordinary person in need of accommodation; and
  2. likely to suffer greater harm in the same situation.

See also Appendix 1: Further Information, The vulnerability test.

Vulnerability in this context relates to a person’s vulnerability if they are not provided with accommodation, not their general ‘need of care and support’.

4.3.3 Section 189A: Assessments and Personalised Housing Plans where the person is homeless or threatened with homelessness.

Local housing authorities must carry out an assessment where an eligible applicant is homeless or threatened with homelessness. This should identify what has caused the homelessness or threat of homelessness, the applicant’s housing needs and any support they need in order to be able obtain and stay in new accommodation.

Following the assessment, the local authority must work with them to develop a personalised housing plan. This should contain actions for the local authority to help them secure new suitable accommodation. A copy of the assessment and the plan must be given to the person, and both must be reviewed whilst the local authority continues to have any duty to them.

Practically, the local authority must try to agree a written list of the actions that each party will take. If they cannot be agreed, the local authority must produce a record of the reasons for the disagreement and detail what steps the local authority will take and those steps expected from the applicant. Until a point at which the local authority decides it does not owe a duty to the applicant, it has to keep the assessment under review, together with the appropriateness of any agreement reached or steps taken.

4.3.4 Section 189B: Relief Duty

The local authority has a duty to provide support and help to all eligible people who are homeless. This is met by helping a person secure suitable accommodation, where they have a reasonable possibility of staying for at least six months. The relief duty can remain in place for up to 56 days. If the applicant is still homeless at the end of this period the local authority must decide what further duty, if any, is owed to them.

The relief duty applies to all eligible applicants who are homeless; it is not conditional upon them being in a priority group.

The local authority can consider a person’s local connection when a relief duty is in place. If they do not have a local connection to the local authority and have a safe local connection to another local authority area, the local authority can decide to refer their case to the other area.

4.3.5 Duty to help to secure accommodation

Housing authorities have a number of duties and powers to secure accommodation for an applicant. The HRA introduces a duty of ‘help to secure’ accommodation for all applicants under prevention and relief duties. This does not mean that the housing authority has a duty to directly find and secure the accommodation, but involves them working with an applicant to agree reasonable steps that they and the local authority will take to identify and secure suitable accommodation.

The prevention or relief duty will be met if any type of suitable accommodation can be found when helping the applicant to secure accommodation. It can often be met by helping them to secure a tenancy; it can also be met by helping them to secure any type of suitable accommodation, including accommodation occupied under a licence.

The local authority can secure suitable accommodation in the following ways:

  1. providing it themselves; or
  2. arranging that the applicant obtains it from some other person; or
  3. giving the applicant advice and assistance so that accommodation is available from some other person (in R v (Miah) v Tower Hamlets LBC [2014] EWHC 1029 advice to meet the duty then ends the duty).

The local authority must provide temporary accommodation for applicants who are in a priority need group whilst it performs the relief duty.

4.3.6 Section 191: Intentionally homeless

A person becomes intentionally homeless if they deliberately do something, or fail to do something that as a direct consequence means they no longer live in accommodation that was reasonable for them to stay in.

The local authority must be satisfied that all five elements of the intentional homeless (IH) test apply.

  1. What did the applicant do or fail to do?
  2. Did it lead to a loss of the accommodation as a consequence of an act or omission?
  3. Was there a termination or interruption in the occupation as distinct from a failure to take up accommodation?
  4. Was the accommodation available for the homeless person’s occupation?
  5. Would it have been reasonable for the homeless person to continue to occupy the accommodation?

A person will also be found to be intentionally homeless if they enter into any arrangement under which they are required to leave the accommodation which it would have been reasonable for them to continue live in, if the purpose of that arrangement was to enable them to claim assistance as a homeless person.

In considering whether a person deliberately becomes homeless the local authority has to ask whether the loss of accommodation would reasonably have been regarded as a likely consequence of that person’s deliberate conduct:

  • ‘deliberate’ relates to the act or omission;
  • ‘likely’ means a real or serious possibility;
  • the link between the act and the homelessness must be judged objectively;
  • the deliberate act must have contributed in some measure to the loss of the home.

There may be a number of causes of the homelessness, some of which may be ‘innocent’ but the applicant will still be IH if the local authority – on the balance of probabilities – is satisfied that homelessness was a likely consequence of a deliberate act. Examples are:

  • the applicant’s tenancy was not renewed by the landlord and was a reasonable result of the behaviour of not paying rent or withholding rent;
  • an applicant guilty of ASB or criminal behaviour is forced to leave their home because of i.e. threats. They are IH because the accommodation would have been reasonable to occupy but for ASB.

Where the homeless person took action or failed to act, there is a good faith test that has to be considered in regard to a deliberate act, that is, was the applicant acting honestly or were they genuinely ignorant of a relevant fact?

If it is decided that a person is intentionally homeless, this limits the duties and assistance the local authority can give them. At the most, if they are also in priority need, they will be provided with temporary accommodation for a reasonable period only. This period – usually around 28 days – is to allow them to make their own arrangements to secure alternative accommodation.

4.3.7 Section 195: The Prevention Duty

The local authority has a prevention duty to provide support and help to all eligible people who are threatened with becoming homeless within the next 56 days. This duty is often be met by providing assistance to enable a person to remain in their current home, where possible, however where this is not feasible it can be met by helping them move to another home in a planned way, without them becoming homeless.

This duty applies to all eligible applicants who are threatened with homelessness, it is not conditional upon the applicant being in a priority group and it does not require an applicant to have a local connection to the area. The duty remains in place for up to 56 days, although it can be longer, if required.

4.3.8 Section 195: A change to the meaning of ‘threatened with homelessness’

Under the HRA, households are considered to be threatened with homelessness if they are considered to be threatened with homelessness in the next 56 days. This period has been doubled from previous legislation in the HA, previously it was 28 days from date they presented for accommodation.

This is to require local authorities to intervene to provide assistance at an earlier stage, so there is increased opportunity to achieve a successful homelessness prevention outcome. The local authority is obliged to take reasonable steps to help the applicant secure that accommodation so it does not cease to be available for their occupation. In deciding the steps to take the authority must have regard to its own assessment.

4.3.9 Section 199: Local connection and a local connection for care leavers

An applicant has a local connection to an area if they are:

  1. normally resident in the area (usually for six of the past 12 months, or for three out of the past five years);
  2. employed in the area;
  3. have family associations to the area; or actual relationships are often considered more important than blood ties
  4. have other special circumstances that give them a connection.

A local connection is determined by the facts and circumstances at the date that the local authority completed its enquiries.

A care leaver aged under 21 who was previously in care in the area for at least 2 years has a local connection, even if they were placed there by another council.

They will also have a local connection if the are under 25 and get advice and support from the local authority Children’s Social Care department under a pathway plan.

If the pathway plan is provided by a county council, the care leaver will have a local connection to every local housing department in the county council area.

4.3.10 Section 213B: Duty to Refer

The HRA introduced a duty to refer, which is placed on other public sector bodies, not the local housing authority. Social care services, including adult social care, are subject to this duty.

The aim of this duty is to help early identification of households who are homeless or threatened with homelessness, and to build on / develop joint working relationships between organisations in order to effectively prevent and relieve homelessness. The following organisations are subject to the duty to refer, and must refer people who they come into contact with, who are experiencing homelessness or who are threatened with becoming homeless:

  • prisons;
  • youth offender institutions;
  • secure training centres;
  • secure colleges;
  • youth offending teams;
  • the probation service;
  • Job Centre Plus;
  • social service authorities;
  • emergency departments;
  • urgent treatment centres;
  • hospitals in their function of providing inpatient care;
  • the Secretary for Defence in relation to former members of the regular armed forces.

The organisation must first have consent from the person they are going to refer. The person must then nominate a local authority in England where they want the referral to be sent. The referral itself will not mean a homelessness application has been made.

4.4 Summary of the main provisions of HRA

  1. The legislation introduces requirements for local housing authorities to carry out homelessness prevention work with all those persons who are eligible for help and threatened with homelessness.
  2. The HRA changes the point at which a person is classed as being threatened with homelessness from 28 days to 56 days.
  3. It makes changes to the way local authorities assess and the point in time in which a person becomes homeless or is threatened with homelessness. The HRA requires local housing authorities to carry out an assessment of the applicant’s needs and that the steps agreed between the local housing authority and the applicant are set out in writing in the form of a personalised plan.
  4. A duty is placed on local housing authorities to take steps for 56 days to relieve homelessness by helping any eligible homeless applicant to secure accommodation.
  5. A further duty was introduced that is owed to certain applicants who deliberately and unreasonably refuse to co-operate with local housing authorities.
  6. The legislation specifies that local agencies should refer those persons who are either homeless or at risk of being homeless to local housing authority teams.
  7. Provisions are made for certain care leavers to make it easier for them to show they have a local connection with both the area of the local authority responsible for them and the area in which they lived while in care if that was different.

4.5 Applying the Equality Act 2010 in regard of Priority Need and Disability

The definition of disability in the Equality Act 2010 (EA) is “a person has a disability if s/he has a physical or mental impairment which has a substantial and long term adverse effect on that person’s ability”.

When making decisions about priority need under the EA, the local authority must ensure it has taken all steps to gather all relevant information relating to the applicant’s mental or physical disability.  Workers should undertake a full assessment interview with the applicant, focus on questions that relate to any physical or mental impairment and ask how the impairment might impact on them if they were to become or remain homeless.

The Supreme Court stated that the EA is ‘engaged’ when making decisions on vulnerability where the applicant has a relevant protected characteristic: age; disability; gender; gender reassignment; pregnancy and maternity; race; religion or belief and sexual orientation. The court accepted that on priority need a protected characteristic will be a disability and these questions should be considered:

  1. What is the extent of the applicant’s disability?
  2. What is the likely effect of the disability on the applicant when taken together with that person’s other problems?
  3. Is the worker satisfied that relevant third party inquiries have been undertaken into any mental or physical impairment to demonstrate that the applicant meets the requirements set down by the EA?

If the applicant is found not to have a priority need category the reasons must be set out.

The local authority may find an applicant comes under the definition for the disability protected characteristic in a priority need, but does not automatically become eligible because they meet the definition.

If a local authority reaches a decision that on the evidence they are not vulnerable, despite coming under the disability protected characteristic, it must justify the decision as a proportionate means of achieving a legitimate aim, which is to meet the obligation set by the homeless legislation to decide when a person’s disability makes a person vulnerable under the EA.

5. Useful Resources

5.1 Homelessness Code of Guidance for Local Authorities

The Homelessness Code of Guidance for Local Authorities provides statutory guidance that all local authorities must consider when carrying out their duties relating to homelessness and preventing homelessness. The code is issued specifically for local authority members and staff, including social care services (see Section 4.3.10, Section 213B: Duty to Refer).

The guidance includes information on preventing and tackling homelessness, including joint working between housing and other services to secure accommodation and provide support. It also covers the duty to refer, although it was published prior to the implementation of the HRA.

5.2 Other useful resources

  • National Homelessness Advice Service NHAS: Useful information and resources for local authority staff, housing providers and members of the public. Requires a log in to access some resources.
  • Shelter Legal: Detailed and useful resources on homelessness applications, legal duties, security of tenure, rents, benefits etc.

Appendix 1: Further Information

  1. Residential accommodation

In R v Kensington and Chelsea RLBC Ex p Kujtim [1999] CCLR 340 CA the Court of Appeal held that residential accommodation could include ‘ordinary’ housing accommodation. A duty to supply such accommodation arose where a person needed care and attention, including housing accommodation when it is not available. The need for care is a precondition for this duty. Although CA uses the phrase ‘care and support’ instead of the term under the National Assistance Act 1948 (NAA) ’care and attention’, it has been held that the case law under the NAA still applies.

In R (SG) v Haringey LBC [2015] EWHC 2579 (Admin) it was held a local authority needs only provide under CA a response to an accommodation related need.

Deputy High Court Judge Bowers “The service provided in a non-home environment, would be rendered effectively useless if the claimant were homeless sand sleeping on the street”.

2. The vulnerability test

The vulnerability test is practically applied by asking the following questions:

  1. What are the person’s problems?
  2. What is the impact of those problems on them?
  3. What is their ability to manage their problems by themselves and with the help of others?
  4. Taking into account investigations from questions 1-3 how would they suffer more harm than an ordinary person without access to a home? i.e. would they suffer more harm than you or I if they were to become homeless?
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1. Introduction

Sections 20 and 21 of the Criminal Justice and Courts Act 2015 are a part of the Government’s response to the public inquiry conducted by Sir Robert Francis QC into the events at Mid-Staffordshire NHS Foundation Trust (Report of the Mid Staffordshire NHS Foundation Trust  Public Inquiry, also known as the Francis Report). There were already offences in relation to the ill-treatment and wilful neglect of adults receiving treatment for mental disorder (under the Mental Health Act 1983) and of those who lack mental capacity. However, there was previously no equivalent specific offence in relation to those being cared for who had full mental capacity (see Mental Capacity chapter).

Under these sections of the Act, it is a criminal offence for an individual to ill treat or wilfully or deliberately neglect a person for whom they care, in their role of being a care worker.

‘Wilful’ means that the care worker has acted deliberately or recklessly in relation to the person who they are paid to care for.

‘Ill-treatment’ is also a deliberate act, where the individual knew that they were ill treating a person, or were being reckless as to whether they were.

Ill treatment and neglect are separate concepts. Ill treatment does not necessarily have to result in physical harm and can involve emotional and psychological damage – that the actions have caused or have the potential to cause to the adult and their family (see case law R v Newington1990, 91 Cr App R 254). It can also include a failure to protect the privacy and dignity of a vulnerable adult when the victim is unaware that they are being ill treated.

These offences apply to both organisations and individuals.

The Care Quality Commission (CQC) has a role to play as the regulator in setting standards and ensuring adults are safeguarded from abuse and improper treatment. CQC can prosecute registered care providers whom they have judged to have breached the standard. Criminal offences only apply to cases of wilful neglect where there is evidence of the worker or organisation acting or omitting to act deliberately, even though they know there is some risk to the adult as a consequence or because they do not care about that risk. Genuine errors or accidents by a care worker should not be caught within these offences.

2. Care Worker Offence

Under the Act a ‘care worker’ means an individual, who, is paid to provide health or social care. They may also be a director or be in a similar post within an organisation that provides health or social care.

‘Paid work’ means when a person is paid for carrying out care (see Appendix 1, Further Information, Paid work).

Health care includes all types of physical health or mental health care provided to adults. This also includes health care in relation to protecting or improving public health, and procedures that are similar to types of medical or surgical care but are not provided in connection with medical conditions which are excluded health care (see Excluded Healthcare) .

Social care includes all types of personal care, physical support and other practical assistance provided for people who need such care or assistance. This may because of:

  • age;
  • Illness;
  • disability;
  • pregnancy;
  • childbirth;
  • dependence on alcohol or drugs; or
  • any other similar circumstances.

This would not include a person who provided such care which was secondary to carrying out other activities.

A care worker found guilty of such an offence could receive a prison sentence of up to five years or a fine (or both); or for a less serious charge a prison sentence of up to 12 months or a fine (or both).

Unpaid family carers and friends cannot be charged with these offences. They may be investigated and charged under different legislation, however.

3. Care Provider Offence

The term ‘care provider’ means:

  • a corporation or association that provides and / or arranges health care (apart from excluded health care – see Section 2, above) or social care for an adult;
  • a person who is not the care provider, but provides health care or social care which has been arranged by the care provider, including where the individual does not provide care but supervises or manages those who do;
  • a director or similar post holder in an organisation which provides health care or social care;
  • a person who provides such care and employs or has arrangements with other people to assist them in providing such care.

A care provider commits an offence if:

  • a care worker who is caring for an individual (as part of the care provider’s arrangements) ill treats or wilfully neglects that individual;
  • if the care provider’s activities are managed or organised in a way which leads to a gross breach of a duty of care by the care provider to the individual who is ill-treated or neglected, and if that had not happened, the ill treatment or wilful neglect would not have occurred or would have been less likely to occur.

A person arranging for the provision of such care does not include someone who makes arrangements under which the provision of such care is secondary to carrying out other activities.

References made to providing or arranging the provision of health care or social care do not include making:

  • direct payments for community services and carers;
  • direct payments for health care;
  • direct payments for care and support.

4. Duty of Candour

See also Duty of Candour chapter

There is a requirement on health and social services to be open and honest with patients and service users when things go wrong. Professionals are expected to be candid with adults who use their services and their families when serious events occur and not obstruct fellow professionals who raise concerns.

The Francis Report recommends that healthcare providers must inform patients or other authorised persons as soon as practicable when they believe that the treatment of care provided has caused death or serious injury to that patient and provide information and explanation as the patient may reasonably request.

It also recommends a duty of candour on individual professionals to inform their employers where they believe or suspect that the treatment has caused death or injury. It is a criminal offence to obstruct a person in the performance of these duties or provide misleading information.

The Care Act includes a duty of candour as one of the requirements for providers registered with the CQC. All providers must act in open and transparent manner with adults who use their services and their families about their care and treatment.

There is also a requirement to notify and provide information and support to the adult or the person acting on their behalf where:

(i) an incident has resulted in or appears to have resulted in the death of an adult who uses the service ; or

(ii) caused severe harm or moderate harm or prolonged psychological harm to them.

The regulations also set out a notification requirement and it is a criminal offence for workers who commit breaches of the duty of candour.

Appendix 1: Further Information

  1. Meaning of Wilful

The meaning of “wilful “has been developed in the case of R v Sheppard [1981) AC the House of Lords  held that a man “wilfully” fails to provide adequate medical attention for [P] if he either

(a)  Deliberately does so knowing that there is some risk that P’s health may suffer unless he receives such attention; or

(b) Does so because he does not care whether P may in need of medical treatment, or not’

  1. Paid work

Paid work does not include:

  • payment in respect of the individual’s expenses;
  • payment to which the individual is entitled as a foster parent;
  • a benefit under social security legislation;
  • or a payment made under arrangements under Section 2 of the Employment and Training Act 1973 (arrangements to assist people to select, train for, obtain and retain employment).
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1. Introduction

Learning from safeguarding adult reviews (SARs) has highlighted the need for staff across all agencies to have a clear understanding about their responsibility for professional challenge and to know how to escalate concerns about decisions made where there are concerns about the welfare and safety of an adult at risk.

This protocol has been developed with the aim of supporting positive resolution of professional difference between agencies working with adults and their families in South Tyneside. Whilst there is generally a good working relationship between agencies and professional difference can be a driving force in developing practice, occasionally disagreements may arise which requires timely resolution so as not to delay decision making.

This guidance is aimed at colleagues across all services and agencies working with adults. It relates specifically to inter-agency disagreement and does not cover disagreement within single agencies which should be addressed by their agency’s own escalation policy.

At no time should professional disagreement detract from ensuring that an adult at risk is safeguarded. The adult’s welfare and safety must remain a priority. Any unresolved issues between professionals should therefore be escalated on the same working day with due consideration to the risks that might exist for the adult.

This protocol must be read in conjunction with the Safeguarding Adults Thresholds Guidance .This provides partner agencies with clear criteria for taking action and providing the right help at the right time to adults at risk in order to effectively meet their needs. If the matter is related to a disagreement within a single agency then this must be addressed within  that gency using their protocols.

Please note that this protocol does not apply to cases where there may be concerns about the behaviour or conduct of another professional that may impact on an adult’s safety and well-being.  In such cases, reference should be made to the Person / People in Positions of Trust (PIPOT) – Multi-Agency Practice Guidance.

2. Areas of Possible Dissent

There is a range of situations in which professional disagreements may occur. Examples are given below although this list is not exhaustive.

Disagreements can arise in a number of areas, but are most likely to arise around thresholds, roles and responsibilities, the need for action and communication.  Some examples may include:

  • the referral is deemed not to meet the eligibility criteria for assessment;
  • Adult Social Care conclude that further information should be sought by the referrer before a referral is progressed;
  • there is disagreement as to whether adult safeguarding procedures should be invoked;
  • partners place different interpretations on the need for a single / joint response;
  • there is disagreement over the sharing of information and /or provision of services;
  • disagreements over the outcome of any enquiry or concern raised and whether the appropriate plan is in place to safeguard and promote the welfare of an adult at risk.

3. Key Principles

The safety of the adult at risk is the paramount consideration in any professional disagreement and staff should be mindful of the risks in considering escalation and resolve difficulties quickly and openly.

Professional disagreement is reduced by clarity about roles and responsibilities.

The best way of resolving difference is through open and transparent discussion and where possible a face to face meeting between those concerned which will enable clear identification of the specific areas of difference and the desired outcomes for the adult. Email communication, whilst important, can be open to misinterpretation or make for stilted exchange of views.

Disagreement should be resolved at the lowest possible stage between the people who disagree but any worker who feels that a decision is unsafe should consult their manager or designated safeguarding lead.  It should be acknowledged that differences in status and/or experience may affect the confidence of some workers to pursue this unsupported.

4. Timescales

The safety of an adult at risk must not be compromised by using the escalation process (see Section 5, Escalation Process).  In most cases it is expected that the matter will be resolved by partners escalating the matter with managers or supervisors the same day. If the matter is escalated to the South Tyneside Safeguarding Adults Board (SAB) representative and finally to the SAB Manager, this process should still be completed and resolved the same day.

If the matter takes longer than a day to resolve, the reasons for this should be recorded with the agency escalating the matter. The manager for that agency must ensure that the safety of an adult at risk has not been compromised by the delay.

It is expected that all issues will be resolved within a maximum of five working days

5. Escalation Process

5.2 Stage 1

If professionals are unable to reach agreement about the way forward in an individual case, their disagreement must be addressed by more senior staff. In most cases this will mean the first line managers within the relevant organisations. Records of discussions must be maintained by all agencies involved. The outcome of discussions and agreed actions should also be recorded.

5.2 Stage 2

If the concern continues the line managers should, without delay, refer to a head of service or equivalent and further discussions should take place with appropriate agencies. In exceptional circumstances the meeting may involve the chair or vice chair of the Safeguarding Adults Board to discuss the situation involves all parties.

Contemporaneous written records must be kept of all discussions and these should be retained on the adult’s case file / agency database.  It is important that timely feedback is given to the person who raised the concern as to what action has been taken in response.

It may also be useful for individuals to debrief following some disputes in order to promote continuing good working relationships, identify possible training needs or gaps in policies and procedures.

Appendix 1: Escalation Process Flowchart

Note: At no time must professional disagreement detract from ensuring an adult at risk is safeguarded – the adult’s welfare and safety must remain the paramount concern throughout.  Any resolved issues between workers should therefore be escalated on the same working day with due consideration to the risks that might exist for the adult at risk.

Click here to view the Escalation Process Flowchart

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1. Introduction

Staff across all organisations must treat adults with care and support needs, and their carers, friends and family with dignity, compassion and respect at all times and in all circumstance.

Staff must adopt a culture of care that respects the privacy, dignity, culture and individuality of all patients under its care and staff (see also Equality, Diversity and Human Rights in a Safeguarding Context).

2. Principles

All staff must:

  • recognise the diversity, values and human rights of adults;
  • uphold and maintain their privacy, dignity and independence;
  • provide care, support and treatment in a way that ensures their dignity, and treats them with compassion and respect at all times;
  • ensure that they have privacy when they want it, treating them as equals;
  • provide any support they might need to be autonomous, independent and involved in their community;
  • help adults maintain relationships that are important to them
  • put adults at the centre of their care and support by enabling them to make decisions (see Making Safeguarding Personal chapter);
  • all communication with adults and their families must be respectful and compassionate. This includes using or facilitating the most suitable means of communication and respecting their right to engage or not to engage in communication;
  • provide information that supports them in the safeguarding process, or others acting on their behalf, to make decisions;
  • support adults, or others acting on their behalf, to understand the care and support provided, including risk and benefits and their rights to make decisions;
  • staff must make sure that they provide appropriate care and support that meets people’s needs, but this does not mean that care and support should be given if it would be against the consent of the person (see the chapters on Consent in Relation to Safeguarding and Mental Capacity);
  • address them in the way they prefer, including their favoured name;
  • have regard for the protected characteristics as defined in the Equality Act 2010, that is: age; disability; gender reassignment; marriage and civil partnership; pregnancy and maternity; race; religion or belief; sex; sexual orientation (see also Equality, Diversity and Human Rights in a Safeguarding Context).

3. Personalised Care and Support through Involvement

Adults should be involved in and receive care and support that respects their right to make or influence decisions. Staff should:

  • explain and discuss their care and support options with them in a way that makes sense to them;
  • respect their right to take informed risks, while balancing the need for preference and choice with safety and effectiveness (see Managing Risk);
  • ensure that things that are important to the adult in relation to their care and support are established as part of their assessment, development and review of their plans;
  • promote and respect their autonomy, privacy, dignity, compassion, independence and human rights at all times by:
    • placing their needs, wishes, preferences and decisions at the centre of assessment, planning and delivery of care and support;
      • respect their personal preferences, lifestyle and care choices;
      • when providing intimate or personal care, the organisation must make every reasonable effort to make sure that they respect the preferences of individuals in relation to who delivers their care and treatment, such as requesting staff of a specified gender;
    • have clear procedures followed in practice, monitored and reviewed that ensure staff understand the concepts of privacy, dignity, independence and human rights and how they should be applied;
    • ensuring that the need to maintain confidentiality or disclose information is taken account in the assessment of the individual circumstances (see South Tyneside Multi Agency Information Sharing Agreement);
    • actively listening to and involving adults, or others acting on their behalf, in decision making and ensuring there are clear records that evidence the decisions made and methods in which the decision was achieved;
    • provide information to help them, or others acting on their behalf, to understand their care and support, including the risks and benefits, and their rights to make decisions;
    • make adults aware of independent advocacy services wherever they are available, and cooperate with independent advocacy services (see Independent Advocacy);
    • know how to raise a concern or complaint about the organisation, and how it will be dealt with (see Whistleblowing).

4. Managing Risk through Effective Procedures about Involvement

Procedures must ensure that:

  • care and support options, and the risks and benefits of those options, are explained to the adult / their representative;
  • choices and preference of the adult are expressed by them or others acting on their behalf;
  • the choices of adults are respected and accommodated unless:
    • the choice places other people at risk of harm or injury;
    • it would not be reasonable to expect the service to have the resources needed to achieve the choice;
    • if to meet choice is not within the stated aims, objectives and purpose of the service provided;
    • the adult does not have capacity to make that decision or is subject to a legal restriction that prohibits them making a choice (see Mental Capacity and Consent in Relation to Safeguarding);
  • individualised assessments and plans of care and support are based on the adult’s needs, choices and preferences;
  • any reasonable adjustments are made so that the adult is enabled to be involved in decision making.
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This chapter outlines the main issues in relation to equality, diversity and human rights which should be applied when implementing safeguarding adults procedures and process, as well as all other aspects of providing care and support services to adults.

RELEVANT CHAPTER

Dignity, Compassion and Respect

RELEVANT INFORMATION

Equality and Human Rights, Care Quality Commission

Equally outstanding: Equality and human rights – good practice resource (Care Quality Commission)

Culturally Appropriate Care (Care Quality Commission) 

September 2021: This chapter has been amended to add a link to Culturally Appropriate Care published by the Care Quality Commission, as above.

1. Introduction

This chapter outlines the main issues and relevant legislation in relation to equality, diversity and human rights which should be applied when implementing safeguarding adults procedures and processes, as well as all other aspects of providing services to adults with care and support needs.

2. Equality Act 2010

The Equality Act 2010 ensures there is consistency in what an organisation does to provide services in a fair environment and comply with the law. This includes all the people who use its services, their family and friends and other members of the public, staff, volunteers and partner agency staff (see also 5.2, Protected characteristics).

The Equality Act references ‘protected characteristics’: all of which must be considered when implementing safeguarding procedures. These are

  • age;
  • disability;
  • gender reassignment;
  • race;
  • religion or belief;
  • sex;
  • sexual orientation;
  • marriage and civil partnership;
  • pregnancy and maternity.

See Section 5.2, Protected characteristics for more information.

An organisation’s commitment to equality and diversity means that every person supported by it has their individual needs comprehensively addressed. They will be treated equally and without discrimination. This is regardless of any protected characteristics or another aspect that could result in them being discriminated against. The organisation is also committed to protecting individuals’ human rights. Failure to make reasonable adjustments in the care of a certain group with a protected characteristic (for example, a learning disability) may violate the Equality Act. Public bodies should have a process by which they consider how to promote equality.

3. Commitment to Equality, Diversity and Human Rights

The organisation should express its commitment to equality and diversity by:

  • respecting the ethnic, cultural and religious practices of people who use the service and making practical provision for them to be observed as appropriate;
  • reassuring people who use the service that their diverse backgrounds enhance the quality of experience of everyone who lives and works in any service provided by it;
  • protecting people’s human rights – treating them and their family and friends, fairly and with respect and dignity;
  • accepting adults who use the service as individuals;
  • supporting people to express their individuality and to follow their preferred lifestyle, also helping them to celebrate events, anniversaries or festivals which are important to them;
  • showing positive leadership and having management and human resources practices that actively demonstrate a commitment to the principles of equality and diversity;
  • developing an ethos throughout its service that reflects these values and principles;
  • expecting all staff to work to equality and diversity principles and policies and to behave at all times in non-discriminatory ways;
  • provide training, supervision and support to enable staff to do this;
  • having a code of conduct that makes any form of discriminatory behaviour unacceptable. This applies to both staff, people who use services and their family and friends, which is rigorously observed and monitored accordingly.

4. Care Quality Commission and Human Rights

‘Respecting diversity, promoting equality and ensuring human rights will help to ensure that everyone using health and social care services receives safe and good quality care.’ (Care Quality Commission)

The Care Quality Commission employs the commonly agreed ‘human rights principles’ in their inspection frameworks. These are sometimes called the FREDA principles:

  • fairness;
  • respect;
  • equality;
  • dignity; and
  • autonomy (choice and control).

These principles and standards should be at the heart of safeguarding process and in the planning and delivery of care to adults with care and support needs and their family and friends. The organisation should also encourage and support its staff to develop knowledge and skills and, where relevant, provide organisational leadership and commitment to achieve human rights based approaches.

The organisation should encourage positive practice and a learning culture that promotes human rights. Staff must take swift action if they think someone’s human right are being breached (see Responding to Signs of Abuse and Neglect chapter).

5. Guidance

5.1 Types of discrimination

All staff involved in the safeguarding process should be familiar with the following types of discrimination.

  • Direct discrimination occurs when a person is treated less favourably than others in similar circumstances on the grounds of race, colour, national or ethnic origins, sex, marital status, sexuality, disability, membership or non-membership of trade union, ‘spent convictions’ of ex-offenders, class, age, political or religious belief.
  • Discrimination by association applies to race, religion or belief, sexual orientation, age, disability, gender reassignment and sex. This is direct discrimination against someone because they associate with another person who possesses a protected characteristic (see Section 5.2, Protected characteristics below).
  • Perception discrimination is against an individual because others think they possess a particular protected characteristic. It applies even if the person does not actually possess that characteristic.
  • Indirect discrimination occurs when a condition or requirement is imposed which adversely affects one particular group considerably more than another.
  • Harassment is defined as unwanted, unreciprocated and / or uninvited comments, looks, actions, suggestions or physical contact that is found objectionable and offensive. Harassment is particularly liable to occur as part of sexual or racial discrimination.
  • Victimisation occurs when an employee is treated badly because they have made or supported a complaint or raised a grievance under the Equality Act, or because they are suspected of doing so. People are not protected from victimisation if they have maliciously made or supported an untrue complaint.

5.2 Protected characteristics

Under the Equality Act 2010 these are as follows.

  • Age: Where this is referred to, it refers to a person belonging to a particular age (for example 32 year olds) or range of ages (for example 18 – 30 year olds).
  • Disability: A person has a disability if they have a physical or mental impairment which has a substantial and long-term adverse effect on that person’s ability to carry out normal day-to-day activities. The Act includes a protection from discrimination arising from disability. This states it is discrimination to treat a disabled person unfavourably because of something connected with their disability. The Equality Act places a duty on public bodies to promote equality of opportunity between disabled people and others. There is a duty to make reasonable adjustments for disabled people relating to the provisions of services and “encourage persons who share a relevant protected characteristic to participate in public life”.
  • Gender reassignment: A transgender person is someone who proposes to, starts or has completed a process to change their gender. The Act does not require a person to be under medical supervision to be protected – so a woman who decides to live as a man but does not undergo any medical procedures would be covered. It is discrimination to treat transgender people less favourably because they propose to undergo, are undergoing or have undergone gender reassignment than they would be treated if they were ill or injured.
  • Marriage and civil partnership: In England and Wales marriage is not restricted to a union between a man and a woman and includes a marriage between a same-sex couple. Same-sex couples and mixed-sex couples can also have their relationships legally recognised as ‘civil partnerships’. Civil partners must not be treated less favourably than married couples (except where permitted by the Act). The Act protects employees who are married or in a civil partnership against discrimination.
  • Pregnancy and maternity: Pregnancy is the condition of being pregnant or expecting a baby. Maternity refers to the period after the birth. Protection against maternity discrimination is for 26 weeks after giving birth, and this includes treating a woman unfavourably because she is breastfeeding.
  • Race: Race refers to a group of people defined by their race, colour, and nationality (including citizenship) ethnic or national origins.
  • Religion or belief: Religion has the meaning usually given to it but belief includes religious and philosophical beliefs including lack of belief (for example atheism). Generally, a belief should affect life choices or the way a person lives for it to be included in the definition. In the Equality Act, religion includes any religion. It also includes a lack of religion.
  • Sex: Both men and women are protected under the Act.
  • Sexual orientation: Whether a person’s sexual attraction is towards their own sex, the opposite sex or to both sexes. The Act protects bisexual, gay, heterosexual and lesbian people.

6. Human Rights Act 1998

See also Equality and Human Rights Commission

The Human Rights Act 1998 (HRA) lays down the fundamental rights and freedoms to which everyone in the UK is entitled. The rights set out in the European Convention on Human Rights (ECHR) are incorporated in the HRA. It sets out people’s human rights in different ‘articles’, which are all taken from the ECHR. They are:

  • Article 2: Right to life;
  • Article 3: Freedom from torture and inhuman or degrading treatment;
  • Article 4: Freedom from slavery and forced labour;
  • Article 5: Right to liberty and security;
  • Article 6: Right to a fair trial;
  • Article 7: No punishment without law;
  • Article 8: Respect for private and family life, home and correspondence;
  • Article 9: Freedom of thought, belief and religion;
  • Article 10: Freedom of expression;
  • Article 11: Freedom of assembly and association;
  • Article 12: Right to marry and start a family;
  • Article 14: Protection from discrimination in respect of these rights and freedoms;
  • Protocol 1, Article 1: Right to peaceful enjoyment of property;
  • Protocol 1, Article 2: Right to education;
  • Protocol 1, Article 3: Right to participate in free elections;
  • Protocol 13, Article 1: Abolition of the death penalty.

Human rights law applies to public bodies and other organisations carrying out functions of a public nature. A number of these articles relate to working with adults with care and support needs, in particular Articles 2;3;5;8.

The HRA can be breached in three ways by public bodies if they:

  • inflict explicit physical abuse or allow neglect of a person;
  • intervene in a person’s life unlawfully and disproportionately;
  • fail to intervene to protect a person from being abused or neglected by other persons.

6.1 Articles 2, 3, 5 and 8

6.1.1 Article 2 Right to Life

Article 2 applies in health and social care situations and requires an independent investigation into some deaths – coroner inquests – and may involve a breach of human rights with the state or public organisations implicated.

6.2 Article 3 Inhuman and Degrading Treatment

No one shall be subjected to torture or to inhuman or degrading treatment or punishment.

Degrading treatment would occur if it “humiliates or debases an individual showing a lack of respect for or diminishing his or her human dignity or arouses feelings of fear, anguish, or inferiority capable of breaking and individuals moral and physical resistance.” Pretty v UK [2002] 2FC 97

Article 3 is breached most frequently when public bodies carry out or are responsible for abusive care and treatment; that is allowing or ignoring actions when they should not have done so.

There is a positive duty under Article 3 for a public body to intervene when abuse is performed by one private individual against another person.

6.3 Article 5: Deprivation of Liberty

People who lack mental capacity are one of the categories when people can be deprived of their liberty (see Mental Capacity chapter and Deprivation of Liberty Safeguards chapter). Legal procedures are set out in the Mental Capacity Act 2005 (MCA) and the Mental Health Act 1983 and should be followed. If they are not adhered to, it may lead to a breach of Article 5.

A deprivation of liberty under the MCA describes a best interest decision made in regard to a person who lacks mental capacity to decide about care, treatment or living arrangements. Such deprivations must be legally authorised under the provisions of the MCA (sections 4A-4B) or by order of the Court of Protection.

6.4 Article 8: Respect for private and family life, home and correspondence

Article 8 protects a person’s right to respect for their private life, their family life, their home and correspondence (for example, letters, telephone calls and emails).

6.4.1 Private life

A person has the right to live their life privately without government interference. This is a broad concept as interpreted by the courts, and covers areas such as:

  • sexual orientation;
  • lifestyle choices;
  • how someone chooses to look and dress;
  • the right for someone to control who sees and touches their body. In health services, for example, staff cannot leave someone undressed in a ward, or take a blood sample without the person’s permission;
  • the right to develop a personal identity;
  • to make friendships and other relationships;
  • a right to participate in essential economic, social, cultural and leisure activities. In some circumstances, public bodies, such as the local authority, may need to help someone enjoy their ability to participate in society;
  • the media and others being prevented from interfering in someone’s life.
  • personal information (including official records, photographs, letters, diaries and medical records) being kept securely and not shared without the person’s permission, except in certain circumstances (see Data Protection chapter).

6.4.2 Family life

People have the right to enjoy family relationships without interference from government. This includes the right to live with their family and, where this is not possible, the right to have regular contact. This includes couples who are not married, between an adopted child and adoptive parent and a foster carer and foster child.

If a local authority makes an unjustified intervention in the life of person lacking mental capacity it may also breach Article 8: London Borough of Hillingdon v Neary [2011] EWHC 1377 (COP).

6.4.3 Home life

Everyone has a right to enjoy their existing home peacefully. Public bodies, therefore, should not stop a person from entering or living in their home without very good reason. They also cannot enter it without the person’s permission.

A right to home life does not mean, however, a right to be given housing.

6.4.4 Restrictions to Article 8

There are times when public bodies can interfere with someone’s right to respect for private and family life, home and correspondence. In such situations, the authority must be able to show that such action is lawful, necessary and proportionate in order to:

  • protect national security;
  • protect public safety;
  • protect the economy;
  • protect health or morals;
  • prevent disorder or crime; or
  • protect the rights and freedoms of other people.

Article 8 is not an absolute right. Interference with private life and family life is legally permissible but must be justified within the terms set out above.

A breach of Article 8 would occur if interventions are taken which are:

  • inconsistent with the relevant law;
  • consistent with the law but disproportionate and therefore unnecessary; or
  • for a purpose other than the criteria listed above.

6.5 Article 10 Freedom of Expression

Article 10 is the freedom to hold opinions and to receive and impart information and ideas without inference from the State. This right is not absolute but subject to several provisos. Restrictions can only be justified if they are for a specific purpose, for example:

  • public safety;
  • the prevention of disorder or crime;
  • the protection of health and morals;
  • the protection of the reputation or rights of others;
  • preventing the disclosure of confidential information.

The Care Act guidance warns local authorities against “abusive interventions that risk breaching the adult’s right to family life if not justified or proportionate“ Care and Support Statutory Guidance (Department of Health and Social Care).

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1. Introduction

The Mental Health Act (MHA) is the current law which provides legal powers for the admission, detention and treatment of a person against their will in respect of mental illness. Where a person is detained against their will this is commonly known as ‘being sectioned’.

The Act is an extensive legislative framework about which this chapter provides an introduction and basic details of the most commonly known and used sections within the adult social care remit.

The Mental Health Act 1983 was reformed in 2007 which saw a number of key changes to the original Act which placed a larger focus on public protection and risk management. The 2007 amendments were exactly that and the main body of the 1983 Act remains in place, as such the MHA may be referred to as the Mental Health Act 1983 (2007). See Appendix 1: 2007 Amendments to the 1983 Act, for information about changes to the original legislation.

2. Who does the Mental Health Act 1983 apply to?

The MHA provides ways of assessing, treating and caring for people who have a serious mental disorder that puts them or other people at risk. It sets out when:

  • people with mental disorders can be detained in hospital for assessment or treatment;
  • people who are detained can be given treatment for their mental disorder without their consent (it also sets out the safeguards people must get in this situation); and
  • people with mental disorders can be made subject to guardianship or after-care, under supervision to protect them or other people.

Most of the MHA does not distinguish between people who have the mental capacity to make decisions and those who do not. Many people covered by the MHA have the capacity to make decisions for themselves.

Decision makers will need to decide whether to use either the MHA or MCA to meet the needs of people with mental health problems who lack capacity to make decisions about their own treatment. Where someone with a mental health disorder is subject to a Community Treatment Order (CTO) or Guardianship under the MHA, and lacks capacity, they may have a Deprivation of Liberty Safeguards in place; otherwise a person cannot be subject to the two frameworks at the same time.

3. Parts of the Act

The Mental Health Act 1983 is split into ten parts:

  1. The Application of the Act
  2. Compulsory Admission to Hospital and Guardianship
  3. Patients Concerned in Criminal Proceedings or Under Sentence
  4. Consent to Treatment
  5. Treatment of Community Patients not Recalled to Hospital
  6. Mental Health Review Tribunals
  7. Removal and Return of Patients Within the United Kingdom
  8. Management of Property and Affairs of Patients
  9. Miscellaneous Functions of Local Authorities and Secretary of State
  10. Offences
  11. Miscellaneous and Supplementary

The Mental Health Act 1983 was reformed in 2007 when a number of key amendments were made placing a greater focus on public protection and risk management. See Appendix 1: 2007 Amendments to the 1983 Act.

These parts are the ones most commonly used and key to adult social care practice:

  • Compulsory Admission to Hospital and Guardianship;
  • Miscellaneous Functions of Local Authorities and Secretary of State;
  • Miscellaneous and Supplementary.

Further detail about each section is outlined below.

4. Part 2: Compulsory Admission to Hospital and Guardianship

4.1. Section 2 Admission for Assessment

Allows for:

  • a person to be detained in hospital for assessment of their mental health;
  • treatment to be forcibly administered as part of the assessment period (excluding use of Electro-Convulsive Therapy (ECT);
  • a detention period of up to 28 days, however discharge can be arranged sooner.

Section 2 cannot be renewed. If further detention is required beyond the 28 day period, assessment under section 3 should be considered. In certain cases where there may be issues relating to a person’s nearest relative, Section 2 can be extended by the powers of the Court until such decision regarding the nearest relative are resolved.

4.1.1 Criteria

For a person to be detained under section 2 they must have:

  • been assessed by two doctors – one of whom must be section 12 approved. It is preferable that at least one of the doctors involved in the assessment has previous acquaintance with the person being assessed;
  • both doctors need to be of the opinion that compulsory admission is required and must complete a medical recommendation;
  • there must be no longer than five clear days between each of the medical assessments, for example if an examination is completed on a Monday, the five days are not inclusive of this day (meaning Tuesday to Saturday are clear days therefore Sunday is the last possible day for the second medical examination);
  • the Approved Mental Health Professional (AMHP) must be in agreement with the two doctors’ recommendations and have completed a valid application for admission;
  • the AMHP must complete the application for admission within 14 days of the latter dated medical recommendation;
  • a person’s nearest relative is also able to make an application for admission.

4.1.2 Appeal

Patients have the right to appeal against the detention within the first 14 days.

4.2 Section 3: Admission for treatment

For a person to be detained under section 3 the criteria for section 2 must all be met. Section 3 can be used where a person is well known to mental health services and it is clear what illness is to be treated and therefore no assessment period is required.

Alternatively, it may be used due to the need for continued detention after the 28 day period of section 2.

4.2.1 Provisions

The Act allows the following provisions:

  • a person to be detained in hospital for treatment of their mental health. Appropriate medical treatment must be available;
  • forcible administration of treatment (excluding use of ECT. Where there is non-compliance with medication this will need to be reviewed by a second opinion appointed doctor (SOAD) after three months.;
  • a detention period of up to six months, after which it can be renewed for a further six months and on a 12 monthly basis thereafter.

4.2.2 Appeal

Patients have the right to appeal against the detention within the first six months.

4.3 Section 4 – Admission for Assessment in case of emergency

4.3.1 Criteria

Section 4 is used in emergency situations where is it deemed not practicable to arrange two doctors and assess under section 2.

Unlike assessment for sections 2 and 3 there needs only to be one doctor involved – preferably one whom previous acquaintance. An AMHP is still required to make an application.

4.3.2 Provisions

The Act allows the following provisions:

  • detention period of up to 72 hours following which further assessment by a second doctor should be arranged and the decision made whether to detain under section 2 or to arrange discharge;
  • treatment can be refused, however where there is concern regarding capacity to consent, treatment can be provided in the best interests of the individual detained. It can also be provided where it is necessary to prevent harm to themselves or to others.

4.3.3 Appeal

There is no right of appeal against section 4.

4.4 Section 5: Application in respect of a patient already in hospital (holding powers)

The Act:

  • provides powers to doctors and nurses to prevent a person from leaving hospital where by doing so there may be a risk posed to the individual themselves or to others as a result of the individuals mental health;
  • may be used to prevent informal patients from leaving a mental health ward or prevent a person from leaving a general ward where they may be receiving treatment for a physical condition.

There are two parts to section 5 which are outlined below.

4.4.1 Section 5 (2)

This is often referred to as doctor’s holding powers. The provisions are:

  • it gives the doctor in charge of the individuals the power to detain for up to 72 hours;
  • further assessment by an AMHP and second doctor should be arranged as soon as possible and the decision made whether to detain under a section of the M HA or to arrange discharge;
  • section 5 (2) cannot be renewed.

4.4.2 Section 5 (4)

This is often referred to as nurse’s holding powers. The provisions are:

  • it gives certain nurses the power to detain for up to six hours;
  • a doctor should be requested to attend as soon as possible;
  • section 5(4) ends when the doctor arrives. The doctor must assess if the person can be transferred onto section 5(2) or whether the person can remain on an informal basis;
  • section 5(4) cannot be renewed.

4.5 Section 7: Application of Guardianship Order

Guardianship gives someone (usually a local authority social care department) the exclusive right to decide where a person should live. However in doing so they cannot unlawfully deprive the person of their liberty. Where restrictions amount to a deprivation, authorities should seek to apply for a DoLS authoriationt to run concurrent with the Guardianship Order (see Deprivation of Liberty Safeguards).

The guardian can also require the person to attend for treatment, work, training or education at specific times and places, and they can demand that a doctor, approved mental health professional or another relevant person have access to the person wherever they live.

Guardianship can apply whether or not the person has the capacity to make decisions about care and treatment.

It does not give anyone the right to treat the person without their permission or to consent to treatment on their behalf (see also Interface between Mental Capacity Act and Mental Health Act)

4.6 Section 17: Leave of absence from hospital

The Act makes the following provisions:

  • the Responsible Clinician (RC) to grant a detained patient leave of absence from hospital;
  • leave can be provided as escorted or unescorted and the time allowed is controlled by the RC;
  • leave can be used to allow a person to have home leave including overnight stays and can often be useful to trial how a person is likely to function in the community when discharged from hospital.

A person is still a detained patient when section 17 is in place.

4.7 Section 17A: Community Treatment Orders

Community Treatment Orders (CTO’s) are used to support people in the community that have mental health needs and require continued treatment under supervision.

The aim of the community treatment or was to reduce the number of ‘revolving door’ patients who would typically become non-compliant with treatment once discharged from hospital, and as a result experience deterioration in their mental state often resulting in further admission.

The provisions are:

  • CTO’s can only be used where a person is detained under section 3, 37, 45A, 47 or 48;
  • a CTO allows for conditions to be attached to a person’s discharge;
  • any individual considered for a CTO should have a degree of understanding in relation to the conditions attached as they must comply with these conditions in order to avoid recall to hospital;
  • CTO timeframes mirror those of Section 3, that is six months, six months, annual;
  • an AMHP needs to be in agreement with the proposal of a CTO before it can be enforced.

4.8 Section 26: Nearest Relative

The MHA provides safeguards to those who are detained, one of these being the role of the nearest relative (NR).

The NR is different from next of kin and is identified using the list below:

  • husband, wife or civil partner;
  • son or daughter;
  • father or mother;
  • brother or sister;
  • grandparent;
  • grandchild;
  • uncle or aunt;
  • niece or nephew.

Determining a person’s NR can at times be complex, however to simplify it whoever appears first in the above list in defaults to the role.

The NR must be over 18 (unless husband, wife or civil partner) and where there are both parties available, for example mother and father, the eldest would fulfil the role.

The NR has the right to request that a MHA assessment is completed; they are able to make an application for detention and can also request that their relative is discharged from hospital.

An identified NR can be displaced by the courts if it is deemed that they are unsuitable. The NR is also able to delegate the role and function.

5. Part 9: Miscellaneous Functions of Local Authorities and the Secretary of State

5.1 Section 117 Aftercare – Introduction

Section 117 of the Mental Health Act 1983 (2007) imposes a duty upon local authorities and Integrated Care Boards (ICBs) to provide aftercare services for anybody who has been detained under Sections 3, 37, 45A, 47 or 48 of the Mental Health Act (MHA). This includes patients granted leave of absence under section 17 and patients being discharged on community treatment orders (CTOs). The Care Act 2014 implemented some changes to the MHA.

As Section 117 enforces a duty on the local health authority and adult social care services to provide care to meet eligible needs, Section 117 needs that arise directly because of or from the person’s mental disorder and are likely to prevent a deterioration in their condition and therefore lead to a readmission. If a person has additional social care needs, such as a physical disability, that do not arise because of a mental disorder, the usual social care eligibility criteria under the Care and Support Statutory Guidance would need to be applied to these needs.

If, at any point, it becomes apparent that a person who is be eligible for Section 117 aftercare has been paying for services, they can reclaim these payments as long as with clear evidence is provided of their detention.

6. Part 11: Miscellaneous and Supplementary

6.1 Section 135 – Warrant to search and remove to a place of safety

6.1.1 Section 135 (1)

The provisions are:

  • professionals have the power of entry to a person’s private dwelling for the purpose of assessment under the MHA;
  • for entry to be gained by force if required under the powers of a warrant issued by the county court;
  • for a person to be removed to a place of safety for the purpose of assessment or where appropriate, remain in their own home.
  • An AMHP, a police officer and a doctor is required to be present for the execution of a 135 (1) warrant.

6.1.2 Section 135 (2)

The provisions are:

  • for forcible entry if required to access a person who is liable to be detained under the MHA or who need to be retaken to hospital (for example if they have gone absent without leave from the ward when detained and have returned home and refusing to allow entry);
  • a warrant is again required to act out these powers of entry, however an AMHP or doctor is not required to execute the warrant under this section.

6.1.3 Section 136 – Removal of Mentally Disordered Persons Without a Warrant – Police Powers of detention

The provisions are:

  • section 136 is an emergency power which allows police officers to remove a person from a public place to a place of safety for the purpose of further assessment under the MHA where there are concerns that a person may be suffering from mental illness and in need of immediate care and / or control. The timeframes of section 136 were reduced from 72 to 24 hours in December 2017;
  • if a person is initially seen by a doctor before the AMHP has coordinated a full assessment and it is deemed that there is no evidence of mental illness, the person must be discharged from the 136 immediately;
  • a person can be discharged with or without follow up from services once assessed or may be detained under the MHA.

Appendix 1: 2007 Amendments to the Mental Health Act 1983

The key amendments to the Act were as follows.

The Fundamental Principles – Section 118 of the Act says that the Code of Practice (which was given legal stature as part of the reform) must provide a statement of principles to inform all decision making within the remit of the mental health act.

Chapter 1 of the Code of Practice for England outlines the following guiding principles:

  • purpose principle;
  • least restriction principle;
  • respect principle;
  • participation principle;
  • effectiveness, efficiency and equity principle.

Section 1: Definition of mental disorder – The definition of mental disorder in Section 1 of the Act was split into 4 classifications; psychopathic disorder, mental illness, mental impairment and severe mental impairment.

The 2007 Act broadened the term of mental disorder as below:

“mental disorder” means any disorder or disability of the mind.

Prior to the changes to the Act there were grounds to detain those with Learning Disability under mental impairment and severe mental impairment. The amendment now makes clear that the disability itself does not meet the criteria for detention unless it is:

“associated with abnormally aggressive or seriously irresponsible conduct on his part”

Professional roles – The role of the Approved Social Worker (ASW) was opened up to healthcare professionals including nurses, occupational therapists and psychologists. It was renamed the Approved Mental Health Professional (AMHP).

The role of the Responsible Medical Officer (RMO) became that of the Responsible Clinician (RC).

Supervised Discharge /Community treatment Orders – Section 25A Supervised Discharge of the 1983 Act was abolished other than for those already subject to it and was replaced with the introduction of section 17A Community Treatment Orders (CTO’s).

Introduction of Appropriate Medical Treatment – The 1983 Act stated that treatment had to be likely to be effective upon a person’s condition which allowed for a greater degree of detentions to take place, whereas the Act now concurs that treatment is only to be provided where there is purpose outlining that the purpose of any treatment is to:

“alleviate, or prevent a worsening of, the disorder or one or more of its symptoms or manifestations” (section 145).

The definition of medical treatment was also changed itself to outline that medical treatment can be provided in the absence of medical supervision.

Those of 16 and 17 years of age and Parental Responsibility – The 2007 Act introduced the notion that any person aged 16 or 17 who is deemed to have capacity cannot be detained on basis of parental consent – outlined in section 131 MHA.

Appendix 2: The Policing and Crime Act 2017

Further to the 2007 Amendments to the MHA 1983, the introduction of the Policing and Crime Act 2017 has more recently had an impact on the application of the Act. The

Guidance for the implementation of changes to police powers and places of safety provisions in the mental health act 1983 published by the Home Office and Department of Health usefully outlines these changes as below:

  • section 136 powers may now be exercised anywhere other than in a private dwelling;
  • it is now unlawful to use a police station as a place of safety for anyone under the age of 18 in any circumstances;
  • a police station can now only be used as a place of safety for adults in specific circumstances, which are set out in regulations;
  • the previous maximum detention period of up to 72 hours has been reduced to 24 hours (unless a doctor certifies that an extension of up to 12 hours is necessary);
  • before exercising a section 136 power police officers must, where practicable, consult one of the health professionals listed in section 136(1C), or in regulations made under that provision;
  • a person subject to section 135 or 136 can be kept at, as well as removed to, a place of safety. Therefore, where a section 135 warrant has been executed, a person may be kept at their home (if it is a place of safety) for the purposes of an assessment rather than being removed to another place of safety;
  • a new search power allows police officers to search persons subject to section 135 or 136 powers for protective purposes.
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This chapter outlines the main issues involved in the criminal exploitation of adults by organised crime groups.

RELEVANT CHAPTERS

Cuckooing

Modern Slavery

Safeguarding Enquiries Process

Working with Adults affected by Child Sexual Exploitation and Organised Sexual Abuse

RELEVANT INFORMATION

County Lines: Criminal Exploitation of Children and Vulnerable Adults (Home Office)

July 2020: Appendix 1: Posters was added with links to Home Office published posters for different sectors.

1. Introduction

The term county lines refers to organised crime gangs / groups who operate in urban areas who supply drugs to suburbs, market and coastal towns; often crossing county borders. The gangs use dedicated mobile phone lines, sometimes known as “deal lines”.  They use adults (and children) to move drugs and money.

Organised crime gangs create a base in their chosen target area, usually by taking over the homes of local adults who gang members have identified as vulnerable (see Section 4, Vulnerability Factors). They do this either by force or coercion (known as ‘cuckooing’ – see Cuckooing chapter).

County lines exploitation is widespread, with gangs from big cities including London, Manchester and Liverpool operating throughout England, Wales and Scotland.

This chapter is a summary of the Home Office County Lines guidance in relation to adults.

2. County Lines Crime Types

The different types of crimes that involve crossing county lines include:

  • drug use and supply;
  • violence;
  • gang activity;
  • safeguarding offences;
  • criminal and sexual exploitation;
  • modern slavery;
  • and missing persons.

These crimes and the behaviour of the gangs involved, has a ruinous impact on the lives of the adults and local communities who are targeted.

The response to tackle county lines crimes involves a number of partner agencies of the South Tyneside Safeguarding Children and Adults Partnership, including the police, local authorities and voluntary and community sector organisations. It also includes the National Crime Agency and a number of Government departments.

3. Victims

County lines crimes operate similarly to other types of abuse or exploitation. Such crimes can:

  • still be exploitative even if people seem to consent to being involved;
  • involve force and /or enticement and is often accompanied by violence or threats of violence;
  • be committed by individuals or groups, males or females, and young people or adults.
  • Such crimes usually involve an imbalance of power between the abuser and the abused usually related to:
    • age;
    • gender;
    • cognitive ability;
    • physical strength;
    • status;
    • access to money or other resources.

Just because a person receives something in exchange for their involvement, this does not make them any less of a victim.

County lines exploitation often involves some form of exchange, where the victim is asked / told to carry drugs in return for something they want or need, for example:

  • money;
  • drugs;
  • clothes;
  • other rewards such as status, protection or ‘friendship’ or affection;
  • the prevention of threats by gangs / groups being carried out against the victim’s family or friends.

4. Vulnerability Factors

Vulnerability factors for country lines victims include:

  • previous experience of neglect, physical and / or sexual abuse, either as a child or adult;
  • unsafe or unstable home or homelessness now or in the past (this may be due to domestic abuse, parental substance misuse, mental health issues or criminality);
  • social isolation or difficulties in forming friendships or relationships;
  • no / lack of stable or regular income;
  • connections with gang / group members;
  • physical or learning disabilities;
  • mental health or substance misuse issues – Class A drug users are often targeted as their lifestyles leave them vulnerable to exploitation, particularly in relation to gangs taking over their accommodation (see Cuckooing chapter);
  • history of being in care (particularly those in residential care or with an unsettled care history).

5. Risk Indicators

The following are indicators of county lines involvement and exploitation. Whilst the guidance references these in relation to young people, they also apply to adults who are targeted:

  • missing from home / college or work and being found in another town / city / county;
  • unexplained possession of money, clothes, or mobile phone etc;
  • receiving an excessive number of texts or phone calls
  • involvement with controlling individuals or gangs / groups;
  • leaving home without saying where they are going;
  • concerns that they have been physically assaulted / have unexplained injuries;
  • concerns about them expressed by parents / carers / family / friends;
  • known or suspected of carrying weapons;
  • significant decline in education or work results / performance;
  • associating with group / gang members or isolating themselves from their previous friends or social groups;
  • self-harming and / or significant changes in their psychological wellbeing.

Any sudden changes in an adult’s lifestyle should be discussed with them.

6. Taking Action

6.1 Adult with Care and Support Needs

If you believe an adult is being forced to participate in County Lines activity, a safeguarding referral should be made (see Safeguarding Enquiries Process section).

If the adult consents, a referral should also be made to the National Referral Mechanism (NRM) so they can receive appropriate support. Only a designated First Responder can make a referral to the NRM.  First responder organisations include the police and local authorities.

If the adult does not give their consent to a referral to the NRM, there is still a duty to notify the Home Office of potential victims using an online form.

6.2 Adults without Needs for Care and Support

If you believe an adult is being forced to participate in County Lines activity but they do not have needs for care and support this is still a crime and you should report this to the police (see Local Contacts).

Appendix 1: County Lines Posters

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1. Introduction

Duty of candour relates to an organisation being open and transparent with people who use its services and other relevant people (that is those who are acting lawfully on the person’s behalf) in relation to care and treatment. An organisation should be open and honest when things go wrong.

It applies to all NHS trusts, foundation trusts, special health authorities and all other service providers or registered managers.

Specific requirements must be followed in relation to an adult’s care and treatment, including:

  • informing people about an incident;
  • providing reasonable support;
  • providing truthful information;
  • giving an apology if procedures have not been followed or things go wrong.

2. Openness and Transparency

The organisation must promote a culture that encourages candour, openness and honesty at all levels. This is an integral part of a culture of safety that supports organisational and staff learning. This commitment to openness and transparency extends to all levels of the organisation, from senior and middle managers, care and support workers and ancillary staff, including temporary staff. These policies and procedures support a culture of openness and transparency, as they can be accessed by adults and their families as well as by staff.

Staff operating at all levels must understand their individual responsibilities in relation to the duty of candour, and are supported to be open and honest with adults and apologise when things go wrong. Staff should receive appropriate training, and there should be arrangements in place to support staff who are involved in a notifiable safety incident. In cases a manager is made aware that something untoward has happened, they should treat the allegation seriously, immediately consider whether this is a notifiable safety incident and take appropriate action (see Section 3, Notification Process following an Incident).

2.1 Bullying

The organisation should be committed to taking action to tackle bullying and harassment in relation to duty of candour, and must investigate any instances where a member of staff may have obstructed another in exercising their duty of candour. A possible breach of the professional duty of candour by staff who are professionally registered, including the obstruction of another in such a duty, may lead to an investigation, disciplinary action and referral to the Care Quality Commission and / or their professional body.

3. Notification Process following an Incident

When a notifiable safety incident has occurred, the adult and / or relevant person must be informed as soon as reasonably practicable after the incident has been identified.

The organisation should inform its regulator and / or commissioner of any unintended or unexpected incident that occurred in respect of an adult when providing regulated activity that, in the reasonable opinion of a health care professional:

  • appears to have resulted in:
    • the death of the adult, where the death relates directly to the incident rather than to the natural course of their illness or underlying condition (see Safeguarding Adult Reviews);
    • an impairment of the sensory, motor or intellectual functions of the adult which has lasted, or is likely to last, for a continuous period of at least 28 days;
    • changes to the structure of the adult’s body;
    • the adult experiencing prolonged pain or prolonged psychological harm; or
    • the shortening of the life expectancy of the adult; or
  • requires treatment by a health care professional in order to prevent:
    • the death of the adult; or
    • any injury to the adult which, if left untreated, would lead to one or more of the outcomes mentioned above.

Where the degree of harm to the adult is not yet clear but may fall into the above categories in future, the adult and / or relevant person must be informed of the notifiable safety incident. There must be appropriate arrangements in place to notify the adult who is affected by an incident if they are aged 16 and over and lack the mental capacity to make a decision about their care or treatment (see Mental Capacity chapter). A person acting lawfully on behalf of the adult must be notified as the relevant person where they are under 16 and lack the mental capacity to make a decision regarding their care or treatment. A person acting lawfully on behalf of the adult must be notified as the relevant person, upon the adult’s death.

Other than the situations outlined above, information should only be disclosed to family members or carers where the adult has given their consent. A step by step account of all relevant facts known about the incident at the time must be given, in person, by one or more member of staff including a service manager as relevant. This should include as much or as little information as the adult and / or relevant person wants to hear, be jargon free and explain any complicated terms. The account of the facts must be given in a manner that the adult and / or relevant person can understand. Staff should consider whether interpreters, advocates, or other communication aids should be used, while being conscious of any potential breaches of confidentiality in doing so.

Staff must also explain to the adult and / or relevant person what further enquiries they will make. One or member of staff should give a meaningful apology, which is an expression of sorrow or regret, in person, to the adult and / or relevant person. In making a decision about who is most appropriate to provide the notification and / or apology, the organisation should consider seniority, relationship to the adult, and experience and expertise in the type of notifiable incident that has occurred. Following the notification of the incident given face to face, the relevant person must receive written notification of the incident, even though enquiries may not yet be complete. This must contain all the information that was provided at the face-to face meeting, including an apology and as well as the results of any enquiries that have been made since. The outcomes or results of any further enquiries and investigations must also be provided in writing to the adult and / or relevant person through further written notifications, if they wish to receive them.

The organisaiton must make every reasonable attempt to contact the relevant person through all available means of communication. All attempts to contact the relevant person must be documented (see Section 5, Record Keeping). If the relevant person does not wish to communicate with the organisation or a senior manager, their wishes must be respected and a record of this must be kept. If the relevant person has died and there is nobody who can lawfully act on their behalf, a record of this should also be kept. The organisation is not required by regulation to inform an adult when a ‘near miss’ has occurred and the incident has resulted in no harm to that person.

4. Action following an Incident

The organisation must give the adult and / or relevant person all reasonable support necessary to help overcome the physical, psychological and emotional impact of the incident. This could include all or some of the following:

  • treating them with respect, consideration and empathy;
  • offering the option of direct emotional support during the notifications, for example from a family member, a friend, a care professional or a trained advocate;
  • offering help to understand what is being said, for example, through an interpreter, non-verbal communication aids, written information, Braille etc;
  • providing access to any necessary treatment and care to recover from or minimise the harm caused where appropriate;
  • providing the adult and / or relevant person with details of specialist independent sources of practical advice and support or emotional support / counselling;
  • providing the adult and / or relevant person with information about available impartial advocacy and support services, their local Healthwatch and other relevant support groups, for example Cruse Bereavement Care and Action against Medical Accidents (AvMA), to help them deal with the outcome of the incident;
  • arranging for care and treatment from another professional, team or provider if this is possible, if the adult and / or relevant person wishes;
  • providing support to access the organisation’s complaints procedure.

See also South Tyneside Multi Agency Information Sharing Agreement

5. Record Keeping

See also Case Recording.

The organisation must keep a record of the written notification, along with any enquiries and investigations and the outcome or results of the enquiries or investigations. Any correspondence from the adult and / or relevant person relating to the incident must be responded to in an appropriate manner and a record of communications should be kept.

6. Organisational Learning

The organisation should ensure a culture in which it learns from incidents at all levels in order to ensure the future protection and safety of adults who use its services.

7. Training and Support

See also Safeguarding Training for Staff and Volunteers

Staff should receive appropriate training and there should be arrangements in place to support staff who are involved in a notifiable safety incident.

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1. Introduction

As people get older, they sometimes find that loss of memory becomes problematic. It is normal for memory to be affected by age, stress, tiredness, menopause or certain illnesses and medications, but there may also be underlying medical reasons that may require investigation and treatment, including dementia.

The following statistics relate to dementia in the UK:

  • there are currently an estimated 944,000 people with dementia;
  • the number of people with dementia is predicted to rise to 1.1m by 2030, 1.4m by 2040 and will reach 1.6m by 2050;
  • one in 14 people in the UK aged over 65 have dementia;
  • the financial cost is £34.7 billion per annum;
  • women are more likely than men to develop dementia in their lifetimes, partly due to the fact that women live longer than men.

(Alzheimer’s Society; Dementia Statistics Hub).

2. What is Dementia?

Dementia is a common condition which is more likely to develop with age, usually occurring in people over the age of 65.

It is a syndrome (which is a group of related symptoms) associated with an ongoing decline of brain function. It affects:

  • memory loss;
  • thinking speed;
  • mental agility;
  • language;
  • understanding;
  • judgement.

An adult with dementia may experience different mental changes. This includes losing empathy with other people, hearing or seeing things that are not real (auditory or visual hallucinations), becoming up and down in their mood (being less emotionally stable), not having any interest in things and losing interest in past activities. Social situations may become more difficult as their personality changes.

Where there are concerns that an adult with dementia no longer has mental capacity, safeguards should be put in place to ensure decisions are made in their best interests (see also Mental Capacity chapter).

The speed at which a person’s symptoms get worse and the way they develop depends on the cause of the dementia, as well as their overall health. This means that the symptoms, the rate of progress and experience of dementia can be different for each person. There are no treatments yet that can slow the progression or delay the onset of the diseases which cause dementia, but a number of treatments which are currently available on the NHS can help to temporarily reduce symptoms.

An adult who is experiencing a number of the symptoms related to dementia may find it difficult to keep being independent and may often need help from family or friends, including help to make decisions.

If a person – or their family or friends – is worried that they may be developing dementia, in the first instance they should see their GP.  Following investigations, early diagnosis can help people get the right treatment, care and support and help those close to them to prepare, access support for themselves and plan ahead. With treatment, care and support many adults can lead active and fulfilled lives.

3. Different Types of Dementia

3.1 Alzheimer’s disease

Alzheimer’s disease is the most common cause of dementia, it causes changes to the chemistry and structure of the brain, which results in brain cells dying off. Common symptoms of Alzheimer’s disease and other forms of dementia include:

  • memory loss – especially recent events, such as forgetting messages, remembering routes or names and asking questions repetitively;
  • having increasing difficulty with everyday tasks and activities;
  • becoming confused in places they don’t know / don’t know well;
  • having difficulty finding the right words;
  • having difficulty with numbers and / or paying in shops, particularly with cash;
  • changes in personality and mood;
  • feeling depressed.

Early symptoms of dementia (sometimes called cognitive impairment) are often mild and may get worse very gradually. This means that some people – and their family and friends – do not notice them or take them seriously for quite a while.

3.2 Vascular dementia

Vascular dementia is caused when the oxygen supply to the brain fails and brain cells die as a result. This can either happen suddenly such as after a stroke, or over time  as a result of a number of small strokes. Symptoms can start quite suddenly and quickly get worse, although they can also develop gradually over many months or years.

People with vascular dementia may also experience stroke-like symptoms, including weakness or paralysis on one side of their body.

3.3 Dementia with Lewy bodies

This form of dementia is caused by tiny round structures that develop inside nerve cells in the brain, which leads to a deterioration of brain tissue. Dementia with Lewy bodies has many of the symptoms of Alzheimer’s disease, but people with the condition also usually experience:

  • periods of being awake or drowsy, or fluctuating levels of confusion;
  • seeing things that are not there (visual hallucinations);
  • becoming slower in their way they move.

3.4 Frontotemporal dementia

In this type of dementia, damage usually occurs in the front part of the brain, so an adult’s personality and behaviour are more affected to start with than their memory. An adult with this type of dementia may become less sensitive to other people’s emotions, perhaps seeming cold and insensitive. They may also behave in a way that is out of character for them, such as making inappropriate comments. Some adults also experience language problems, which may result in them not speaking, speaking less than usual or having problems finding the right words.

4. Symptoms in Later Stage Dementia

As dementia progresses, memory loss and difficulties with communication often become very severe. In the later stages of their life, the affected adult is unlikely to be able to care for themselves and will require constant care and attention.

  • Memory symptoms: adults may not recognise close family and friends, remember where they live, know where they are, and find it impossible to understand simple bits of information or carry out basic tasks or follow instructions.
  • Communication problems: adults may have increasing difficulty speaking and may eventually not be able to speak at all.
  • Mobility problems: adults may become less mobile, eventually becoming unable to walk and may be mostly in a bed and / or chair.
  • Incontinence: urinary incontinence is common (wetting), and some people will also experience faecal (bowel) incontinence.
  • Eating, appetite and weight: losing their appetite and having difficulties eating or swallowing are common. This may lead to choking, followed by chest infections. People with these problems may lose weight as well.

As well as issues of mental capacity, care should be taken to make sure the adult’s human rights are not breached if they lack capacity to consent to care and treatment (see the chapters on Mental Capacity, Deprivation of Liberty Safeguards and Equality, Diversity and Human Rights in a Safeguarding Context).

5. Adults with Care and Support Needs

Getting a dementia diagnosis is a frightening time and receiving the right treatment  and care and support early when a person has starting noticing symptoms, are some of the key points in the Care Act 2014 (see Promoting Wellbeing).

Whilst an adult with an early diagnosis of dementia may not require care and support services at first, they will inevitably do so as the disease progresses. Their carers may also require assessment and a support plan from the local authority.

Some adults with dementia will be self-funders, when care and support is paid by them or a family member for example. They may not then want an assessment by the local authority.

Where an adult is assessed by the local authority, a care and support plan should be developed with them, to make sure that they are able to state what their needs are and what they want to happen wherever possible, as well as those of their carer (see Care and Support Planning chapter).

6. Carers

See also Carers chapter

Dementia is a very distressing illness for the person’s family and friends, as well as the person themselves. They often see the personality and abilities of their loved one change so much, sometimes to the point of being unrecognisable to how they were before. For couples who have been together a long time, for example, it is very upsetting when their partner or spouse no longer recognises them or the person physically or verbally abuses them.

When adults with dementia are being looked after at home by family or friends, it is very important that they receive all the multi-agency support needed to be able to best care for them for as long as they are able. This should include an assessment by the local authority if they wish, and the development of a support plan for the carer to put in place to support them to continue caring for their loved one, if this is what they wish to do. This may include home visits from care workers to help with care and support needs, day centre placements, short breaks in residential homes or having someone live in at home whilst they go on holiday.

Carers may feel a range of emotions, including not wanting their loved one to go into long-term care, when in reality they are struggling to cope looking after them at home. A review of the carer’s support plan should include discussions about the longer term future for the adult and their carer, Staff should sensitively discuss with them what may happen, and any preferences they may have, if there comes a time when they can no longer care for the adult.

Both the adult’s care and support plan and the carer’s support plan should include plans for what should happen if the carer cannot care for the adult on either a short term (illness for example) or permanent basis, including planning for what may happen in an emergency situation.

7. Making Advance Decisions

People can make some decisions to make sure their wishes and views are respected should they lose mental capacity in the future, as a result of dementia for example. This includes decisions about their health care treatment and authorising lasting power of attorney in relation to their health and welfare and / or property and financial affairs. See the chapter on Planning Ahead for Health and Social Care Decisions.

8. Safeguarding Adults with Dementia

As discussed above, common symptoms for adults with dementia include memory loss, disorientation, confusion, communication difficulties, behavioural issues, low mood and cognitive impairment. One or more of these factors can put an adult who may be at risk of suffering or experiencing abuse or neglect.

They are vulnerable to abuse or neglect because:

  • dementia can affect a person’s ability to communicate or can make them confused, so they may be unable to tell anyone about what is happening to them;
  • they may not be able to manage their own financial affairs, Icf an unsuitable person takes this over for them, it gives them opportunity to steal money or other possessions;
  • they can be susceptible to psychological or physical abuse because carers cannot cope – either on a temporary or long term basis – and for example become angry, shout, care for them roughly or are otherwise unkind;
  • they can be targeted by abusers who take advantage of their condition and know they may be unable to refuse them or give in to people who are bossy and over-bearing;
  • the adult may forget about the abuse that has happened and not tell anyone.

As the condition  progresses and the adult gets worse, their ability to protect themselves  lessens and often disappears completely.

Where there are safeguarding concerns, see the Safeguarding Enquiries Process section.

9. Training and Supervision

Training should be available for all staff working directly with adults with dementia, but also to other frontline staff to ensure they have an awareness and understanding of the issues that are important for both adults and their carers when managing the person’s symptoms.

This is particularly important considering the expected rise in the number of people who will be affected by dementia over the next 10 years.

Staff supervision sessions need to recognise the difficulties that working with adults with dementia can present for staff, who are involved in supporting both them and their carer. The symptoms of dementia can result in behaviour that is difficult to manage, whilst also being emotionally distressing for the individual member of staff.

Support for these issues needs to be available for staff through supervision, as well as external sources of specialised support where required.

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RELEVANT CHAPTER

Stage 1: Concerns

Safeguarding: What is it and Why does it Matter?

RELEVANT INFORMATION

Pressure ulcers: how to safeguard adults (Department of Health and Social Care)

Helping to Prevent Pressure Ulcers: A Quick Guide for Registered Managers of Care Homes (NICE)

Amendment  – In January 2024, a link to the revised Department of Health and Social Care protocol for safeguarding adults with pressure ulcers was added.

1. Introduction

Safeguarding an adult from harm and exploitation is one of the key responsibilities of all care providers, and is a basic human right as laid down in the Human Rights Act 1998. All health and social care practitioners must ensure that adults are safeguarded against the risk of abuse or neglect by early identification of potential risks, prevention of risks and responding appropriately to any allegation or suspicion of abuse.

Older people and those with disabilities may be frail and have restricted mobility and will, therefore, be at higher risk of developing pressure areas, especially if they are towards the end of life. Pressure sores may start simply with skin changing colour but, if left untreated can become deep or infected. They can be life threatening if infections develop which are not treated.  With good management and care, they can be improved in many cases.

Staff from all agencies must have an awareness of when tissue damage or pressure ulcers may be a result of poor practice or neglect, and what action to take. Not all pressure ulcers occur as a result of neglect by professionals, however, and care should be taken not to automatically make such assumptions.

Cases should be treated individually taking into account the person’s medical condition, prognosis, skin conditions, self-neglect, poor personal hygiene, living environment, poor nutrition and hydration and their own views on their care and treatment. The police must be involved where there is a possibility the pressure sores are a result of wilful neglect by a family member or by a practitioner or service (see Stage 1: Concerns).

2. Preventing Pressure Areas: Checklist

The following factors are a guide to identifying risk in relation to pressure sores, and to prevent them occurring wherever possible:

  • all care staff should receive training on how to prevent and identify pressure sores;
  • adults with care and support needs should be regularly assessed on their risk of developing pressure sores;
  • individuals at risk of developing pressure sores should be assessed to ensure that appropriate equipment is provided promptly;
  • timely referrals should be made to community health professionals in pressure sore management;
  • body maps should be completed to identify and monitor pressure sores;
  • care and support plans and action plans should be regularly reviewed by managers.

3. Pressure Area Assessment Checklist

If a pressure ulcer or tissue damage is at risk of occurring, or has already occurred, the following information should be obtained by the relevant practitioner from the adult, family member or carer:

3.1 History

  • Does the adult have any significant health history, including physical or mental health issues that would impact on their mobility or general physical health, for example?
  • Has there been a rapid onset or deterioration in the adult’s health? If so how has this affected them?
  • Does the adult have any issues related to mental capacity, compliance with practitioners, challenging behaviour, for example, that could impact on any required care and support interventions in related to tissue damage?

3.2 Care and support

  • Where was the adult living at the time the pressure ulcer was identified
  • Was the adult admitted with the pressure ulcer or has it developed since admission?
  • Were they receiving support from a regulated service?
  • What are the adult’s views of their condition? Are they in pain as a result of the ulcer? Do they have an infection or any other symptoms that may need immediate medical intervention?
  • What are the views of their carers or family members about the care and support the adult has received, and do they have any safeguarding concerns in relation to practitioners or service quality?
  • What is the Care Quality Commission’s assessment of the quality of care provided by this service? Are there other recent similar incidents? What was their rating at their last inspection?
  • Are there any concerns that the adult’s pressure ulcer is related to the level of care from the service provider? If so, please see Stage 1: Concerns.
  • Has a skin care assessment and care and support plan been completed? Was the assessment robust,for example were pressure areas identified as a risk and if so were specific of concern were noted; was a body map completed (see Appendix 1: Resources)? Was regular monitoring of the adult’s skin undertaken?
  • Does the adult’s care and support plan identify pressure area risks and appropriate measures to be taken to minimise risk, for example regular moving with the aid of staff?
  • Was specialist equipment in place and was it being appropriately used? If not, record the reason.
  • Were staff involved in the adult’s care and support adequately trained and competent in relation to skin care and pressure ulcer interventions? Was staff cover sufficient, both days and nights?

3.3 Mobility

  • What was the adult’s mobility just prior to identification of the pressure ulcer?
  • Does their care and support plan include needs relating to their mobility?
  • Have there been any changes to their mobility recently that are not reflected in the care and support plan?
  • Where the adult has mobility problems, do care and support staff regularly help them move – either in bed, in the chair or help them have a short walk for example?

3.4 Hydration and nutrition

  • What is the adult’s nutritional intake? Are there any concerns related to how much and the quality of the food they eat? Is there any concern they may be malnourished? Does their care and support plan reflect any such concerns?
  • Does the adult have an adequate, healthy intake of fluids? If not, does their care and support plan reflect this?
  • If they are in residential care or hospital are their food and fluid intake adequately recorded in their case notes?
  • Does the adult need a referral to a doctor or nutritionist?
  • Is the adult’s weight regularly recorded, monitored and concerns raised with the relevant health care professional?

3.5 Medication

  • Is the adult receiving any medication which may contribute to immobility, for example sedatives or medication that is making them feel nauseous?
  • If they are sedated, this may lead to the adult being immobile for extended periods of time.
  • Is their pain assessed and adequately managed?

3.6 General appearance

  • General indicators of care: how does the adult present in relation to their appearance? Are their hair and nails clean, their clothes clean, do they have any personal odour which suggests they may not have washed, bathed or showered recently, are they emaciated, is their oral care adequate?

3.7 Mental capacity

  • Are there any concerns about the adult’s ability to make informed choices? If so has a mental capacity assessment been completed?
  • If not, make arrangements for one to be completed (see Mental Capacity chapter).

3.8 Equipment

  • Is relevant pressure relieving equipment in place, for example specialist mattresses, chair or feet cushions or beds? If not, and it is assessed as being required, make a referral to the relevant service.

3.9 Where the adult is living in the community

  • Do they live alone? If so, who is providing support?
  • What is the relationship to the adult of the person / people providing support to the care and support needs of the adult?
  • Provide the carer’s age, any disability and how they are coping.
  • What support networks do both the adult and the carer have?
  • Has the adult and the carer had care and support assessments conducted by the local authority? If not, do they need a referral?
  • Was support and help sought? If so, when and from whom?
  • Was support accepted – all, in part or none?

4. Assessment Outcome

Following completion of the assessment, including the above information, there are three possible outcomes:

  • no further action – the assessment has concluded that the pressure ulcer was unavoidable due to the adult’s individual’s health issues. The service they have been receiving had taken all appropriate measures available to them in a timely manner;
  • quality alert action required – the assessment has concluded that poor quality care may have contributed to the development of the ulcer and a Quality Alert Action required
  • safeguarding referral required – the assessment has concluded that the pressure ulcer may have been avoidable – the result of neglect because the service and support they were receiving had not taken all appropriate measures available to them in a timely manner.  A safeguarding referral should be made to the local Safeguarding Adults Team; the police may also be notified where there are concerns of wilful neglect (see Stage 1: Concerns).

Consideration should be given to any risks posed to other service uses, residents or patients, including gathering information as to the prevalence of other people who have developed pressure ulcers over a specified period of time.

Appendix 1: Resources

Pressure ulcers: prevention and management  (NICE)

Body map for Initial Recording

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This chapter provides information for multi-agency practitioners about how to keep safe, both professionally and personally, when using social media.

RELEVANT INFORMATION

Using Social Media Wisely, Health and Care Professions Council

1. Introduction

This guidance provides information about how to minimise risk to yourself, and others, whilst using social media sites. Commonly used social media sites include Facebook, Twitter, Instagram, TikTok and YouTube, through which users create online communities to share information, ideas, personal messages, and other content such as videos and photographs.

As a health or social care professional it is your responsibility to protect yourself as far as possible from allegations of wrongdoing online and whilst using digital technology, to avoid potentially inappropriate or damaging situations. As your job involves direct work with adults and their families who may be experiencing challenging and stressful circumstances, it is possible that some people may post information online about staff or the service that is wrong or upsetting.

It is vital therefore that, in order to protect the reputation of the organisation and staff, the response is always professional, proportionate and measured.

In such situations, managers may need to respond to and take action against those posting such material; guidance is provided below to help protect staff and volunteers working with the public.

2. Steps to Minimise Risk

2.1 Privacy settings and passwords

Check your privacy settings across all social networks. This can be done by going to ‘Settings’ and reviewing the current privacy settings. Updating privacy settings is vital to being able to protect yourself online and is just as important as keeping a credit card safe, for example.

The privacy settings of some social media sites can be set up to send posts just to particular groups, such as close friends, rather than all ‘friends’. Such options are worth considering when thinking about sharing information that you would not necessarily want all people to know.

Remember some information cannot be hidden however tight privacy settings. Names and profile images will always be visible on Facebook for example, so choose images or photos carefully.

By logging out of your social networks and then searching for yourself you can see how your profile appears to the public.

Regularly update your passwords. Do not use the same one across all social media accounts. This will help avoid someone hacking into your account and posting inappropriate status updates or images.

You can also make it more difficult to be found online, by changing your name or surname for example.

2.2 Connect wisely

Many people have far more friends on social media than they know personally. But it is wise only to connect with people that you know and trust. Even people you know, however, may post comments or share material that you do not like or agree with.

In such cases think about whether to ‘unfriend’ that person rather than be associated with someone whose views you do not share.

If it is someone you know and like, discuss their posts with them if you find it uncomfortable.

Consider the purpose of the site, and use it accordingly. For example, LinkedIn is for professional connections. It is best, therefore, not to accept requests to connect if the message contains suspicious text or the person seems to have no connections, location, education or vocation similar to you.

2.3 Post, share and access wisely

2.3.1 Personal information

Think carefully before you post photos and text.

If you would not say it in public or to your manager, or want them to see certain images, you should not put it on social media however tight your privacy settings. Online friends can share or repost / re-tweet your updates, so you can lose control of what you say and display.

Remember, some things are best only shared in person or by telephone or even not at all, not via social media including email.

It is illegal to access or download material that promotes or shows criminal behaviour. Do not access any illegal or inappropriate websites on your personal computer or mobile phone, not even for personal or professional research purposes. This includes illegal or inappropriate images of children, some pornography or extremist websites.

Photos and texts sent to mobile phones and tablets can also be shared by others, so be careful what you send to others or what images you allow people to take of you. Sometimes images are accompanied by personal information, including name, address and links to their social media profiles. Sharing certain private images or films may be an offence under the Criminal Justice and Courts Act 2015. It applies both on and offline, and to images which are shared electronically or more traditionally so includes uploading of images on the internet, sharing by text and email, or showing someone a physical or electronic image.

Be careful using social media whilst under the influence of alcohol. Whilst your own posts can be edited the next day, there is often not much that can be done about other people’s replies.

Take care when in contact with others via web cam internet sites (for example chat rooms, message boards, social networking sites and newsgroups). Avoid inappropriate communication with anyone you think may be under 18, or anyone with whom who you may be considered to be in a position of trust. Avoid inappropriate communication with those who you do not know. Adults can pose as children using interactive technology; likewise some children can pose as adults.

2.3.2 Professional Information

See also Using Social Media Wisely, Health and Care Professions Council and Professional Standards Guidance, Social Work England

Posting information in relation to adults with whom you work, or their family or friends, is allowed. This is likely to be a breach of data protection legislation and confidentiality requirements (see Data Protection: Legislation and Guidance chapter), and even if it is illegal, it is professionally unethical and may result in disciplinary action being taken. For example, families have seen and subsequently made formal complaints about social workers who – whilst not disclosing any personal information – have posted following court cases which have found in the local authority’s favour.

Posting information about work colleagues of any grade, whilst not illegal, is not advised. It can damage working relationships and cause difficulties in the work environment. Again, it may lead to disciplinary action being taken.

Consider also the possible implications of out of office hours discussions with colleagues via social media about controversial issues such as politics, for example. Working relationships can sometimes be negatively affected by such disagreements.

2.4 Review content

If you have used social media accounts over a number of years, it may be useful to review earlier entries to see if there is any content you posted when you were younger that you would not now post. If so, it would be best to delete it.

Check what others post about you, as this also contributes to your social media profile even if you did not post it yourself. If you are not happy with being tagged in a particular photo or status update, contact the person or organisation concerned via messaging or email (rather than via a public discussion) and politely ask them to remove it, explaining why.

Getting content taken down by the social media company can be difficult and may have to involve the police, which should only be reserved for extreme cases.

2.5 Act wisely

Whilst you should always share personal information with caution, in particular do not contact adults or their families via personal email, social media or telephone. This includes former users of the service. If you wish to keep in contact with any such person, only use work emails or telephone numbers to communicate with them. Discuss your intention with your line manager in advance, and seek their advice.

In order to further protect yourself, do not geotag or location tag your photographs.  Whilst the photos might not be easily identifiable, the location could lead to identification and let others know your whereabouts including your home address or those of your family and friends.

Ensure you follow your organisation’s Acceptable Use Policy / IT and email procedures. If you breach any part, report it immediately to your manager or other designated member of staff, as set out in the policy.

If there is any incident regarding the use of social media that concerns you, report it immediately to your line manager. Document it as soon as possible, according to your workplace procedures.

4. In Summary

Use common sense and professional judgement at all times to avoid circumstances which are, or as importantly could be viewed by others, to be inappropriate.

Remember, computers, tablets and mobile phone technology may be the virtual world, but they very much impact on real life. Treat people the same through electronic communications as you would on a personal basis.

Do’s

  • Think carefully before you post anything online;
  • Search on your own name to see what others can see about you and take action if there is anything that makes you feel uncomfortable;
  • Protect and regularly change your passwords;
  • Regularly review your privacy settings;
  • Make it more difficult to be found online (for example, change your surname).

Don’ts

  • Use inappropriate language;
  • Expect your friends or family to know how to protect your online reputation and how information they may post could impact on you professionally;
  • Have a public social media presence – do not set your privacy settings to public unless relevant;

Tag yourself or allow yourself to be tagged photos or videos;

Accept or send friend requests to adults who you have met through the course of your work who use services, their family or friends.

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1. Introduction

Local authorities and Integrated Care Boards (ICBs) have equal and joint duties to prepare Joint Strategic Needs Assessments (JSNAs) and Joint Local Health and Wellbeing Strategies (JLHWSs), through the health and wellbeing board.

The purpose of the JSNA and JLHWS is to identify local needs to inform strategies and services to improve the health and wellbeing of the local community and reduce inequalities for all ages.

2. Joint Strategic Needs Assessment

A JSNA is an assessment of the current and future health and social care needs of the local community. These are needs that could be met by the local system and its partners, for example the local authority, Integrated Care Board, voluntary sector or the NHS.

The JSNA is produced by the local health and wellbeing board, and is unique to the local area. The health and wellbeing board should also consider a wide range of factors that impact on their communities’ health and wellbeing, and local assets that can help to improve outcomes and reduce inequalities. JSNAs should include information and outcomes for adult safeguarding. Each local area is free to undertake the JSNA in a way best suited to its local circumstances; there is no template or format that must be used and no mandatory data set to be included.

Within South Tyneside the approach taken includes asset within any assessment carried out and is therefore referred to as the JSNAA. The process of developing the key documents focuses on specific themes or topics rather than providing one overall needs assessment for South Tyneside. This approach enables individuals to access the relevant information more easily and allows documents to be updated more frequently as well as hosted on the website with a range of links to other supporting documents.

A range of quantitative (numeric) and qualitative (non-numeric) evidence should be used in the JSNA. There are a number of data sources and tools that the health and wellbeing board may find useful for obtaining quantitative data. Qualitative information can be gathered in a variety of ways, including views collected by the local Healthwatch organisation or by local voluntary sector organisations, feedback given to local providers by service users, and views fed in as part of community participation within the JSNA and JLHWS process.

3. Joint Local Health and Wellbeing Strategy

The JLHWS should turn the JSNA findings into clear outcomes that the health and wellbeing board wants to achieve, which will inform local commissioning, and the development of locally led initiatives that meet the outcomes agreed and the needs identified.

The JLHWS is the strategy for meeting the needs identified in the JSNA. As with JSNAs, it is produced by the health and wellbeing board, is unique to each local area, and there is no prescribed format.

However, the board must have regard to the integrated care strategy when preparing their joint local health and wellbeing strategies, as well as having regard to the NHS priorities and the statutory guidance.

The JLHWS should explain what priorities the health and wellbeing board has set in order to tackle the needs identified in the JSNA.

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RELEVANT CHAPTERS

Safer Recruitment and Employment

Person / People in Positions of Trust (PIPOT) – Multi-Agency Practice Guidance

RELEVANT INFORMATION

Check someone’s criminal record as an employer (gov.uk)

DBS Checks for Adult Social Care Roles (Disclosure and Barring Service)

Criminal Record Support Service (Nacro)

March 2022: A new section 4.2 has been added to provide detail on the adult first service provided by the Disclosure and Barring Services (DBS). Organisations can use adult first to request a check of the DBS adults’ barred list. Depending on the result, a person can be permitted to start work, under supervision, with adults before a DBS certificate has been obtained.

1. Introduction

Employers need to make sure, to the best of their ability, that the people who they employ – as paid staff, volunteers or contractors – are committed to providing good quality care and support to adults who receive care and support services from them, their carers or other family members including children.

Undertaking robust criminal records checks is part of a number of safer recruitment measures, which are designed to try to prevent unsuitable people being employed to work with vulnerable groups.

As well as thorough recruitment processes, training, staff supervision and appraisal programmes are all important to ensuring good working practices.

2. Disclosure and Barring Service

The Disclosure and Barring Service (DBS) helps employers make safer recruitment decisions. It is responsible for:

  • processing requests from organisations for criminal records checks (know as DBS checks) on individuals;
  • deciding whether it is right that a person should be put on, or removed from, a barred list;
  • placing or removing people from the DBS children’s barred list and adults’ barred list for England, Wales and Northern Ireland.

As well as processing requests and making decisions, the DBS maintains the adults’ and children’s Barred Lists (see Section 3, Barred Lists and Duty to Refer) which bar someone from working in a job that involves regulated activity.

3. Barred Lists and Duty to Refer

There are two barred lists maintained by the Disclosure and Barring Service in relation to those who are:

  • barred from working with children;
  • barred with working with adults.

A person who is barred from working with children or adults will be committing a criminal offence if they work, volunteer or try to work or volunteer with the group from which they have been barred.

An organisation which knows they are employing someone who is barred to work with that particular group, will also be committing a criminal offence.

Legally an organisation has to inform the DBS if a member of its staff or a volunteer is dismissed (or they would have been dismissed if they had not resigned or otherwise left first) because they pose a risk of harm or have caused harm to a child or adult.

See the DBS referral flowchart.

4. DBS Checks

Click here to access the DBS tool to Find out which DBS Check is Right for your Employee

Through undertaking checks the DBS helps organisations identify people who may be unsuitable for the job.

4.1 Types of Disclosures

  • a basic check: which shows unspent convictions and conditional cautions.
  • a standard check: which shows spent and unspent convictions, cautions, reprimands and final warnings;
  • an enhanced check: which shows the same as a standard check plus any information held by local police that’s considered relevant to the role;
  • an enhanced check with a check of the barred lists: which shows the same as an enhanced check plus whether the applicant is on the adults’ barred list, children’s barred list or both.

4.2 Adult first check

See Types of DBS checks and how to apply (DBS)

DBS adult first is a service available to organisations who can request a check of the DBS adults’ barred list. Depending on the result, a person can be permitted to start work, under supervision, with adults before a DBS certificate has been obtained.

There are strict criteria:

  • the role must require a criminal record check by law;
  •  it must be eligible for access to the DBS adults’ barred list;
  • the organisation must have requested a check of the DBS adults’ barred list on the DBS application form.

The DBS’ reply to an adult first check request will state either:

  • option 1: ‘Registered Body must wait for the DBS certificate’; or
  • option 2: ‘no match exists for this person on the current adults’ barred list’

It will also state that it is only the first part of the criminal record check application process and that further information will follow.

f the adult first check indicates that the Registered Body must wait for the DBS certificate, it may indicate there is a match on the DBS adults’ barred list. However, further investigation is required to confirm this and the organisation should wait to receive the certificate.

4.3 Update Service

The DBS also provides an online Update Service, to which staff or volunteers can subscribe and review annually for a small fee (free for volunteers). This helps them keep their DBS certificate up to date, so it can be taken with them from one job to another, as long as they remain within the same workforce (working with adults for example) unless:

  • an employer asks them to get a new certificate;
  • they need a certificate for a different type of ‘workforce’ (for example, they have an ‘adult workforce’ certificate and need a ‘child workforce’ certificate);
  • they need a different level certificate (for example, they have a standard DBS certificate and need an enhanced one).

Employers can do immediate online checks of a person’s status, as long as the person has registered with the update service. The Update Service is for standard and enhanced DBS checks only (see 4.1 Types of Disclosures).

A new DBS check will only be required if the Update Service check indicates there has been a change in the person’s status, due to new information added.

4.4 Cautions and convictions

Before an organisation asks a person to apply for a standard or enhanced check through the Disclosure and Barring Service, it is legally responsible for ensuring the job is eligible (see Eligibility, DBS).

Please note that certain old and minor cautions and convictions are no longer subject to disclosure; see Disclosure and Barring Service Filtering Guide.

4. Regulated Activity with Adults

See Regulated activity (adults) – Department of Health and Social Care

Regulated Activity is work which involves close and unsupervised contact with adults, and which cannot be undertaken by a person who is on the Disclosure and Barring Service’s Barred List for adults.

There are six categories of people who will fall within the definition of Regulated Activity (including anyone who provides day to day management or supervision of those people):

  • providing health care;
  • providing personal care (e.g. providing/training/instructing/or offering advice or guidance on physical assistance with eating or drinking, going to the toilet, washing or bathing, dressing, oral care or care of the skin, hair or nails because of an adult’s age, illness or disability; or prompting and supervising an adult to undertake such activities where necessary because of their age, illness or disability);
  • providing social work;
  • providing assistance with cash, bills and/or shopping;
  • providing assistance in the conduct of a person’s own affairs, e.g. by virtue of an enduring power of attorney;
  • conveying / transporting an adult (because of their age, illness or disability) either to or from their place of residence and a place where they have received, or will be receiving, health care, personal care or social care; or between places where they have received or will be receiving health care, personal care or social care. This will not include family and friends or taxi drivers.

There is a duty on a ‘regulated activity provider’ to find out whether a person is barred before allowing that person to carry out regulated activity tasks in their work.

It is a criminal offence for a person on one of the barred lists to carry out regulated activity tasks, or for an employer / voluntary organisation knowingly to employ a barred person in a regulated activity role.

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1. Introduction – Using Data to Improve Services

NHS Digital collect a range of data covering many aspects of adult health and social care. This includes data submitted by NHS trusts, local authorities, and providers.  Reports published by NHS Digital can be used to look at trends in adult social care and safeguarding adults activity at the national, regional and local level.

However, to measure the effectiveness of safeguarding adults practice locally, the Safeguarding Adults Board will also need to collect and analyse its own data. The Safeguarding Adult Board (SAB) is required under the Care Act 2014 to be able to share strategic information to improve local safeguarding practice.

Information which could be useful locally includes:

  • data on safeguarding notifications to increase the SAB’s understanding of how widespread abuse and neglect is and how this may change over time;
  • evidence of community awareness of adult abuse and neglect and how to respond.

The SAB annual report will also provide a summary of safeguarding adults activity in the local area and outline how it is meeting the aims of its business plan / strategic plan.

2. Safeguarding Adults Collection

Each year NHS Digital publishes the findings from data collected from local authorities under the Safeguarding Adults Collection (SAC).

The reports published provide details of safeguarding activity relating to adults aged 18 and over in England.

Data collected covers the following:

  • number of safeguarding concerns;
  • number of section 42 enquiries;
  • types of risk;
  • risk assessment and outcomes;
  • making safeguarding personal;
  • safeguarding adult reviews.

This data can be used by safeguarding adult partners to:

  • understand trends in safeguarding concerns raised and enquiries conducted;
  • analyse the profile of people involved in safeguarding enquiries, and the nature of the risk of abuse or neglect involved;
  • supplement local data collected in relation to safeguarding practice and outcomes.

For more information see NHS Digital.

3. Deprivation of Liberty Safeguards

NHS Digital also collects a statutory annual return for Deprivation of Liberty Safeguards (DoLs).

Data collected from local authorities covers the following:

  1. the number of DoLS application requests made;
  2. the number of authorisation requests granted;
  3. the number of authorisation requests not granted;
  4. time taken to process DoLS applications.

See also  Deprivation of Liberty Safeguards (DoLS), under the Mental Capacity Act 2005 .

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CARE ACT 2014

The Act introduced duties on the Care Quality Commission to assess financial sustainability of the most difficult to replace providers, and support local authorities to ensure continuity of care if providers fail. There is a general duty for the local authority to promote diversity and quality in the market of local care and support providers. It must ensure a range of providers available; shaped by demands of individuals, families and carers; services are of high quality and meet needs and preferences of those wanting to access services.

RELEVANT CHAPTER

Promoting Wellbeing

RELEVANT INFORMATION

Chapter 4, Market Shaping and Commissioning of Adult Care and Support, Care and Support Statutory Guidance (Department of Health and Social Care)

1. Introduction

High quality, personalised care and support can only be achieved where there is a vibrant, responsive market of service providers. The role of the local authority is critical to achieving this, both through the actions it takes to commission services directly to meet needs and the broader understanding of and interactions it undertakes with, the wider market, for the benefit of all local people and communities.

The Care Act 2014 places duties on local authorities to promote the efficient and effective operation of the market for adult care and support as a whole. This can be considered a duty to facilitate the market, in the sense of using a wide range of approaches to encourage and shape it, so that it meets the needs of all people in their area who need care and support, whether arranged or funded by the state, by the individual themselves, or in other ways. The ambition is for local authorities to influence and drive the pace of change for their whole market, leading to a sustainable and diverse range of care and support providers, continuously improving quality and choice, and delivering better, innovative and cost effective outcomes that promote the wellbeing of people who need care and support.

The market for care and support services is part of a wider system in which much of the need for care and support is met by people’s own efforts, by their families, friends or other carers, and by community networks. Local authorities have a vital role in ensuring that universal services are available to the whole population and where necessary, tailored to meet the needs of those with additional support requirements (for example housing and leisure services). Market shaping and commissioning should aim to promote a market for care and support that should be seen as broadening, supplementing and supporting all these vital sources of care and support.

Local authorities should review the way they commission services, as this is a prime way to achieve effective market shaping and directly affects services for those whose needs are met by the local authority, including where funded wholly or partly by the state.

At a time of increasing pressure on public funds, changing patterns of needs, and increasing aspirations of citizens, together with momentum for integrated services, joint commissioning, and choice for individuals, it is suggested that fundamental changes to the way care and support services are arranged may be needed, driven through a transformation of the way services are led, considered and arranged. Commissioning and market shaping are key levers for local authorities in designing and facilitating a healthy market of quality services.

2. Definitions

2.1 Market shaping

Market shaping means the local authority collaborating closely with other relevant partners, including people with care and support needs, carers and families, to facilitate the whole market in its area for care, support and related services.

This includes:

  • services arranged and paid for by the state through the authority itself;
  • those services paid by the state through direct payments;
  • those services arranged and paid for by individuals from whatever sources (self-funders);
  • services paid for by a combination of these sources.

Market shaping activity should stimulate a diverse range of appropriate high quality services (both in terms of the types, volumes and quality of services and the types of provider organisation), and ensure the market as a whole remains vibrant and sustainable.

The core activities of market shaping are to engage with stakeholders to develop understanding of supply and demand to understand likely trends that reflect people’s needs and aspirations. It should be based on evidence, to signal to the market the types of services needed now and in the future to meet them, encourage innovation, investment and continuous improvement.

It includes working to ensure that those who purchase their own services are empowered to be effective consumers, for example by helping people who want to take direct payments make informed decisions about employing personal assistants. A local authority’s own commissioning practices are likely to have a significant influence on the market to achieve the desired outcomes, but other interventions may be needed, for example, incentivising innovation by user-led or third sector providers, possibly through grant funding.

2.2 Commissioning

Commissioning is the local authority’s cyclical activity to assess the needs of its local population for care and support services, determining what element of this needs to be arranged by the authority, then designing, delivering, monitoring and evaluating those services to ensure appropriate outcomes. Commissioning has come to be shaped more by the outcomes commissioners and individuals identify, rather than volumes of activity expected and commissioners have sought to facilitate flexible arrangements with providers for other forms of service to support choice and control, such as Individual Service Funds (ISFs).

2.3 Procurement

Procurement is the specific functions carried out by the local authority to buy or acquire the services the local authority has a duty to arrange to meet people’s needs, to agreed standards to provide value for money to the public purse and deliver its commissioning strategy.

2.4 Contracting

Contracting is the means by which that process is made legally binding. Contract management is the process that ensures that the services continue to be delivered to the agreed quality standards. Commissioning encompasses procurement but includes the wider set of strategic activities.

Market shaping, commissioning, procurement and contracting are inter-related activities and the themes of the Care and Support Statutory Guidance apply to each to a greater or lesser extent depending on the specific activity.

3. Principles of Market Shaping and Commissioning

3.1 Focusing on outcomes

The local authority must ensure the promotion of the wellbeing of individuals who need care and support, and the wellbeing of carers. The outcomes they require, are central to all care and support functions in relation to individuals, emphasising the importance of enabling people to stay independent for as long as possible. See the chapters on Promoting Wellbeing and Preventing, Reducing and Delaying Needs.

The local authority will need to understand the outcomes which matter most to people in its area, and demonstrate that these outcomes are at the heart of its local strategies and approaches.

The local authority should consider the Measures from the Adult Social Care Outcomes Framework in addition to any locally collected information on outcomes and experiences, when framing outcomes for its locality and groups of people with care and support needs. The local authority should have regard to guidance from the Think Local Act Personal (TLAP) Partnership when framing outcomes for individuals, groups and their local population. In particular Making It Real which sets out what good personalised care and support should look like from the perspective of people with care and support needs, carers and family members.

Outcomes should be considered both in terms of outcomes for individuals and outcomes for groups of people and populations. Local authorities should consider the Care Quality Commission standards for quality and any emerging national frameworks for defining outcomes.

Local authorities should consider analysing and presenting local needs for services in terms of outcomes required. Local authorities should ensure that achieving better outcomes is central to its commissioning strategy and practices, and should be able to demonstrate that they are moving to contracting in a way that has an outcome basis at its heart. Local authorities should consider emerging best practice on outcomes based commissioning.

Outcomes based services are service arrangements that are defined on the basis of an agreed set of outcomes; either for an individual or a group of people. Moving more to an outcomes-based approach therefore means changing the way services are bought: from units of provision to meet a specified need (for example, hours of care provided) to what is required to ensure specified measurable outcomes for people are met.

The approach should emphasise:

  • prevention;
  • enablement;
  • ways of reducing loneliness and social isolation;
  • promotion of independence as ways of achieving and exceeding desired outcomes;
  • choice in how people’s needs are met.

Moving to an outcomes based approach will need to recognise that some outcomes are challenging to assess and local authorities may wish to consider involving service providers when considering how service evaluations can be interpreted.

In encouraging outcomes based services, consideration should be given to how services are paid for. The local authority should consider incorporating elements of ‘payments by outcomes’ mechanisms, where practical, to emphasise and embed this commissioning approach which is based on specifying the outcomes to be achieved, rather than the service outputs to be delivered. Whilst payments by outcomes may be theoretically the most appropriate approach for outcomes based services, it is recognised that proxies for outcomes may be required to make the approach practical. For example, an outcome an authority may wish to measure might be someone’s personal outcome ‘I want to maintain a nutritious and balanced diet’, but a proxy measure that is observable, attributable and capable of being described, may be the person receiving help with meal preparation at agreed and specified times. Care logs documenting punctual assistance in meal preparation, in conjunction with positive feedback from the person receiving care about support received might be used as part of the basis of payment.  It is also recognised that whilst these mechanisms are more commonplace in other types of commissioning, they are in their infancy for adult social care.

The design of any mechanism should, however, be introduced in cooperation with stakeholders and partners to ensure it is sustainable and ensure that innovation, and individual choice and control are not undermined. Any move to payments by outcomes should be achieved such that smaller, specialist, voluntary sector and community-based providers are not excluded from markets or disadvantaged, because for example, they do not have appropriate IT systems.

The local authority should keep under review emerging ideas and best practice about outcomes based commissioning and payments by outcomes. For example the New Economics Foundation (NEF).

Local authorities should have regard to the evolving guidance Commissioning for Better Outcomes that was co-produced by the Department of Health, ADASS,LGA together with provider representatives and people with lived experience of care and support. This guidance is intended to support peer review and self-assessment of local authority commissioning, and represents a practical approach that underpins the themes of the Care and Support Statutory Guidance (2016).

The Care Act outlines local authorities’ role in preventing, reducing or delaying the need for care and support. This includes how the authority facilitates and commissions services and how it works with other local organisations to build community capital and make the most of the skills and resources already available in the area. Local authorities should consider working not just with traditional public sector partners like health, but also with a range of other partners to engage with communities to understand how to prevent problems from arising.

3.2 Promoting quality

The local authority must facilitate markets that offer a diverse range of high quality and appropriate services. In doing so, they must have regard to ensuring the continuous improvement of those services and encouraging a workforce which effectively underpins the market through:

The quality of services provided and the workforce providing them can have a significant effect on the wellbeing of people receiving care and support, and that of carers, and it is important to establish agreed understandable and clear criteria for quality and to ensure they are met (see also Promoting Wellbeing chaper).

When considering the quality of services, the local authority should be mindful of:

  • capacity;
  • capability;
  • timeliness;
  • continuity;
  • reliability;
  • flexibility;
  • wellbeing,

Where appropriate, using the definitions that underpin the CQC’s Fundamental Standards of Care as a minimum, and having regard to the ASCOF framework of population outcomes.

High quality services should enable people who need care and support, and carers, to meet appropriate personal outcome measures, for example, a domiciliary care service which provides care two days a week so that a carer who normally provides care can go to work, is not a quality service if it is not available on the specified days, or the care workers do not arrive in time to allow the carer to get to work on time.

Local authorities should also consider other relevant national standards including those that are aspirational, for example, any developed by the National Institute of Health and Care Excellence (NICE).

It should encourage a wide range of service provision to ensure that people have a choice of appropriate services; appropriateness is a fundamental part of quality. Appropriate services will meet people’s needs and reasonable preferences.

When arranging services itself, the local authority must ensure its commissioning practices and the services delivered on its behalf comply with the requirements of the Equality Act 2010, and do not discriminate against people with protected characteristics; this should include monitoring delivery against the requirements of that Act. When shaping markets for services, it should work to ensure compliance with this Act for services provided in their area that it does not arrange or pay for. Local authorities should consider care and support services for their appropriateness for people from different communities, cultures and beliefs.

The local authority should encourage services that respond to the fluctuations and changes in people’s care and support needs, for example someone with fluctuating mobility or visual impairment. It should support the transition of services throughout the stages of people with care and support needs’ lives to ensure the services provided remain appropriate. This is particularly important, for example, for young people with care and support needs and young carers transitioning to adulthood (see Transition to Adult Care and Support chapter.

The local authority should commission services having regard to the cost-effectiveness and value for money that the services offer for public funds. See the Local Government Association Adult Social Care Efficiency Programme.

People working in the care sector play a central role in providing high quality services. The local authority must consider how to help foster, enhance and appropriately incentivise this vital workforce to underpin effective, high quality services. In particular, it should consider how to encourage training and development for the workforce, including for the management of care services, though, for example, national standards recommended by Skills for Care:

and have regard to funding available through grants to support the training of care workers in the independent sector.

The local authority should consider encouraging the training and development of care worker staff to at least the standard of the Care Certificate being developed by Skills for Care and Skills for Health.

When commissioning services, the local authority should assure itself and have evidence that service providers employ staff who are remunerated to a level that enables them to retain an effective workforce. Remuneration must be at least sufficient to comply with the national minimum wage legislation for hourly pay or equivalent salary. This will include appropriate remuneration for any time spent travelling between appointments. Guidance on these issues can be found at the HMRC website.

When commissioning services, the local authority should assure itself and have evidence that contract terms, conditions and fee levels for care and support services are appropriate to provide the delivery of the agreed care packages with agreed quality of care. This should support and promote the wellbeing of people who receive care and support, and allow for the service provider ability to meet statutory obligations to pay at least the national minimum wage and provide effective training and development of staff and enable retention of staff. It should also allow retention of staff commensurate with delivering services to the agreed quality, and encourage innovation and improvement. Local authorities should have regard to guidance on minimum fee levels necessary to provide this assurance, taking account of the local economic environment. This assurance should understand that reasonable fee levels allow for a reasonable rate of return by independent providers that is sufficient to allow the overall pool of efficient providers to remain sustainable in the long term. The following tools may be helpful as examples of possible approaches:

The local authority should also ensure that it has functions and systems in place to fulfil its duties on market shaping and commissioning itself that are fit for purpose, with sufficient capacity and capability of trained and qualified staff to meet the requirements set out in the Care Act 2014 and the Care and Support Statutory Guidance.

In particular, local authorities should encourage relevant staff to be trained or developed to meet the National Skills Academy standards and programmes of training for care and support Commissioners or equivalent, and appropriate standards for commissioning related services such as housing services where appropriate. Local authorities should consider the skills and capabilities needed to support new approaches to commissioning, for example, outcomes-based and integrated commissioning. Local authorities should have regard to the emerging skill levels and qualifications being developed for commissioning staff by Skills for Care.

3.3 Supporting sustainability

The local authority must work to develop markets for care and support that – whilst recognising that individual providers may exit the market from time to time – ensure the overall provision of services remains healthy in terms of the sufficiency of adequate provision of high quality care and support needed to meet expected needs. This will ensure there are a range of appropriate and high quality providers and services from which people can choose.

The local authority should understand the business environment of providers offering services in its area and seek to work with those facing challenges and understand their risks. Where needed, based on expected trends, the local authority should consider encouraging service providers to adjust the extent and types of service provision. This could include signalling to the market as a whole the possible need to extend or expand services, encourage new entrants to the market in the area, or if appropriate, signal likely decrease in needs – for example, drawing attention to a possible reduction in home care needs, and changes in demand resulting from increasing uptake of direct payments. The process of developing and articulating a Market Position Statement or equivalent should be central to this process.

The local authority should consider the impact of its own activities on the market as a whole, in particular the potential impact of its commissioning and re-commissioning decisions, how services are packaged or combined for tendering, and where they may also be a supplier of care and support. The local authority may be the most significant purchaser of care and support in an area, and therefore its approach to commissioning will have an impact beyond those services which it contracts. It must not undertake any actions which may threaten the sustainability of the local market as a whole, for example, by setting fee levels below an amount which is not sustainable for providers in the long term.

The local authority should have effective communications and relationships with providers in its area that should minimise risks of unexpected closures and failures. It should have effective interaction and communication with the Care Quality Commission (CQC) about the larger and most difficult to replace providers for which the CQC will provide financial oversight. It should review the intelligence it has about the sustainability of care providers drawn from market shaping, commissioning and contract management activities.

Where the authority believes there is a significant risk to a provider’s financial viability, and where they consider it would be in the best interests of service users, the authority should consider what assistance may be provided or brokered to help the provider return to viability, and consider what actions might be needed were that provider to fail. For example, where a local authority has arranged services for people with a provider that appears to be at risk, it should undertake early planning to identify potential replacement service capacity. Where it is apparent to a local authority that a provider is likely to imminently fail financially, either through its own intelligence or through information from the CQC, the authority should prepare to step in to ensure continuity of care and support for people who have their care and support provided by that provider.

3.4 Ensuring choice

The local authority must encourage a variety of different providers and different types of services. This is important in order to facilitate an effective open market, driving quality and cost-effectiveness so as to provide genuine choice to meet the range of needs and reasonable preferences of local people who need care and support services, including for people who choose to take direct payments, recognising, for example, the challenges presented in remote rural areas for low volume local services.

It must encourage a range of different types of service provider organisations to ensure people have a genuine choice of different types of service. This will include independent private providers, third sector, voluntary and community based organisations, including user-led organisations, mutual and small businesses. Local authorities should note that the involvement of people with specific lived experience of the type of needs being met, may lead to better outcomes for people who use services and carers as they directly empathise with service users. This should recognise that the different underpinning philosophies, cultural sensitivity and style of service of these organisations may be more suited to some people with care and support needs. The local authority should consider encouraging and supporting providers or taking other steps to promote an appropriate balance of provision between types of provider, having regard to competition rules and the need for fairness and legal requirements for all potential providers who may wish to compete for contracts.

When commissioning services to meet people’s eligible needs, where a local authority develops approved lists and frameworks that are used to limit the number of providers they work with, for example within a specific geographical area or for a particular service type to achieve strategic partnerships and value for money, the local authority must consider how to ensure that there is still a reasonable choice for people who need care and support.

It should encourage a genuine choice of service type, not only a selection of providers offering similar services, encouraging, for example, a variety of different living options such as shared lives, extra care housing, supported living, support provided at home, and live-in domiciliary care as alternatives to homes care, and low volume and specialist services for people with less common needs.

Choice for people who need care and support and carers should be interpreted widely. The local authority should encourage choice over the way services are delivered, for example:

  • developing arrangements so that care can be shared between an unpaid carer or relative and a paid care worker;
  • choice over when a service is delivered;
  • choice over who is a person’s key care worker;
  • arranging for providers to collaborate to ensure the right provision is available, for example, a private provider and a voluntary organisation working together;
  • choice over when a service is delivered.

The local authority must have regard to ensuring a sufficiency of provision – in terms of both capacity and capability – to meet anticipated needs for all people in its area needing care and support – regardless of how they are funded. This will include regularly reviewing trends in needs including multiple and complex needs, outcomes sought and achieved, and trends in supply, anticipating the effects and trends in prevention and community-based assets, and through understanding and encouraging changes in the supply of services and providers’ business and investment decisions.

When considering the sufficiency and diversity of service provision, it should consider all types of service that are required to provide care and support for the local authority’s whole population, including for example:

  • support services and universal and community services that promote prevention;
  • domiciliary (home) care;
  • homes and other types of accommodation care;
  • nursing care;
  • live-in care services;
  • specialist care;
  • support for carers;
  • reablement services;
  • sheltered accommodation and supported living;
  • shared lives services;
  • other housing options;
  • community support;
  • counselling;
  • social work;
  • information, brokerage, advocacy and advice services;
  • direct payment support organisations.

This will include keeping up to date with innovations and developments in services, networking through for example, the Association of Directors of Adult Social Services (ADASS), Think Local Act Personal (TLAP) and the Local Government Association (LGA).

The local authority should facilitate the personalisation of care and support services, encouraging services (including small, local, specialised and personal assistant services that are highly tailored), to enable people to make meaningful choices and to take control of their support arrangements, regardless of service setting or how their personal budget is managed. Local authorities should have regard to the TLAP Partnership agreement that sets out how shaping markets to meet people’s needs and aspirations, including housing options, can promote choice and control. Alongside the suitability of living accommodation, the local authority should consider how it can encourage the development of accommodation options that can support choice and control and promote wellbeing. Personalised care and support services should be flexible so as to ensure people have choices over what they are supported with, when and how their support is provided and wherever possible, by whom. The mechanism of Individual Service Funds by service providers, which are applicable in many different service types, can help to secure these kinds of flexibilities for people and providers.

The local authority should help people who fund their own services or receive direct payments, to ‘micro-commission’ care and support services and / or to pool their budgets, and should ensure a supporting infrastructure is available to help with these activities. Many local authorities, for example, are utilising web based systems such as e-Marketplaces for people who are funding their own care or are receiving direct payments to be able to search for, consider and buy care and support services online, or consider joint purchases with others. This often involves offering information and advice about, for example, the costs and quality of services and information to support safeguarding (see also Information and Advice chapter). This should include facilitating organisations that support people with direct payments and those whose care is funded independently from the local authority to become more informed and effective consumers and to overcome potential barriers such as help to recruit and employ personal assistants and to assist in overcoming problems and issues. This activity should help to match people’s wider needs with services.

Local authorities must facilitate information and advice to support people’s choices for care and support. This should include where appropriate through services to help people with care and support needs understand and access the systems and processes involved and to make effective choices. This is a key aspect of the duty to establish and maintain a universal information and advice service locally. Information and advice services should be reviewed for effectiveness using people’s experiences and feedback. This feedback forms part of the overall information a local authority considers about people’s needs and aspirations.

The local authority should facilitate local markets to encourage a sufficiency of preventative, enablement and support services, including support for carers to make caring more sustainable, such as interpreters, signers and communicator guides, and other support services such as telecare, home maintenance and gardening that may assist people achieve more independence and supports the outcomes they want.

The local authority should encourage flexible services to be developed and made available that support people who need care and support, and carers who need support, to take part in work, education or training. Services should be encouraged that allow carers who live in one local authority area but care for someone in another local authority area to access services easily, bearing in mind guidance on ordinary residence.

3.5 Co-production with stakeholders

Local authorities should pursue the principle that market shaping and commissioning should be shared endeavours, with commissioners working alongside people with care and support needs, carers, family members, care providers, representatives of care workers, relevant voluntary, user and other support organisations and the public to find shared and agreed solutions (see also the TLAP guidance on co-production).

3.6 Developing local strategies

Commissioning and market shaping should be fundamental means for local authorities to facilitate effective services in their area and it is important that authorities develop evidence-based local strategies for how they exercise these functions, and align these with wider corporate planning.  It should publish strategies that include plans that show how its legislative duties, corporate plans, analysis of local needs and requirements (integrated with the Joint Strategic Needs Assessment and Joint Local Health and Wellbeing Strategy), thorough engagement with people, carers and families, market and supply analysis, market structuring and interventions, resource allocations and procurement and contract management activities translate (now and in future) into appropriate high quality services that deliver identified outcomes for the people in their area and address any identified gaps.

Market shaping and commissioning intentions should be cross-referenced to the JSNA, and should be informed by an understanding of the needs and aspirations of the population and how services will adapt to meet them. Strategies should be informed and emphasise preventative services that encourage independence and wellbeing, delaying or preventing the need for acute interventions (see also Joint Strategic Needs Assessments and Joint Local Health and Wellbeing Strategies chapter).

Market shaping and commissioning should become an integral part of understanding and delivering the whole health and care economy, and reflect the range and diversity of communities and people with specific needs, in particular:

  • people needing care and support themselves (through for example, consumer research);
  • carers;
  • carer support organisations;
  • health professionals;
  • care and support managers and social workers (and representative organisations for these groups);
  • relevant voluntary, user and other support organisations;
  • independent advocates;
  • wider citizens;
  • provider organisations (including where appropriate housing providers); and
  • other tiers of local government.

A co-produced approach will stress the value of meaningful engagement with people at all stages, through design, delivery and evaluation, rather than simply as ‘feedback’. The local authority should publish and make available its local strategies for market shaping and commissioning, giving an indication of timescales, milestones and frequency of activities, to support local accountability and engagement with the provider market and the public.

The local authority can best start implementing its statutory responsibilities in relation to market shaping and commissioning and provider failure by developing with providers and stakeholders a published Market Position Statement. It may be helpful for Market Position Statements from neighbouring local authority areas to be coordinated to ensure a degree of consistency for people who will use the documents; this is particularly true for urban areas.

The local authority should review strategies related to care and support together with stakeholders to ensure they remain fit for purpose, learn lessons, and adapt to incorporate emerging best practice, noting that peer review has a strong track record in driving improvement. It is suggested that reporting against strategies for care and support should form part of the local authority’s Local Account.

Many public sector bodies, including local authorities, have radically transformed services by reconsidering commissioning in a strategic context. The Government’s Commissioning Academy is working to promote such transformational approaches and local authorities should have regard to the emerging best practice it is producing.

Developing a diverse market in care and support services can boost employment and create opportunities for local economic growth, through for example, increasing employment opportunities for working age people receiving care and carers, and developing the capacity of the care workforce. Local authorities should consider how their strategies related to care and support can be embedded in wider local growth strategies, for example, engaging care providers in local enterprise partnerships.

The local authority should have regard to best practice on efficiency and value for money.

The local authority strategies should adhere to general standards, relevant laws and guidance, including the Committee on Standards in Public Life principles of accountability, regularity and ensuring value for money alongside quality, and the HM Treasury guidance on Managing Public Money.

The local authority should develop standards on transparency and accountability to ensure citizens are able to contribute to and understand policy and review delivery. Standards should be in line with the codes of practice drawn up by the Department for Levelling Up, Housing and Communities

Local authorities should take the lead to engage with a wide range of stakeholders and citizens in order to develop effective approaches to care and support, including through developing the JSNA and a Market Position Statement. While the duties under the Care Act fall upon local authorities, successful market shaping is a shared endeavour that requires a range of coordinated action by commissioners and providers, working together with the citizen at the centre.  Local authorities should engage and cooperate with stakeholders to reflect the range and diversity of communities and people with specific needs, for example:

  • people needing care and support themselves and their representative organisations;
  • carers and their representative organisations;
  • health professionals;
  • social care managers and social workers;
  • independent advocates;
  • support organisations that help people who need care consider choices (including financial options);
  • provider organisations (including where appropriate housing providers and registered social landlords);
  • wider citizens and communities including individuals and groups who are less frequently heard (for example, LGBT communities where there may be a lack of data on care and support needs and preferences) or at risk from exclusion, including those who have communication issues and involving representatives of those who lack mental capacity.

Engagement with people needing care and support, people likely to need care and support, carers, independent advocates, families and friends, should emphasise understanding the needs of individuals and specific communities, what aspirations people have, what outcomes they would like to achieve, their views on existing services and how they would like services to be delivered in the future. It should also seek to identify the types of support and resources or facilities available in the local community which may be relevant for meeting care and support needs, to help understand and build community capacity to reinforce the more formal, regulated provider market. In determining an approach to engagement, local authorities should consider methods that enable people to contribute meaningfully to:

  • setting the strategic direction for market shaping and commissioning;
  • engaging in planning – using methods that support people to identify problems and solutions, rather than relying on ‘downstream’ consultation;
  • identifying outcomes and set priorities for specific services;
  • setting measures of success and monitor ongoing service delivery, including through the experience of people who use services and carers;
  • playing a leading role throughout tendering and procurement processes, from developing specifications to evaluating bids and selecting preferred providers;
  • contributing to reviews of services and strategies that relate to decommissioning decisions and areas for new investment;
  • managing any changes to service delivery, recognising that long-term relationships may have developed in the community and with individual people receiving care and support and carers.

Engagement with service providers should emphasise understanding the organisation’s strategies, risks, plans, and encourage building trusting relationships and fostering improvement and innovation to better meet the needs of people in the area. The local authority should consider engagement with significant suppliers of services to provider organisations, where this would help improve its understanding of markets, for example, engaging with employment and training services that might enable local authorities to gain access to frontline insights on care provision and the local workforce supply and training.

The local authority should ensure that active engagement and consultation with local people is built into the development and review of their strategies for market shaping and commissioning, and is demonstrated to support local accountability (for example, via the Local Account).

The local authority should make available to providers available routes to register concerns or complaints about engagement and commissioning activities. Local authorities should consider the adequacy and effectiveness of these routes and processes as part of their engagement and trust building activities.

4. Undertaking Market Shaping and Commissioning

4.1 Understanding the market

The local authority must understand local markets and develop knowledge of current and future needs for care and support services, and, insofar as they are willing to share and discuss, understand providers’ business models and plans. This is important so that the authority can articulate likely trends in needs and signal to the market the likely future demand for different types of services for its market as a whole, and understand the local business environment, to support effective commissioning. Activities to understand the market should appropriately reflect an authority’s strategic plans for integrating health, social care and related services and will require the cooperation of those other parties, as well as other authorities in the region, to ensure a complete picture.

The local authority (through an engagement process, in concert with commissioners for other services where appropriate) should understand and articulate the characteristics of current and future needs for services. This should include reference to underpinning demographics, drivers and trends, the aspirations, priorities and preferences of those who will need care and support, their families and carers, and the changing care and support needs of people as they progress through their lives. This should include an understanding of:

  • people with existing care needs drawn from assessment records;
  • carers with existing care needs drawn from carers’ assessment records;
  • new care and support needs;
  • those whose care and support needs will transition from young people’s services to adult services;
  • those transitioning from working-age adults to services for older people;
  • people whose care and support needs may fluctuate;
  • people moving to higher needs and specialised care and support; and
  • those that will no longer need care and support.

It should include information and analysis of low incidence needs and multiple and complex conditions, as well as more common conditions such as sensory loss. It should also include information about likely changes in requirements for specialist housing required by people with care and support needs. See also the online tool shop@, Housing Learning and Improvement Network.

The local authority should have in place robust methods to collect, analyse and extrapolate this information about care and support needs, including as appropriate information about specific conditions (for example, neurological conditions such as Stroke, Parkinson’s, Motor Neurone Disease), and multiple and complex needs. This should sit alongside information about providers’ intentions to deliver support over an appropriate timescale – likely to be at least five years hence, with alignment to other strategic time frames. Data collection should include information on the quality of services provided in order to support local authority duties to foster continuous improvement. This could be achieved, for example, by collecting and acting on feedback from people who receive care, their families and carers alongside information on the specific nature of the services people receive (e.g. regularity and length of homecare visits). This will allow for an assessment of correlation between customer experience and service provision. Data collection must be sufficient to allow local authorities to meet their duties under the Equality Act 2010.

The local authority should include in its engagement and analysis services and support provided by voluntary, community services, supported housing providers, and other groups that make up ‘community assets’ and plan strategically to encourage, make best use of and grow these essential activities to integrate them with formal care and support services.

The local authority should also seek to understand trends and changes to the levels of support that are provided by carers, and seek to develop support to meet its needs, noting that amongst other sources, census data include information on carers and their economic activity. It should understand the trends and likely changes to the needs of carers in employment, so as to better plan future support.

In order to understand future trends in needs and demands, the local authority should include an understanding of people who are or are likely to be both wholly or partly state funded, and people who are or are likely to be self-funding. It should also include an analysis of those self-funders who are likely to move to state funding in the future.

The understanding of needs should also include an understanding of the likely demand for state funded services that the local authority will need to commission directly, and state funded services likely to be provided through direct payments and require individuals to ‘micro-commission’ services. The local authority should also consider the extent to which people receiving services funded by the state may wish to ‘top up’ their provision to receive extra services or premium services; that is, the assessment of likely demand should be for services that people are likely to need and be prepared to pay for through top ups.

The assessment of needs should be integrated with the process of developing, refining and articulating a local authority’s Joint Strategic Needs Assessment. Where appropriate, needs should be articulated on an outcomes basis.

In order to gather the necessary information to shape its market, the local authority should engage with providers (including the local authority itself if it directly provides services) to seek to understand and model current and future levels of service provision supply, the potential for change in supply, and opportunities for change in the types of services provided and innovation possible to deliver better quality services and greater value for money. It should understand the characteristics of providers’ businesses, their business models, market concentration, investment plans etc. Information about both supply and expected demand for services should be made available publicly to help facilitate the market and empower communities and citizens when considering care and support. Smaller care providers should be included in engagement. Local authorities may find helpful the guidance Market Shaping Tool: Supporting Local Authority and SME Care Provider Innovation and Collaboration that was co-produced by the Department of Health with ADASS and LGA, provider organisations and people with lived experience.

Assessment of supply and potential demand should include an awareness and understanding of current and future service provision and potential demand from outside the local authority area where this is appropriate, for example in considering services to meet highly specialised and complex needs, care and support may not be available in the local authority area, but only from a small number of specialised providers in the country. Consideration should be given to whether such services might better be commissioned and facilitated regionally.

4.2 Facilitating the development of the market

The local authority should collaborate with stakeholders and providers to bring together information about needs and demands for care and support with that about future supply, to understand for their whole market the implications for service delivery. This will include understanding and signalling to the market as a whole the need for the market to change to meet expected trends in needs, adapt to enhance diversity, choice, stability and sustainability, and consider geographic challenges for particular areas. To this picture, the local authority should add their own commissioning strategy and future likely resourcing for people receiving state funding. The local authority should consider coordinating these market shaping and related activities with other neighbouring authorities where this would provide better outcomes.

The local authority should consider how to support and empower effective purchasing decisions by people who self-fund care or purchase services through direct payments, recognising that this can help deliver a more effective and responsive local market.

It should ensure that the market has sufficient signals, intelligence and understanding to react effectively and meet demand, a process often referred to as market structuring or signalling. The local authority should publish, be transparent and engage with providers and stakeholders about the needs and supply analysis to assist this signalling. It is suggested that this is best achieved through the production and regular updating of a document like a Market Position Statement that clearly provides evidence and analysis and states the local authority’s intent. A Market Position Statement is intended to encourage a continuing dialogue between a local authority, stakeholders and providers, where that dialogue results in an enhanced understanding by all parties is an important element of signalling to the market.

A Market Position Statement should contain information on: the local authority’s direction of travel and policy intent, key information and statistics on needs, demand and trends, (including for specialised services, personalisation, integration, housing, community services, information services and advocacy, and carers’ services), information from consumer research and other sources about people’s needs and wants, information to put the authority’s needs in a national context, an indication of current and future authority resourcing and financial forecasts, a summary of supply and demand, the authority’s ambitions for quality improvements and new types of services and innovations, and details or cross-references to the local authority’s own commissioning intentions, strategies and practices.

Developing and publishing a Market Position Statement is one way a local authority can meet its duties to make available information about the local market, and demonstrate activity to meet other parts of the Care Act 2014. Market Position Statements for care and support services should combine, cross refer or otherwise complement other similar statements for related services, particularly where there is an integrated approach or ambition, for example, housing.

As part of developing and publishing a document like a Market Position Statement, the local authority should engage with stakeholders and partners to structure their markets. This could include:

  • discussions with potential providers;
  • actively promoting best practice and models of care and support;
  • understanding the business planning cycles of providers;
  • aligning interactions and supporting the provider’s business planning;
  • identifying and addressing barriers to market entry for new providers;
  • facilitating entry to the market through advice and information;
  • streamlining the authority’s own procurement processes;
  • promoting diversification of provider organisations;
  • working with providers on an ‘open-book accounting’ approach to cost current and future services and ensure provider sustainability;
  • supporting providers through wider local authority activity – planning, business support and regeneration.

The local authority may consider that market structuring activity – signalling to the market and providing assistance – is not achieving the strategic aims as quickly or as effectively as needed, and may wish to consider more direct interventions in the market. Market interventions may also be planned as part of the market shaping and commissioning strategies where there is an immediate need for intervention.

Market interventions could for example include: refocusing local authority business support initiatives onto the care and support sector, exploring how local care and support projects could attract capital investments and support and what guarantees may be needed, encouraging and supporting social enterprises, micro-enterprises, Community Interest Companies, and User Led Organisations (for example, incentivising innovation by third sector providers, possibly through grant funding), exploring planning barriers and using planning law, offering access to training and development opportunities.

The local authority should consider monitoring progress toward the ambitions set out in the Market Position Statement, and making the progress public along with information about its own commissioning decisions, as part of a commitment to transparency and accountability. This would demonstrate that the authority’s commissioning activity is in line with the ambition and direction of travel articulated in its Market Position Statement, and might be achieved by including this information in regular updates to the Market Position Statement.

4.3 Promoting integration with local partners

The Health and Social Care Act 2012 sets out specific obligations for the health system and its relationship with care and support services. It gives a duty to NHS England, Integrated Care Boards and Health and Wellbeing Boards to make it easier for health and social care services to work together to improve outcomes for people. The local authority has a corresponding duty to carry out their care and support functions with the aim of integrating services with those provided by the NHS or other health-related services, such as housing.

It should also consider working with appropriate partners to develop integration with services related to care and support such as housing, employment services, transport, benefits and leisure services. Local authorities should prioritise integration activity in areas where there is evidence that effective integration of services materially improves people’s wellbeing, for example, end of life care, and should take account of the key national and local priorities and objectives of the Better Care Fund, for example, stopping people reaching crisis and reducing the emergency admissions to hospitals.

Integrated services built around an individual’s needs are often best delivered in the home. The suitability of living accommodation is a core component of an individual’s wellbeing and when developing integrated services, the local authority should consider the central role of housing within integration, with associated formal arrangements with housing and other partner organisations.

The local authority should work towards providing integrated care and support, providing services that work together to provide better outcomes for individuals who need care and support and enhancing their wellbeing, noting that this will require the sharing of information about current and future needs and likely service provider’s responses to underpin a holistic approach to developing integrated care and support pathways. See also Integration, Cooperation and Partnerships chapter.

The local authority should consider with partners the enabling activities, functions and processes that may facilitate effective integrated services. These will include consideration of: joint commissioning strategies, joint funding, pooled budgets, lead commissioning, collaborative commissioning, working with potential service providers to consider innovative ways of arranging and delivering services, and making connections to public health improvement.

4.4 Securing supply in the market and assuring its quality and value for money through contracting

Local authorities should consider best practice on commissioning services, for example the National Audit Office guidance Value for Money to ensure they deliver quality services with value for money. This means optimal use of resources to achieve intended outcomes, and must reference the quality of service delivered and the outcomes achieved for people’s wellbeing, and should not be solely based on achieving the lowest cost. Achieving value for money may mean arranging service provision collaboratively with other authorities, in order to secure viable, quality services that meet the demands identified, for example, low volume services.

Commissioning and procurement practices must deliver services that meet the requirements of the Care Act and all related statutory guidance. Re-commissioning and replacing services represents a particular challenge and should be carried out so as to maintain quality and service delivery that supports the wellbeing of people who need care and support and carers, and guards against the risk of a discontinuity of care and support for those receiving services. For example, multiple contracts terminating around the same time may destabilise local markets if established providers lose significant business rapidly and staff do not transfer smoothly to new providers.

Decommissioning services where there is to be no replacement service should similarly be carried out so as to maintain the wellbeing of people who need care and support, and carers, and ensures that their eligible needs continue to be met.

The local authority should consider the contract arrangements they make with providers to deliver services, including the range of block contracts, framework agreements, spot contracting or ‘any qualified provider’ approaches, to ensure that the approaches chosen do not have negative impacts on the sustainability, sufficiency, quality, diversity and value for money of the market as a whole – the pool of providers able to deliver services of appropriate quality.

A local authority’s own commissioning should be delivered through a professional and effective procurement, tendering and contract management, monitoring, evaluation and decommissioning process that must be focused on providing appropriate high quality services to individuals to support their wellbeing and supporting the strategies for market shaping and commissioning, including all the themes set out in this guidance.

The local authority should ensure that it understands relevant procurement legislation, and that its procurement arrangements are consistent with such legislation and best practice. It should be aware there is significant flexibility in procurement practices to support effective engagement with provider organisations and support innovation in service delivery, potentially reducing risks and leading to cost-savings. The Government has produced guidance on when reserved contracts may be allowable for organisations employing a significant number of disabled people.

4.5 Front line social work practice

The local authority should ensure that its procurement and contract management and monitoring systems provide direct and effective links to care service managers and social workers to ensure the outcomes of service delivery matches the individual’s care and support needs, and that where the local authority arranges services, people are given a reasonable choice of provider. Contract management should take account of feedback from people receiving care and support.

The local authority should ensure that where they arrange services, the assessed needs of a person with eligible care and support needs is translated into effective, appropriate commissioned services that are adequately resourced and meet the wellbeing principle (see Promoting Wellbeing chapter). For example, short home-care visits of 15 minutes or less are not appropriate for people who need support with intimate care needs, though such visits may be appropriate for checking someone has returned home safely from visiting a day centre, or whether medication has been taken (but not the administration of medicine) or where they are requested as a matter of personal choice.

4.6 Preventing abuse and neglect

When commissioning services, the local authority should pay particular attention to ensuring that providers have clear arrangements in place to prevent abuse or neglect. This should include assuring itself, through its contracting arrangements, that a provider is capable and competent in responding to allegations of abuse or neglect, including having robust processes in place to investigate the actions of members of staff. The local authority should be clear what information they expect from providers (for example, where there are allegations of abuse, what action the provider is taking or has taken and what the outcome is) and where providers are expected to call upon local authorities to lead a section 42 enquiry (where the management of the provider is implicated for instance), or to involve the Integrated Care Board (for health matters) or police (for example, in the case of potential crimes). There should be clear agreement about how local partners work together on investigations and their respective roles and responsibilities.

4.7 Financial sustainability

When commissioning services, the local authority should undertake due diligence about the financial sustainability and effectiveness of potential providers to deliver services to agreed criteria for quality, and should assure themselves that any recent breaches of regulatory standards or relevant legislation by a potential provider have been corrected before considering them during tendering processes. For example, where a provider has previously been in breach of national minimum wage legislation, a local authority should consider every legal means of excluding them from the tendering process unless they have evidence that the provider’s policies and practice have changed to ensure permanent compliance.

Contracts should incentivise value for money, sustainability, innovation and continuous improvement in quality and actively reward improvement and added social value. Contracts and contract management should manage and eliminate poor performance and quality by providers and recognise and reward excellence.

The local authority has a duty to consider added social value when letting contracts through the Public Services (Social Value) Act 2012, and are required to consider how the services it procures, above relevant financial thresholds, might improve the economic, social and environmental wellbeing of the area. The local authority should consider using this duty to promote added value in care and support both when letting contracts to deliver care and support, and for wider goods and services. This should include considering whether integrated services, voluntary and community services and ‘community capital’ could be enhanced, recognising that these community assets provide the bedrock of care and support that commissioned and bought services supplement. Local authorities should consider the range of funding mechanisms that are available to support market interventions to support community based organisations such as seed funding and grants.

All services delivered should adhere to national quality standards, with procedures in place to assure quality, safeguarding, consider complaints and commendations, and continuing value for money, referencing the Care Quality Commission (CQC) standards for quality and its quality ratings.

The local authority may consider delegating some forms of contracting to brokers and people who use care and support to support personal choice for people who are not funded by the local authority and those taking direct payments, with appropriate systems in place to underpin the delivery of safe, effective appropriate high quality services through such routes. Where functions and activities are delegated, local authorities should ensure that appropriate elements of this statutory guidance are included in contractual conditions, for example, allowing engagement in developing Market Position Statements. Local authorities should also consider providing support to people who wish to use direct payments to help them make effective decisions through, for example, direct payment support organisations.

Local authority procurement and contract management activities should seek to minimise burdens on provider organisations and reduce duplications, where appropriate, using and sharing information, with for example the CQC.

Recognising that procurement is taking place against a backdrop of significant demand on commissioners to achieve improved value for money and make efficiencies, local authorities should consider emerging practice on achieving efficiencies without undermining the quality of care.

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This chapter provides information for multi-agency practitioners in relation to how local agencies must work together, with the aim of preventing, delaying or reducing needs and promoting the wellbeing of adults with care and support needs.

RELATED SECTIONS AND CHAPTERS

Safeguarding Enquiries Process

Out of Area Arrangements

South Tyneside Multi Agency Information Sharing Agreement

Safeguarding Children

1. Introduction

Under the Care Act 2014, the local authority has a duty to carry out their care and support responsibilities – including carer’s support and prevention services – with the aim of joining up services with those provided by the NHS and other health related services, for example, housing or leisure services.

The duty applies where the local authority considers that integration of services would promote the wellbeing of adults with care and support needs – including carers, contribute to the prevention or delay of developing care needs, or improve the quality of care in the local authority’s area.

2. Integrating Care and Support with other Local Services

There is a requirement that:

  • the local authority must carry out its care and support responsibilities with the aim of promoting greater integration with NHS and other health related services;
  • the local authority and its relevant partners must cooperate generally in performing their functions related to care and support; and supplementary to this;
  • in specific individual cases, the local authority and its partners must cooperate in performing their respective functions relating to care and support and carers wherever they can.

This applies to all the local authority’s care and support functions for adults with needs for care and support and for carers, including:

The local authority is not solely responsible for promoting integration with the NHS, and this responsibility reflects similar duties placed on NHS England and Integrated Care Boards (ICBs) to promote integration with care and support. There is also an equivalent duty on local authorities to integrate care and support provision with health related services, for example housing.

3. Multi Agency Working: Preventing Abuse and Neglect

See also Preventing Abuse and Neglect

Safeguarding adults from abuse and neglect is a fundamental part of the Care Act 2014. Identification and management of risk is an essential part of any assessment undertaken by a professional working with adults.

As noted above, the local authority must cooperate with its partners, and those partners must also cooperate with the local authority to provide care and support, and safeguard adults.

Relevant partners of the local authority include neighbouring authorities with whom they provide joint shared services and the following agencies or bodies who operate within the local authority’s area including:

  • NHS England;
  • Integrated Care Boards (ICBs);
  • NHS trusts and NHS foundation trusts;
  • Department for Work and Pensions;
  • the police;
  • prisons;
  • probation services.

The local authority must also cooperate with such other agencies or bodies as it considers appropriate in exercising its adult safeguarding functions, including (but not limited to):

  • general practitioners;
  • dentists;
  • pharmacists;
  • NHS hospitals;
  • housing, health and care providers.

All agencies should stress the need for preventing abuse and neglect wherever possible. Observant professionals and other staff making early, positive interventions with individuals and families can make a significant difference to their lives; preventing the deterioration of a situation or the breakdown of a support network. It is often when people become increasingly isolated and cut off from families and friends that they become extremely vulnerable to abuse and neglect.

All agencies should implement robust risk management processes in order to prevent concerns escalating to a crisis point and requiring intervention under safeguarding adult procedures.

Partners should ensure that they have the mechanisms in place that enable early identification and assessment of risk, through timely information sharing and multi-agency working. Multi-agency safeguarding hubs may be one model to support this but are not the only one. Policies and strategies for safeguarding adults should include measures to minimise the circumstances, including isolation, which make adults vulnerable to abuse.

See also Safeguarding Case Studies.

4. Integration and Cooperation: Safeguarding

Safeguarding requires collaboration between partners in order to create a framework of inter-agency arrangements.

The Care Act 2014 requires that local authorities and their relevant partners must collaborate and work together as set out in the cooperation duties in the Care Act and, in doing so, must, where appropriate, also consider the wishes and feelings of the adult on whose behalf they are working.

Local authorities may cooperate with any other body they consider appropriate where it is relevant to their care and support functions. The lead agency with responsibility for coordinating adult safeguarding arrangements is the local authority, but all the members of the South Tyneside Safeguarding Children and Adults Partnership should designate a lead officer. Other agencies should also consider the benefits of having a lead for adult safeguarding.

5. Strategic Planning

5.1 Integration with health and health related services

To ensure greater integration of services, the local authority should consider the different mechanisms through which it can promote integration, for example:

  • planning: using adult care and support and public health data to understand the profile of the population and the needs of that population, for example, using information from the local Joint Strategic Needs Assessments (JSNA) to consider the wider need of that population in relation to housing (see Joint Strategic Needs Assessments and Joint Local Health and Wellbeing Strategies);
  • commissioning: utilising JSNA data, joint commissioning can result in better outcomes for populations in the local area. This may include jointly commissioned advice services covering healthcare and housing, and services like housing related support that can provide a range of preventative interventions alongside care;
  • assessment and information and advice: this may include integrating an assessment with information and advice about housing options on where to live, and adaptations to the home, care
  • and related finance to help develop a care plan, and understand housing choices reflecting the person’s strengths and capabilities to help achieve their desired outcomes;
  • delivery or provision of care and support: this is integrated with an assessment of the home, including general upkeep or scope for aids and adaptations, community equipment of other modifications could reduce the risk to health, help maintain independence or support reablement or recovery.

Joint Strategic Needs Assessments and Joint Local Health and Wellbeing Strategies are, therefore, key means by which local authorities work with Integrated Care Boards (ICBs) to identify and plan to meet the care and support needs of the local population, including carers.

6. Cooperation of Partner Organisations

Cooperation between partners should be a general principle for all those concerned, and all should understand the reasons why cooperation is important for those people involved. There are five aims of cooperation relevant to care and support, although the purposes of cooperation should not be limited to these matters:

  1. promoting the wellbeing of adults needing care and support and of carers;
  2. improving the quality of care and support for adults and support for carers (including the outcomes from such provision);
  3. smoothing the transition from children’s to adults’ services;
  4. protecting adults with care and support needs who are currently experiencing or at risk of abuse or neglect;
  5. identifying lessons to be learned from cases where adults with needs for care and support have experienced serious abuse or neglect.

6.1 Who must cooperate?

The local authority must cooperate with each of its relevant partners, and the partners must also cooperate with the local authority, in relation to relevant functions. There are specific ‘relevant partners’ who have a reciprocal responsibility to cooperate. These are:

  • other local authorities within the area (in multi-tier authority areas, this will be a district council);
  • any other local authority which would be appropriate to cooperate with in a particular set of circumstances (for example, another authority which is arranging care for a person in the home area);
  • NHS bodies in the authority’s area (including primary care, Integrated Care Boards, any hospital trusts and NHS England, where it commissions health care locally);
  • local offices of the Department for Work and Pensions (such as Job Centre Plus);
  • police services in the local authority areas and prisons and probation services in the local area.

There may be other persons or bodies with whom a local authority should cooperate, in particular independent or private sector organisations for example care and support providers, NHS primary health providers, independent hospitals and private registered providers of social housing, the Care Quality Commission and regulators of health and social care professionals.

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This chapter provides information for multi-agency practitioners about how to raise concerns at work, known as whistleblowing. It includes information for staff who have concerns about something they have witnessed, been told about or have other suspicions about wrongdoing in the workplace.

RELEVANT GUIDANCE

Speak Up – free, independent, confidential advice on the speaking up process

Whistleblowing for Employees (gov.uk)

Whistleblowing (Social Work England) 

Raising a Concern with CQC: A Quick Guide for Health and Social Care Staff about Whistleblowing

September 2022: This chapter has been reviewed and updated throughout. Links to sources of support and advice for staff who have concerns have also been added.  See above and the appendices.

1. Introduction

Whistleblowing, or raising a concern, is where a worker (an employee, former employee, trainee, volunteer, agency worker or member of an organisation) reports a wrongdoing to their employer or another relevant organisation. Any wrongdoing reported in this way must be in the public interest. This means it must affect others, for example the general public.

Such wrongdoing may specifically relate to:

  • criminal activity;
  • a miscarriage of justice;
  • danger to the health and safety of any individual;
  • damage to the environment;
  • a failure to comply with any legal obligation; and / or
  • the deliberate concealment of any of the above matters.

There is a difference between a member of staff raising a concern / whistleblowing and making a complaint or grievance. A grievance or private complaint is about a person’s own employment position and there is no public interest element in this. For example, a worker may raise a grievance against a colleague for breaching their confidentiality. Organisations will have a specific grievance procedure to cover such situations. This is not whistleblowing.

Adults who use services, their relatives or members of the public can also make complaints about staff or services. They can do so by making a complaint to the organisation using their complaints procedure, or something to another body such as the Care Quality Commission for example (see Section 2.1 Raising a concern). This is not whistleblowing.

Any concerns relating to an adult who is experiencing or at risk of abuse or neglect must be reported via these safeguarding adults procedures (see Safeguarding Enquiries Process section).

Legal protections for whistleblowers mean that no one acting in good faith when raising a concern will be penalised for doing so (See Section 4, Protection and Support for Whistleblowers). Any attempt to victimise employees for raising genuine concerns or attempts to prevent such concerns being raised should be regarded as a disciplinary matter.

However, knowingly and intentionally raising malicious, unfounded allegations should also be regarded as a disciplinary matter.

Whistleblowing does not:

  • require employees to investigate in any way in order to prove that their concerns are well founded (although they should have reasonable grounds for their concerns);
  • replace the organisation’s grievance procedure which is available to employees concerned about their own situation;
  • replace the organisation’s disciplinary procedure; or
  • replace the complaints procedure (whistleblowing is not the same as a complaint).

2. Information for Concerned Members of Staff

2.1 How to raise a concern

A worker can blow the whistle to their employer following the guidance in their local whistleblowing policy or to a “prescribed person or body”. Employers should investigate concerns reported to them thoroughly, promptly and confidentially. The person who has raised the concern should be told how the concern will be dealt with and provided with a timescale for a response.

A prescribed person or body provides staff with a way to raise their concern with an independent body when they do not feel able to disclose directly to their employer. When reporting concerns to a prescribed body, it must be the one which deals with the type of issue being raised, for example a disclosure about possible wrongdoing in a care home can be made to the Care Quality Commission. See Whistleblowing: list of prescribed people and bodies (gov.uk)

Workers can also report concerns to a third party such as a professional body or a member of the press. This is known as a ‘wider disclosure’. This type of disclosure must meet tougher tests in order for it to be protected, than a disclosure made to an employer or prescribed person or body.

2.2 Reporting concerns anonymously or confidentially

Concerns can be raised anonymously, but the employer or prescribed body may not be able to take the claim further if they have not been provided with all the information they need.

Whistleblowers can give their name but request confidentiality – in this situation, the person or body you tell should make every effort to protect the person’s identity.

2.3 Action as a result of raising concerns

This will depend largely on the nature of the concerns raised; the most likely outcome is that the concern will be investigated by staff within the organisation.

Where appropriate, concerns that are raised may:

  • be investigated by management, internal audit, or through the disciplinary process;
  • be investigated under another procedure, for example safeguarding adults;
  • be reported to the organisation’s standards or management committee / team;
  • be referred to the police;
  • be referred to an external auditor;
  • form the subject of an independent inquiry.

Where possible, within 10 working days, the member of staff raising the concern should receive in writing:

  • an acknowledgment the concern has been received;
  • an indication how the matter will be dealt with;
  • where applicable, an estimate of how long it will take to provide a final response;
  • information on staff support mechanisms;
  • contact details of the designated contact person dealing with their concern.

If, during the investigation, the staff member is concerned about what progress is being made, requires support or reassurance, or feel they may be being victimised or harassed as a result of making the disclosure, they should raise this with the designated contact /supporting organisation.

The designated contact should inform the staff member in writing of the outcome of their concern. However, this will not include details of any disciplinary action that may result, as this will remain confidential to the individual/s concerned.

Please note: due to the likely sensitive nature of raising concerns at work, the member of staff should discuss the matter with as few people as possible.

2.4 The staff member does not agree with the outcome

If the member of staff does not agree with the way their concerns have been dealt with by local management, they may choose to escalate their concerns to senior management.

The staff member may otherwise feel it necessary to report their concerns to an external body, however this must be appropriate for the issue concerned. See Appendix 2, Useful Organisations for a list of prescribed persons.

3. Recording

A record of concerns raised together with a record of action taken in response should be provided to the staff member who raised the concern.

4. Protection and Support for Whistleblowers

The Public Interest Disclosure Act 1998 provides legal protection against detriment for workers who raise concerns in the public interest.

Bullying, harassment or victimisation (including informal pressures) by other members of staff towards someone who raises a concern will not be tolerated.

Senior management should be vigilant and may need to take appropriate action to protect staff who raise a concern in good faith.

Staff must not threaten or take retaliatory action against whistleblowers. Anyone involved in such conduct will be subject to disciplinary procedures.

If a staff member believes they have suffered any such treatment, they should inform their manager – or suitable other person – immediately. If the matter is not remedied they should raise it formally through the organisation’s grievance procedure.

Appendix 1: Advice for Workers

Online tool to help employees decide how to raise their concern – Employees Online Tool for Raising Concerns, Whistleblowing Hotline Speak Up.

Appendix 2: Useful Organisations

Whistleblowing: list of prescribed people and bodies – contains a list of the prescribed persons and bodies.

Protect; Speak up, Stop harm – a UK whistleblowing charity which provides free independent legal advice to staff and others who wish to raise concerns about the workplace.

Speak Up – Whistleblowing Helpline

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This chapter provides outline information for multi-agency practitioners to consider when they are working with adults with care and support needs or their carers who have communication needs.

RELEVANT CHAPTERS

Information and Advice

Independent Advocacy

Independent Mental Capacity Advocates and Independent Mental Health Advocates

This chapter was added to the APPP in July 2018.

1. Introduction

Some adults with care and support needs, and their carers, may require the services of an interpreter, signer or another professional who has specific communication skills. This may be as a result of not having sufficient comprehension or command of spoken English or other communication difficulties, as the result of hearing problems or learning or physical disabilities for example.

Adults and carers with specific communication needs should be supported to access interpreters, signers and other communicators to ensure  their needs are met, their wellbeing promoted and their needs prevented, reduced or delayed (see Promoting Wellbeing and Preventing, Reducing or Delaying Needs). This includes adults and carers who are involved in the safeguarding process. The use of interpreters, signers or other communication aids must be considered at the very beginning of the safeguarding process to ensure that the adult is included and involved in the process, as much as possible. They should receive the same level of service as those in the local population who do not have communication needs.

2. Principles of Communication Services

There are a number of main principles that should be considered when a person has communication needs:

  • family members should not be used as interpreters / communicators;
  • neither should children (within the family or extended network) should not be used as interpreters / communicators;
  • the person acting as the interpreters / communicator should be acceptable to both the adult / carer and the local authority;
  • the adult / carer should be consulted in relation to any concerns they may have about an interpreter’s / communicator’s gender and / or religion, and issues of confidentiality and potential conflicts of interest;
  • the interpreter / communicator should declare in advance of providing the service if they have any personal knowledge of the adult / carer;
  • the interpreter / communicator should also be asked in advance about any needs they may have themselves, for example disability access, water and so on
  • the importance of confidentiality should be discussed with the interpreter / communicator prior to them first meeting the adult / carer. They should be sourced from an agency who is already contracted with the local authority and where there is an existing confidentiality agreement. If this is not possible, they must sign a confidentiality agreement prior to undertaking any work;
  • the role of the interpreter / communicator is to act solely in relation to issues of communication, not as a mediator between the adult / carer and the local authority;
  • the interpreter / communicator should be briefed before the meeting. This may include preparing them for possible disclosure and discussion of sensitive or harrowing information. They should also be briefed if an advocate will also be present (see Independent Advocacy and Independent Mental Capacity Advocates and Independent Mental Health Advocates).

Decisions about the way in which the interpreter / communicator will be used will depend on their skills and training, the needs of the adult / carer and the purpose of the meeting.

Staff working with interpreters / communicators should not use them to obtain information about racial, cultural, religious or language issues. This is not a proper use of an interpreter; also their mores and life experiences may not necessarily reflect those of the adult / carer.

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Multi-Agency Risk Panels or High Risk Panels are one type of multi-agency working on complex and high risk cases, often where agencies spend significant amounts of time responding to difficult, chaotic or problematic behaviour or lifestyles that place the person, and possibly others, at significant risk. Panels can be created with all necessary partners, both statutory and third party and will vary depending on local need of the case in question. Any situation calling for multi-agency action could be discussed at panel meetings. The panel will support agencies in their work to lower and manage risk for both individuals and the wider community.

Multi-Agency Risk Panels are based on the belief that shared decision making is the most effective, transparent and safe way to reach a decision, where there is challenge with the adult and professionals working with them to mitigate the risk; or where there is a high complex case and the risk needs to be escalated for consideration by such a panel. The purpose of the Panel is to agree a risk reduction plan that is owned and progressed by the most relevant agency with the support of necessary partners.

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This chapter provides information for practitioners about the Multi-Agency Risk Assessment Conference (MARAC) process which is a local multi-agency meeting aimed at protecting victims of domestic abuse through a range of multi-agency interventions.

RELEVANT CHAPTER

Types and Indicators of Abuse and Neglect

Domestic Abuse

RELEVANT INFORMATION AND FURTHER RESOURCES

SafeLives 

1. Introduction

A Multi-Agency Risk Assessment Conference (MARAC) is a local, multi-agency victim focused meeting where professionals meet to share information on high risk cases of domestic abuse.

Information about the risks faced by those victims, the actions needed to ensure safety, and the resources available locally are discussed, and used to create a risk management plan involving all agencies. The MARAC is part of a coordinated response to domestic abuse, incorporating representatives from statutory, community and voluntary agencies working with victims, adults experiencing or at risk of abuse or neglect, children and alleged perpetrators.

The MARAC aims to:

  • share information to increase the safety, health and wellbeing of victims / survivors and their children;
  • determine whether the alleged perpetrator poses a significant risk to any particular individual or to the general community;
  • construct and jointly implement a risk management plan that provides professional support to all those at risk and that reduces the risk of harm;
  • reduce repeat victimisation;
  • improve agency accountability; and
  • improve support for staff involved in high risk domestic abuse cases.

2. MARAC Attendance

The MARAC consists of a core group of professionals, representing the statutory and voluntary sectors. The meeting involves contribution and commitment from agencies including police, probation, children’s social care, adult social care (mental health, safeguarding adults), health, education, housing, substance misuse services, and specialist domestic abuse services. Other agencies can attend as required, when they have involvement in a case which is being discussed.

In South Tyneside, the MARAC meets fortnightly, and is chaired by a Detective Inspector from the Police’s PVP (Protecting Vulnerable People) Unit.

The victim does not attend the meeting, nor the perpetrator or Crown Prosecution Service.

3. Independent Domestic Violence Advisors

Each victim referred to the MARAC will be allocated an Independent Domestic Violence Advisor (IDVA). The IDVA is a trained specialist whose goal is the safety of domestic abuse victims, focusing on victims at high risk of harm.

The IDVA will attempt to make contact with the referrer and the victim following receipt of a MARAC referral. The IDVA’s job is to be a bridge between victims and the MARAC meeting. The IDVA will try and meet the victim beforehand, or at least talk to them on the phone, and explain how the meeting works, what it can do, and what the options are.

The IDVA will also ask if there is anything the victim would want to be discussed at the meeting.

4. Making a Referral to MARAC

Referrals can be made (and are encouraged) by any agency who identifies a victim of domestic abuse as being high risk. To make a referral into the MARAC, a Risk Checklist  needs to be completed (see Section 5 below).

A DASH Risk Checklist will enable the practitioner to determine the level of risk posed to a victim. Upon meeting the MARAC threshold for high risk, the local MARAC coordinator / administrator should be contacted regarding making a referral. The case will be submitted for the next available MARAC; however in some circumstances, an emergency MARAC meeting may be called.

5. DASH Checklist

See Resources for Identifying the Risk Victims Face, DASH Checklist (SafeLives)

The DASH Risk Checklist is for all professionals working with victims of domestic abuse, stalking and honour based abuse.

The purpose of the checklist is to give a consistent and simple to use tool to practitioners who work with victims of domestic abuse in order to help them identify those who are at high risk of harm and whose cases should be referred to a MARAC meeting in order to manage the risk. The primary audience is front line practitioners working with victims of domestic abuse who are represented at MARAC.  This will include both domestic abuse specialists, such as independent domestic violence advisors (IDVAs), and generic practitioners such as those working in a primary care health service or housing.  However, a range of agencies can use the checklist with their clients or service users.

Risk in domestic abuse situations is dynamic and can change very quickly.  Therefore, as well as being used when you receive an initial disclosure of domestic abuse, it may be appropriate to review the checklist with a client on more than one occasion.  It is designed to be used for those suffering current rather than historic domestic abuse and ideally would be used close in time to the last incident of abuse that somebody has suffered. Using an evidence based risk checklist tool increases the likelihood of the victim being responded to appropriately and therefore of addressing the risks they face.  The risk checklist provides practitioners with common criteria and a common language of risk. The risk checklisy should be introduced to the victim within the framework of an agency’s confidentiality policy, information sharing policy and protocols and its MARAC referral policies and protocols.

6. Assessing Risk

Practitioners must follow agreed protocols when referring to MARAC and children’s social care (see Local Contacts).  It is important for practitioners to use professional judgement in all cases.  The results from a checklist are not a definitive assessment of risk; they merely provide a structure to inform judgement and act as prompts to further questioning, analysis and risk management whether via a MARAC or in another way.

6.1 High risk victims

If the victim is assessed as high risk, a referral should be made to both the MARAC Coordinator and to the IDVA service. This, in itself, will not keep a victim safe and practitioners should consider what other actions are necessary including making a safeguarding referral where appropriate. Further information can be found in the South Tyneside Domestic Abuse Guide and Service Directory.

7. Interface with Safeguarding Adults

When deciding whether MARAC or safeguarding is the most appropriate process for a particular case, consideration should be given as to which process is most relevant in order to be able to resolve the issue. All involved professionals should discuss and agree the most appropriate process.

Referrals and involvement in both processes at the same time may result in confusion and duplication. Whichever process is followed, the main priority is always the safety and wellbeing of the adult (and any other adults at risk / children involved). Multi-agency safeguarding planning will be key in whatever process is used.

At MARAC meetings the adult will not be present (as may also be the case for safeguarding meetings); however either an IDVA or a victim support worker will be present to advocate on behalf of the adult.

Multi-Agency Public Protection Arrangements (MAPPA) may also need to be considered in relation to an offender (see Multi-Agency Public Protection Arrangements chapter).  Again, consideration needs to be given by all professionals as the most appropriate process.

When considering a referral to MARAC or adult safeguarding, professionals from any agency should adhere to these procedures and work to ensure the best interest of the adult.

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This chapter provides information for multi-agency practitioners about Multi-Agency Public Protection Arrangements (MAPPA) which are the statutory processes for managing violent and sexual offenders living in the community, with the aim of reducing offending and protecting the public.

RELEVANT CHAPTER

Multi-Agency Risk Assessment Panels

RELEVANT GUIDANCE

MAPPA Guidance (Ministry of Justice)

1. Introduction

The purpose of MAPPA is to help reduce the re-offending behaviour of sexual and violent offenders in order to protect the public, including previous victims, from serious harm. It should also ensure that comprehensive risk assessments are undertaken and robust risk-management plans put in place. MAPPA takes advantage of coordinated information-sharing across the agencies on each MAPPA offender, and ensures that appropriate resources are directed in a way which enhances public protection.

MAPPA is not a statutory body in itself but is a mechanism through which agencies can better discharge their statutory responsibilities and protect the public in a coordinated way.

It aims to do this by ensuring that all relevant agencies work together effectively to:

  • identify all relevant offenders complete comprehensive risk assessment that takes advantage of coordinated information sharing across the agencies; and
  • devise, implement and review robust risk management plans and focus the available resources to best protect the public from serious harm.

The NPS, police and prison service are responsible authorities required to ensure the effective management of offenders. However NHS, social services, education and housing all have a duty to cooperate under the Criminal Justice Act 2003.

2. Responsible Authorities and Duty to Cooperate Agencies

The Responsible Authority is the primary agency for MAPPA. This is the police, prison and probation service in each area, working together. The Responsible Authority has a duty to ensure that the risks posed by specified sexual and violent offenders are assessed and managed appropriately.

Other bodies have a duty to cooperate with the Responsible Authority in this task. These duty to cooperate agencies (DTC agencies) will need to work with the Responsible Authority on particular aspects of an offender’s life, for example education, employment, housing, social care. These agencies include:

  • adult and children’s social care services;
  • local education authorities;
  • youth offending teams;
  • National Health Service providers;
  • local housing authorities;
  • registered social landlords who accommodate MAPPA offenders;
  • Jobcentre Plus;
  • electronic monitoring providers;
  • UK Visas and Immigration.

3. Identification and Notification

The first stages of the process are to identify offenders who may be liable to management under MAPPA as a consequence of their caution or conviction and sentence. This responsibility falls to the agency that has the leading statutory responsibility for each offender. Offenders are placed into one of three MAPPA categories according to their offence and sentence:

  • category 1: registered sexual offenders;
  • category 2: violent and other sexual offenders (violent – 12 months or more sentence of imprisonment for violent offence, other sexual offenders and those subject to hospital orders with restrictions);
  • category 3: other dangerous offenders – a person who has been cautioned for or convicted of an offence which indicates that he or she is capable of causing serious harm and which requires multi-agency management. It could also include those offenders on a community order who are, therefore, under the supervision of the probation service.

4. Levels of Management

MAPPA offenders are managed at one of three levels according to the extent of agency involvement needed and the number of different agencies involved.

Level 1: ordinary agency management – ordinary agency management level 1 is where the risks posed by the offender can be managed by the agency responsible for the supervision or case management of the offender. The majority of offenders are managed at level 1. This involves the sharing of information but does not require multi-agency meetings.

Level 2: active multi-agency management – cases should be managed at level 2 where the offender:

  • is assessed as posing a high or very high risk of serious harm; or
  • the risk level is lower but the case requires the active involvement and co-ordination of interventions from other agencies to manage the presenting risks of serious harm; or
  • the case has been previously managed at level 3 but no longer meets the criteria for level 3; or
  • multi-agency management adds value to the lead agency’s management of the risk of serious harm posed;

Level 3: active enhanced multi-agency management – level 3 management should be used for cases that meet the criteria for level 2 but where it is determined that the management issues require senior representation from the Responsible Authority and DTC agencies. This may be when there is a perceived need to commit significant resources at short notice or where, although not assessed as high or very high risk of serious harm, there is a high likelihood of media scrutiny or public interest in the management of the case and there is a need to ensure that public confidence in the criminal justice system is maintained.

5. MAPPA Meetings

The vast majority of MAPPA offenders will be managed through the ordinary management of one agency, although this will usually involve the sharing of information with other relevant agencies.

The structural basis for the discussion of MAPPA offenders who need active interagency management, including their risk assessment and risk management, is the MAPP meeting.

The Responsible Authority agencies and the MAPPA Coordinator are permanent members of these meetings. The DTC agencies should be invited to attend for any offender in respect of whom they can provide additional support and management. The frequency of meetings depends on the level of management deemed appropriate for each offender.

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1. Introduction

In previous years the professional and media focus was only on children who were victims of sexual exploitation, not adults. However, there is now a greater understanding of the issues faced by those aged 18 and over in relation to previous sexual harm they have suffered, or are suffering, in adulthood.

There are a number of different groups of adult victims and survivors of this type of sexual abuse. First are those who were sexually abused as children and continue to be abused by perpetrators once they turn 18, who should subsequently become the subject of a safeguarding adult enquiry if they have not already been subject to safeguarding children procedures (see South Tyneside Safeguarding Children Procedures). Second are those who are no longer being abused but disclose historic CSE to which the statutory adult agencies have a duty to respond. Third, even when the sexual abuse, physical abuse and psychological abuse has stopped, many survivors will require some level of care and support as adults, due to the complex personal issues which they suffer as a result of the trauma they experienced.  These can include mental ill health, self-harm, problematic use of illicit drugs or alcohol which can be compounded by interrupted education resulting in unemployment or low paid jobs with resulting economic insecurity. They may have already been involved with children’s social care, especially if they have been looked after children (see Section 5.2, Transition from children’s to adults’ services).

In addition, some young adults may also be vulnerable to organised sexual abuse (OSA); being targeted for the first time as adults not as children. Those who have care and support needs due to learning or physical disabilities, especially if they are in residential accommodation, can be particularly vulnerable to abuse.

The needs of these adults must be recognised by the adult services which are responsible for their care and support, in order to be able to offer them the most appropriate support  and promote their wellbeing. Whilst the focus has been on girls and young women, it also applies to young men who are often hidden victims.

This chapter provides guidance to practitioners and managers working in adult care services about working with adults affected by CSE or OSA.

2. The Chief Social Workers’ Annual Report

The Chief Social Workers’ note in their Annual Report: 2019 to 2020:

‘Transitional safeguarding: criminal and sexual exploitation

It has been positive to see this subject aired more widely, but we still have some way to go in adult social care to understand how to respond to sexual and criminal exploitation.

It is important to remember this does not stop at eighteen and is not an issue which children’s services can tackle alone – our safeguarding services need a different response. Unfortunately, they are often configured in ways which do not support young people after the age of eighteen unless they have a disability.

Social work, informed and skilled in this area, could really make a difference with its strong professional influence in partnership arrangements, helping to prevent long-term mental health issues, avoid further harm and put an end to exploitation.

Building and sustaining relationships is fundamental to our profession, but in building them with people affected by exploitation, we need to be well-educated about trauma-informed practice.’ (Department of Health and Social Care, 2020; 3.1)

3. Definition and Terminology

3.1 Definition of sexual exploitation

McNamara (2017) states:

‘Sexual exploitation is a form of sexual abuse. A person can be a victim of sexual exploitation if sex takes place and:

  • it is in exchange for basic necessities, such as food, shelter or protection
  • it is in exchange for something they need or want
  • they are made to feel frightened of the consequences if they do not (coercion)
  • the person who is exploiting them stands to gain financially or socially.’

Newcastle Safeguarding Adult Board’s definition similarly states:

‘Someone taking advantage of you sexually, for their own benefit. Through threats, bribes, violence, humiliation, or by telling you that they love you, they will have the power to get you to do sexual things for their own or other people’s benefit or enjoyment (including: touching or kissing private parts, sex or taking sexual photos.)’ (Spicer, 2018; p27)

These definitions stress a particularly important factor – the adult’s vulnerability in the relationship with their abuser/s. It must be stressed that adults can be victims too and turning 18 does not automatically result in safety and security for all.

3.2 Definitions of gangs and groups

While there are undoubtedly perpetrators who operate alone, in this context sexual exploitation / abuse relates to organised, planned abuse by a number of criminals who are either:

  • gangs who are street based, social groups who a) are involved in different types of crimes and violence; b) who operate in certain geographical areas; c) and are in conflict with similar groups. Sexual abuse and violence are part of their overall criminality, rather than their only focus;
  • groups of two or more people connected through formal or informal associations or networks including, but not exclusively, friendship groups. Their main purpose is to sexually exploit others.

3.3 Terminology

The term ‘exploitation’ means to make use of a situation by a person to gain unfair advantage over another. It is commonly used to describe the behaviour of some perpetrators in relation to children and also adults. However, whilst it may be appropriate at the grooming stage of adult sexual exploitation (ASE) (see Section 4, Indicators of Sexual Exploitation / Organised Abuse), in the most serious cases it involves rape, multiple rape, gang rape, which is often carried out with physical violence and emotional / psychological abuse. Using ‘exploitation’ in relation to such circumstances can disguise the level of harm that is perpetrated and the seriousness of sexual offences committed. This chapter therefore uses the term ‘sexual exploitation / organised abuse’. This is also the approach adopted by a number of agencies, including the National Crime Agency (NCA).

3.4 Grooming

Grooming is when someone builds an emotional connection with an adult, to gain their trust for the purposes of sexual abuse / exploitation. This can happen face to face and online. Groomers can spend considerable time gaining their victim’s trust, hiding their true abusive intentions. Their methods include:

  • giving the victim a lot of attention and making them feel wanted and loved, often through flattery;
  • being understanding and listening to them;
  • buying or giving them gifts;
  • taking them out,
  • giving them drugs or alcohol – often for the first time – and making life with them seem exciting;
  • making them believe they are in a relationship together.

Organised sexual abuse by groups includes:

  • repeated sexual abuse / rape by their ‘boyfriend’ and his friends;
  • being trafficked to other towns and cities for the purposes of organised sexual abuse;
  • being verbally and physically threatened / abused if they try to exit the abuse;
  • family and friends being physically threatened;
  • attempts to groom younger siblings or friends;
  • being plied with alcohol and drugs to make them compliant to the point of addiction.

4. Indicators of Sexual Exploitation / Organised Abuse

The following are key indicators of sexual exploitation / organised abuse, of which practitioners working with adults with care and support needs should be particularly aware:

  • having money, clothes, mobile phones etc without an acceptable explanation of where they got them;
  • being associated with gangs and / or no longer having the same friends or friendship groups;
  • exclusion or unexplained absences from school, college or work;
  • leaving home / care without explanation and persistently going missing or coming back late;
  • receiving lots of texts or phone calls, particularly when they do not say who from;
  • returning home under the influence of drugs / alcohol;
  • showing inappropriate sexualised behaviour and / or having sexually transmitted infections;
  • there is evidence or suspicions of physical or sexual assault;
  • having relationships with people who are controlling in their behaviour or are significantly older than them;
  • having a number of different people call for them or contact them (unknown adults);
  • are seen or known to be in areas known for sex work;
  • use of internet or other social media that causes concern;
  • being increasingly secretive around behaviours; and
  • self-harm or significant changes in emotional wellbeing.

McNamara (2017) says ‘there can be some circumstances where adults are at increased risk of being sexually exploited. For example, if they:

  • are homeless
  • are using drugs or alcohol
  • are lacking the mental capacity to consent to sexual activity
  • are being trafficked
  • were sexually abused as a child.’

Adults who are being sexually exploited and abused can also be victims of ‘cuckooing’ – where criminals exploit people who are often vulnerable adults and take over their homes for criminal purposes usually supplying drugs (see County Lines: Criminal Exploitation of Adults, Cuckooing and Gang Activity, Youth Violence and Criminal Exploitation affecting Children, Young People and Vulnerable Adults chapters).

It is important that all practitioners are aware of the issues of sexual exploitation and organised abuse. Adult care services should provide appropriate training sessions for staff (see Section 7, Training and Supervision).

The Care Act 2014 places a duty on local authorities to make enquiries if there are concerns that an adult with care and support needs is experiencing or at risk of abuse or neglect, and, as a result of those needs, is unable to protect themselves. This applies, for example, where an adult discloses sexual exploitation / organised abuse or if a member of the public or parent expresses concerns about an adult.

5. Local Information

In order to protect both children and adults from organised sexual abuse the following information should be shared between children’s and adult services:

  • the profile of young adults currently found to be most likely to be at risk in the local area;
  • particular residential homes which have been / are targeted by perpetrators (see below);
  • the profile of offenders (for example, gang associated, single perpetrator or organised groups);
  • specific ‘hotspots’/ locations (such as takeaway shops, hostels, party houses or transport hubs); and
  • local structures for response (for example, voluntary and statutory sector service providers, referral pathways, multi-agency working arrangements).

5.1 Residential care / supported living

When managers suspect that adults living in residential homes or supported living arrangements – for which they are responsible – are being targeted by perpetrators, they should undertake an assessment in relation to this specific risk and in order to  identify adults who are experiencing or at risk of sexual exploitation/organised abuse. This should include people in residential care, supported living environments, and those in the process of transition from children’s services (including child protection) to adult / safeguarding services.

5.2 Transition from children’s to adults’ services

For those transitioning from children’s services to adult care who have been sexually exploited / abused, it is crucial that the needs of the young person are clearly identified and action is put in place to ensure ongoing support and protection, and that the support needs of their parents are also identified and addressed. See also Transition to Adult Care and Support chapter.

6. Social Work Assessments / Risk Assessments

6.1 Initial contact and building relationships

CSE and OSA reports and inquiries have often found that professionals, family members and the public who were raising concerns were not properly listened to. There are other difficulties which prevent victims coming forward. Those who may be victims of abuse often find it difficult to speak out about their situation, particularly when they have been sexually abused as it will require disclosing very personal details. Undertaking assessments is a key time for victims / survivors, in both disclosing very distressing intimidate information as well as taking initial steps to form trusting relationships with the professionals tasked with protecting them (see Case Recording chapter).

Relationships of trust need to be built over time and staff need to be appropriately skilled in active listening to pick up on small clues or unexplained changes in behaviour, which may arise during contact with adults who are experiencing / have experienced sexual abuse. Where adults do disclose concerns about sexual exploitation/abuse, these must be ‘heard’, taken seriously and acted upon.

7. Taking Action

Staff should follow local safeguarding procedures and  involve a discussion / meeting to plan who takes what action. This must  include the police whose role is to investigate crimes that have been committed, collect evidence and – where they believe they have a case – present to the Crown Prosecution Service to decide whether it is appropriate to charge individuals. If  there is no law enforcement action against alleged perpetrators, it allows them to further traumatise current victims and groom new ones. This has a significant impact on families of victims, who feel unable to help their child / sibling, or may be victims of bullying and intimidation from the perpetrators themselves (see Safeguarding Enquiries Process).

7.1 Post-abuse support

It is recognised that sexual abuse, including that of an organised nature, has long-lasting effects for victims and their families. These may range from psychological and emotional trauma affecting relationships and future parenting abilities, to mental health and substance misuse issues. These place further stress on victims and their families and further demand on health and social care services.

The provision of appropriate support to those who have suffered trauma can significantly improve their lives in terms of health and family relationships. Survivors are likely to require support and therapeutic intervention for an extended period of time. The South Tyneside Safeguarding Children and Adults Partnership should work with its partners to ensure the delivery of post-abuse support, and that staff, frontline managers and victims and their families know how to access this support.

8. Training and Supervision

See also Supervision chapter

Services should ensure that their staff receive regular, high quality supervision which enables them to reflect on their practice. Those who offer direct support to sexually exploited adults may also require further intensive training and specialist support.

For social workers involved in adult safeguarding, it is suggested that the standards for employers of social workers in England including standard 5 which covers supervision for social workers are in place, or local policy and procedure on supervision is followed. All other professionals should follow their own profession’s supervision standards, and/or their agency’s supervision policy and procedures. Social work and other professional interventions need to be supported by clear skills and set of competences.

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1. Introduction

People in custody or custodial settings who have needs for care and support should be able to access the care they need, just like anyone else. In the past, responsibilities for meeting the needs of prisoners were not always clear, and this led to confusion between local authorities, prisons and other organisations and made it difficult to ensure people’s eligible needs were met. The Care Act 2014 clarifies local responsibilities for people in custody with care and support needs.

Prisoners often have complex health and care needs and experience poorer health and mental health outcomes than the general population. Research has found higher rates of mental illness, substance misuse and learning disabilities among people in custody than in the general population. Access to good, joined up health and care support services is therefore important for these groups.

All adults in custody, as well as offenders in the community, should expect the same level of care and support as the rest of the population. This is crucial to ensure that those in the criminal justice system who are in need of care and support achieve the outcomes that matter to them, and that will support them to live as independently as possible at the end of their detention.

This chapter relates only to custodial settings in England.

1.1 Local Authority Role

Adults in a custodial setting should be treated as if they are ordinarily resident in the local authority area where the custodial setting is located (see Ordinary Residence chapter).

Adults who are bailed to a particular address in criminal proceedings are treated as ordinarily resident in the local authority area where they are required to reside as part of their bail conditions.

Local authorities are responsible for the assessment of all adults who are in custody in their area and who appear to be in need of care and support, regardless of which area they came from at the start of their detention or where they will be released to. If an adult is transferred to another custodial establishment in a different local authority area, responsibility will transfer to the new area. The prison or approved premises to which an adult is allocated is decided by the Ministry of Justice.

Prisoners, especially those serving long sentences, may develop eligible needs over the course of their prison sentence. Local authorities have a duty to provide information and advice on what can be done to prevent or delay the development of such care and support needs. Access to the internet may be limited in prisons and other custodial settings, so it is important to consider the most appropriate format for information and advice to be provided, such as easy read leaflets.

Although not all local authority areas contain prisons or approved premises, all areas will be responsible for ensuring continuity of care for adults with eligible needs who are released into their area with a package of care . Similarly local authorities must support continuity of care for any of their residents moving into custody.

2. Definitions

Prison: References to a prison include young offender institutions (which hold young people aged 15 -21 years), secure training centres or secure children’s homes. A reference to a governor, director or controller of a prison includes a reference to the governor, director or controller of a young offender institution, to the governor, director or monitor of a secure training centre and to the manager of a secure children’s home. A reference to a prison officer or prisoner custody officer includes a reference to a prison officer or prisoner custody officer as a young offender institution, to an officer or custody officer at a secure training centre and to a member of staff at a secure children’s home.

Approved premises: These are premises which are approved as accommodation under the Offender Management Act 2007 for the supervision and rehabilitation of offenders, and for people on bail. They are usually supervised hostel type accommodation.

HM Prison and Probation Service (HMPPS): is an executive agency, sponsored by the Ministry of Justice. The agency is made up of HM Prison Service, Probation Service and Youth Custody Service. Within England and Wales, HMPPS are responsible for:

  • running prison and probation services;
  • rehabilitation services for people leaving prison;
  • ensuring the availability of support to stop people reoffending;
  • contract managing private sector prisons and services such as:
    • the prisoner escort service;
    • electronic tagging.

Through HM Prison Service they manage public sector prisons and the contracts for private prisons in England and Wales

Probation Service: the probation service is responsible for working with adult offenders, both in the community and during a move from prison to the community, to reduce reoffending and improve rehabilitation. The probation service sits within HMPSS

HM Inspectorate of Prisons / Probation: HMI Prisons is an independent inspectorate which reports on conditions for and treatment of those in prison, young offender institutions and immigration detention facilities. HMI Probation is an independent inspectorate on the effectiveness of work with adults, children and young people who have offended aimed at reducing reoffending and protecting the public.

Prisons and Probation Ombudsman (PPO): PP) investigates complaints from prisoners, those on probation and those held in immigration removal centres. The Ombudsman also investigates all deaths that occur among prisoners, immigration detainees and the residents of approved premises.

3. Information Sharing

See also South Tyneside Multi-Agency Information Sharing Agreement

Local authorities are responsible for the security of information held on people who are in custodial settings, and should develop agreements with partner agencies in line with the policies and procedures of Ministry of Justice and HMPPS which enable appropriate information sharing on individuals, including the sharing of information about risk to the prisoner and others where this is relevant. See also Information Sharing Policy Framework (gov.uk).

If a local authority is providing care and support to a person who is remanded (awaiting trial) or sentenced to custody, bailed to approved premises, or required to live in approved premises as part of a community sentence, the recent assessment and care and support plan should be shared with the custodial setting and the local authority in which it is based (if different) so that care and support may continue.

Prisons and /or prison health services should inform their local authority when someone they believe has care and support needs arrives at their establishment (see Integration, Cooperation and Partnerships chapter). The local authority may also receive requests for information from managers of custodial settings or the probation service when an adult who has already received care and support in the community is remanded or sentenced to custody. The information requested should be provided as soon as possible.

The local authority and partners in the criminal justice system should put in place processes for identifying people in custodial settings who are likely to have or to develop care and support needs. This could include when the adult is screened on arrival at the prison or during health assessments.

4. Assessments of Need

When a local authority is informed that an adult in a custodial setting may have care and support needs, they must carry out an assessment as they would for someone in the community. The same standards and approach to assessment and decision making about whether someone has care and support needs should apply to adult in custodial settings, as to those who are not in the criminal justice setting, bearing in mind that an adult in prison will no longer have the same level of support they may have relied upon in the community. It is likely that there will be complexities for carrying out assessments in custodial settings and consideration should be given to how such assessments will be carried out in the most efficient way for all involved.

The local authority may also combine a needs assessment with any other assessment it is carrying out, or it may carry out assessments jointly with, or on behalf of another organisation, for example prisoners’ health assessments.

Adults in a custodial setting also have a right to self-refer for an assessment. The local authority should provide appropriate types of care and support prior to completion of the assessment, if the person has urgent needs.

If an adult in a custodial setting refuses a needs assessment, the local authority is not required to carry out the assessment, unless:

Once a local authority has assessed an adult in custody as needing care and support it must decide if some or all of these needs meet the eligibility criteria.

Where an adult does not meet the eligibility criteria, they must be given written information about:

  • what can be done to meet or reduce their needs and what services are available; and
  • what can be done to prevent or delay the development of needs for care and support in the future.

4.1 Eligibility

The threshold for the provision of care and support does not change in custodial settings. When an adult is in a custodial setting, this should not in any way affect the assessment and recording of their eligible needs. However, the setting in which the care and support will be provided is likely to be different from community or other settings, and this should be taken into account during the care and support planning process when agreeing how best to meet the adult’s care and support needs. The extent and nature of their needs should be identified before taking into account the environment in which they live.

If a safeguarding issue is identified, the prison or approved premises management should be notified in line with with HMPPS policy on adult safeguarding.

4.2 Information

See also Information and Advice chapter

For any of the adult’s needs that are not eligible, the local authority must provide information and advice to them on how those needs can be met, and how they can be prevented from getting worse. It is good practice to copy this information to managers of custodial settings, with the adult’s consent, as this will help them manage their needs.

Prisoners, especially those serving long sentences, may develop eligible needs over the course of their prison sentence. Local authorities have a duty to provide information and advice on what can be done to prevent or delay the development of care and support needs (see Preventing, Delaying or Reducing Needs chapter). Low level preventative support and information and advice can help adults in custody maintain their own health and wellbeing.

4.3 Choice of accommodation

The right to a choice of accommodation does not apply to those in a custodial setting except when an adult is preparing for release or resettlement in the community.

It is important that, where appropriate, adults in custodial settings, are supported to maintain links with their families, as long as this in the best interests of the adult and there are no public protection requirements or safeguarding concerns which may limit or prohibit family or other personal contact. While it may not always be possible or appropriate to involve family members directly in assessment or care planning, the adult should be asked whether they would like to involve others in these processes.

If it is not possible to involve families directly, the local authority should ask the adult if they would like others to be informed that an assessment is taking place and the outcome of that assessment and any care and support plan.

5. Carer’s Assessments

Prisoners, residents of approved premises or staff in prisons or approved premises will not take on the role of carer as defined by the Care Act and should therefore not in general be entitled to a carer’s assessment.

6. Charging and Assessing Financial Resources

As in the community, adults in custodial settings will be subject to a financial assessment to decide how much they may pay towards the cost of their care and support. Where it is unlikely the adult will be required to contribute towards the cost of their care and support ‘light touch’ assessments can be carried out. It the adult does not meet the eligibility threshold for local authority support, but wants to purchase care services, this request should be referred for decision to HMPPS.

7. After the Assessment

The local authority should ensure that all relevant partners are involved in care and support planning and take part in joint planning with health partners.

Where a local authority is required to meet needs for care and support, a care and support plan must be prepared.  The adult should be involved in this process. The local authority should also involve others concerned with the adult’s health and wellbeing, including prison staff, probation offender managers, staff of approved premises and health care staff, to ensure integration of care, as well as what is possible within the custodial regime. Any safeguarding issues are to be addressed in the care and support plan.

While every effort should be made to put adult’s in control of their care and for them to be actively involved and be able to influence the planning process. It should be explained that the custodial setting may limit the range of care options available and some,such as direct payments, do not apply in a custodial setting. Where an adult’s ability to exercise choice and control is limited in this way, this should be discussed with them and recorded as part of the care planning process. However, the plan must contain the elements as outlined in Chapter 10 Care and Support Planning, Care and Support Statutory Guidance, including the allocated personal budget. This will ensure that the adult is clear about the needs to be met, the cost of meeting those needs and how being in custody means their choice and control is limited.

The local authority should seek consent from the adult so that their care plans can be shared with other providers of custodial and resettlement services including custodial services, the probation service, prison healthcare providers and managers of approved premises as relevant. For residents of approved premises, the local authority should always liaise with the responsible offender manager in probation services.

7.1 Equipment and adaptations

If an adult needs equipment or adaptations to meet their care and support needs, this should be discussed with the prison, approved premises and health care services to identify which agency is responsible for providing them. Where this relates to fixtures and fittings (for instance a grab rail or a ramp), it will usually be for the prison to deliver this. But for specialised and moveable items such as beds and hoists, then it may be the local authority that is responsible. Aids for adults are the responsibility of the local authority, whilst more significant adaptations would the responsibility of the custodial establishment. See Adult Social Care Prison Service Instruction.

Care and support plans for those in custodial settings are reviewed in the same way as all other plans. The local authority should also review the adult’s care and support plan each time they go into custody from the community, or are released from custody.

8. Direct Payments

Direct payments do not apply in prisons and approved premises, and cannot be made to people in custodial settings.

Adults living in bail accommodation or approved premises who have not yet been convicted are entitled to direct payments, as they would have been whilst in their own homes.

9. Continuity of Care and Support when an Adult Moves

Adults in custody with care and support needs must have continuity of care if they are moved to another custodial setting and when they are being released from prison back into the community. Adults in custody cannot be said to be ordinarily resident there because the concept of ordinary residence is based on the person living there voluntarily. This means they might be ordinarily resident where they previously lived. However, it is the local authority where the custodial setting is situated which is responsible for assessments and services while the adult is in custody. When an adult is being released from prison, their ordinary residence will generally be in the local authority where they intend to live on a permanent basis.

There will be circumstances where the process to ensure continuity of care will need to differ, for example when a prisoner is moved between establishments or when they are released in another area because of the nature of their offence. The prison or approved premises to which an adult is allocated is decided by the Ministry of Justice, and adults can be moved between different custodial settings. In such cases, the Governor of the prison or a representative, should inform the local authority in which the prison is located (the first authority) that the adult is to be moved or is being released to a new area. If this is a move to a custodial setting or release into the community in the same authority, then the first authority will remain responsible for meeting the adult’s care and support needs. Where the new custodial setting or the community, if being released, is in a different local authority area (second authority), the first authority must inform the second authority of the move once it has been told by the prison.

The prison, both local authorities and where practicable, the adult should work together to ensure that the adult’s care and support is continued during the move. It is good practice for the first and second local authority (and the transferring and receiving prisons where appropriate) to have a named member of staff to lead on arrangements for individuals during the transfer. Both local authorities must share relevant information, including the adult’s care and support plan.

The second authority should assess the adult before they are moved, but this may not always be possible (for example, if they were informed of the transfer at short notice). In such circumstances the second authority must continue to meet the care and support needs that the first authority was meeting until it has carried out its own assessment.

10. People Leaving Prison: Ordinary Residence

The Care Act states that in most circumstances, a person’s ordinary residence is retained where they have their needs met in certain types of accommodation in another local authority area. However, this does not apply to people who are leaving prison.

Therefore, where an adult requires a specified type of accommodation (see Ordinary Residence chapter) to be arranged on release from prison to meet their eligible needs, the local authority should start from an assumption that they remain ordinarily resident in the area in which they were ordinarily resident before the start of their sentence.

However, deciding an adult’s ordinary residence on release from prison will not always be straightforward and each case must be considered on an individual basis. For example, it may not be possible for an adult to return to their prior local authority area due to the history of their case and any risks associated with them returning to that area.

In situations where an adult is likely to have needs for care and support services on release from prison or approved premises and their place of ordinary residence is unclear and / or they express an intention to settle in a new local authority area, the local authority to which they plan to move should take responsibility for carrying out their needs assessment.

Given the difficulties associated with deciding ordinary residence on release, prisons or approved premises, the probation service and the local authority providing care and support should initiate joint planning for release in advance. Early involvement of all agencies, particularly the probation service, should ensure that the resettlement plan is workable in the local authority area where the adult will live.

11. End of Life Care

The provision of care and support for those in custodial settings also applied to those who reach the end of life whilst in prison. Some adults will transfer to a local hospital, hospice or care home or move to an alternative prison for palliative care. In these cases, responsibility for care and support will pass to the NHS or new local authority, once the adult arrives at the new location. Approved premises are not usually a suitable location for the provision of end of life care.

Prison managers and health care providers should consider informing local authorities when a prisoner receives a terminal diagnosis or their condition deteriorates significantly. The adult’s consent to share such information should be obtained where possible.

Where it is not possible to obtain consent to share this information, managers of custodial settings and health care providers should make an individual assessment and consider the legal basis for sharing information (see Data Protection chapter).

Local authorities should work with the prison healthcare provider to ensure that the care and support needs of the prisoner are met throughout the provision of end of life care.

12. NHS Continuing Healthcare

NHS Continuing Healthcare (CHC) is care which is arranged and funded by the NHS and provided to adults who have been assessed as having a ‘primary health need’. It is provided to people aged 18 or over, to meet needs that have arisen as a result of disability, accident or illness. NHS Continuing Healthcare is not dependent on a person’s condition or diagnosis but is based on their specific care needs.

13. Safeguarding Adults

See Safeguarding Enquiries Process

Local authority staff and care providers must understand what to do where they have a concern about abuse and / or neglect of an adult in custody. Prison and probation staff may approach the local authority for advice and assistance with adult safeguarding concerns in individual, but the local authority does not have the legal duty to lead safeguarding enquiries in any custodial setting.

14. Transition from Children’s to Adult Care and Support

Local authorities should have processes to identify young people in young offender institutions, secure children’s homes, secure training centres or other places of detention as well as young people in the youth justice system, who are likely to have eligible needs for care and support as adults, and who are approaching their eighteenth birthday. These young people should receive a transition assessment when appropriate (see Transition to Adult Care and Support chapter).

This also applies where a young person moves from a young offender institution to an adult prison, which may change which local authority is responsible for them. A request for an assessment can be made on the young person’s behalf by the professional responsible for their care in the young offenders’ institution, secure children’s home or secure training centre.

15. Care Leavers

If a young person is entitled to care and support and services as a care leaver, this status remains unchanged while they are in custody and the local authority that looked after the young person retains responsibility for providing leaving care services during their time in custody and on release.

Local authorities have a duty to provide personal adviser (PA) support to all care leavers up to age 25, if they want this support.

16. Independent Advocacy Support

Adults in custody are entitled to the support of an independent advocate during needs assessments and care and support planning and reviews of plans if they would have significant difficulty in being involved in the process. It is the local authority’s duty to arrange an independent advocate, as they would for an individual in the community (see Independent Advocacy chapter).

The local authority should agree with managers of custodial establishments how the advocacy scheme will work in their establishments.

17. Investigations and Inquests

The Prisons and Probation Ombudsman (PPO) conducts investigations in prisons following complaints about prison services, as well as deaths in custody or other significant events. The PPO will commission a relevant body to assist their investigations where it is felt that an aspect of care and support provision has contributed to the event. The local authority should co- operate with any investigations as required.

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RELEVANT CHAPTERS

Modern Slavery

Interpreting, Signing and Communication Needs

Stage 1: Concerns

RELEVANT GUIDANCE AND INFORMATION

No Recourse to Public Funds Network

Assessing and Supporting Adults who have No Recourse to Public Funds (England) (NRPF Network)

Guidance for Adult Social Care (NRPF Network)

March 2022: This chapter has been reviewed throughout and extensively updated. New sections have been added on: Asylum Seekers and Modern Slavery

1. Definition and Eligibility

1.1 Definition of No Recourse to Public Funds

The term no recourse to public funds (NRPF) applies to people who are subject to immigration control in the UK and who do not have any entitlement to welfare benefits or public housing.

The definition of ‘subject to immigration control’ is set out in section 115 Immigration and Asylum Act 1999 (‘exclusion from benefits’), and includes people who:

  • require leave to enter or remain in the UK but do not have it (e.g. an illegal entrant, Appeal Rights Exhausted asylum seeker or visa overstayer);
  • have leave to enter or remain in the UK which is subject to a condition that they do not have recourse to public funds( e.g. a spouse of a settled person, a Tier 4 student and their dependents or those with leave to remain as a visitor or under ‘family or private life rules’); or
  • have leave to enter or remain in the UK given as a result of a maintenance undertaking (e.g. they are adult dependant relatives of people with settled status).

The statement ‘no public funds’ will be written on the person’s immigration documentation if they have immigration permission with NRPF.

People who have no recourse to public funds are not usually entitled to receive welfare benefits.

They also have no entitlement to local authority housing or assistance from the local authority in relation to homelessness.

However, there are several exceptions to the rules regarding public funds, which are set out in the Home Office Guidance on Public Funds. This means that a person who has leave to remain with NRPF may be able to claim certain benefits without this affecting their immigration status when they:

  • are a national of a country that has a reciprocal arrangement with the UK;
  • have an EEA national family member, including a British citizen;
  • make a joint claim for tax credits with a partner who has recourse to public funds; or
  • have indefinite leave to enter or remain as an adult dependent relative during the first five years they are in the UK (during which time they can claim non-means tested benefits).

1.2 Recourse to Public Funds

People with the following types of immigration status will have recourse to (be able to access) public funds:

  • indefinite leave to enter or remain or no time limit (apart from an adult dependent relative);
  • right of abode;
  • exempt from immigration control;
  • refugee status;
  • humanitarian protection;
  • have leave to remain granted under the family or private life rules where they are accepted by the Home Office as being destitute or at risk of imminent destitution;
  • discretionary leave to remain, for example:
    • leave granted to a person who has received a conclusive grounds decision that they are a victim of trafficking or modern day slavery;
    • destitution domestic violence concession;
  • unaccompanied asylum-seeking child leave.

See Who has NPRF? Assessing and Supporting Adults who have no Recourse to Public Funds (England) for further information

2. Asylum Seekers

When an asylum seeker or refused asylum seeker (asylum seeker) requests care and support from social care, a local authority will be able to refer such a person to the Home Office for asylum support.

In certain circumstances, destitute refused asylum seekers may be provided with support from the Home Office under section 4 of the Immigration and Asylum Act 1999. They need to show that they:

  • are taking all reasonable steps to leave the UK;
  • are unable to leave the UK due to physical impediment;
  • have no safe route of return;
  • have been granted leave to appeal in an application for judicial review concerning their asylum claim; or
  • require support to avoid a breach of their human rights, for example they have made further submissions for a fresh asylum claim.

The support provided comprises accommodation and subsistence, which is intended to cover the costs of food, clothing and toiletries, through a card that can be used in shops but not to withdraw cash. Subsistence support cannot be provided independently of accommodation.

The following organisations provide information and asylum support:
Home Office
Migrant Help (assistance with applications)
Asylum Support Appeals Project (assistance when support is refused)

3. Modern Slavery

See also Modern Slavery chapter.

Local authorities must consider and investigate when they suspect a person may be a victim of trafficking or modern slavery, or when a confirmed victim who has NRPF requests care and support or requires housing.

4. Human rights considerations

Whilst taking into account legal restrictions, local authorities cannot carry out their duties in any way that breaches a person’s human rights. In all situations, the local authority should provide support where necessary to avoid a breach of their human rights. The local authority should assess the person’s needs if there would be a breach of human rights if support is not provided.

In practice this means that local authorities must undertake a human rights assessment to consider whether, or to what extent, the circumstances are such that the bar on providing support or assistance under the Care Act should be lifted in order to avoid a breach of human rights.

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Ordinary Residence is crucial for deciding which local authority is responsible for providing an adult with care and support. This chapter provides an overview for multi-agency practitioners.

RELEVANT CHAPTERS

Promoting Wellbeing

Preventing, Reducing or Delaying Needs

RELEVANT INFORMATION

Chapter 19, Ordinary Residence, Care and Support Statutory Guidance (Department of Health and Social Care)

See also Ordinary Residence Case Studies

1. Introduction

It is critical that local authorities understand which people they are responsible for, and that people themselves know who to contact when they need care and support. The local authority is only required to meet the needs of those who are ‘ordinarily resident’ in their area (or are present there but have no settled residence (see Section 5, Persons with no Settled Residence). Ordinary residence is crucial in deciding which local authority is required to meet the care and support needs of adults, and their carers. Whether the person is ordinarily resident in the area of the local authority is a key test in determining where responsibilities lie between local authorities for the funding and provision of care and support.

Ordinary residence is not a new concept; it has been used in care and support for many years. However, there will always be cases in which it is difficult to establish precisely where a person is ordinarily resident. The Care Act extends the principle of ‘deeming’ certain people to be ordinarily resident in a particular local authority’s area, when some types of accommodation are arranged for them in another area. Local authorities cannot escape the effect of the deeming provision where they are under a duty to provide or to arrange for the provision of services.

2. How does Ordinary Residence affect the Provision of Care and Support?

The test for ordinary residence, which determines which local authority would be responsible for meeting needs, applies differently in relation to adults with needs for care and support and carers. For adults with care and support needs, the local authority in which the adult is ordinarily resident will be responsible for meeting their eligible needs. For carers, however, the responsible local authority will be the one where the adult for whom they care is ordinarily resident.

Local authorities must determine whether an individual is ordinarily resident in their area following the needs or carer’s assessment, and after determining whether the person has eligible needs.

The determination of ordinary residence must not delay the process of meeting needs. In cases where ordinary residence is not certain, the local authority should meet the individual’s needs first, and then resolve the question of ordinary residence subsequently. This is particularly the case where there may be a dispute between two or more local authorities.

3. How to Determine Ordinary Residence

The local authority’s responsibility for meeting a person’s eligible needs is based on the concept of ordinary residence. There is, however, no definition of ordinary residence in the Care Act. Therefore, the term should be given its ordinary and natural meaning.

In most cases, establishing the person’s ordinary residence is a straightforward matter. However, this is not always the case. There will be circumstances in which ordinary residence is not clear cut, for example when people spend their time in more than one area, or move between areas. Where uncertainties arise, local authorities should always consider each case on its own merits.

Local authorities should in particular apply the principle that ordinary residence is the place the person has voluntarily adopted for a settled purpose, whether for a short or long duration. Ordinary residence can be acquired as soon as the person moves to an area, if their move is voluntary and for settled purposes, irrespective of whether they own, or have an interest in a property in another local authority area. There is no minimum period in which a person has to be living in a particular place for them to be considered ordinarily resident there, because it depends on the nature and quality of the connection with the new place.

For people who lack capacity to make decisions about their accommodation and for children transitioning into adult social care services, the judgment in the case of R (on the application of Cornwall Council) Secretary of State & Ors [2015] UKSC46 (Cornwall) is appropriate because a person’s lack of mental capacity may mean that they are not able to voluntarily adopt a particular place of residence.

4. Cases where a Person Lacks Capacity

See also Mental Capacity

All issues relating to mental capacity should be decided with reference to the Mental Capacity Act 2005 (MCA). Under this Act, it must be assumed that adults have capacity to make their own decisions, including decisions relating to their accommodation and care, unless it is established to the contrary.

The test for capacity is specific to each decision at the time it needs to be made, and a person may have capacity to make some decisions but not others. It is not necessary for a person to understand local authority funding arrangements to have capacity to decide where they want to live.

If it can be shown that a person lacks capacity to make a particular decision, the MCA makes clear how decisions should be made for that person. For example, if a person lacks capacity to decide where to live, a best interests decision about their accommodation should be made under the Act. Any act done, or decision made (which would include a decision relating to where a person without capacity should live), must be done or made in the best interests of the person who lacks capacity. The MCA sets out how to work out the best interests of a person who lacks capacity and provides a checklist of factors for this purpose.

5. Persons of No Settled Residence

Where doubts arise in respect of a person’s ordinary residence, it is usually possible for local authorities to decide that the person has resided in one place long enough, or has sufficiently firm intentions in relation to that place, to have acquired an ordinary residence there. Therefore, it should only be in rare circumstances that local authorities conclude that someone is of no settled residence. For example, if a person has clearly and intentionally left their previous residence and moved to stay elsewhere on a temporary basis during which time their circumstances change, a local authority may conclude the person to be of no settled residence.

Local authorities have a duty to meet the eligible needs of people if they are present in its area but of no settled residence. In this regard, people who have no settled residence, but are physically present in the local authority’s area, should be treated in the same way as those who are ordinarily resident.

A local authority may conclude that a person arriving from abroad is of no settled residence, including those people who are returning to England after a period of residing abroad and who have given up their previous home in this country. See Ordinary Residence Case Studies.

6. Ordinary Residence when Arranging Care and Support in another Area

There may be some cases where the local authority considers that the person’s care and support needs can only be met if they are living in a specified type of accommodation. This could be in a care home, or other kinds of premises as specified below. If the specified accommodation in which the care is provided is located in the area of another authority, it is important that there is no question as to which local authority is responsible for meeting the person’s needs.

The Care Act and associated regulations set out what should happen in these cases. The person placed ‘out of area’ is deemed to continue to be ordinarily resident in the area of the first authority, and does not acquire an ordinary residence in the ‘host’ or second authority. The local authority which arranges the care in the specified accommodation retains responsibility for meeting the person’s needs.

The regulations specify the types of accommodation to which this provision applies. It explicitly sets out three types of accommodation:

1) nursing homes/care homes: accommodation which includes either nursing care or personal care

2) supported living/extra care housing this is either:

  • specialist or adapted accommodation: this means accommodation which includes features that have been built in or changed to in order to meet the needs of adults with care and support needs. This may include safety systems and features which enable accessibility and navigation around the accommodation and minimise the risk of harm, as appropriate to the individual;
  • accommodation which is intended for occupation by adults with care and support needs, in which personal care is also available, usually from a different provider

3) shared lives schemes: accommodation which is provided together with care and support for an adult by a shared lives carer, approved by the scheme, in the shared lives carer’s home under the terms of an agreement between the adult, the carer and any local authority responsible for making the arrangement. The shared lives carer will normally be providing personal care but they will not need to provide it in every case.

There may be occasions where a provider chooses to change the type of care which it provides, for instance to de-register a property as a care home and to redesign the service as a supported living scheme. Where the person remains living at the same property, and their needs continue to be met by the new service, then ordinary residence should not be affected, and the duty to meet needs will remain with the first authority. This will occur even if the person temporarily moves to another address whilst any changes to the property occur.

7. NHS Accommodation

Where a person goes into hospital, or other NHS accommodation, there may be questions over where they are ordinarily resident, especially if they are subsequently discharged into a different local authority area. For this reason, the Care Act makes clear what should happen in these circumstances.

A person for whom NHS accommodation is provided is to be treated as being ordinarily resident in the local authority where they were ordinarily resident before the NHS accommodation was provided. This means that where a person, for example, goes into hospital, they are treated as ordinarily resident in the area where they were living before they went into hospital. This applies regardless of the length of stay in the hospital, and means that responsibility for the person’s care and support does not transfer to the area of the hospital, if this is different from the area in which the person was ordinarily resident previously.

If a person who is ordinarily resident in England goes into hospital in Scotland, Wales or Northern Ireland, their ordinary residence will remain in England (in the local authority in which they ordinarily resided before going into hospital) for the purposes of responsibility for the adult’s care and support.

8. Mental Health Aftercare

Under section 117 of the Mental Health Act 1983 (the 1983 Act), local authorities together with Integrated Care Boards have a joint duty to arrange the provision of mental health aftercare services for people who have been detained in hospital for treatment under certain sections of the 1983 Act. After-care services must have both the purposes of ‘meeting a need arising from or related to the person’s mental disorder’ and ‘reducing the risk of a deterioration of the person’s mental condition and, accordingly, reducing the risk of the person requiring admission to a hospital again for treatment for mental disorder.’ The range of services which can be provided is broad.

The duty on local authorities to commission or provide mental health after-care rests with the local authority for the area in which the person concerned was ordinarily resident immediately before they were detained under the 1983 Act, even if the person becomes ordinarily resident in another area after leaving hospital.

9. Other Common Situations

9.1 Temporary absences

Having established ordinary residence in a particular place, this should not be affected by the individual taking a temporary absence from the area. The courts have held that temporary or accidental absences, including for example holidays or hospital visits in another area, should not break the continuity of ordinary residence, and local authorities should take this into account.

The fact that the person may be temporarily away from the local authority in which they are ordinarily resident, does not preclude them from receiving any type of care and support from another local authority if they become in urgent need. Local authorities have powers to meet the needs of people who are known to be ordinarily resident in another area, at their discretion and subject to their informing the authority where the person is ordinarily resident.

9.2 People with more than one home

Although in general terms it may be possible for a person to have more than one ordinary residence (for example, a person who divides their time equally between two homes), this is not possible for the purposes of the Care Act. The purpose of the ordinary residence test in the Act is to determine which single local authority has responsibility for meeting a person’s eligible needs, and this purpose would be defeated if a person could have more than one ordinary residence.

If a person appears genuinely to divide their time equally between two homes, it would be necessary to establish (from all of the circumstances) to which of the two homes the person has the stronger link. Where this is the case, it would be the responsibility of the local authority in whose area the person is ordinarily resident, to provide or arrange care and support to meet the needs during the time the person is temporarily away at their second home.

Further scenarios which may occur are set out in Annex H, and may be used by local authorities to support cases where there may be uncertainty as to an individual’s ordinary residence.

9.3 People who arrange and fund their own care

People who self-fund and arrange their own care (self-funders) and who choose to move to another area and then find that their funds have depleted can apply to the local authority area that they have moved to in order to have their needs assessed. If it is decided that they have eligible needs for care and support, the person’s ordinary residence will be in the place where they moved to and not the first authority.

9.4. Resolving Ordinary Residence and Continuity of Care Disputes

In the majority of cases, determining ordinary residence should be straightforward. However, there will be occasions where a person’s residency status is more complicated to establish.

A question as to a person’s ordinary residence can only arise where two or more local authorities are in dispute about the place of ordinary residence of a person. In such a case, the authorities may apply for a determination to the Secretary of State or appointed person. Where the local authorities concerned are in agreement about a person’s ordinary residence, but the person is unhappy with the decision, the person would have to pursue this with the authorities concerned and could not apply to the Secretary of State or an appointed person for a determination.

9.5 Process for seeking a determination

There are regulations in place to resolve any dispute which arises in relation to a person’s ordinary residence. It is the responsibility of the lead local authority to make a request in writing to the Secretary of State or appointed person, together with a statement of facts and other documentation.

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This chapter provides information for multi-agency practitioners in relation to young people transitioning to adult services. It outlines the role of the local authority and partner agencies in this process when working with the young person and their carer / family.

SOUTH TYNESIDE SPECIFIC INFORMATION

Bridging the Gap: Transitional Safeguarding and the Role of Social Work with Adults – A Knowledge Briefing 

Children, Young People and Modern Slavery: A Guide for Professionals (NERSOU and the Children’s Society)

RELEVANT CHAPTERS

Integration, Cooperation and Partnerships

RELEVANT INFORMATION

Chapter 16, Transition to Adult Care and Support, Care and Support Statutory Guidance (Department of Health and Social Care)

See also Transition to Adult Care and Support Case Studies

September 2021: This chapter has been updated to include a link to Bridging the Gap: Transitional Safeguarding and the Role of Social Work with Adults – A Knowledge Briefing and Children, Young People and Modern Slavery: A Guide for Professionals, as above.

1. Introduction

Transition is the term used to describe the process which is in place to support young people and their families move from services they have received as a child into those that they need when they become an adult.

Effective person centred transition planning is essential to help young people and their families prepare for adulthood. Transition to adult care and support comes at a time when a lot of change can take place in a young person’s life. It can also mean changes to the care and support they receive from education, health and care services, or involvement with new agencies such as those who provide support for housing, employment or further education and training.

The years in which a young person is approaching adulthood should be full of opportunity. Some of the issues that matter for young people approaching adulthood, and their families, may include (but are not limited to):

  • paid employment;
  • good health;
  • completing exams or moving to further education;
  • independent living (choice and control over one’s life and good housing options);
  • social inclusion (friends, relationships and community).

The wellbeing of each young person or carer must be taken into account so that assessment and planning is based around the individual needs, wishes, and outcomes which matter to that person (see Promoting Wellbeing chapter).

Historically, there has sometimes been a lack of effective planning for people using children’s services who are approaching adulthood. Looked after children, young people with disabilities, and carers are often among the groups of people with the lowest life chances. Early conversations provide an opportunity for young people and their families to reflect on their strengths, needs and desired outcomes, and to plan ahead for how they will achieve their goals.

Professionals from different agencies, families, friends and the wider community should work together in a coordinated manner around each young person or carer to help raise their aspirations and achieve the outcomes that matter to them.

The purpose of carrying out transition assessments is to provide young people and their families with information so that they know what to expect in the future and can prepare for adulthood.

Transition assessments can develop solutions which do not necessarily involve the provision of services, and which may aid planning that helps to prevent, reduce or delay the development of needs for care or support.

2. When a Transition Assessment must be Carried Out

Transition assessments should take place at the right time for the young person or carer and at a point when the local authority can be reasonably confident about what the young person’s or carer’s needs for care or support will look like after the young person in question turns 18. There is no set age when young people reach this point; every young person and their family are different, and as such, transition assessments should take place when it is most appropriate for them.

The local authority must carry out a transition assessment of anyone in the three  groups when there is significant benefit to the young person or carer in doing so, and if they are likely to have needs for care or support after turning 18. The provisions in the Care Act relating to transition to adult care and support are not only for those who are already receiving children’s services, but for anyone who is likely to have needs for adult care and support after turning 18.

3. Significant Benefit

When considering if it is of ‘significant benefit’ to assess, the local authority should consider the circumstances of the young person or carer, and whether it is an appropriate time for the young person or carer to undertake an assessment which helps them to prepare for adulthood.

The consideration of ‘significant benefit’ is not related to the level of a young person or carer’s needs, but rather to the timing of the transition assessment.

When considering whether it is of significant benefit to assess, a local authority should consider factors which may contribute to establishing the right time to assess (including but not limited to the following):

  • the stage they have reached at school and any upcoming exams;
  • whether the young person or carer wishes to enter further / higher education or training;
  • whether the young person or carer wishes to get a job when they become a young adult;
  • whether the young person is planning to move out of their parental home into their own accommodation;
  • whether the young person will have care leaver status when they become 18;
  • whether the carer of a young person wishes to remain in or return to employment when the young person leaves full time education;
  • the time it may take to carry out an assessment;
  • the time it may take to plan and put in place the adult care and support;
  • any relevant family circumstances;
  • any planned medical treatment/

For young people with special educational needs or disabilities (SEND) who have an education, health and care (EHC) plan under the Children and Families Act 2014, preparation for adulthood must begin from year 9 – see Special Educational Needs & Disability (SEND) Code of Practice. The transition assessment should be undertaken as part of one of the annual statutory reviews of the EHC plan, and should inform a plan for the transition from children’s to adult care and support.

Equally for those without EHC plans, early conversations with local authorities about preparation for adulthood are beneficial – when these conversations begin to take place will depend on individual circumstances.

For care leavers, local authorities should consider using the statutory Pathway Planning process as the opportunity to carry out a transition assessment where appropriate.

Local authorities should not carry out the transition assessment at inappropriate times in a young person’s life, such as when they are sitting their exams and it would cause disruption. The SEND Code of Practice similarly states that local authorities must minimise disruption to the child and their family – for example by combining multiple appointments where possible. Local authorities should seek to agree the best time for assessments and planning with the young person or carer, and where appropriate, their family and any other relevant partners.

In more complex cases, it can take some time not only to carry out the assessment itself but to plan and put in place care and support. Social workers will often be the most appropriate lead professionals for complex cases. Transition assessments should be carried out early enough to ensure that the right care and support is in place when the young person moves to adult care and support.

When transition assessments take place too late and care and support is arranged in a hurry, it can result in care and support which does not best meet the young person or carer’s needs – and sometimes at greater financial cost to the local authority than if it had been planned properly in advance.

4. Requests for Transition Assessment

A young person or carer, or someone acting on their behalf, has the right to request a transition assessment. The local authority must consider such requests and whether the likely need and significant benefit conditions apply – and if so it must undertake a transition assessment.

5. Refusal of Transition Assessment

If the local authority thinks these conditions do not apply and refuses an assessment on that basis, it must provide its reasons for this in writing in a timely manner, and it must provide information and advice on what can be done to prevent or delay the development of needs for support.

Where someone is refused (or they themselves refuse) a transition assessment, but at a later time makes a request for an assessment, the local authority must again consider whether the likely need and significant benefit conditions apply, and carry out an assessment if so.

6. Identifying Young People and Young Carers who are not already receiving Children’s Services

Most young people who receive transition assessments will be children in need under the Children Act 1989 and will already be known to local authorities.

However, local authorities should consider how they can identify young people who are not receiving children’s services who are likely to have care and support needs as an adult. Key examples include:

  • young people with degenerative conditions;
  • young people (for example with autism) whose needs have been largely met by their educational institution, but who once they leave, will require their needs to be met in some other way;
  • young people detained in the youth justice system who will move to the adult custodial estate;
  • young carers whose parents have needs below the local authority’s eligibility threshold but may nevertheless require advice or support to fulfil their potential, for example a child with deaf parents who is undertaking communication support;
  • young people and young carers receiving Children and Adolescent Mental Health Services (CAMHS) may also require care and support as adults even if they did not receive children’s services from the local authority.

Even if they are not eligible for services, a transition assessment with good information and advice about support in the community can be particularly helpful for these groups as they are less likely to be aware of this.

When young people who have not been in contact with children’s services present to the local authority as a young adult, they often do so with a high level of need for care and support. Local authorities should consider how to work with education and health services to identify these groups as early as possible so they can plan and prevent the development of care and support needs (see Integration, Cooperation and Partnerships and Special Educational Needs & Disability (SEND) Code of Practice ‘Preparing for Adulthood’).

7. Adult Carers and Young Carers

Preparation for adulthood will involve assessing how the needs of young people change as they approach adulthood and also how carers’, young carers’ and other family members’ needs might change over time.

The local authority must assess the needs of an adult carer where there is a likely need for support after the child turns 18 and it is of significant benefit to the carer to do so. For instance, some carers of disabled children are able to remain in employment with minimal support while the child has been in school. However, once the young person leaves education, it may be the case that the carer’s needs for support increase, and additional support and planning is required from the local authority to allow the carer to stay in employment.

The local authority must also assess the needs of young carers as they approach adulthood. For instance, many young carers feel that they cannot go to university or enter employment because of their caring responsibilities. Transition assessments and planning must consider how to support young carers to prepare for adulthood and how to raise and fulfil their aspirations.

The local authority must consider the impact on other members of the family (or other people the authority may feel appropriate) of the person receiving care and support. This will require the authority to identify anyone who may be part of the person’s wider network of care and support. For example, caring responsibilities could have an impact on siblings’ school work, or their aspirations to go to university. Young carers’ assessments should include an indication of how any care and support plan for the person/s they care for would change as a result of the young carer’s change in circumstances. For example, if a young carer has an opportunity to go to university away from home, the local authority should indicate how it would meet the eligible needs of any family members that were previously being met by the young carer.

8. Features of a Transition Assessment

The transition assessment should support the young person and their family to plan for the future, by providing them with information about what they can expect. All transition assessments must include an assessment of:

  • current needs for care and support and how these impact on wellbeing;
  • whether the child or carer is likely to have needs for care and support after the child in question becomes 18;
  • if so, what those needs are likely to be, and which are likely to be eligible needs;
  • the outcomes the young person or carer wishes to achieve in day to day life and how care and support (and other matters) can contribute to achieving them.

Transition assessments for young carers or adult carers must also specifically consider whether the carer:

  • is able to care now and after the child in question turns 18;
  • is willing to care now and will continue to after 18;
  • works, or wishes to do so;
  • is or wishes to participate in education, training or recreation.

The young person or carer in question must be involved in the assessment for it to be person centred and reflect their views and wishes. The assessment must also involve anyone else who the young person or carer wants to involve in the assessment. For example, many young people will want their parents involved in their process.

9. Capacity

See also Mental Capacity chapter

In all cases, the young person or carer in question must agree to the assessment where they have mental capacity and are competent to agree. Where a young person or carer lacks mental capacity or is not competent to agree, the local authority must be satisfied that an assessment is in their best interests. Everyone has the right to refuse a transition assessment, however the local authority must undertake an assessment regardless if it suspects that a child is experiencing or at risk of abuse or neglect.

The right of young people to make decisions is subject to their capacity to do so as set out in the Mental Capacity Act 2005. The underlying principle of the Act is to ensure that those who lack capacity are supported to make as many decisions for themselves as possible, and that any decision made or action taken on their behalf, is done so in their best interests. This is a necessity if the transition assessment is to be person centred.

For young people below the age of 16, local authorities will need to establish a young person’s competence using the test of ‘Gillick competence’ (whether they are able to understand a proposed treatment or procedure). Where the young person is not competent, a person with parental responsibility will need to be involved in their transition assessment, – or an independent advocate provided if there is no one appropriate to act on their behalf (either with or without parental responsibility).

10. Independent Advocacy

The Care Act places a duty on local authorities to provide an independent advocate to facilitate the involvement in the transition assessment where the person in question would experience substantial difficulty in understanding the necessary information or in communicating their views, wishes and feelings – and if there is nobody else appropriate to act on their behalf (see Independent Advocacy chapter). This duty applies for all young people or carers who meet the criteria, regardless of whether they lack mental capacity as defined under the Mental Capacity Act 2005.

11. Information Sharing

When sharing information with a young carer about the person they care for a supported self-assessment during transition, the local authority must be satisfied that it is appropriate for the young carer to have the information. They must have regard to all circumstances in taking this decision, especially the age of the young carer, however each case will be different and there is no one age at which a young carer is necessarily old enough to receive information. The local authority must ensure that the adult consents to have their information shared in this way.

12. Cooperation between Professionals and Organisations

People with complex needs for care and support may have several professionals involved in their lives, and numerous assessments from multiple organisations. For children with special educational needs, the Children and Families Act 2014 brings these assessments together into a coordinated EHC plan (see SEND Code of Practice, Chapter 9).

Local authorities must cooperate with relevant partners, and this duty is reciprocal (see Integration, Cooperation and Partnerships chapter). This includes an explicit requirement which states that children and adult services must cooperate for the purposes of transition to adult care and support. Often, staff working in children’s services will have built relationships and knowledge about the young person or carer in question over a number of years. As young people and carers prepare for adulthood, children’s services and adults’ services should work together to pass on this knowledge and build new relationships in advance of transition.

It can be frustrating for children and families who have to attend multiple appointments for assessments, and who have to give out the same information repeatedly. The SEND Code of Practice highlights the importance of the ‘tell us once’ approach to gathering information for assessments and this will be important in other contexts as well. The local authority should consult with the young person and their family to discuss what arrangements they would prefer for assessments and reviews.

All relevant partners should be involved in transition planning where they are involved in the person’s care and support.

Equally, the local authority should be involved in transition planning led by another organisation, for example a child and adolescent mental health service, where there are also likely to be needs for adult care and support.

Agencies should agree how to organise transition assessments so that all the relevant professionals are able to contribute. For example, this might involve arranging a multi-disciplinary team meeting with the young person or carer. However, it may not always be possible for all the professionals from different agencies to be present at appointments, but they should still be enabled to contribute. Transition assessments must be person centred, which means that contributions by different agencies should reflect the views of the person to whom the assessment relates.

12.1 Care coordination

Many people value having one designated person who coordinates assessments and transition planning across different agencies, and helps them to navigate through numerous systems and processes that can sometimes be complicated.

Often there is a natural lead professional involved in a young person’s care who fulfils this role and the local authority should consider formalising this by designating a named person to coordinate transition assessment and planning across different agencies, and may also wish to consider setting up specialist posts carry out this coordination function for people who are preparing for adulthood.

This coordinating role, sometimes referred to as a ‘key working’ or ‘care coordination’, can not only help to deliver person centred, integrated care, but can also help to reduce bureaucracy and duplication for local authorities, the NHS and other agencies. Care coordinators are also often able to build close relationships with young people and families and can act as a valuable provider of information and advice both to the families and to local authorities. Care leavers will have Personal Advisers to provide support, for example by providing advice or signposting the young person to services. The Personal Adviser will be a natural lead in many cases to coordinate a transition from children’s to adult care and support where relevant (see also Transitions Case Studies).

13. Eligibility

Having carried out a transition assessment, the local authority must give an indication of which needs are likely to be eligible needs (and which are not likely to be eligible) once the young person in question turns 18, to ensure that the young person or carer understands the care and support they are likely to receive and can plan accordingly.

There is a particularly important role for local authorities in ensuring that young people and carers understand their likely situation when they reach adulthood. The different systems for children’s and adult care and support mean that there will be circumstances in which needs that were being met by children’s services may not be eligible needs under the adult system.

Adult care and support is subject to means testing and charging.

Where the transition assessment identifies needs that are likely to be eligible, local authorities should consider providing an indicative personal budget, so that young people, carers and their families are able to plan their care and support before entering the adult system (see SEN code of practice for further information about right to a personal budget for people with EHC plans).

For any needs that are not eligible under the adult statute, local authorities must provide information and advice on how those needs can be met, and how they can be prevented from getting worse.

14. Transition Plans

The local authority and relevant partners should consider building on a transition assessment to create a person-centred transition plan that sets out the information in the assessment, along with a plan for the transition to adult care and support, including key milestones for achieving the young person or carer’s desired outcomes.

In the case of an adult carer, if the local authority has identified needs through a transition assessment which could be met by adult services, it may meet these needs under the Care Act in advance of the child being cared for turning 18.

In deciding whether to do this the local authority must have regard to what support the adult carer is receiving under children’s legislation.

If the local authority decides to meet the adult carer’s needs through adult services, as for anyone else under the adult legislation, the adult carer must receive a support plan and a personal budget – as well as a financial assessment if they are subject to charges for the support they will receive.

15. Moving to Adult Care after the Young Person or Carer turns 18

There is no obligation on the local authority to move from children’s social care to adult care and support as soon as someone turns 18.

Very few moves will take place on the day of someone’s 18th birthday.

For the most part, the move to adult services begins at the end of a school term or another similar milestone, and in many cases should be a staged process over several months or years.

Prior to the move taking place, the local authority must decide whether to treat the transition assessment as a needs or carers assessment under the Care Act.

In making this decision the local authority must take into account when the transition assessment was carried out and whether the person’s circumstances have changed.

If the local authority will meet the young person’s or carer’s needs under the Care Act after they have turned 18 (based either on the existing transition assessment or a new needs assessment if necessary), the local authority must then undertake the care planning process as for other adults – including creating a care and support plan and producing a personal budget.

The local authority should ensure that this happens early enough that a package of care and support is in place at the time of transition.

16. Continuity of Care after the age of 18

Young people and their carers have sometimes faced a gap in provision of care and support when they turn 18, and this can be distressing and disruptive to their lives.

The local authority must not allow a gap in care and support when young people and carers move from children’s to adult services.

If transition assessment and planning is carried out as it should be, there should not be any gap in provision of care and support.

However, if adult care and support is not in place on a young person’s 18th birthday, and they or their carer have been receiving services under children’s legislation, the local authority must continue providing services until the relevant steps have been taken, so that there is no gap in provision.

The ‘relevant steps’ are if the local authority:

  • concludes that the person does not have needs for adult care and support;
  • concludes that the person does have such needs and begins to meet some or all of them (the local authority will not always meet all of a person’s needs – certain needs are sometimes met by carers or other organisations);
  • concludes that the person does have such needs but decides they are not going to meet any of those needs, for instance, because their needs do not meet the eligibility criteria under the Care Act 2014.

In order to reach such a conclusion, the local authority must have conducted a transition assessment (that they will use as a needs or carers assessment under the adult statute).

Where a transition assessment was not conducted and should have been (or where the young person’s circumstances have changed), the local authority must carry out an adult needs or carer’s assessment.

In the case of care leavers, the Staying Put Guidance (HM Government, 2013) states that local authorities may choose to extend foster placements beyond the age of 18. All local authorities must have a Staying Put policy to ensure transition from care to independence and adulthood that is similar for care leavers to that which most young people experience, and is based on need and not on age alone.

For some people with complex SEN and care needs, local authorities and their partners may decide that children’s services are the best way to meet a person’s needs – even after they have turned 18. Both the Care Act 2014 and the Children and Families Act 2014 allow for this.

The Children and Families Act enables local authorities to continue children’s services beyond age 18 and up to 25 for young people with EHC plans if they need longer to complete or consolidate their education and training and achieve the outcomes set out in their plan.

Under the Care Act 2014, if, having carried out a transition assessment, it is agreed that the best decision for the young person is to continue to receive children’s services, the local authority may choose to do so.

Children and adults’ services must work together, and any decision to continue children’s services after the child turns 18 will require agreement between children and adult services.

Where a person over 18 is still receiving services under children’s legislation through their EHC plan and the EHC plan ceases, the transition assessment and planning process must be undertaken. Where this has not happened at the point of transition, the requirement under the Care Act to continue children’s services (as set out above) applies.

Both the Children and Families Act 2014 and the Care Act 2014 also require young people and their parents to be fully involved making decisions about their care and support. This includes decisions about the most appropriate time to make the transition to adult services.

The EHC plan or any transition plan should set out how this will happen, who is involved and what support will be provided to make sure the transition is as seamless as possible.

17. Safeguarding after the age 18

Where someone is over 18 but still receiving children’s services and a safeguarding issue is raised, the matter should be dealt with by the adult safeguarding team (see Safeguarding Enquiries Process).

Where appropriate, they should involve the local authority’s children’s safeguarding colleagues as well as any relevant partners (for example police or NHS) or other persons relevant to the case.

The same approach should apply for complaints or appeals, as well as where someone is moving to a different local authority area after receiving a transition assessment but before moving to adult care and support.

18. Transition from Children’s to Adult NHS Continuing Health Care

ICBs should use the National Framework for NHS Continuing Healthcare and supporting guidance and tools (especially the Decision Support Tool) to determine what ongoing care services people aged 18 years or over should receive.

The framework sets out that ICBs should ensure that adult NHS continuing healthcare is assessed at all transition planning meetings for all young people whose may be potential eligibility.

ICBs and LAs should have systems in place to ensure that appropriate referrals are made whenever either organisation is supporting a young person who, on reaching adulthood, may have a need for services from the other agency.

The framework sets out best practice for the timing of transition steps as follows:

  • children’s services should identify young people with likely needs for NHS Continuing Health Care and notify the relevant ICB when such a young person turns 14;
  • there should be a formal referral for adult NHS CHC screening at 16;
  • there should be a decision in principle at 17 so that a package of care can be in place once the person turns 18 (or later if agreed more appropriate).

Where a young person has been receiving children’s continuing health care, it is likely that they will continue to be eligible for a package of adult NHS CHC when they reach the age of 18.

Where their needs have changed such that they are assessed as no longer requiring such a package, they should be advised of this and of their right to request an independent review and mediation

The ICB should continue to participate in the transition process, in order to ensure an appropriate transfer of responsibilities, including consideration of whether they should be commissioning, funding or providing services towards a joint package of care.

Where it will benefit a young person with an EHC plan, local authorities have the power to continue to provide children’s services past a young person’s 18th birthday for as long as is deemed necessary.

Where there is a change in CHC provision, this must be recorded in the young person’s EHC plan, where they have one, and the young person must be advised of their right to ask the local authority for mediation up to the age of 25 (see SEND Code of Practice).

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This chapter provides guidance for practitioners about the importance of case recording in adult safeguarding, including the principles for good recording and other issues for consideration.

RELEVANT CHAPTER

Supervision

South Tyneside Multi Agency Information Sharing Agreement

1. Introduction

Good case recording is a vital component of professional practice. It supports continuity of care, risk assessment and risk management, and documents thinking, decision making and actions taken. It is a professional aid to planning and analysis. Case files are also legal documents providing an evidence trail of the work done with an adult, and their carer.

Good case recording includes a record of:

  • views of the adult and their carer;
  • work that has been undertaken;
  • the adult’s life history;
  • progress adults make towards their desired outcomes;
  • decisions made and reasons for those decisions;
  • actions undertaken and reasons for those actions;
  • professional assessment and analysis of risk.

Learning lessons from past mistakes and missed opportunities highlighted in Safeguarding Adult Reviews (see Safeguarding Adults Reviews chapter), Child Safeguarding Practice Reviews and other review reports have emphasised the need for good quality case recording especially when managing abuse, neglect and risk. This includes providing rationales for actions and decisions, whether or not they were taken, and if not the reasons for this.

Quality recording of adult safeguarding work not only helps to keep adults safe, but also protects workers by evidencing decision making based on information which was available at the time.

Case records are also a vital tool to enable staff to reflect on their practice and identify any gaps for support or development. They should be used as part of supervision, in conjunction with supervisors / managers (see Supervision chapter)

The South Tyneside Safeguarding Safeguarding Adults Board will regularly review the quality of recording as part of its performance and quality data scrutiny.

1.1 Access to records

Practitioners should bear in mind that adults, or their representatives, can request access to their files at any time. Records should, therefore, be made in line with the guidance in Section 4, Case Recording Checklist).

Case records may also be made available to the courts in the event of a safeguarding or criminal enquiry.

1.2 Using case records to support practice

Good record keeping is a vital practitioner practice tool, enabling staff to reflect on their practice, demonstrate their thinking, the rationale behind decision making, analysis of complex situations and management oversight.

The case record is not simply a record of what is happening; it should be actively used as a tool to provide a professional analysis of the situation and to develop plans to support the adult and carer.

The use of genograms, chronologies and assessment records can help organise and analyse information.

Good record keeping enables managers to identify practice gaps and ensure additional support or development opportunities are offered to staff.

Management review of adults records with their staff should be a routine part of supervision and appraisal (see Supervision chapter).

2. How Should Information be Recorded?

Social care and health staff will often be working with adults with complex needs and their carers, over a period of time. In such situations it is crucial recording is well structured in order to ensure readability, and also to allow analysis and practitioner assessments to follow on from evidence based content.

Principles of case recording include:

  • professionals must ensure records are accurate and up to date and kept in line with the recording keeping guidance of their own organisation and / or professional body;
  • records should be written with the readership in mind. They should be drawn up in partnership with the adult, and easy for them to read and understand;
  • language should be plain, clear and respectful, keeping jargon to a minimum;
  • the record should clearly separate fact from opinion;
  • there should be a clear link between evidence recorded and actions planned / recommended;
  • if handwritten, records must be legible and in black ink;
  • any alterations to handwritten records must be made by drawing a single line through the word, and correction fluid must not be used.

3. What Information should be Recorded?

The following information should be documented in each adult’s records:

  • biographical details;
  • history;
  • facts;
  • events;
  • ongoing work including discussions with other agencies and professionals, telephone calls / emails and responses to these;
  • actions taken and in relation to them the adults wishes, feelings, views and understanding of the actions should be recorded;
  • decisions made;
  • plans and contingency plans;
  • professional analysis / assessment  of evidence rationale for these and recommendations.

4. Case Recording Checklist

Case records should be recorded in accordance with the following:

  • completeness: all information relevant to the adult and their circumstances should be documented. All action plans, decisions and key conversations and phone calls should be recorded;
  • openness: as adults may request access to their file at any time;
  • accuracy: all content must be accurate, facts must be distinguished from opinion;
  • the adult’s voice: records should be drawn up in partnership with the adult and record their views, in their own words where appropriate, including whether they have given permission to share information. The adult’s voice should not be ‘missing’ from the case record. Practitioners may inadvertently focus on the views of a carer who may be more vocal, rather than the adult who may have difficulty expressing themselves;
  • up to date: records should be up to date and written up as soon as possible;
  • management oversight: files should be regularly reviewed by managers. Management involvement in casework should be clear, and decisions and recommendations dated and signed off by the relevant manager
  • summaries / continuity of care: large files should be summarised at regular intervals as the size of the record may otherwise make it difficult to manage. Records should, therefore, be focused. Important information should be highlighted and regular summaries / transfer summaries included, to make it easier to read and hand over from one member of staff to another;
  • decision making: files must include a record of decisions taken and reasons for them;
  • chronology of significant events: this should be included in the record;
  • evidence based: so all decisions are supported by facts;
  • partnership working: records should show evidence of partnership working between staff, other professionals, other agencies, adults and their carers;
  • communication needs: should be clearly addressed within the record;
  • risk management and contingency planning: files should incorporate assessment, including risk assessment and contingency plans where appropriate;
  • equalities issues: record the adult’s race  /ethnicity, gender, religion, language, disability;
  • security: all files must be kept securely and shared in accordance with data protection principles.

5. Adult Safeguarding

Safeguarding cases are some of the most high risk situations for adults and their carers. Good case recording is therefore essential to ensuring the safety and wellbeing of adults and their carers in situations where abuse or neglect are of concern.

In the case of providers registered with the Care Quality Commission (CQC), records of these should be available to service commissioners and the CQC so they can take the necessary action.

All agencies should keep clear and accurate records and follow their own agency’s recording policies.

In general, where there are safeguarding concerns regarding an adult,  there should be an audit trail of:

  • date and circumstances of concerns and subsequent action;
  • a full assessment including past incidents, concerns, risks and any patterns, as abuse and neglect often arise over a period of time, including risk assessments and risk management plans;
  • if the alleged abuser is using care and support services themselves, information about their involvement in a safeguarding enquiry, including the outcome, should be included in their case record;
  • if it is assessed that the adult continues to pose a threat to other people, this should be included in any information that is passed on to service providers or other people who need to know;
  • all contact with any adults at risk of, or experiencing abuse or neglect, and alleged perpetrators must be recorded;
  • feedback from the adult and their personal support network, using the adult’s own words where appropriate;
  • recording the exact words of alleged perpetrators;
  • all consultations with a line or senior manager;
  • consultations and correspondence with key people;
  • decision making processes and rationales;
  • advocacy and support arrangements;
  • if a decision is made not to contact the police in the case of an adult at risk of, or experiencing abuse or neglect, the details of why this decision was made and on whose authority must be recorded;
  • those who attend key meetings and safeguarding meetings must be documented;
  • the decisions taken at all meetings must be recorded;
  • safeguarding plans;
  • outcomes;
  • differences of professional opinion;
  • referrals to professional bodies;
  • it is essential to demonstrate how an assessment of risk, responsibility, rights, autonomy and protection of the adult was undertaken;
  • if no investigation is to take place, the reasons why and on whose authority this decision was taken must be recorded;
  • use a body map to illustrate physical injuries or pressure ulcers etc, when necessary.
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RELEVANT CHAPTER

Mental Capacity

RELEVANT INFORMATION

Court of Protection

Office of the Public Guardian

Advance Decision to Refuse Treatment (Living Will (NHS)

Universal Principles for Advance Care Planning

November 2023: A new section 1, Advance Care Planning, has been added to reflect guidance contained in ‘Universal principles for advance care planning’ which was published in response to the Care Quality Commission report ‘Protect, Connect, Respect – decisions about living and dying well’

1. Advance Care Planning

Advance Care Planning (ACP) is a process of discussions which an adult can choose to have with their care providers about their preferences and priorities for their future care, while they have the mental capacity to be able to have such meaningful conversations. The process, which is person-centred and likely to involve a number of conversations over time, should include whoever the adult wishes to involve, including family members or friends.

The process will enable the adult to feel more involved in their care and treatment and gives them the opportunity to reflect and share with those involved what matters most to them.

The result of these discussions may include the adult deciding one, or more, of the following:

1.1 Universal principles

The following are the universal principles of ACP and describe ‘what good looks like’ in advance care planning:

  1. The adult is central to developing and agreeing their advance care plan including deciding who else should be involved in the process.
  2. The adult has personalised conversations about their future care, focused on what matters to them and their needs.
  3. The adult agrees the outcomes of their advance care planning conversation through a shared decision making process in partnership with relevant professionals.
  4. The adult has an advance care plan which records what matters to them and their preferences and decisions about future care and treatment, that they can share with others.
  5. They have the opportunity, and are encouraged, to review and revise their advance care plan.
  6. Anyone involved in the adult’s advance care planning process is able to speak up if they feel that these universal principles are not being followed.

2. Advance Statements

An advance statement is a written statement that sets down a person’s preferences, wishes, beliefs and values regarding their future care. Its aim is to provide a guide to anyone who might have to make decisions in the person’s best interests if they lose the ability to make or communicate decisions.

A health or social care professional making a best interests decision on behalf of an adult who lacks mental capacity must take into account any advance statement that has been made, as laid down in the Mental Capacity Act (MCA). However, the advance statement is an expression of the adult’s preference and is not legally binding for a health or social care professional.

It may be difficult to challenge a professional’s decision to disregard the adult’s wishes, because they can argue they have considered  the advance statement but were acting in the person’s best interests (see Best Interests chapter).

3. Advance Decision to Refuse Treatment

An advance decision is different from an advance statement. An advance decision is a document which contains a statement that stands even if the person’s life is at risk; such as where they have refused life sustaining (continuing) treatment. This is laid out in the MCA.

The advance decision is designed to express the desires of a person who may later lack mental capacity to refuse all or some medical treatment and overrides the best interests test. It is legally binding provided the criteria under the MCA are met. In relation to refusal of treatment, the advance decision must be:

  • written;
  • made when the person has capacity;
  • made by a person over the age of 18 years and has been witnessed.

The MCA says the advance decision is not applicable to life sustaining treatment unless “it contains a statement … that it is to apply … even if the life is at risk”.

The advance decision is not applicable to life sustaining treatment unless:

  • the treatment is not the treatment specified in the advance decision;
  • any circumstances specified in the advance decision are not present;
  • there are reasonable grounds for believing that circumstances exist which the person did not anticipate at the time they made the advance decision and which would have affected their decision had they anticipated them.

An advance decision is not valid if the person:

Practitioners should be clear that advance decisions are different from advance statements.

3.1 End of life

At end of life, the best interest test applies when a patient does not have the mental capacity to make their own decisions (see Best Interests chapter). This can be a result of losing mental capacity (see Mental Capacity chapter), or through a loss of consciousness (temporary or permanent). It will cover decisions relating to palliative care (in the case of serious or life-threatening disease) and withdrawing treatment.

In the absence of a legitimate advance decision or health and welfare Lasting Power of Attorney (LPA), the decision on which treatments should or should not be provided should be made by the healthcare professionals, not the person’s relatives.

The healthcare professional must decide what is in the person’s best interests, taking all the relevant medical and non-medical circumstances into account.

4. Do Not Resuscitate

Refusing Cardiopulmonary Resuscitation (CPR) in advance (NHS) 

DNACPR stands for do not attempt cardiopulmonary resuscitation. DNACPR is sometimes called DNAR (do not attempt resuscitation) or DNR (do not resuscitate) but they all refer to the same thing

Everyone has the right to refuse Cardiopulmonary Resuscitation (CPR) if they do not want to be resuscitated, if they stop breathing or their heart stops beating.

Where the do not resuscitate decision has been made in advance, it will be recorded on a special form and kept in the person’s medical records. A DNACPR order is not permanent; it can be changed at any time.

People’s views and wishes may also be recorded in their Last Powering of Attorney (see Section 5 or Advanced Decision documents (see Section 3).

People who have a serious illness or are undergoing surgery that could cause respiratory or cardiac arrest, should be asked by a member of the medical team about their wishes regarding CPR if they have not previously made their wishes known. This should take place before they have surgery.

People should always be advised to discuss such decisions with their family or other carers, so that it is not a surprise to them should the situation arise.

If the person does not have the mental capacity to decide about CPR when a decision needs to be made (see Mental Capacity chapter) and has not made an advance decision to refuse treatment, the healthcare team should consult with their next of kin about their wishes so a decision can be made in their best interests (see Best Interests chapter).

Medical staff have a legal duty to consult and involve patients in a decision to place a ‘Do Not Resuscitate’ (DNR) order on their medical notes. Patients should always be involved in a DNR decision. There must be a convincing reason not to involve the patient, otherwise a failure to consult with them may breach their human rights. Causing potential distress to a patient is not a good enough reason not to consult with them.

5. Lasting Powers of Attorney, Court Appointed Deputy, Court of Protection and Office of the Public Guardian

5.1 Lasting Power of Attorney

Any person who has the mental capacity to understand the nature and implications of doing so may appoint another person/s to look after their affairs on their behalf. This can cover either all their affairs or be limited to specific issues. This power can be changed by the donor (the person) at any time.

A Lasting Power of Attorney (LPA) is a legal document which allows an adult to appoint an attorney to act on their behalf if they should lose mental capacity in the future. It enables the person to instruct an attorney to make decisions about their property and affairs and / or health and welfare decisions. Attorneys, in this case, can be family members or friends, who have to be registered with the Office of the Public Guardian. See Make, register or end a lasting power of attorney (gov.uk).

5.2 Court Appointed Deputy and Court of Protection

A Court Appointed Deputy is appointed by the Court of Protection (CoP). The Court of Protection has authority to make decisions on financial or welfare matters for people who cannot make decisions at the time they need to be made (because they lack mental capacity). Depending on the terms of their appointment, Court Appointed Deputies can take decisions on welfare, healthcare and financial matters as authorised by the CoP but they are not able to refuse consent to life sustaining treatment.

Any decisions made by the CoP can be challenged; for example where it is believed that a deputy is not acting in the best interests of the person they are representing and there are safeguarding concerns as a result.

5.3 Office of the Public Guardian

The Office of the Public Guardian (OPG) is the body which registers authority for LPAs and court appointed deputies. It supervises deputies appointed by the CoP and provides information to help the CoP make decisions. The OPG also works with other agencies, for example the police and adult social care, to respond to any concerns raised about the way in which an attorney or deputy is behaving.

5.4 Abuse by an Attorney or Deputy

Anyone who has concerns about the actions of a person who is a registered LPA, or a deputy appointed by the CoP, they should contact the OPG. The OPG can investigate their actions  and can also refer concerns to other relevant agencies. For more information see Report a concern about an attorney, deputy or guardian (gov.uk).

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1. Introduction

Mental health and mental wellbeing can have different meanings to each individual. If a person feels well they have good mental health they will be able to cope well with day to day life, make the most of their potential and partake fully in social, family, community and work related activity.

When a person does not feel that they are in a state of good mental health, it can affect their daily activity and their perception on life, so daily life, work and socialising with family, friends, colleagues and the wider community becomes difficult.

2. Mental Health Act 1983

In legal terms, the Mental Health Act 1983 (amended 2007) does not use the expression mental health, but refers to mental disorder.

2.1 Amendments to the Act

The amendments of the MHA in 2007 simplified the previous criteria and outlined mental disorder to be ‘any disorder or disability of the mind’.

Whist mental disorder is now classified as such, a diagnosis of a learning disability does not count for detention or treatment under the Act unless it is ‘associated with abnormally aggressive or seriously irresponsible conduct.’

People with a learning disability are considered under the MHA only if they exhibit behaviour that is ‘abnormally aggressive or seriously irresponsible’. A person cannot be detained under the Act purely as a result of their learning disability alone.

Amendments to the Act also mean that people with personality disorders who used not to be detainable under the Act (because their disorders did not result in ‘abnormally aggressive or seriously irresponsible conduct on the part of the person concerned’) can now be detained.

There is still an exclusion that relates to a dependence on drink or drugs which means a person cannot be detained under the MHA 1983 solely for such a dependency, but they can be detained if it arises because of or from a mental disorder.

Chapter 2 of the Code of Practice to the MHA 1983 (2007) explains in further detail what illnesses may be considered under the Act and also references personality disorders and the MHA.

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1. Introduction

If a person has been assessed as lacking capacity, any action taken or any decision made or on behalf of that person, must be made in their best interests. This is the fourth principle of the five principles of the Mental Capacity Act 2005 (MCA) (see Mental Capacity chapter).

The person who has to make the decision is known as the ‘decision maker’. The decision maker is usually the person closest to the decision, that is a clinician for healthcare decisions, social worker for social care decisions and a carer for day to day care decisions.

2. What are ‘Best Interests’?

The law requires a number of factors to be considered when deciding what is in the best interests of a person who lacks capacity. The checklist below details these factors. This list is not exhaustive and the MCA Code of Practice should be referred to for more details.

  • It is important not to make assumptions about someone’s best interests merely on the basis of their age, appearance, condition or any aspect of their behaviour.
  • The decision maker must consider all the relevant circumstances relating to the decision in question.
  • The decision maker must consider whether the person is likely to regain capacity (for example after receiving medical treatment). If they are likely to, can the decision or act wait until then?
  • The decision maker must involve the person as fully as possible in the decision that is being made on their behalf.
  • If the decision concerns the provision or withdrawal of life sustaining treatment, the decision maker must not be motivated by a desire to bring about the person’s death.

The decision maker must in particular consider:

  • the person’s past and present wishes and feelings (in particular if these have been written down);
  • any beliefs and values of the person (for example religious, cultural or moral) that would be likely to influence the decision in question and any other relevant factors.

As far as possible, the decision maker must consult other people if it is appropriate to do so and take into account their views as to what would be in the best interests of the person wo lacks mental capacity, especially:

The decision maker must take the above steps, amongst others, and weigh up the above factors when deciding what decision or course of action is in the person’s best interests.

For decisions about serious medical treatment or certain changes of accommodation and where there is no one who fits into any of the above categories, the decision maker may need to instruct an IMCA.

3. Where there is a Dispute about Best Interests

Family and friends may not always agree about what is in the best interests of an individual. Case records should record any details of disputes, must clearly demonstrate that decisions have been based on all available evidence and have taken into account all the conflicting views. If there is a dispute, the following courses of action can help in determining what is in a person’s best interests:

  • involve an advocate who is independent of all the parties involved;
  • get a second opinion;
  • hold a formal or informal case conference;
  • go to mediation;
  • as a last resort, an application could be made to the Court of Protection for a ruling.

4. Recording

Comprehensive recording is key in all cases, but particularly in safeguarding adults cases which are likely to be the most complex and present the highest levels of risk. In such cases, full records of best interest decision making should be kept, including:

  • how the decision about the person’s best interests was reached;
  • the reasons for reaching the decision;
  • who was consulted to help decide the best interests;
  • what particular factors were taken into account;
  • if written requests from person concerned were not followed, why not;
  • the content and results of any disputes;
  • what has been decided in the person’s best interests and reasons for that decision.

People lacking mental capacity have the same rights as those with capacity to have their outcomes realised. Although it may be challenging, a good best interests decision reflects the wishes, feelings, values and needs of the person.

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This chapter outlines the importance of close working between children and adult practitioners. Practitioners working with adults who are concerned about a child have a duty to report their concerns.

SOUTH TYNESIDE SPECIFIC LINK

South Tyneside Safeguarding Children Procedures

1. Introduction

Although the South Tyneside Safeguarding Adults Board and Safeguarding Children Partnership have has statutory duties and responsibilities as a result of different legislation (Care Act 2014; Children Act 1989, Children Act 2004, Children and Social Work Act 2017), there are significant overlaps in the processes they use, and the organisations and professionals which support the adults and children’s safeguarding partnerships to deliver their objectives.

Such areas of common work include young people transitioning between children’s and adult services (see Transition to Adult Care and Support chapter), domestic abuse (see Domestic Abuse chapter), and working with complex families. These provide potential for joint working between children’s and adults practitioners and senior managers. It is important therefore that any joint working practices or opportunities for joint working and sharing of information are explored. This offers opportunities to develop direct formal links between members who sit on the Safeguarding Adults Board and Safeguarding Children Partnership.

2. Responsibilities to Safeguard Children

See Working Together to Safeguard Children (Department for Education)

If a professional working with an adult becomes aware a child is suffering or is likely to suffer significant harm, they have a duty to safeguard and promote the welfare of the child. All staff must be aware that where there is a concern that an adult experiencing or at risk of abuse or neglect and there are children in the same household, the children too could be at risk.

As well as safeguarding and child protection issues, agencies or professionals who work with adults can also have a key role in referring a child for early help which involves relevant services providing support as soon as a problem emerges at any point in a child’s life.

In such instances staff should make reference to the South Tyneside Safeguarding Children Procedures  and / or contact South Tyneside Children’s Social Care (see Local Contacts).

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This chapter outlines the circumstances in which a referral should be made to Adult Social Care in relation to concerns about a person / people in a position of trust. It contains advice for employers / volunteer organisations and student bodies on their responsibilities to assess potential risks posed by a person in a position of trust and if necessary, to take action to prevent abuse or neglect. It also provides guidance as to how and when concerns about a person in a position of trust can be appropriately shared with an employer / volunteer organisation or student body.

RELEVANT CHAPTERS

Safer Recruitment and Employment 

Disclosure and Barring

Whistleblowing

RELATED GUIDANCE

Managing Allegations Against Staff (North East NHS)

Amendment  – In January 2023, this guidance was reviewed throughout and extensively updated. The appendices which contain the PIPOT referral form, additional guidance and templates have also been updated.

1. Introduction

This guidance has been created to support implementation of the requirements in the Care and Support Statutory Guidance that deal with ‘allegations against people in a position of trust’ (paragraphs 14.120 to 14.132). This guidance is designed to be read in conjunction with the statutory guidance and relevant information sharing guidance/ legislation.

The Care Act 2014 recognises that safeguarding concerns are not always in relation to the safety and wellbeing of an individual, but rather they relate to the possible risk posed more widely by a person in a position of trust to people with care and support needs.

Where a person is experiencing or is at risk of abuse, the online multi-agency safeguarding adults policies and procedures should be followed (see How to Report a Concern). The purpose of the online multi-agency safeguarding adults policies and procedures is to provide guidance for organisations to work together, and with one or more specific people at risk of abuse, to support them to be safe.

In both cases, this guidance will be relevant in supporting the work of all agencies to prevent abuse and neglect. Its purpose is to:

  • Explain the circumstances in which a referral can and should be made to Adult Social Care at South Tyneside Council in relation to concerns about a person / people in a position of trust;
  • Advise employers / volunteer organisations and student bodies of their responsibilities (as set out in the Care Act 2014) to assess potential risks posed by a person in a position of trust to those who use their services, and if necessary, to take action to prevent abuse or neglect;
  • Provide guidance as to how concerns about a person in a position of trust can be appropriately shared with an employer / volunteer organisation or student body to prevent abuse or neglect.

This guidance is designed to inform and support the decision making of Partnership member organisations and wider partner agencies once they become aware of a concern within the scope of this guidance.

2. Scope of this Guidance

For the purposes of this guidance:

A person in a position of trust is an employee, volunteer or student who works with adults with care and support needs. This work may be paid or unpaid

The nature of the concerns about a person in a position of trust or the risk they may to post to adults with care and support needs may be varied and wide ranging.

Examples of such concerns could include allegations that the person in a position of trust has:

  • behaved in a way that has harmed, or may have harmed an adult or child
  • possibly committed a criminal offence against, or related to, an adult or child
  • behaved towards an adult or child in a way that indicates they may pose a risk of harm to adults with care and support needs.

(Care and Support Statutory Guidance, paragraph 14.123)

Such incidents may have occurred within the person’s home / personal life, as well as within their employment, volunteering role or studies. Wherever it has occurred however, there is now a potential risk to adults with care and support needs.

3. Referrals / Pathways: Person / People in Positions of Trust

3.1 Safeguarding Adults Concerns

Please note: if you have concerns that a specific person with care and support needs it as risk or is experiencing abuse or neglect, follow the South Tyneside Multi Agency Safeguarding Adults Policies and Procedures

Report your concerns by contacting:

0191 424 6000 (Monday to Thursday – 8.30am to 5pm, Friday 8.30am to 4.30pm)

0191 456 2093 (outside of the above office hours).

3.2  People in Position of Trust Concerns

A person in a position of trust is an employee, volunteer or student who works with adults with care and support needs. This work may be paid or unpaid.

Examples of such concerns could include allegations that they have:

  • behaved in a way that has harmed, or may have harmed an adult or child
  • possibly committed a criminal offence against, or related to an adult or child
  • behaved towards an adult or child in a way that indicates they may pose a risk of harm to adults with care and support needs.

3.2.1 What you should do

If you are an organisation i.e. employer, volunteer manager, student body, of the person in a position of trust; you must assess and manage risk as set out in this guidance. If the person also works with another organisation, you will need to consider the need to share information to also protect people within that service (See Section 6, Information Sharing).

If you are not the person’s employer, volunteer manager, student body, or the concerns are in relation to a personal assistant, employed by a person with care and support needs; or if you need additional advice and support in relation to people in positions of trust concerns contact the South Tyneside PIPOT Lead by emailing safeguardingadults@southtyneside.gov.uk  to request a referral form or for someone to call you back to discuss the case.

See Appendix E for the PIPOT Referral Form.

4. Responsibilities of Employers / Volunteer Organisations and Student Bodies

The Care and Support Statutory Guidance sets out the responsibilities of employers:

  • The local authority’s relevant partners[1], as set out in Section 6 (7) of the Care Act 2014, and those providing universal care and support services[2], should have clear policies in line with those from the safeguarding adults board for dealing with allegations against people who work, in either a paid or unpaid capacity, with adults with care and support needs (Section 14.120)
  • Where such concerns are raised about someone who works with adults with care and support needs, it will be necessary for the employer (or student body or voluntary organisation) to assess any potential risk to adults with care and support needs who use their services, and, if necessary, to take action to safeguard those adults (Section 14.122)
  • Employers, student bodies and voluntary organisations should have clear procedures in place setting out the process, including timescales, for investigation and what support and advice will be available to individuals against whom allegations have been made (Section 14.126)
  • Employers, student bodies and voluntary organisations should have their own sources of advice (including legal advice) in place for dealing with such concerns (Section 14.126)
  • …action necessary to address the welfare of adults with care and support needs should be taken without delay and in a coordinated manner, to prevent the need for further safeguarding in future (Section 14.128)
  • If an organisation [permanently] removes an individual (paid worker or unpaid volunteer) from work with an adult with care and support needs (or would have, had the person not left first) because the person poses a risk of harm to adults, the organisation must make a referral to the Disclosure and Barring Service. It is an offence to fail to make a referral without good reason (Section 14.127. Italics comment added)

Each organisation must therefore ensure they have policies and procedures in place that enable them to respond to concerns about people in positions of trust. This must include arrangements for raising concerns to the local authority in accordance with the multi-agency safeguarding adults policies and procedures where this is appropriate, as well as the management of concerns within their own organisation.

Employers and student bodies are responsible for working with the person in a position of trust to understand the issues, assess any risk in the context of their service; and take appropriate actions that safeguard people who use their services. This will include supporting the person in position of trust to understand the process being followed and decisions reached in accordance with the organisations policies.

Only an employer has the power to suspend an employee, redeploy them or make other changes to their working arrangements, and so must be responsible and accountable for the decisions reached.  Actions taken should take into account their own internal policies and procedures, their responsibilities to provide safe services, and employment law.  According to the nature of the concerns raised, and employer/volunteers organisation/student body may also have a responsibility to inform overseeing bodies according to their requirements, such as:

  • Care Quality Commission (CQC)
  • Charity Commission
  • Commissioning Bodies
  • Disclosure and Barring Service (DBS)
  • Professional Bodies

[1] Relevant partners include NHS bodies, chief officer of the police, relevant provider of probation services.

[2] Universal care and support services will include those services available to all, such as leisure and housing services, preventative services, as well as services provided in relation to the care and support needs of adults.

5. Guidance for the Local Authority

5.1 Concerns about a person in a position of trust

If the local authority is given information about concerns that do not relate to the safety of identified adults with care and support needs, but rather the potential risk posed by a person in a position of trust, use of multi-agency procedures will not usually be the way to respond to the concerns.

In these situations, this people in positions of trust guidance will need to be followed:

Where the concern is raised by an employer, volunteer manager or student body: 

  • The local authority may need to signpost agencies to this guidance for them to take precautionary actions as appropriate in relation to identified risks.
  • Employers, volunteer managers and student bodies would need to be responsible for taking actions within this guidance as set out in Section 4, Responsibilities of Employers / Volunteer Organisations and Student Bodies.
  • Employers, volunteer managers and student bodies that are raising concerns will often be best placed to share information with another employer, volunteer manager or student body, if it is so justified and necessary to do so as set out in Section 6, Information Sharing. There may, however, be circumstances where the local authority is best placed and so this decision will need to made on a case by case basis.
Where the concern is not raised by an employer, volunteer manager or student body:

  • The local authority will need to determine whether it is justified and necessary to share the concerns with an employer, volunteer manager or student body as set out in Section 6, Information Sharing.
  • The local authority may need to signpost agencies to this guidance, for them to take precautionary actions as appropriate in relation to identified risks.
  • Employers, volunteer managers and student bodies would need to be responsible for taking actions within this guidance as set out in Section 4, Responsibilities of Employers / Volunteer Organisations and Student Bodies.
Where the person in a position of trust is a personal assistant, employed by a person with care and support needs, the local authority may need to provide the employing individual with additional support to understand and manage the risks effectively and to access appropriate support.

5.2 Working within the multi-agency safeguarding adults procedures

Where the concern involving a person in a position of trust relates to an identified person or people with care and support needs, use of the multi-agency safeguarding adults policies and procedures will usually be appropriate.

In such a situation:

  • The people in positions of trust practice guidance should be followed alongside the multi-agency safeguarding adults policies and procedures.
  • Employers, volunteer organisations and student bodies retain responsibility for actions as set out in Section 4, Responsibilities of Employers / Volunteer Organisations and Student Bodies.
  • to prevent abuse or neglect in their setting.
  • If, during the course of working within the multi-agency safeguarding adults policies and procedures, it is identified that the person in a position of trust may pose a risk in another setting, there will need to be a consideration as to which agency is best placed to share information as may be required with other employers, volunteer managers or student bodies to prevent abuse or neglect (see Section 6, Information Sharing). This will need to be on a case-by-case basis, taking into account the need to assess the risk and engage with the person in a position of trust as set out in this guidance.

6. Information Sharing

Where an organisation has information relating to the risk posed by a person in a position of trust, they have a responsibility to consider whether this information needs to be passed on to ensure risks are appropriately considered and managed.

Each organisation is individually responsible for ensuring that concerns relating to a person in a position of trust are shared, where necessary and appropriate, with other organisations to prevent abuse and neglect.

The potential need to share information with an employer / volunteer organisation or student body will be indicated when there is a reasonable cause to suspect that a person in a position of trust may pose a risk to adults with care and support needs within another service. This may include situations such as where:

  • a member of staff has been suspended pending a disciplinary or safeguarding enquiry, and who is known to be carrying out a similar role working within another organisation where they are assessed as potentially posing an immediate risk to others.
  • a member of staff has been dismissed due to their behaviour towards adults with care and support needs, and is also known to be undertaking professional training, for example, as a social worker or as a health professional.
  • an employee’s role and responsibilities have been changed in response to dangerous practice, but they continue to have a similar role within another organisation, where they may pose a risk to people who use that service.

Public bodies or organisations commissioned by them should be considered to be undertaking a public task as a lawful basis for sharing information. Other agencies not fulfilling public tasks should consider relying on legitimate interests as a lawful basis for sharing information.

Even where you do not have consent to share confidential information, you may lawfully share it in the public interest. Seeking consent should be the first option. However, where consent cannot be obtained or is refused, or where seeking it is inappropriate or unsafe, the question of whether there is enough public interest must be judged by the practitioner on the facts of each case. Therefore, where you have a concern about a person, you should not regard refusal of consent as necessarily precluding the sharing of confidential information.

A public interest can arise in a wide range of circumstances, for example, to protect children from significant harm, protect adults from serious harm, promote the welfare of children or prevent crime and disorder. There are also public interests which may, in some circumstances, weigh against sharing, including the public interest in maintaining public confidence in the confidentiality of certain services.

In both cases however, the judgement to be made is the same. In deciding whether sharing the information is justified and necessary, a professional judgement will be required based upon balancing the safety and needs of those potentially at risk, and the rights of the employee / volunteer or student as described below:

  • A fair balance must be struck between the rights of the person in a position of trust to privacy and the interests of those at risk of abuse and neglect. This requires a careful assessment of the severity and consequences of the interference in the life of the person in a position of trust and the risk posed to others.
  • The risks to adults with care and support needs must be sufficient to justify interfering with the person in a position of trusts’ right to privacy. The consideration is therefore one of proportionality – there should be a need for the disclosure in order to protect adults with care and support needs.

Ask yourself: is this sharing of information fair? I.e. is sharing this information something people would reasonably expect you to do in these circumstances?

  • If it is reasonably believed that the sharing of information will achieve the aim of preventing abuse or neglect, there should be no more interference in the person’s right to privacy than is necessary to achieve this aim.

Ask yourself: Am I only sharing information that it is necessary to share? You should always ensure you share no more information than is necessary to achieve your purpose.

It will be important to record your judgement, your reasons for sharing or not sharing the information, the factors you have considered and why you have give weight to some factors more than others. The recording templates (Appendix H – Template Minutes for Planning Meeting and Appendix I – Template Minutes for Case Closure Meeting can be used where it is helpful, to support decision making and the recording of decisions).

6.1 Consent and involvement of the person in a position of trust

Unless wholly impractical, before disclosing information to another employer, volunteer manager or student body, there is a need to consult with the person whose information is to be shared. This will give them the opportunity to respond to the concerns and make representation on the need to share the information.

If it is assessed as justified and necessary for the employer to be informed of the concerns / allegations, the person in a position of trust may wish to inform the employer / volunteer organisation / student body themselves.

If this is the case, their wish should be respected, but it will still be necessary to contact the employer / volunteer organisation / student body to subsequently check that relevant information has actually been passed on. It should be made clear to the person in a position of trust that this is required.

Whilst it is important to work with the person in a position of trust and seek their agreement to share information wherever possible, consent will not always be considered a lawful basis to share information in such situations. Consent must be freely given, specific and informed and the imbalance of power in such situations may mean that it cannot always be relied upon. In such cases, decisions need to be proportional to the concern as set out above.

However, this does not preclude in any way the responsibility to consult with the person in the position of trust unless it is wholly impractical to do or may place someone at risk.

7. Working with the Local Authority Designated Officer (LADO)

If there is concern that a person in a position of trust may, in the course of their work, pose a risk to child or young person under the age of 18 years, then the local authority designated officer should be notified and actions taken within the LADO process.

Sometimes, however, the risk may relate to both children / young people and adults. In such cases, there will be a need for organisations and safeguarding leads to consider their responsibilities under both this guidance and the LADO process.

For more information about the LADO and referral information:

Email: LADO@Southtyneside.gov.uk

Tel: 0191 424 6293

8. Record Keeping

Recording of discussions, decisions and disclosures are essential, and each organisation must ensure that it has process for recording this information in accordance with their own policies and any legal requirements.

Templates are available in the appendices:

Appendix H – Template Minutes for Planning Meeting

Appendix I – Template Minutes for Case Closure Meeting

9. Illustrative Examples

The examples below show how to apply this the guidance as part of an organisation’s management process:

Example 1 – John and Mary

Example 2 – Tina

Example 3 – Emma

Appendix A – Flowchart: Managing Concerns and Allegations Against People who Work with Adults with Care and Support Needs

Appendix A – PIPOT Flowchart

Appendix B – Best Practice Guidance when Deciding to Disclose Information.

Appendix B – Best Practice when Deciding to Disclose Information

Appendix C – Position of Trust Risk Balance Sheet

Appendix C- Position of Trust Risk Balance Sheet

Appendix D – Factors to Consider Regarding PIPOT Notifications

Appendix D – Factors to Consider Regarding PIPOT Notifications

Appendix E – PIPOT Referral Form

Appendix E – Allegations Against People who Work in Positions of Trust with Adults Referral / Reporting Form

Appendix F – Template Agenda for Planning Meeting

Appendix F – Template Agenda for Planning Meeting or Planning Discussion

Appendix G – Template Agenda for Case Closure Meeting

Appendix G – Template Agenda for Case Closure Meeting

Appendix H – Template Minutes for Planning Meeting

Appendix H – Template Minutes for Planning Meeting or Planning Discussion

Appendix I – Template Minutes for Case Closure Meeting

Appendix I – Template Minutes for Case Closure Meeting

 

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This chapter provides information for practitioners in relation to local multi-agency training in relation to safeguarding adults from abuse or neglect.

RELEVANT CHAPTERS

Supervision

Safer Recruitment and Employment

SOUTH TYNESIDE SPECIFIC INFORMATION

Safeguarding Training Programme Calendar

The South Tyneside Safeguarding Adults Board should ensure that relevant partners provide training for staff and volunteers on the policy, procedures and professional practices that are in place locally, which reflects their roles and responsibilities in safeguarding adult arrangements. Employers, student bodies and voluntary organisations should also undertake this, recognising their critical role in preventing and detecting abuse. This should include:

  • basic mandatory induction training with respect to awareness that abuse and neglect can take place and duty to report;
  • more detailed awareness training, including training on recognition of abuse and neglect and responsibilities with respect to the procedures in their particular agency;
  • specialist training for those who will be undertaking enquiries, and managers; and
  • training for elected members and others for example Healthwatch members; and
  • post qualifying or advanced training for those who work with more complex enquiries and responses or who act as their organisation’s expert in a particular field, for example in relation to legal or social work, those who provide medical or nursing advice to the organisation or the Safeguarding Adults Board.

Training should take place at all levels in an organisation and be updated regularly to reflect best practice. To ensure that practice is consistent – no staff group should be excluded.

Training should include issues relating to staff safety within a health and safety framework and also include volunteers. In a context of personalisation, the Safeguarding Adults Board should seek assurances that directly employed staff (for example personal assistants) have access to training and advice on safeguarding.

Training is a continuing responsibility and should be provided as a rolling programme. Whilst training may be undertaken on a joint basis and the Safeguarding Adults Board has an overview of standards and content, it is the responsibility of each organisation to train its own staff.

Regular face to face supervision from skilled managers and reflective practice is essential to enable staff to work confidently and competently with difficult and sensitive situations.

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Each partner agency should have its own supervision policy and procedure, which is tailored to meet the needs of its staff, service and the adults and carers with whom it works.

Supervision is an accountable process which supports, assures and develops the knowledge, skills and values of an individual, group or team. The purpose of supervision is to improve the quality of work to achieve agreed objectives and outcomes. Effective supervision is an integral part of adult safeguarding practice; it is also an essential element of the performance management framework. It should support staff in developing and maintaining effective working relationships with adults and their carers and with other professionals, whilst simultaneously exercising professional judgement, effective decision making and carrying out other duties associated with their individual role. It should also tie the overarching strategic objectives of the service with the individual personalised objectives of each member of staff.

It must be educative, supportive, empowering and a benefit to supervisor, supervisee and the organisation. Supervision must be sensitive to the individuals ethnic and cultural background, disability, gender and sexual orientation.

In the reflective environment of supervision, and in conjunction with their manager, staff should be able to consider their developmental and learning needs, review identified actions necessary to address such needs and subsequently evidence practice improvement.

Good quality supervision can help to:

  • avoid drift;
  • keep focus on the adult with care and support needs;
  • maintain a degree of objectivity and challenge fixed views;
  • test and assess the evidence base for assessment and decisions;
  • address the emotional impact of work.

The supervision process should incorporate four main functions:

  • management, including performance management;
  • professional development;
  • support;
  • practice reflection.

At the outset of the supervisory relationship expectations of the supervisor and the supervisee should be established and recorded. This includes frequency of meetings, content of supervision sessions, recording of meetings and sign off, and action to be taken if either party becomes dissatisfied with the relationship, or outcomes of the sessions.

Supervision usually takes place on a one to one basis, although can also be part of a group session as well. It is a process rather than a series of single events or sessions and should complement and support the appraisal process by evidencing the continuous improvement and performance of the supervisee.

Issues discussed at each supervision session should be recorded and signed by the manager and counter signed by the staff member, who should also be provided with a copy. This may be done via email as an electronic documentation of the agreement.

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1. Introduction

The role of social worker brings with it a variety of challenges and complex situations: practical, social, emotional. Social workers work closely with individuals and families who are in need of support, usually at a time of stress or crisis. All social work interventions should begin with a conversation with the person and an appraisal of the person’s outcomes strengths, and needs.

In order to understand the particular situation of the person and their family / carers fully, and to appreciate the challenges that they are facing and the outcomes that they would like to achieve, social workers need to be able to engage with people, build relationships with them and their  families. This includes being able to form a professional judgement of how all elements of the person’s life impact upon them and to keep this under regular review so that risks can be identified and addressed in a positive way.

When social workers start working with an adult, it is often a difficult time for the people involved. The offer of support from the local authority may be rejected, people may be angry, suspicious, depressed, upset, defensive and anxious. Even when people are welcoming of intervention there remains the need to maintain the appropriate professional boundary.

In this complex and demanding role supervision is the main mechanism to ensure that the appropriate support is offered to enable people to keep safe and well by supporting, managing and developing professionals who deliver a social work service.

Supervision has two main functions, learning and support and management, as outlined below.

2. Learning and Support

Social workers are enabled to:

  •  reflect and share their actions, feelings and concerns about their work in a safe environment with an experienced practitioner who can challenge, guide and encourage;
  • actively engage with supervision that aims to help them uncover assumptions and analyse judgements, clarify the focus of their work and identify changes that they need to make to their approach;
  • recognise when there are multiple and conflicting ideas, interpretations and perspectives to reach a professional judgement taking account of the complexity of people’s lives;
  • develop skills and identify strengths and areas for further learning so that social workers are aware of their own practice skills and needs for training and development;
  • feel supported so that they are able to continue to work well in a stressful and demanding environment with people who are often at risk;
  • adopt a strengths based and human rights approach to intervention, assessment and support planning which is informed by the principles of the Care Act 2014, the Mental Capacity Act 2005 and the Mental Health Act 2007;
  • review decisions to ensure that they are based on observation, evidence and analysis, exploring differences between opinion and fact, addressing any bias in situations of uncertainty in order to ensure that clear conclusions are reached and defensible judgements made.

3. Management: Quality and Accountability

The organisation is enabled to ensure that:

  • a culture of focused and critical thinking which is informed by the views of the individual, carers and professionals and a chronology of critical events, social, economic, emotional / mental health issues;
  • social work interventions are planned and monitored, risks are identified and escalated as needed;
  • workloads are monitored to ensure safe practice;
  • the quality of work is reviewed and records kept to ensure clarity of purpose is clear and that decisions made are defensible and evidence based and underpinned by relevant legislation;
  • a person centred, holistic approach is taken to practice ensuring that actions are proportionate to risks and the procedures of their organisations.

4. Strengths Based Approach

This ensures that:

  • practice reflects the requirements of the Care Act to ‘consider the person’s own strengths and capabilities, and what support might be available from their wider support network or within the community to help’ in considering ‘what else other than the provision of care and support might assist the person in meeting the outcomes they want to achieve’;
  • an approach that looks at a person’s life holistically, considering their needs in the context of their skills, ambitions, and priorities;
  • individuals’ strengths are identified, including– personal, community and social networks – and these strengths are maximised to help people achieve the outcomes they want;
  • support available from family and friends is considered in the light of their appropriateness, willingness and ability to provide this support, taking into account the impact on them;
  • the implementation of a strengths-based approach includes cultural and organisational commitment as well as frontline practice implementation;
  • practitioners have time to research and become familiar with community resources and that time is allowed for assessments to be undertaken appropriately and proportionately”.

See also Strength-Based Approaches (SCIE)

5. Supervision in Multi-Disciplinary Teams

Models for multi-disciplinary working vary from co-located, fully integrated teams to virtual teams working in an integrated manner.

Whatever the model, arrangements for line management and supervision will be in place. In multi-disciplinary teams, workers may not be managed by someone of their own profession. The manager will be responsible for the day to day running of the service, allocation and review of workloads, risk management and the performance of the service.

In these circumstances it is crucial to the safe running of the service that staff have supervision from someone from their own discipline to support and develop their clinical practice, professional development and service offered to clients.

6. Standards for Employers of Social Workers

The Local Government Association has produced standards for employers of social workers in England. This section outlines those standards.

6.1 Purpose

The purpose of the Standards is to sustain high quality outcomes for people who have care and support needs and their families / carers / communities in three focal areas:

  • enabling employers to provide a well led professional environment;
  • enabling social work professionals to maintain their professionalism;
  • enabling them to practice more effectively.

6.2 Standards

  • Standard 1 – Clear Social Work Accountability Framework: Employers should have in place a clear social work accountability framework informed by knowledge of good social work practice and the experience and expertise of service users, carers and practitioners.
  • Standard 2 – Effective Workforce Planning: Employers should use effective workforce planning systems to make sure that the right number of social workers, with the right level of skills and experience, are available to meet current and future service demands.
  • Standard 3 – Safe Workloads and Case Allocation: Employers should ensure social workers have safe and manageable workloads.
  • Standard 4 – Managing Risks and Resources: Employers should ensure that social workers can do their jobs safely and have the practical tools and resources they need to practice effectively. Assess risks and take action to minimise and prevent them.
  • Standard 5 – Effective and Appropriate Supervision: Employers should ensure that social workers have regular and appropriate social work supervision.
  • Standard 6 – Continuing Professional Development: Employers should provide opportunities for effective continuing professional development, as well as access to research and-relevant knowledge.
  • Standard 7 – Professional Registration: Employers should ensure social workers can maintain their professional registration.
  • Standard 8 – Effective Partnerships: Employers should establish effective partnerships with higher education institutions and other organisations to support the delivery of social work education and continuing professional development.

Some of the standards relate to the wider organisation.

6.3 Frontline Practice Supervision

The following standards relate specifically to frontline practice supervision.

6.3.1 Standard 3 – Safe workloads and case allocation

Ensure social workers have safe and manageable workloads.

This Standard is about protecting employees and service users from the harm caused by excessive workloads, long waiting lists and unallocated cases.

All employers should:

  • use a workload management system which sets transparent benchmarks for safe workload levels in each service area;
  • ensure each social worker’s workload is regularly assessed to take account of work complexity, individual worker capacity and time needed for supervision (Standard 5) and CPD (Standard 6);
  • ensure that cases are allocated transparently and by prior discussion with the individual social worker, with due consideration of newly qualified social workers on ASYE;
  • ensure that a social worker’s professional judgment about workload capacity issues is respected in line with the requirements of their professional registration (Standard 7);
  • take contingency action when workload demand exceeds staffing capacity report regularly to strategic leaders about workload and capacity issues within services;
  • publish information about average caseloads for social workers within the organisation (Standard 1).

6.4 Standard 5 – Effective and appropriate supervision

Ensure that social workers have regular and appropriate social work supervision.

This Standard is about making high quality, regular supervision an integral part of social work practice. This should start with students on placement, and continue through ASYE and throughout the individual’s social work career. Supervision should be based on a rigorous understanding of the Professional Capabilities Framework (PCF) and the Knowledge and Skills Statement for Social Workers in Adult Services. Supervision should challenge students and qualified practitioners to reflect critically on their practice and should foster an inquisitive approach to social work.

6.4.1 Frequency of supervision

All employers should make sure that supervision takes place:

  • regularly and consistently and last at least an hour and a half of uninterrupted time;
  • for students on placement – as agreed with student and their higher education institution;
  • for newly qualified social workers – at least weekly for the first six weeks of employment as a newly qualified social worker, at least fortnightly for the duration of the first six months, and a minimum of monthly supervision thereafter;
  • for social workers who have demonstrated capability at ASYE level and above – in line with identified needs, and at least monthly;
  • monitor actual frequency and quality of supervision against clear statements about what is expected.

6.4.2 Quality of supervision

All employers should:

  • ensure that social work supervision is not treated as an isolated activity by incorporating it into the organisation’s social work accountability framework (Standard 1);
  • promote continuous learning and knowledge sharing through which social workers are encouraged to draw out learning points by reflecting on their own practice in the light of experiences of peers;
  • ensure that the Professional Capabilities Framework and the Knowledge and Skills Statement, at an appropriate level, are used as the basis for evaluating capability and identifying development needs;
  • ensure that supervision supports students and qualified social workers to meet the Social Work England Standards;
  • encourage social workers to plan, reflect on and record Continuing Professional Development (CPD) activity, including logging it online with Social Work England;
  • provide regular supervision training for social work supervisors;
  • assign explicit responsibility for the oversight of appropriate supervision and for issues that arise through supervision;
  • provide additional professional supervision by a registered social worker for practitioners whose line manager is not a social worker.

6.4.3 Useful information

6.5 Standard 6 – Continuing Professional Development (CPD)

Provide opportunities for effective continuing professional development, as well as access to research and relevant knowledge.

This Standard is about social workers being able to build a robust and up to date knowledge and skill base through effective continuing professional development (CPD) and access to research, evidence and best practice guidance. Employers should facilitate career-long learning and empower social workers to work confidently and effectively with the children, adults and families they have been trained to support. Employers should also understand the statutory requirement for social workers in England to undertake CPD, as outlined in Social Work England Guidance.

6.5.1 Supporting staff development

All employers should:

  • have effective induction systems and put in place tailored support programmes for Assessed and Supported Year in Employment (ASYE)s, including protected development time, a managed workload, tailored supervision and personal development plans;
  • have an appraisal or performance review system which assesses how well professional practice is delivered and identifies a learning and development plan to support the achievement of objectives;
  • provide time, resources and support for CPD;
  • have fair and transparent systems to enable social workers to develop their professional skills and knowledge throughout their careers through an entitlement to formal and informal CPD, including Practice educator and/or specialist training as appropriate;
  • encourage social workers to plan, reflect on and record CPD activity, including logging it online with Social Work England.

6.5.2 Promoting research based practice

All employers should:

  • support their social workers to make decisions and pursue actions that are informed by robust and rigorous evidence so that adults can have confidence in the service they receive;
  • enable social workers to work with others engaged in research and practice development activities in universities, professional bodies and trade unions to develop the evidence base for good practice;
  • ensure that practice educators are able to contribute to the learning, support, supervision and assessment of students on qualifying and CPD programmes.

6.5.3 Useful information

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This chapter provides information about the recruitment and employment processes which organisations should use to safeguard adults from abuse and neglect.

RELEVANT CHAPTER

Disclosure and Barring

Person / People in Positions of Trust (PIPOT) – Multi-Agency Practice Guidance

Whistleblowing

1. Introduction

Safer recruitment, induction and supervision of staff are essential to the safeguarding of adults with care and support needs. All organisations should have generic recruitment policies and procedures in place. This chapter provides additional, specific guidance in relation to safer recruitment practices at each step of the generic recruitment process, which aims to prevent unsuitable persons from working with adults, either as a paid member of staff or volunteer whether they are permanent, temporary or agency staff or recruited from abroad. In addition, it applies to staff / volunteers who are seen by adults with care and support needs as trustworthy and / or have access to confidential information. This may include administrative staff, caretakers, and maintenance workers for example.

Commissioners should ensure the principles of safer recruitment and employment are included in service level agreements or contracts drawn up between them and service providers. A service level agreement or contract should also contain the service’s safeguarding statement (see Section 2.1 Commitment to safeguarding).

2. Safer Recruitment Practices

2.1 Commitment to safeguarding

All organisations should have a statement about their commitment to the prevention of abuse and neglect and promoting the wellbeing of adults with care and support needs, to which it is expected all staff and volunteers will abide and embed in their daily practice. This should include that robust recruitment and selection procedures are in place to identify and deter people who might abuse or neglect adults with care and support needs or who are otherwise unsuitable for employment / volunteering. The statement should be included in recruitment material such as job adverts, candidate information packs and person specifications.

2.2 Safeguarding policies

Organisations should publish a safeguarding policy for staff which clearly relates to these Safeguarding Adults Procedures, and sets out the responsibilities of all staff. It should include information on:

  • identifying adults who are particularly at risk;
  • recognising risk from different sources and in different situations and recognising abusive or neglectful behaviour from other service users, colleagues, and family members;
  • routes for making a referral and channels of communication within and beyond the agency;
  • organisational and individual responsibilities for whistleblowing (see Whistleblowing chapter);
  • assurances of protection for whistleblowers;
  • working within best practice as specified in contracts;
  • working within and co-operating with regulatory mechanisms;
  • working within agreed operational guidelines to maintain best practice in relation to:
    • challenging or distressing behaviour;
    • personal and intimate care;
    • control and restraint;
    • gender identity and sexual orientation;
    • medication;
    • handling of people’s money;
    • risk assessment and management (read risk guidance for people living with dementia).

Organisations should also produce guidance outlining the rights of staff and how employers will respond where abuse is alleged against them within either a criminal or disciplinary context (see Person / People in Positions of Trust (PIPOT) – Multi-Agency Practice Guidance)

2.3 Job adverts

The advertisement should include the organisation’s policy statement (see Section 2.1, Commitment to safeguarding). It should also include reference to the requirement for the successful applicant to undertake a Disclosure and Barring Service check, as appropriate.

2.4 Job description

The job description (JD) should be specific about extent of contact and levels of responsibility the post holder will have for adults with care and support needs, including prevention of abuse or neglect at operational and / or strategic levels.

2.5 Person specification

The person specification (PS) should include any other requirements the post holder will need in order to perform the role in relation to working with adults with care and support needs, including experience specific to the post, for example working with adults with learning disabilities or dementia. The successful candidate should be able to demonstrate such required competencies and qualities.

2.6 Candidate information pack

The information pack should also highlight that a robust selection process is in place, and include reference to the organisation’s safeguarding adults’ policy. It should state proof of identity will be required, as well as a Disclosure and Barring Service check, as appropriate.

2.7 Application form

Employers should only use their own application forms for applicants. It is not good practice to accept curriculum vitae (CVs) instead of an application form as this may only contain information the person wants to present rather than all the information the organisation requires to enable shortlisting. The applicant form should again include reference to the organisation’s commitment to safeguarding adults with care and support needs.

2.8 Shortlisting

Application forms should be scrutinised for any unexplained gaps in employment history, or other potential concerns in relation to safeguarding adults. References should be sought on all candidates who are shortlisted for interview.

2.8.1 Requesting references

Where an applicant is not currently working with adults with care and support needs, but has done so previously, a reference should also be obtained from the last such employer, in addition to the current / most recent employer. This should include confirmation of the reason why the applicant left the post.

The referee should state:

  • whether they are satisfied the applicant has the ability and is suitable to undertake the job, and if not why;
  • whether they were the subject of any disciplinary sanctions or any allegations made against them, which relate to adults (including outcomes).

2.9 Interviews

The interview should assess the merits of the candidate against the JD and PS, and explore their suitability to work with adults with care and support needs.

The panel should state to each candidate there will be a requirement to complete an application for a Disclosure and Barring Service check, confirm their identity and receive satisfactory references.

One member of the panel should be trained in safer recruitment practice.

The panel should explore with the candidate:

  • their attitude towards adults with care and support needs, including any specific needs of adults of the service, including reasons why they want to work with such adults;
  • their ability and commitment to the organisation’s agenda for safeguarding and promoting wellbeing;
  • any gaps in their employment history;
  • discrepancies / concerns in relation to any information provided by either them or a referee;
  • if they wish to declare anything in relation to applying for a Disclosure and Barring Service check;
  • their understanding of appropriate relationships and personal boundaries;
  • emotional resilience in working with in challenging situations.

2.9.1 Participation of adults with care and support needs

Adults who use the service can make very valuable contributions as part of recruitment of new staff positions. Their participation should be built into the process at all levels, from administration posts to senior positions. Their roles should be clarified with the adults who participate, so they understand how their views will be considered and what weighting they will be given.

2.10 Conditional offer of appointment

Offers of appointment will be conditional on receipt of satisfactory checks and references.

In the following circumstances the applicant should be reported to the police:

  • they are found to be on a list concerning their suitability to work with adults / have been disqualified from working with adults by a Court;
  • they provided false information in relation to their application;
  • there are serious concerns about their suitability to work with adults.

2.10.1 Disclosure and Barring Service checks

See also Disclosure and Barring Service chapter.

The level of Disclosure and Barring Service (DBS) check requested – either Standard or Enhanced – should reflect the nature of the post and degree of contact with adults or with confidential information.

Types of DBS check are as follows:

  • Basic check: The basic check can be used for any position or purpose. A basic certificate will contain details of convictions and cautions from the Police National Computer (PNC) that are considered to be unspent under the terms of the Rehabilitation of Offenders Act (ROA) 1974.
  • Standard check: This allows employers to access the criminal record history of people working, or seeking to work, in certain positions, especially those that involve working with children or adults in specific situations. A standard check discloses details of an individual’s convictions, cautions, reprimands and warnings recorded on police systems and includes both ‘spent’ and ‘unspent’ convictions;
  • Enhanced check: This discloses the same information provided on a Standard certificate, together with any local police information that the police believe is relevant and ought to be disclosed;
  • Enhanced with barred list check: This check includes the same level of disclosure as the enhanced check, plus a check of the appropriate barred lists. An individual may only be checked against the children’s and adults’ barred lists if their job falls within the definition of ‘regulated activity’ with children and/or adults;
  • • Adult First check: adult first is a service available to organisations who can request a check of the DBS adults’ barred list. Depending on the result, a person can be permitted to start work, under supervision, with vulnerable adults before a DBS certificate has been obtained.

For guidance on which type of DBS check is appropriate for the role being advertised, please see the DBS website. 

A record of the following should be kept; date the disclosure was obtained, by whom, level of disclosure and unique reference number.

In relation to adults with care and support needs, it should be noted that in ‘signing off’ or agreeing a personal budget or personal health budget a local authority may add conditions such as a DBS check as part of its risk assessment of safeguarding in specific cases. The local authority may also require personal budget holders using direct payments to tell them who they employ.

2.10.2 Checks on overseas staff

The same checks should be made on overseas staff as for all other staff, however the Disclosure and Barring Service. cannot access criminal records held overseas, so a DBS check may not provide a complete view of an applicant’s criminal record if they have lived outside the UK.

Where an applicant has worked or been resident overseas in the previous five years, the employer should obtain a check of the applicant’s criminal record from the relevant authority in that country as well as information about their conduct. It should be noted that not all overseas organisations / countries are able to provide such information. The application process for criminal records checks or ‘Certificates of Good Character’ for someone from overseas varies between different countries. For further information, see GOV.UK – Criminal records checks for overseas applicants.

2.10.3 Agency staff

Written confirmation should be provided by the agency that the necessary checks have been undertaken and are satisfactory.

2.11 Record Keeping

In relation to each candidate who is appointed, records should be made of:

  • any specific information raised with them (for example gaps in employment history) and their explanation and any corroborating information;
  • the outcome of their Disclosure and Barring Service check including unique reference number and date (please note – DBS information should, in general, only be retained for six months after the recruitment decision, then destroyed);
  • reasons for decision to appoint despite criminal convictions, including risk assessment undertaken.

3. Induction

On starting in a new post, the member of staff should be given written information in relation to:

4. Supervision and Staff Review and Development

Regular supervision sessions should take place as per the organisation’s policies and procedures, as should annual staff reviews. Both processes aide both the organisation and member of staff by ensuring:

  • staff are up to date with current practices in relation to their specific area of work and safeguarding adults in general (both local and national issues);
  • identify areas for development;
  • provide opportunities to identify and address any concerns about behaviour and / or attitudes;
  • develop any required action plans and review arrangements.

5. Disclosure and Barring Service Rechecking

The DBS also provides an online Update Service, to which staff or volunteers can subscribe and renew annually for a small fee (free for volunteers). This helps them keep their DBS certificate up to date, so it can be taken with them from one job to another, as long as they remain within the same workforce (adults, for example). See Disclosure and Barring Service chapter, Update Service.

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This chapter provides information for practitioners about the process for adults or carers who wish to make a complaint about their experience of the safeguarding adults process, or appeal a decision that was made during the process.

Please note, the Safeguarding Partnership is not responsible for the delivery of services in partner agencies; therefore complaints and concerns in relation to individual services/agencies do not fall within the scope of this procedure and should be dealt with directly by the responsible agency according to their own complaints process.

RELEVANT CHAPTER

Escalation Protocol: Resolution of Professional Disagreements between Workers Relating to the Safety of Adults

1. Introduction

Being involved in a safeguarding process is a difficult experience for any adult who has experienced neglect or abuse, and the people who care for them.

Practitioners should make every effort to ensure that adults and their carers are fully consulted and involved in the safeguarding process, kept informed of the progress of any investigation and are at the centre of work to ensure their safety and wellbeing (see Making Safeguarding Personal chapter).

However, there will be occasions when an adult or their carer wish to make a complaint about their experience or the outcome of the safeguarding process.

Where the adult or carer wishes to make a complaint about an individual organisation, they should be directed to the organisation’s complaints procedure.

For professionals who wish to complain about an aspect of the process, please see Escalation Protocol: Resolution of Professional Disagreements between Workers Relating to the Safety of Adults.

At any stage of the complaints process, the adult or carer may bring an advocate or friend to support them. An independent advocate can make a complaint on behalf of an adult (see Independent Advocacy chapter). Some adults or carers may require interpreting or communication services (see the chapter on Interpreting, Signing and Communication Needs).

When a representative makes a complaint on behalf of the adult, written confirmation will normally be required – as far as this is possible to give – that the person is happy for this representation to take place and if appropriate for relevant information to be shared directly with the representative.

The representative in a complaint covered by this procedure will be expected to discuss  and disclose relevant details of the complaints and its progress with the adult as far as possible, and ensure that any decisions made about the complaint has their full agreement.

South Tyneside Council has the discretion to decide whether or not the person is suitable to act as a representative.  If the representation is considered to be unsuitable, or not in the adult’s best interests, the person acting as a representative will be informed in writing of the reasons why their representation has been refused.  This test of suitability will be applied when the complaint is first made, and also at relevant stages of the complaint, as appropriate.

The local authority should ensure people are given information and advice about the complaints process, that they are supported throughout and kept fully informed in writing of progress and the outcome.

2. Grounds for Complaint or Appeal

The adult who is experiencing or at risk of abuse or neglect (or advocate on their behalf) or their carer has grounds for making a complaint if they are unhappy with the manner in which they feel they have been treated during the safeguarding process.

3. Complaints Procedure

The complaints procedure has three stages.

3.1 Stage 1

The focus on Stage 1 is on putting things right.

The adult or their carer who wishes to make a complaint should first speak to a practitioner involved in the safeguarding process. This may be a social worker or health professional.

If they are not satisfied with the discussion at this level, the practitioner should ask them if they would like to speak to their line manager or the organisation’s safeguarding adult lead. The manager should discuss the situation with the adult / carer, and try to resolve the situation informally. This may be by explaining processes to them and the rationale for the decisions made or actions taken or taking action to remedy an aspect of the process. The adult / carer should be reassured that their concerns are taken seriously.

If the complaint is straightforward, it may be resolved at this stage.

The practitioner / manager should record a summary of all discussion/s which take place and the outcome (see Case Recording).

If the adult / carer remains dissatisfied ,they can ask for a formal investigation of their complaint under Stage 2 of the complaints procedure.

3.2 Stage 2

Where it has not been possible to resolve the complaint via discussion, the Customer Services Department will be informed.  The complaint will be  passed to a senior manager to carry out an investigation. That person will not have had any prior involvement in investigating the complaint.

The complainant will be sent a letter from the Customer Services Department to acknowledge that their complaint has been moved to Stage 2. The target response time is 15 working days.  If more time is needed to complete the investigation, the complainant will be contacted within the 15 working days and informed of what is happening by the Investigating Officer.

The Customer Services department and South Tyneside Safeguarding Children and Adults Partnership Manager should be informed of the outcome of Stage 2.

Should the complainant remain dissatisfied with the outcome of the investigation they can write to the Chief Executive within 28 days, requesting that their complaint is investigated under Stage 3 of the Complaints procedure

3.3 Stage 3

The Chief Executive will appoint a colleague to investigate the complaint on their behalf.  The Investigating Officer will not have had any prior involvement in dealing with the complaint and will not be employed in the service area that is being complained about.  The Customer Services Department will write to the complainant to advise them that their complaint will be investigated at Stage 3 and inform them of the name of the person dealing with it.  The Investigating officer will respond to the complainant directly with their findings. A full response will then be sent to them within 20 working days.  If more time is needed to complete the investigation the complainant will be informed  by the Investigating Officer within the 20 working days.

Should the complainant remain unhappy with the response they can ask the Local Government and Social Care Ombudsman to take up their complaint.

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This chapter provides information for multi-agency practitioners about the roles and responsibilities of partner agencies of the South Tyneside Safeguarding Adults Board.

RELEVANT CHAPTER

South Tyneside Safeguarding Adults Structures and Organisations

1. Introduction

Roles and responsibilities should be clear and collaboration should take place at all the following levels:

  • operational;
  • supervisory line management;
  • practice leadership;
  • strategic leadership within the senior management team;
  • corporate / cross authority;
  • chief officers / chief executives;
  • local authority members and local police and crime commissioners;
  • commissioners;
  • providers of services;
  • voluntary organisations;
  • regulated professionals.

2. Operational Frontline Staff

See also Safeguarding Enquiries Process, Making Safeguarding Personal, Supervision, Safeguarding Training for Staff and Volunteers.

Operational frontline staff are responsible for identifying and responding to allegations of abuse and substandard practice. Staff at operational level need to share a common view of what types of behaviour may be abuse or neglect and what to do as an initial response to a suspicion or allegation that it is or has occurred. This includes GPs. It is the employers and commissioners duty to set these out clearly and reinforce regularly.

It is not for frontline staff to second guess the outcome of an enquiry in deciding whether or not to share their concerns. There should be effective and well publicised ways of escalating concerns where immediate line managers do not take action in response to a concern being raised.

Concerns about abuse or neglect must be reported whatever the source of harm is. It is imperative that poor or neglectful care is brought to the immediate attention of managers and responded to swiftly, including ensuring immediate safety and wellbeing of the adult. Where the source of abuse or neglect is a member of staff it is for the employer to take immediate action and record what they have done and why (similarly for volunteers and or students).

There should be clear arrangements in place about what each agency should contribute at this level. These will cover approaches to enquiries and subsequent courses of action. The local authority is responsible for ensuring effective co-ordination at this level.

See also Safeguarding Case Studies.

3. Line Managers’ Supervision

See also Safeguarding Enquiries Process, Making Safeguarding Personal, Supervision, Safeguarding Training for Staff and Volunteers.

Skillful and knowledgeable supervision focused on outcomes for adults is critically important in safeguarding work. Managers have a central role in ensuring high standards of practice and that practitioners are properly equipped and supported. It is important to recognise that dealing with situations involving abuse and neglect can be stressful and distressing for staff and workplace support should be available.

Managers need to develop good working relationships with their counterparts in other agencies to improve cooperation locally and swiftly address any differences or difficulties that arise between front line staff or managers.

They should have access to legal advice when proposed interventions, such as the proposed stopping of contact between family members, or if it is unclear whether proposed serious and / or invasive medical treatment is likely to be in the best interests of the adult who lacks capacity to consent, require applications to the Court of Protection.

4. Practice Leadership

All social workers undertaking work with adults should have access to a source of additional advice and guidance particularly in complex and contentious situations. Principal social workers are often well placed to perform this role or to ensure that appropriate practice supervision is available.

Principal social workers in the local authority are responsible for providing professional leadership for social work practice in their organisation and organisations undertaking statutory responsibilities on behalf of the local authority. Practice leaders / principal social workers should ensure that practice is in line with the Care and Support Statutory Guidance.

Making safeguarding personal represents a fundamental shift in social work practice and underpins all healthcare delivery in relation to safeguarding, with a focus on the person not the process. As the professional lead for social work, principal social workers and senior healthcare safeguarding professionals should have a broad knowledge base on safeguarding and making safeguarding personal and are confident in its application in their own and others’ work.

All providers of healthcare should have in place named professionals, who are a source of additional advice and support in complex and contentious cases within their organisation. There should be a designated professional lead in the ICB, who is a source of advice and support to the governing body in relation to the safeguarding of individuals and is able to act as the lead in the management of complex cases.

All commissioners and providers of healthcare should ensure that staff have the necessary competences and that training in place to ensure that their staff are able to deliver the service in relation to the safeguarding of individuals. Many of the police investigators involved in safeguarding investigations are specially trained for that role and work in specialist units. Each of those units has a set of arrangements to help provide advice and guidance to ensure that a thorough investigation takes place in order to achieve successful outcomes for the individual.

The police service itself has identified ways that enable non-specialist officers to seek advice from supervisors at every stage of the safeguarding process, even when specialist departments are unavailable.

5. Strategic Leadership within the Senior Management Team

Each Safeguarding Adults Board (SAB) member agency – local authority, Integrated Care Board (ICB) and police, should identify a senior manager to take a lead role in the organisational and in inter-agency arrangements, including the SAB.

In order for the SAB to be an effective decision making body providing leadership and accountability, members need to be sufficiently senior within their organisation and have the authority to commit the required resources and able to make strategic decisions.

To achieve effective working relationships, based on trust and transparency, members will need to understand the contexts and restraints within which their counterparts work.

Police forces in England and Wales have a head of public protection who has strategic management responsibility for all aspects of protecting people in vulnerable situations, including adults at risk of, or are experiencing, abuse or neglect. The role of the head of public protection is to build an effective working team and develop a multi-agency approach into alleged offences involving people in vulnerable circumstances. They will also have responsibility for managing and developing policy that ensures standardised processes of investigation and working practice throughout each force. The police and ICBs are represented at a strategic level on every local Safeguarding Adults Board and contact details for the individuals concerned will be available to the SAB and all its members.

6. Corporate / Cross Authority Roles

To ensure effective partnership working, each organisation must recognise and accept its role and functions in relation to adult safeguarding. These should be set out in the Safeguarding Adults Board strategic plan as well as its own communication channels. They should also have protocols for mediation and family group conferences and for various forms of dispute resolution.

7. Chief Officers and Chief Executives

As chief officer for the leading adult safeguarding agency, the Director of Adult Social Services (DASS) has a particularly important leadership and challenge role to play in adult safeguarding including promoting prevention, early intervention and partnership working.

Taking a personalised approach to adult safeguarding requires a DASS promoting a culture that is:

  • person-centred;
  • supports choice and control;
  • aims to tackle inequalities.

However, all officers, including the chief executive of the local authority, NHS and police chief officers and executives should lead and promote the development of initiatives to improve the prevention, identification and response to abuse and neglect.

They need to be aware of and able to respond to national developments and ask searching questions within their own organisations to assure themselves that their systems and practices are effective in recognising and preventing abuse and neglect. The chief officers must sign off their organisation’s contributions to the strategic plan and annual reports.

Chief officers should receive regular briefings of case law from the Court of Protection and the High Courts.

8. Local Authority Member Level

Local authority members need to have a good understanding of the range of abuse and neglect issues that can affect adults and of the importance of balancing safeguarding with empowerment.

They need to understand prevention, proportionate interventions, the dangers of risk averse practice and the importance of upholding human rights.

Some Safeguarding Adults Board include elected members and this is one way of increasing awareness of members and ownership at a political level.

Others take the view that members are more able to hold their officers to account if they have not been party to decision making, though they should always be aware of the work of the SAB.

Managers must ensure that members are aware of any critical local issues, whether of an individual nature, matters affecting a service or a particular part of the community.

Local Authority Health Scrutiny Functions, such as the local authority’s Health Overview and Scrutiny Committee, Health and Wellbeing Boards (HWBs) and Community Safety Partnerships can play a valuable role in assuring local safeguarding measures, and ensuring that the SAB is accountable to local communities. Similarly, local Health and Wellbeing Boards:

  • provide leadership to the local health and wellbeing system;
  • ensure strong partnership working between local government and the local NHS; and
  • ensure that the needs and views of local communities are represented.

HWBs can therefore play a key role in assurance and accountability of the Safeguarding Adults Board, and local safeguarding measures. Equally the Safeguarding Adults Board may on occasion challenge the decisions of HWBs from that perspective.

9. Commissioners

Commissioners from the local authority, NHS and ICBs are all vital to promoting adult safeguarding. Commissioners have a responsibility to assure themselves of the quality and safety of the organisations they place contracts with and ensure that those contracts have explicit clauses that holds the providers to account for preventing and dealing promptly and appropriately with any example of abuse and neglect.

10. Providers of Services

All service providers, including housing and housing support providers, should have clear operational policies and procedures that reflect the framework set by the Safeguarding Adults Board in consultation with them.

This should include what circumstances they need to report outside their own chain of line management, including outside their organisation to the local authority.

They need to share information with relevant partners such as the local authority even where they are taking action themselves.

Providers should be informed of any allegation against them or their staff and treated with courtesy and openness at all times. It is of critical importance that allegations are handled sensitively and in a timely way both to stop any abuse and neglect but also to ensure a fair and transparent process. It is in no one’s interests to unnecessarily prolong enquiries. However some complex issues may take time to resolve.

Provider agencies should produce for their staff a set of internal guidelines which relate clearly to the multi-agency policy and which set out the responsibilities of all staff to operate within it. These should include guidance on:

  • identifying adults who are particularly at risk of experiencing abuse or neglect;
  • recognising risk from different sources and in different situations and recognising abusive or neglectful behaviour from other service users, colleagues, and family members;
  • routes for making a referral and channels of communication within and beyond the agency;
  • organisational and individual responsibilities for whistleblowing;
  • assurances of protection for whistleblowers;
  • working within best practice as specified in contracts;
  • working within and co-operating with regulatory mechanisms;
  • working within agreed operational guidelines to maintain best practice in relation to:
    • challenging or distressing behaviour;
    • personal and intimate care;
    • control and restraint;
    • gender identity and sexual orientation;
    • medication;
    • handling of people’s money;
    • risk assessment and management.

Internal guidelines should also explain the rights of staff and how employers will respond where abuse is alleged against them within either a criminal or disciplinary context.

11. Voluntary Organisations

Voluntary organisations need to work with commissioners and the Safeguarding Adults Board to agree how their role fits alongside the statutory agencies and how they should work together. This will be of particular importance where they are offering information and advice, independent advocacy, and support or counselling services in safeguarding situations. This will include telephone or online services. Additionally, many voluntary organisations also provide care and support services, including personal care. All voluntary organisations that work with adults need to have safeguarding procedures and lead officers.

12. Regulated Professionals

Staff governed by professional regulation (for example, social workers, doctors, allied health professionals and nurses) should understand how their professional standards and requirements underpin their organisational roles to prevent, recognise and respond to abuse and neglect.

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South Tyneside Safeguarding Children and Adults Partnership Strategic Plan – the Strategic Plan provides an overview of local safeguarding arrangements and sets out the strategic priority areas of focus for 2021-2024.

See also Safeguarding Posters and Safeguarding Leaflets

 

 

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This chapter provides information for multi-agency practitioners about carers of adults with care and support needs in relation to adult safeguarding. Specifically, it outlines their role in preventing and detecting abuse or neglect of those for whom they care, but it also discusses potential harm that may be caused by carers. Multi-agency practitioners need to be aware of such possible risks to adults with care and support needs.

RELEVANT CHAPTERS

Care and Support Planning

RELEVANT INFORMATION

Supporting Adult Carers (NICE)

Social Work Practice with Carers (Research in Practice for Adults)

Quick Guide: Supporting People who Provide Unpaid Care for Adults with Health or Social Care Needs (SCIE)

see also  Support for Carers, South Tyneside Council

September 2022: Links to the following guidance for workers supporting carers have been added:

  • Social Work Practice with Carers (Research in Practice for Adults)
  • Quick Guide: Supporting People who Provide Unpaid Care for Adults with Health or Social Care Needs (SCIE)

1. Introduction

Carers, in this context, are usually family members or a friends.

Carers can play an important role in preventing and detecting abuse and neglect of the people they care for.  The vast majority of carers strive to act in the best interests of the person they support. There are times, however, when carers may themselves experience abuse from the person to whom they are offering care and support or from the local community in which they live.

Risk of harm to the supported person may also arise because of carer stress, tiredness, or lack of information, skills or support. Also, there may be times where the harm caused is deliberate.

Circumstances in which a carer could be involved in a situation that may require a safeguarding response from agencies include:

  • a carer may witness or talk about abuse or neglect in relation to the adult they care for, or another person;
  • a carer may experience intentional or unintentional harm from the adult they are supporting, or from professionals and organisations they are in contact with;
  • a carer may harm or neglect the adult they support on their own or with others. This may, or may not, be deliberate.

Where there is intentional abuse, adult safeguarding under the Care Act should always be considered.

All staff and professionals should support a human rights based approach to issues of abuse and neglect and to the recognition and support of carers.

Work developed by the Association of Directors of Adult Social Services (ADASS), carers groups, commissioners and organisations working with carers, identify six distinct areas related to carers and safeguarding:

  • partnership working;
  • prevention;
  • support;
  • information and advice;
  • advocacy;
  • role of carers in strategic planning.

2. Partnership Working

Carers have a wealth of information and knowledge about the person that they support. As well as raising concerns, carers are able to support safeguarding enquiries by sharing information and are valued partners in such enquiries. Their views may hold the key to protecting people. If a carer speaks up about abuse or neglect, it is essential that they are listened to and appropriate enquiries made carers may identify and mitigate risk and act as advocates. The lessons from Transforming Care (Local Government Association) and other public inquiries need to be taken forward in viewing carers as equal partners unless there are valid reasons not to.

Where the adult lacks capacity, carers may reasonably provide professionals with the outcome they consider the adult at risk would want, as they know the persons likes and dislikes, what relationships are important to them and what relationships they may find difficult. Consideration for the carer and adult in safeguarding plans, in for example family conferences that have their own dynamics, need to take into account conflicting views as carers may not want the same outcome as the adult they are supporting (see the chapter on Stage 3: Plan / Review).

3. Support

‘If a carer experiences intentional or unintentional harm from the adult they are supporting, or if a carer unintentionally or intentionally harms or neglects the adult they support, consideration should be given to whether, as part of the assessment and support planning process for the carer and, or, the adult they care for, support can be provided that removes or mitigates the risk of abuse.’ (Chapter 14, Care and Support Statutory Guidance).

See also Support for Carers, South Tyneside Council

3.1 Information and Advice

See also Information and Advice chapter.

Carers need to know how they can find support and services available in their area, and be able to access advice, information. Carers need to know, that they can raise a concern in a safe environment and be confident that their concerns will be acted upon. It might be that people are unaware that the actions that they take could be perceived by others as abusive. For example, someone with a learning disability entitled to state benefits to meet their living expenses, and to have money as part of their access to leisure and other personal requirements may have this controlled by a family member.

Carers should have access to information and advice in a way that is meaningful to them and may themselves be in need of care and support and need to know how they can access services. See also Support and Care for Adults, South Tyneside Council.

3.2 Assessments

The Care Act includes protection from abuse and neglect as part of the definition of wellbeing (see Promoting Wellbeing chapter). As such, a needs assessment for the carer’s assessment is an important opportunity to explore the individuals’ circumstances and consider whether it would be possible to provide information or support that prevents abuse or neglect from occurring. This may be for example, by providing training to the carer about the condition that the adult they care for has, or to support them to care more safely. Where that is necessary the local authority should make arrangements for providing such interventions.

The carer’s assessment is distinct from a needs assessment. Safeguarding should always be at the forefront of assessments. Professionals need to be candid with carers about the risks that a carer’s assessment may identify for either preventing the need for safeguarding to them, or preventing the risk of the carer abusing the person that they are caring for.

Whole family assessments might also be considered using the framework of Think Family as an appropriate way forward. Working collaboratively with other agencies, carers may also receive support from a number of agencies.

4. Safeguarding Enquiries

If a carer raises any issues about abuse or neglect, it is essential that they are listened to and that, where appropriate, a safeguarding enquiry is undertaken and other agencies are involved as required.

Families, who view individual benefits as part of the family income, may not view their actions as abusive, but where the adult they are supporting has little or no choice about how their money is spent, this could be seen as financial abuse by others.  Where carers may have acted in a way that constitutes abuse staff should respond according to adult safeguarding procedures so that the adult is safeguarded appropriately. Whilst there may be mitigating circumstances to take into consideration the wellbeing and safety of the adult should be paramount.

If a carer experiences intentional or unintentional harm from the adult they are supporting, or if a carer unintentionally or intentionally harms or neglects the adult they support, consideration should be given to:

  • removing or reducing risk – whether, as part of the assessment and support planning process for the carer and / or the adult they care for, support can be provided that removes or reduces the risk of abuse. This may include, for example, the provision of training, information or other support that minimises the stress experienced by the carer. In some circumstances the carer may need to have independent representation or advocacy (see Independent Advocacy chapter); in others, a carer may benefit from having such support if they are under great stress;
  • involving other agencies – whether other agencies should be involved: in some circumstances where it is possible a criminal offence has been committed this will include alerting the police, or in others the primary healthcare services may need to be involved in monitoring the situation.

Other key considerations for carers should include:

  • involving carers in safeguarding enquiries relating to the adult they care for, as appropriate;
  • whether or not a joint assessment of the adult and the carer is appropriate in each individual circumstance;
  • the risk factors that may increase the likelihood of abuse or neglect occurring;
  • whether a change in circumstance changes the risk of abuse or neglect occurring.

A change in circumstance should also trigger the review of the care and support plan and, or, support plan (see Care and Support Planning chapter).

See Safeguarding Case Studies

5. Advocacy

In some instances, the most appropriate person to support the adult and act as an advocate is the primary carer. Where the carer is acting in the role of advocate, they may need support to do so, therefore professionals need to provide information and ensure that it is understood. The carer themselves may be in need of an advocate. For example, where there are safeguarding concerns about an older person with their own care and support needs caring for a partner with dementia. Assumptions should not be made about carers acting as advocates or being in need of advocacy and each case should take account of the personal circumstances.

Advocacy can be helpful in all kinds of situations when the adult or their carer is finding it difficult to have their opinions and choices heard. There are numerous advocacy services that can offer support depending on the individual’s circumstance and the outcomes they wish to achieve.

Community Advocacy services refers to all advocacy that is not a legal entitlement and offers support with a range of situations. Organisations such as POhWER, SEAP and VoiceAbility can all offer further advice.

Advocacy for a specific cause is offered by charities and organisations which can provide advocacy for a specific issue. Examples include Shelter who offers advocacy for people experiencing housing problems and Coram Voice who offers mental health advocacy for young people in care.

Group advocacy (also known as collective advocacy) is where a group of people with similar experiences meet to support each other and collectively strengthen their voice. Mental health charities, like the National Survivor User Network for Mental Health (NSUN), has a network of mental health service user groups across the UK, as well as Mind and Mind’s Infoline.

Peer advocacy: Peer advocates have lived experience of a mental health problem and can offer support to help adults cope with a range of problems.

Statutory advocacy offers a legal entitlement to advocacy in certain circumstances. There are three types of statutory advocates in England and Wales: Independent Mental Health Advocates (IMHAs), Independent Mental Capacity Advocates (IMCAs) and advocates supporting people under the Care Act 2014.  See Independent Advocacy for further information.

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This chapter provides information for multi-agency practitioners about the duty the local authority has in protecting property and pets of adults who are being cared for away from their own home.

RELEVANT CHAPTER

Mental Capacity

RELEVANT INFORMATION

Chapter 10, Care and Support Planning, Care and Support Statutory Guidance (Department of Health and Social Care) 

Good Practice Guides (RSPCA)

Guidance on Dog Control and Welfare for Police and Local Authorities

Code of Practice for the Welfare of Dogs (Department for Environment, Food and Rural Affairs) 

Code of Practice for the Welfare of Cats (Department for Environment, Food and Rural Affairs)

Code of Practice for the Welfare of Privately Kept Non-Human Primates (Department for Environment, Food and Rural Affairs) 

July 2019: This chapter was amended to include links to good practice from the RSPCA and HM Government codes of practice, as above.

The local authority must take all reasonable steps to protect the movable property of an adult with care and support needs who is being cared for away from home, in a hospital or in accommodation such as a care home, and who cannot arrange to protect their property themselves; this could include their pets as well as their personal property (for example, private possessions and furniture). The local authority must act where it believes that if it does not take action there is a risk of movable property being lost or damaged.

Protecting property may include arranging for pets to be looked after when securing premises for someone who is having their care and support needs provided away from home in a care home or hospital, and who has not been able to make other arrangements for the care of their home or pets.
In order to protect movable property in these circumstances the local authority may enter the property, at reasonable times, with the adult’s consent, ideally in writing; but reasonable prior notice to enter should be given.

If the adult lacks the capacity to give consent to the local authority entering the property, consent should be sought from a person authorised under the Mental Capacity Act 2005 (MCA) to give consent on the adult’s behalf. This might be:

  • an attorney (also known as a donee with lasting power of attorney) that is someone appointed under the MCA who has the legal right to make decisions (for example decisions about their care and support) within the scope of their authority on behalf of the person (the donor) who made the power of attorney;
  • a deputy (also known as a court appointed deputy) that is a person appointed by the Court of Protection under the MCA, to take specified decisions on behalf of someone who lacks capacity to take those decisions themselves;
  • the Court of Protection.

If the adult in question lacks capacity and no other person has been authorised to act on their behalf, the local authority must act in the best interests of the adult (see Mental Capacity).

If a third party tries to stop an authorised entry into the home they will be committing an offence, unless they can give a good reason for why they are obstructing the local authority in protecting the adult’s property. Committing such an offence could, on conviction by a Magistrates’ Court, lead to the person being fined. If a local authority intends to enter a home then it must give written authorisation to an officer of the council and that person must be able to produce it if asked for.

The local authority has no power to apply for a warrant to carry out their duties to protect property. If the Court decides the obstruction is reasonable then the local authority would have no power to force entry.

This duty on the local authority lasts until the adult in question returns home or makes their own arrangements for the protection of property or until there is no other danger of loss or damage to property; whichever happens first. Often a one off event is required such as the re-homing of pets or ensuring that the property is secured.

If costs are incurred or if there are ongoing costs the local authority can recover any reasonable expenses they incur in protecting property under this duty from the adult whose property they are protecting.

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This chapter provides information for multi-agency practitioners in relation to gaining access to adults who are experiencing, or at risk of, abuse or neglect. Only the police are legally allowed to enter premises without permission, in situations that meet specific criteria. The local authority has a number of legal options they can pursue where access to an adult is being denied. Where practitioners from partner agencies have concerns they should first speak to their line manager / designated safeguarding lead, who will decide whether a safeguarding referral is warranted.

RELEVANT CHAPTER

Stage 1: Concerns

RELEVANT GUIDANCE

Gaining access to an adult suspected to be at risk of neglect or abuse: a guide for social workers and their managers in England, SCIE.

1. Introduction

This chapter provides information on legal options for gaining access to adults who are experiencing or at risk of abuse or neglect, where access is restricted or denied. Section 47 of the National Assistance Act 1948 which gave a local authority power to remove a person in need of care from home has been replaced by the Care Act 2014.

2. Safeguarding Enquiries

Local authorities have a duty to make, or cause to be made, enquiries in cases where they reasonably suspect that an adult with care and support needs is experiencing or is at risk of abuse or neglect, and as a result of those needs, is unable to protect themselves from the actual or potential risk.

This duty does not provide for a power of entry, or right of unimpeded access to the adult who is subject to such an enquiry. There are, however, a range of existing legal powers which are available to gain access, where required.

Whether legal intervention is required, and if so which powers would be the most suitable, will always depend on the individual circumstances of the case. The local authority can apply to the courts or seek assistance from the police to gain access in certain circumstances.

3. Difficulty in Gaining Access

Reasons why it may be difficult to gain access to a person who is the subject of an adult safeguarding enquiry may include:

  1. access to the premises denied by a person who is present, usually a family member, friend or informal carer;
  2. access to the premises is given, but it is not possible to speak to the adult alone because a family member, friend or informal carer insists on being present;
  3. the adult themselves (whether or not they are unduly under the influence of the person present) is insisting that the person is present. In such cases if the adult is known to have mental capacity, the issue of access in terms of the law does not apply.

Where access is refused, it should not automatically lead to consideration of the use of legal powers. Attempts should first be made to resolve the situation via negotiation and a professional relationship based on trust; sensitive handling by skilled practitioners may satisfactorily resolve the situation.

If negotiation is not successful, the local authority must consider whether denial of access is unreasonable and whether the concerns justify intervention. This should involve a discussion with the social worker, manager and legal department regarding the level of safeguarding concern, perceived risks, and possible outcomes of both intervening and not intervening. If it is decided that using legal powers is justified, it should be decided which powers would be the most appropriate.

All such discussions and considerations should be fully recorded including objective facts and professional assessment so that the basis of all decision making is clearly based on objective fact, assessment of risk and proportionate action (see Case Recording chapter).

Unlawful intervention could not only have a detrimental effect on the adult concerned, and their carer / family, but also lead to judicial criticism and / or liability to compensation.

4. Proportionality

Where it is decided that the use of any power to gain entry is justified, it should be exercised proportionately, in relation to the risk and the level of safeguarding concern for the adult.

An emergency situation involving significant risk may justify the use of legal powers – such as police entry to save life and limb – where there is insufficient time to negotiate gaining access.

The principle of the least restrictive option helps to ensure that interventions are necessary and proportionate.

In relation to a person who lacks mental capacity, consideration must be given to achieving their best interests using an approach which is least restrictive of the person’s rights and freedom of action (see Independent Mental Capacity Advocates and Independent Mental Health Advocates).

5. Gaining Access

The SCIE guidance for social workers Gaining access to an adult suspected to be at risk of neglect or abuse notes the following legal powers may be considered by the local authority to gain access to the person experiencing, or at risk of, abuse or neglect. The following legal powers may be relevant, depending on the circumstances:

  • If the person has been assessed as lacking mental capacity in relation to a matter relating to their welfare: the Court of Protection has the power to make an order under Section 16(2) of the MCA relating to a person’s welfare, which makes the decision on that person’s behalf to allow access to an adult lacking capacity. The Court can also appoint a deputy to make welfare decisions for that person.
  • If an adult with mental capacity, at risk of abuse or neglect, is impeded from exercising that capacity freely: the inherent jurisdiction of the High Court enables the Court to make an order (which could relate to gaining access to an adult) or any remedy which the Court considers appropriate (for example, to facilitate the taking of a decision by an adult with mental capacity free from undue influence, duress or coercion) in any circumstances not governed by specific legislation or rules.
  • If there is concern about a mentally disordered person: Section 115 of the MHA provides the power for an approved mental health professional (approved by a local authority under the MHA) to enter and inspect any premises (other than a hospital) in which a person with a mental disorder is living, on production of proper authenticated identification, if the professional has reasonable cause to believe that the person is not receiving proper care.
  • If a person is believed to have a mental disorder, and there is suspected neglect or abuse: Section 135(1) of the MHA, a magistrates court has the power, on application from an approved mental health professional, to allow the police to enter premises using force if necessary and if thought fit, to remove a person to a place of safety if there is reasonable cause to suspect that they are suffering from a mental disorder and (a) have been, or are being, ill-treated, neglected or not kept under proper control, or (b) are living alone and unable to care for themselves.
  • Power of the police to enter and arrest a person for an indictable offence: Section 17(1)(b) of PACE.
  • Common law power of the police to prevent, and deal with, a breach of the peace. Although breach of the peace is not an indictable offence the police have a common law power to enter and arrest a person to prevent a breach of the peace.
  • If there is risk to life and limb: Section 17(1)(e) of PACE gives the police the power to enter premises without a warrant in order to save life and limb or prevent serious damage to property. This represents an emergency situation and it is for the police to exercise the power).
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This chapter provides information for multi-agency professionals about criminal offences in relation to adult safeguarding. It outlines some of the special measures that can be taken in relation to gathering evidence and victims and other witnesses giving evidence, as well as supporting victims and witnesses who are vulnerable or intimidated during the investigation and trial process.

RELEVANT GUIDANCE

Ministry of Justice (2011) Achieving Best Evidence in Criminal Proceedings: Guidance on interviewing victims and witnesses, and guidance on using special measures

1. Introduction

Everyone is entitled to be protected by the law and have access to justice. Although the local authority has the lead in making enquiries in adult safeguarding cases, where criminal activity is suspected involving the police as soon as possible is likely to be beneficial in many cases.

Behaviour which amounts to abuse and neglect also often constitute specific criminal offences under various legislation, for example:

  • physical or sexual assault or rape;
  • psychological abuse or hate crime;
  • wilful neglect;
  • unlawful imprisonment;
  • theft and fraud;
  • certain forms of discrimination.

See Safeguarding Case Studies

For the purpose of a court trial, a witness is deemed to be competent if they can understand the questions and respond in a way that the court can understand. Police have a duty to assist witnesses who are vulnerable and intimidated.

2. Special Measures

A range of special measures are available to aid gathering and giving of evidence by vulnerable and intimidated witnesses.

These should be considered from the onset of a police investigation, and can include:

  • an immediate referral from adult social care or other concerned agency
  • discussion with the police will enable the police to establish whether a criminal act has been committed. This will give an opportunity to determine if, and at what stage, the police need to become involved further and undertake a criminal investigation;
  • the police have powers to take specific protective actions, such as Domestic Violence Protection Orders (DVPO);
  • as a higher standard of proof is required in criminal proceedings (‘beyond reasonable doubt’) than in disciplinary or regulatory proceedings (where the test is the balance of probabilities), so early contact with the police may help to  obtain evidence and witness statements;
  • early involvement of the police helps to ensure that forensic evidence is not lost or contaminated;
  • police officers need to have considerable skill in investigating and interviewing adults with different disabilities and communication needs, in order to prevent the adult being interviewed unnecessarily on other occasions. Research has found that sometimes evidence from victims and witnesses with learning disabilities is discounted. This may also apply to others such as people with dementia. It is crucial that reasonable adjustments are made and appropriate support given, so everyone can have equal access to justice;
  • police investigations should be coordinated with health and social care enquiries but  may take priority. The local authority’s duty to ensure the wellbeing and safety of the person continues throughout a criminal investigation;
  • appropriate support during the criminal justice process should be available from local organisations such as Victim Support and court preparation schemes;
  • some witnesses will need protection from the accused or their associates (see Section 3, Adults Witnesses who are Vulnerable or Intimidated, below);
  • the police may be able to arrange support for victims.

Special Measures were introduced in the Youth Justice and Criminal Evidence Act 1999 and include a range of interventions to support witnesses to give their best evidence and to help reduce anxiety when attending court. These include the use of screens around the witness box, the use of live (video) link or recorded evidence and the use of an intermediary to help witnesses understand the questions they are being asked and to give their answers accurately.

3. Adult Witnesses who are Vulnerable or Intimidated

Adults who are deemed as vulnerable witnesses have:

  • a mental health disorder;
  • a learning disability; and / or
  • a physical disability.

These witnesses are only eligible for special measures if the quality of the evidence that will be given by them is likely to be diminished because of their disorder or disability.

Intimidated witnesses are those whose quality of evidence is likely to be diminished because of fear or distress. In deciding whether a witness comes into this category the court takes account of:

  • the nature and alleged circumstances of the offence;
  • the age of the witness;
  • the social and cultural background and ethnic origins of the witness;
  • the domestic and employment circumstances of the witness;
  • any religious beliefs or political opinions of the witness;
  • any behaviour towards the witness by the accused or third party.

Also coming into this category are:

  • complainants in cases of sexual assault;
  • witnesses to specified gun and knife offences;
  • victims of and witnesses to domestic abuse, racially motivated crime, crime motivated by reasons relating to religion, homophobic crime, gang related violence and repeat victimisation;
  • those who are older and frail;
  • the families of murder victims.

Registered Intermediaries (RIs) help communicate with vulnerable witnesses during the criminal justice process.

As noted above, a criminal investigation by the police takes priority over all other enquiries.

However a multi-agency approach should be agreed, to ensure that the interests and personal wishes of the adult are considered throughout, even if the adult decides not  to provide any evidence or support a prosecution.

The welfare of the adult. and others including children, is paramount and requires continued risk assessment to ensure the outcome is in their interests and enhances their wellbeing.

If the adult has the mental capacity to make informed decisions about their safety and they do not want any action to be taken, this does not prevent information being shared with relevant colleagues. This enables all professionals to assess the risk of harm and be confident that the adult is not being unduly influenced, coerced or intimidated and is aware of all the options available to them. This will also enable professionals to share decision making and risk management to ensure that decisions made are safe and valid. The adult should be informed of this action unless doing so would increase the risk of harm to them.

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This chapter provides information for multi-agency practitioners in relation to adults with care and support needs where there are one or more local authorities involved. It also outlines the principles of out of area arrangements, by which the local authorities should abide.

RELEVANT CHAPTER

Ordinary Residence

RELEVANT GUIDANCE

Out-of-Area Safeguarding Arrangements (ADASS)

See also Cross Border Placements case studies

This chapter was added to the APPP in July 2018.

1. Introduction

There is increased complexity in service provision arrangements for adults with care and support needs when they occur across local authority borders. Difficulties may arise where funding or commissioning responsibilities are held by one authority, but concerns about potential abuse or neglect arise in another authority area.

The following terms are adopted in the ADASS Out of Area Safeguarding Adults Arrangements protocol, and are similarly used here:

  • Placing authority: the local authority or NHS body that has commissioned the service for an individual involved in a safeguarding adults allegation.
  • Host authority: the local authority or NHS body in the area where the abuse occurred.

2. ADASS Principles for Out of Area Safeguarding Adult Arrangements

ADASS states the host authority should take overall responsibility for coordinating the safeguarding adults enquiry and ensure there is effective communication between all agencies and professionals involved in the case, including meetings held and planning for any required investigation.

In relation to the placing authority ADASS states it should:

  • have a continuing duty of care to the adult that they have placed;
  • participate in the investigation as required;
  • ensure that the provider has arrangements and procedures in place in relation to safeguarding adults and how staff should respond to concerns, which should also link to the local (host) multi-agency safeguarding adults procedures. This should be a requisite of contracting arrangements. This should include the requirement to inform the host authority of any safeguarding concerns.

Authorities may negotiate certain arrangements, for example relating to another authority undertaking assessments, reviews, investigative activities. In such cases, the placing authority would maintain overall responsibility for the adult they placed. Reimbursement for such actions should be discussed and agreed between the authorities, as appropriate.

Providers of care and support services have rights and responsibilities, and also may be required to undertake their own investigations into an adult safeguarding concern. The host authority must ensure effective and timely communication with the provider throughout the investigation (see also Integration, Cooperation and Partnerships).

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This chapter provides outline information for practitioners on what to do if they have a concern about an adult outside of office hours.

1. Making a Safeguarding Referral to the Local Authority

When an adult is experiencing, or at risk of abuse or neglect but there is no immediate risk of harm, the practitioner should follow their own local processes for raising concerns. This could either mean they contact the local authority safeguarding adults team themselves or they share their concerns with the safeguarding adults lead in their organisation, who will then make the referral to the local authority safeguarding adults team.

However, if there is concern that immediate action is required or there is an urgent risk, a referral should be made to the South Tyneside Safeguarding Adults Out of Hours Team without delay (see Local Contacts). Where it is suspected a crime has been committed the police should also be contacted.

Details of all actions taken should be recorded on the adult’s case file / record.

2. Taking Immediate Action to Protect an Adult

If the Out of Hours Team receives a referral which indicates there is an immediate or urgent risk to the adult, the worker receiving the referral must take all steps necessary to protect the adult. This includes arranging emergency medical treatment, contacting the police (by telephoning 999) and taking any other action to ensure the adult is safe.

3. Case Recording and Handover

The Out of Hours Team worker should record details of the concerns on the adult’s electronic social care record. The worker will pass all necessary information to the relevant team in adult social care before the end of their shift. If the adult is already known to the local authority, the out of hours worker will notify their allocated worker.

See also Case Recording.

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1. Introduction

Data protection legislation should not be seen as an obstacle to sharing information, but as a framework of best practice which helps to ensure that when the local authority uses, records and shares information it does so safely and in a way which is transparent and in line with the law.

Partner agencies of the South Tyneside Safeguarding Adults Board collect, store, use and retain (for specified time periods) information about people with whom they work. This includes:

  • adults who use (or previously used) their services, including their families and any children;
  • staff; and
  • suppliers.

When processing data in this way, organisations must comply with the requirements of the Data Protection Act 2018 (DPA) and the UK General Data Protection Regulation (UK GDPR).

Organisations must also ensure through their procedures and working practices, that all employees, contractors, consultants, suppliers and partners who have access to any personal data held by or on behalf of the organisation are fully aware of and abide by their duties and responsibilities under data protection legislation. Any contracts with service providers must be clear about the different parties’ responsibilities for data processing and information sharing.

Personal information must be handled and dealt with in accordance with data protection legislation however it is collected, stored, recorded and used, and whether it be on paper, on computer or digital records or recorded in any other way.

Organisations may also be required to collect and use information in order to comply with the requirements of central government, such as in the case of a Safeguarding Adults Review or Care Quality Commission inspection.

2. Legislation

2.1 Data Protection Act 2018

The Data Protection Act 2018 (DPA)  aims to ensure that UK data protection legislation keeps pace with technological changes, and the impact these have had on the collection and use of personal data.

2.2 UK General Data Protection Regulation

The UK General Data Protection Regulation (UK GDPR) sets out the key principles, rights and obligations for processing personal data. For more information see, UK GDPR: Guidance and Resources, Information Commissioner’s Office.

The GDPR:

  • gives individuals greater control of their data by improving consent processes; and
  • introduced the ‘right to be forgotten’ which enables the data subject to have their data ‘forgotten’ in certain circumstances.

If staff receive a query about the collection or processing of personal data, they should contact their Information Governance team / Data Protection Lead for advice.

3. Principles of Data Protection: Article 5 DPA

Anyone processing personal data must comply with the principles laid down the DPA and UK GDPR. These are legally enforceable and require that when personal data is processed (see also Section 3.2 What is personal data under Article 4?) it must be:

  • lawful and fair and carried out in a transparent manner in relation to the data subject. (lawfulness, fairness and transparency principle);
  • specified, explicit and legitimate and not further processed for other purposes incompatible with those purposes (purpose limitation principle);
  • adequate, relevant and not excessive to what is necessary in relation to the purposes for which data is processed (the data minimisation principle);
  • accurate and kept up to date (the accuracy principle);
  • kept for no longer than is necessary for the purposes for which the personal data is processed (the storage limitation principle); and
  • stored in a way that ensures appropriate security including protection against unauthorised or unlawful processing and accidental loss, destruction or damage, using appropriate technical or organisational measures (the integrity and confidentiality principle and the accountability principle).

3.1 Handling personal data and or sensitive personal data

The DPA outlines conditions for the processing of personal data, and makes a distinction between personal data and sensitive personal data.

Personal data is is any information relating to a living person who can be identified or who is identifiable, directly from that information, or who can be indirectly identified from that information in combination with other information

3.2 What is Personal Data under Article 4 GDPR?

Personal data is:

  • any information relating to an identified or identifiable natural person such as:
    1. a name;
    2. an identification number;
    3. location data;
    4. an online identifier such as an IP address or cookies; or
    5. an email address.

3.3 Special Categories of Data (sensitive personal data): GDPR Article 9

Special category data is personal data that needs more protection because it is sensitive. It includes personal data which reveals:

  • racial or ethnic origin;
  • political opinion;
  • religious or other beliefs;
  • trade union membership;
  • physical or mental health or condition;
  • sexual life or sexual orientation.

3.4 Identifying a lawful basis for sharing information 

Article 6 of the UK GDPR providers practitioners with a number of lawful bases for sharing information. At least one of these must apply whenever personal data is processed.

Where practitioners need to process and share special category data (sensitive personal data), they need to identify both a lawful basis for processing under Article 6 of the UK GDPR and a special category condition for processing in compliance with Article 9 (see: Information Commissioner’s Office, Lawful basis for processing);

4. Data Protection Practice

The organisation must:

  • observe fully conditions regarding the fair collection and use of personal information;
  • meet its legal obligations to specify the purpose for which information is used;
  • collect and process appropriate information and only to the extent that it is needed to fulfil operational needs or to comply with any legal requirements;
  • ensure the quality of information used;
  • apply strict checks to determine the length of time information is held;
  • take appropriate technical and organisational security measures to safeguard personal information;
  • ensure that personal information is not transferred abroad without suitable safeguards;
  • ensure that the rights of people about whom the information is held can be fully exercised under data protection legislation. These include:
    • the right to be informed that processing is being undertaken;
    • the right of access to one’s personal information within the statutory timescale;
    • the right to prevent processing in certain circumstances;
    • the right to correct, rectify, block or erase information regarded as wrong information.

In addition, the organisation should ensure that:

  • there is someone with specific responsibility for data protection;
  • everyone managing and handling personal information understands that they are contractually responsible for following good data protection practice;
  • everyone managing and handling personal information is appropriately trained to do so;
  • everyone managing and handling personal information is appropriately supervised;
  • anyone wanting to make enquiries about handling personal information, whether a member of staff or a member of the public, knows what to do;
  • queries about handling personal information are promptly and courteously dealt with;
  • methods of handling personal information are regularly assessed and evaluated;
  • performance with handling personal information is regularly assessed and evaluated;
  • data sharing is carried out under a written agreement, setting out the scope and limits of the sharing. Any disclosure of personal data will be in compliance with approved procedures.

All employees should be aware of their organisation’s data protection policy and of their duties and responsibilities under the DPA.

All managers and staff will take steps to ensure that personal data is kept secure at all times against unauthorised or unlawful loss or disclosure and in particular will ensure that:

  • paper files and other records or documents containing personal / sensitive data are kept in a secure environment;
  • personal data held on computers and computer systems is protected by the use of secure passwords, which where possible have forced changes periodically;
  • passwords must not be easily compromised and must not be shared with others;
  • personal data must only be accessible to team members with appropriate access levels;
  • data in all forms must be disposed of