1. Introduction

This chapter summarises the Emerging Concerns Protocol which can be used by organisations who have signed up to the protocol to act early and share information with regulators where there are concerns about risks to people using services, their carers, families or professionals.

Partners to the protocol share a common objective of making sure that health and social care professionals and systems across the UK serve to protect the public, whilst maintaining the health, safety and wellbeing of professionals, people using services and also their families and carers.

The aim of the protocol is to strengthen and encourage good practice by enabling the sharing of information about emerging quality concerns in a timely fashion.

Each of the organisations signed up to the protocol has a responsibility for responding to concerns about care provision and a role in ensuring that those who use services, their carers and families receive high-quality services from professional staff and registered health and social care organisations.

2. Purpose of the Protocol

The Protocol states:

‘The purpose of the Protocol is to provide a clear mechanism for signatories to share information that may indicate risk. This could include risks to people who use services, their carers, families, learners or professionals. Primarily it is a mechanism to triangulate information to support decision making. It aims to enable:

• safe and timely sharing of information, which individually might seem small or insignificant, but when joined together can tell us a problem is emerging
• consideration of any collaborative support, decisions or regulatory activity to address concerns in a proactive way.

This will allow signatories to fulfil our collective role better, as well as improve our ability to fulfil our individual roles. We also believe that working together more effectively can reduce unnecessary burden. For example, we can do this by encouraging our organisations to develop joint plans when we share similar concerns, or by taking assurance from each other’s actions.

3. Principles

The following principles – which underpin the Protocol – have been agreed across all organisations acting as signatories.

The Protocol is:

• open to use irrespective of how small an issue may appear to be
• flexible and empowering, supporting signatories to understand how they can share information
• developed through a collaborative, partnership approach between organisations
• linked to other governance arrangements and tools in the system, such as the National Quality Board’s quality governance and oversight guidance
• not a replacement of existing responsibilities and arrangements for taking emergency action, including arrangements for whistleblowing and responsibilities under Duty of Candour and Fit and Proper Persons Regulations.

Organisations that have signed up to the Protocol commit to:

• promoting the use of the Protocol and considering its use for relevant issues no matter how small
• considering how issues may have implications for system and professional regulators, including in relation to learning environments
• modelling an open culture and encouraging others to openly share information
• being transparent about how the Protocol is used, while maintaining confidentiality of content (in all directions, including the National Quality Board, providers, public, registrants)
• being explicit about confidentiality agreements and parameters (including working with information shared by third parties)
• using the Protocol within the law, including any restrictions on information sharing that are included in each signatory’s statutory role
• respecting the executive autonomy of each individual signatory
• acting in support of good working relationships and existing formal and informal mechanisms that already exist, for example, signatories will continue to use specific Memoranda of Understanding they may share.

4. The Process for Responding to Concerns

4.1 Categories of concern

Concerns may come into three categories:

1. concerns about individual or groups of professionals;
2. concerns about healthcare systems and the healthcare environment (including the learning environments of professionals);
3. concerns that might have an impact on trust and confidence in professionals or the professions overall.

4.2 How to use the protocol

This is a summary of the process. See the Annexes at the bottom of this chapter for more detailed information about each stage.

4.2.1 A concern is identified

• Evaluate information and source;
• Does the protocol need to be triggered?

REMEMBER: no piece of information is too small to invoke the protocol.

At this stage it may be decided that the Protocol does not need to be triggered and the information can be dealt with through other routes.

4.2.2 Consider the interests of partner organisations

• Who do we need to share with?
• Who do we need information from? (See Annex A: Organisations Involved).

At this stage it may be decided that the Protocol does not need to be triggered and the information can be dealt with through other routes.

4.2.3 Contact Organisations B, C & D to share (and request) information

• All organisations store information in their own systems;
• Organisation A responsible for formal recording of the use of the protocol.

See Section 6, Recording Requirements and Section 7, Sharing Personal Data

4.2.4 Hold regulatory review panel (RRP)

• RRP convened, coordinated, chaired and minuted by Organisation A;
• Use the template agenda for a regulatory review panel.

4.2.5 Share outcomes

• RRP record shared with all partners and Health and Social Care Regulators Forum secretariat for monitoring and report at next Forum (including if there is no further action);
• Use of protocol reviewed for learning every time.

5. Safeguarding

Any organisation may receive information that indicates that abuse, harm or neglect has taken place. Any form of abuse, avoidable harm or neglect is unacceptable. Each organisation will have procedures for managing these types of concerns and they must be followed. Each organisation remains responsible for ensuring they follow their own internal safeguarding procedures. Nobody should wait to activate the protocol instead of acting on safeguarding concerns – immediate action should always be taken where necessary (see Safeguarding Enquiries Process section).

6. Recording Requirements

See also Case Recording chapter

Each organisation involved in the use of the protocol should ensure records are made on their own system.

Each organisation should be able to report on:

• the number of times they have initiated use of the protocol;
• anonymised information about information shared;
• RRPs convened;
• RRPs attended;
• actions as a result of the protocol.

The minimum information expected to be stored includes:

• dates;
• providers, professionals, others involved;
• partners contacted;
• actions agreed and taken;
• decisions to call / not call RRP.

7. Sharing Personal Data

See also Annex C, Sharing of Personal Data and South Tyneside Multi Agency Information Sharing Agreement

When using the protocol, mostly there should not be a need to share personal data about individuals. Organisations convening an RRP must ensure however that only those who need to know the information should attend if personal information is to be shared in the panel.

Any processing of personal data is subject to the requirements of the Data Protection Act 2018 and the UK General Data Protection Regulation (see Data Protection Act chapter).

Annexes

Annex A: Organisations Involved

Annex B: An Example of Protocol Use

Annex C: Sharing of Personal Data

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

1. Introduction

Safeguarding is everyone’s business. This section considers a range of issues about quality and safety, positive practice, safeguarding concerns and managing large scale enquiries. Partnerships between safeguarding and commissioning functions, and their interdependent roles and responsibilities towards providers are explored. It is essential to know what works well to support a positive culture of co-operation and information sharing with joint accountability for risk and benefits. It identifies the role and responsibilities of the five groups that influence quality:

1. professionals and staff
2. commissioners and funders (local authorities, Integrated Care Boards and NHS England)
3. regulators – Care Quality Commission (CQC), NHS England;
4. the public, including adults who use services, their families and carers;
5. providers: a provider is any care or health provider who delivers support and care to a group of individuals. This would include but is not exclusive to the following:

• domiciliary care providers;
• residential care homes;
• nursing homes;
• supported living;
• private hospitals;
• day care / opportunities providers;
• rehabilitation units for people who misuse drugs or alcohol;
• voluntary agencies.

Working in partnership these groups can assist in early identification of falling standards in care, that might lead to wider concerns and the need for quality or safeguarding intervention. There is a clear responsibility on commissioners and providers to ensure safe, high quality services are provided.

This chapter is relevant to all providers not just those in the CQC inspection regime. The CQC are responsible for inspecting and monitoring providers registered under the Health and Social Care Act 2008. It has statutory powers to inspect how well services are performing against the CQC’s Fundamental Standards of quality and safety, and can take proportionate enforcement action to ensure providers improve where there is poor care.

For the purpose of the Provider Concerns policy and procedure, this section explores work with local authority commissioned providers as a means for responding to potential business failure (contracts and commissioning responsibilities) and details how allegations of organisational abuse are managed where safeguarding concerns are identified as serious matters within an organisation as opposed to single concerns that may be addressed under Section 42 enquiry (see Stage 2: Enquiry).

Safeguarding concerns in this sense relate to patterns of reported abuse or neglect, about one provider, or where a single concern indicates a serious matter that warrants closer inspection under adult safeguarding processes. In some instances, safeguarding action may be initiated following a Safeguarding Adult Review (see Safeguarding Adult Reviews), or run in parallel to one. The focus of this section is on prevention, in particular actions that might be taken in response to concerns about quality issues, to reduce the risk of escalation to safety and safeguarding issues. Finally, this section aims to ensure that people have a voice in influencing how services are delivered and where there are concerns, and how their views and experiences lay at the heart of improvements.

2. Six Step Process

The working with providers procedures section follows a six step process.

3. Who does this Procedure Apply to?

The procedure applies to all care and support provision, commissioned by a local authority and irrespective of whether or not it is included in the CQC Market Oversight Regime. Services commissioned and managed by the NHS are subject to the same level of scrutiny however the oversight and escalation is managed within the North East and North Cumbria ICB and NHSE governance of Quality Review Groups, Quality Surveillance Groups and Risk Summits.

4. Risk Summits

This guidance should be considered in parallel to Risk Summits within the NHS.  The National Quality Board has published Risk Summit National Guidance.

The risk summit process can be implemented if any part of the local, regional or national system has concerns that there may be serious quality failures within a provider organisation which cannot be addressed through established and routine governance processes.  This includes where there are significant safeguarding breaches and breakdown in systems which compromise the safety of individuals with care and support needs. The Risk Summit can be an effective and non-prejudicial method for facilitating the rapid sharing of information and intelligence across different organisations, and for initiating remedial actions where it is required to safeguard individuals or improve quality. Risk Summits can both inform and be informed by quality concerns raised by Quality of Care Information Sharing Meetings. Where a Risk Summit notes individual safeguarding concerns these should be managed through local adult safeguarding arrangements.

Quality Surveillance Groups bring together different parts of the health system regionally to routinely share information and intelligence to safeguard the quality of care individuals receive (see Safeguarding Adults Structures and Organisations for further information).

5. Working in Partnership with Local Authority Commissioned Providers

A shared goal between all parties is that adults can expect to receive a safe, quality service. Integral to the effectiveness of partnerships is the need to work in a transparent and open way. It is not the intention for this policy and procedures to be punitive in its dealings with providers but to implement quality and safeguarding principles by supporting and giving a helpful steer when concerns arise, to assist providers in getting back on track. Open dialogue can only be achieved where there is trust and a willingness on all parties to work together. The rules of natural justice should be observed, and where there are organisational concerns enquiries or investigations should be based on evidence and a thorough assessment.

Providers should underpin their own policies and procedures under the six safeguarding principles (see Section 4, Principles of Adult Safeguarding, Safeguarding:What is it and Why Does it Matter?). They should empower adults to fully participate in how services are run by creating a culture of dignity and respect. Providers are accountable to adults using their services and commissioners, for meeting the expected standard of care agreed in individual care plans, contracts and commissions. They are expected to have a robust quality assurance framework in place that evidences commitment to prevention and early intervention. Such commitments are about recognising potential abuse and learning from past situations to inform better practice.

Undertaking regular staff training, supervision and appraisals, self-audits and making changes as a result, reduces the risk of matters escalating to safeguarding action. Providers should publish an open and transparent complaint procedure with the assurance of no retribution; and offer ways of gaining customer feedback that supports empowerment and quality assurance. Independent advocacy and regular service user/carer/patient led meetings are equally important to ensuring that services are influenced by adults who use them. Providing Good Care (Local Government Association) gives guidance for providers to audit the quality and safety of their services. Providers have a duty of care to protect adults and meet safeguarding standards; this can be evidenced where there is a clear commitment to protection in their policy and procedures that is observed in practice.  Action taken in response to safeguarding should always be proportionate with the least intrusive response that will effectively manage risk.

5.1 Commissioning support to providers

In turn commissioning organisations should offer support and guidance where it is asked for or identified through constructive dialogue. Provider forums are a constructive mechanism for sharing best practice, and identifying areas of risk, transparency and information sharing.

5.2 Multiple care provision

Where providers support adults in or from a number of different establishments within the same locality, care should be taken that one establishment is not seen in isolation. This is to ensure that any failings are not endemic and embedded in corporate cultures and systems. This may impact on the capacity and capability of the provider to implement agreed improvements, and ensure that improvements are made on firm, sustainable foundations.

5.3 Duty of candour

See Duty of Candour chapter

The Report of the Mid Staffordshire NHS Foundation Trust  Public Inquiry (also known as the Francis Report) recommended the development of a culture of openness, transparency and candour in all organisations providing care and support. NHS providers are required to comply with the duty of candour. Meaning providers must be open and transparent with service users about their care and treatment, including when it goes wrong. The duty is part of the Fundamental Standard requirements for all providers. It applies to all NHS trusts, foundation trusts, special health authorities and all other service providers or registered managers.

6. Natural Justice

The principles of natural justice concern procedural fairness and ensure a fair decision is reached by objective decision making. Where there are concerns about quality or safety these should be evidenced, and parties provided with information and opportunity to take action to address concerns.

7. Workers who raise Concerns within their Organisations

See also Whistleblowing chapter

Each organisation will have its own whistleblowing policy and provide staff with protection from victimisation or detriment when genuine concerns have been raised about malpractice.

8. Allegations against People in a Position of Trust

See Stage 2: Enquiry, Section 3, Criminal Investigations and Person / People in Positions of Trust (PIPOT) – Multi-Agency Practice Guidance

8.1 Suspension of staff pending enquiry outcomes

In the event that staff are suspended, adult safeguarding processes should consider how it can dovetail any agreed disciplinary processes. It should be borne in mind that a provider concerns process may feed into human resource processes, but this provider concerns process in itself cannot determine outcomes for staff under employment laws.

9. People who Fund their own Care

People, who arrange their own care and support, may not be known to either the local authority or its partners. In order to safeguard them and meet the duty of care to offer protection to all people who are in need of care and support, and unable to protect themselves (the majority of people living in a care setting), providers are required to work with the local authority and partners, to ensure that information and advice is readily available, and that information is shared when requested.

10. Adults who Cause Harm

Where the person alleged to cause harm is also an adult who is experiencing or at risk of abuse or neglect, the safety and wellbeing of both the individual subject to possible abuse, and the person alleged to have caused harm needs to be addressed separately. In most cases, this can be considered through the Section 42 enquiries as appropriate. The least intrusive action should be taken to support adults using the service. The provider is responsible for ensuring that actions are taken that support the person alleged to have caused harm in consultation and collaboration with commissioners, and the safety and wellbeing of other adults using the service. Commissioners are responsible for ensuring that the service meets the assessed needs of adults and that regular reviews are carried out to ensure this.

11. Commissioning for Quality

The Care Act 2014 puts emphasis on greater integration of services provided by the local authority and its relevant partners to:

• create a service market of diverse and quality services;
• foster continuous improvements in the quality and effectiveness of provider services; and
• foster a workforce whose members are able to ensure the delivery of high quality services.

Quality services are those that place the health and welfare of people who use services as paramount and deliver positive outcomes. These are evidenced in the characteristics of the service through policy, procedures, standards, and structures for overseeing and maintaining service delivery to the requirements set by the regulator (CQC) and / or by robust contract monitoring. In some instances, the local authority may not contract with a provider; neither may the provider be subject to the CQC inspection regime. Providers, who fall under this category, will still need to maintain health and safety standards and where it delivers care and support through regulated activity, it should still have quality and safeguarding measures in place. See Regulated Activities (CQC).

Commissioners should set out clear expectations of providers within contracts and monitor compliance. Commissioners have a responsibility to ensure that commissioned services:

• know about and adhere to relevant provider registration requirements and guidance;
• meet the CQC, legal or contract standards;
• ensure that all documents such as service specifications, invitations to tender, service contracts and service level agreements adhere to safeguarding principles and standards.

Effective and strong commissioning under the Commissioning for Better Outcomes Framework (see Commissioning for Better Outcomes: A Route Map) supports prevention strategies and sets out the key criteria commissioners are seeking from providers to evidence their commitment to delivering high quality, safe services. The domains stress that services should be:

• person centred and outcomes focused;
• inclusive;
• well led
• promote a sustainable and diverse market place.

Standards developed by health organisations, for example National Institute for Health and Excellence (see NICE Guidance) offers health and social care providers guidance on standards. Additionally Safeguarding Adults: The Role of NHS Commissioners provides helpful advice for NHS commissioners to identify quality services.

12. Business Failure and Service Interruptions: the Impact for Safeguarding

Local authorities should have knowledge of market vulnerabilities in order to respond effectively (see Factsheet 1: General responsibilities of local authorities: prevention, information and advice, and shaping the market of care and support services). Where there is a danger of a provider going into liquidation, commissioners should be informed so adequate safeguards can be put in place for adults currently using the service. Periodic market analysis (market shaping) to assess capacity and viability of services is helpful to ensure that in the event that additional resources might be needed local needs can be met.

The CQC is responsible for market oversight of adult social care in England. This is a statutory scheme through which the CQC assesses the financial sustainability of those care organisations that local authorities would find difficult to replace (due to their size, specialism or concentration in the market) should they fail and become unable to carry on delivering a service. The CQC must give local authorities an early warning of likely failure affecting adults receiving care in their areas, so that local authorities can make contingency plans to enable them to meet their statutory duty to ensure continuity of care.

Most service interruptions are relatively small scale and low risk and are therefore easily managed, but those on a larger scale have much greater potential impact. A key learning point from major commercial failures in recent years was that few local authorities could respond effectively without working with their partners, including other providers. Where the continued provision of care and support to those receiving services is at major risk and there is no likelihood of returning to a ‘business as usual’ situation in the immediate future, adults may have urgent needs which must be met, including safeguarding.

12.1 Contingency planning

Contingency planning sits alongside other emergency planning activities. Not all situations where a service has been interrupted or closed will warrant local authority / ICB involvement because not all cases will have the same risks associated with safeguarding. For example, if a care home closes and residents have agreed to the provider’s plans to move to a nearby care home that the provider also owns, the level of risk or the need to invoke safeguarding will be lessened. The aim is to return to  business as usual, wherever possible, and with the least disruption to adults who use the service.

1. Step 1: Decision to Initiate Provider Concerns

The decision to initiate a Provider Concerns process may be the outcome of a Quality and Safeguarding meeting, or considered through other means for example, consequence of a Safeguarding Adult Review (SAR) (see Safeguarding Adult Reviews) or a serious concern that meets the agreed provider concerns threshold criteria above.

1.1 Action

The following actions should be taken:

• conducting immediate checks on the welfare of adults using the service;
• consult the police about whether there are any possible criminal matters;
• contact the placing authorities;
• agree who will chair the process and which will be the lead organisation;
• convene a Provider Concerns Information meeting;
• set up meeting with the provider;
• map out risk and risk management plan;
• consider commissioning intentions.

1.2 Risk

A risk management plan should be drawn up and updated throughout the process. Where there are high risk concerns, there will be a need to put in place safeguards and agreed triggers to escalate matters. Risk management to be assured that action will be timely and safeguard people on a sustainable basis is essential. Risk will determine commissioning intentions, and be the evidence base upon how decisions are made. Risk management for commissioning authorities may be additional visits both announced and unannounced. Training support for example, an occupational therapist ensuring the right slings are used to reduce immediate risks of falls.

The level of risk should be shared with the provider and frank discussions about any proposed action that might be taken by commissioners, providing adults are not put at further risk by doing so. Providers should be encouraged to find solutions to mitigate against risk. Actions might include providing additional resources to support improvement planning, resourcing training, and purchasing new equipment.

Timescale: Actions to be completed within five working days.

2. Step 2: Initial Provider Information Sharing Meeting

The purpose of the meeting is to:

• identify and clarify concerns;
• devise a communication strategy about how adults using the service will be informed and updated;
• ensure appropriate advocacy and support;
• listen to the views of the provider;
• safeguarding planning to consider the type of enquiries, leads and timescales;
• risk management;
• consider commissioning intentions;
• set date for follow up provider meeting.

2.1 Safeguarding planning

Actions need to be able to support a factually based assessment of the validity and likelihood of concerns, their severity and impact and identify any new concerns. Intelligence as far as possible should be triangulated and the source of information identified and based on:

1. views of adults using the service;
2. factual information for example staff rotas; and
3. professional assessment of documentation for example care plans and risk assessments.

Safeguarding planning will address alleged issues with suggested methodology for enabling decision making about whether improvements are needed or not, and who has the appropriate skills to carry out the enquiry.

2.2 Communication strategy

The strategy should address both internal and external communications. A check list for information might include:

• senior management – need to know;
• information to the provider and how ongoing communication will be managed;
• if a suspension on admissions is considered how this is communicated to front line staff and other commissioners and the public;
• press release;
• briefing for chief executives and /or elected members;
• consultation with adults who use services, their families and friends;
• how information and advice is provided to include adults who fund their own care.

2.3 Meetings with the provider

The chair will inform the provider that it is subject to the Provider Concerns process and share as much information as possible, without compromising any subsequent lines of enquiry. They will be informed of the process and provisional timescales if available. If there is a criminal investigation, the provider will be informed in accordance with Police advice.

2.4 Communication with adults who use services

Adults who use services should be provided with the opportunity of shaping and influencing the quality of services and be kept central to the process. In a residential setting, service users and their families may become anxious about increased activity, seeing more visiting professionals etc, and have the right to be informed, but care should be taken not to raise anxiety. Information sharing should always include adults who use services and their carers so that they are able to make informed choices and retain their independence.

Where there is opportunity for presenting to adults who use the service and carers through a meeting, negotiation with the provider should take place about how this is managed. In those instances where adults receive support at home, as part of the safeguarding plan, care management staff (including Continuing Health Care staff) should make targeted visits to:

1. ensure that people are safe; and
2. record their views so that they are considered in the organisational risk management plan.

Adults should be provided with the means of sharing their experiences independently of the provider, and if it is deemed necessary a link worker for adults and their families should be identified and a dedicated phone line available to raise issues in confidence. At the very minimum, checks that the provider has taken action in relation to complaints and acted upon service user surveys should be made.

Timescales: If possible, actions should be agreed in the risk management plan. Where the concern is about a large organisation or particularly complicated, action may take longer. The provider however should be kept informed.

3. Step 3: Provider 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 safeguarding measures;
• consider actions to monitor the safety of people and agree triggers to escalate risk, whilst improvements are being made;
• consider commissioning intentions (see Appendix 1: Provider Concerns Escalation Process Flowchart);
• preserve information that may be helpful to police investigations.

Where immediate action is needed this should be taken and not be put on hold until the Findings meeting. The chair should be informed and immediate authorisation for action is made.

3.1 Service improvement plan

This is a high level plan for measuring the effectiveness of interventions to ensure safety, governance, compliance, clinical effectiveness referencing throughout the experience of adults using the service and their informal network. The coordinator should set out the concerns and risks, which should also include any concerns in relation to mental capacity and the Deprivation of Liberty Safeguards. It is important to distinguish between what is safeguarding and what are quality issues that may impact on safeguarding and prioritise high risk areas.

3.2 Meetings with the provider

The chair and lead commissioner (if not the chair) should hold a meeting with the provider as soon after the findings meeting as possible. Leads and timescales will be agreed at the provider meeting. The service improvement plan will be the agreed reference point for assessing and monitoring progress and both the coordinator (who is also the chair) and the provider will retain a copy and update it through a series of monitoring meetings. If there is a contract monitoring officer, commissioner or other relevant member of staff they should be part of these meetings. In the event that the provider advises that they are unable to make the improvements or of possible service failure or interruptions, a further meeting with all stakeholders should be convened to assess risks and impact on service users to determine commissioning based on the risk and safety of adults using the service.

Further meetings to update stakeholders will be made, if and when necessary. Where there is wide reaching, complex concerns and high risk, it is likely that updated meetings are needed more frequently. Where there are serious delays by the provider to implement improvements, a further meeting should always be held to consider the level of risk and appropriate action. Focus should be on risk and the impact on adults using the service. It is important to distinguish between what is safeguarding and what are commissioning responsibilities and if further incidents have occurred. Where there is a high risk and likely need to source alternative provision, commissioners should hold a specific contingency meeting. The chair and the coordinator should be invited.

Timescales for further safeguarding meetings are dependent upon progress of the service improvement plan and the level of risk.

4. Step 4: Quality Assurance

A quality assurance strategy should be agreed that will rigorously test whether improvements have been attained and can be sustained. This may involve a range of staff with the right knowledge, skills and experience to assess the viability of the improvements and might be the same staff involved in fact finding so that they can provide a comparative narrative. Quality assurance activities may include testing an on-call emergency out of hour’s system by calling at the evening and weekend; assessing the impact of training by competency testing staff; making both announced and unannounced visits.

Feedback from adults and carers will act as a control measure to assess whether there has been any noted difference in the service delivery. This may be obtained from holding a follow up meeting with adults in care settings or from a sample of telephone calls to those adults who said that they had experienced a poor service, to see if their view has changed. Support from the local Healthwatch may be appropriate, or other locally managed groups for example Quality Checkers, to add an independent view.

5. Step 5: Closing the Provider Concerns process

Following evidence based improvement, the process will formally come to an end via the provider meeting and the relevant parties including the provider, and the CQC should be notified in writing by the chair. For consideration of a lessons learnt exercise, feedback will be reported to the South Tyneside Safeguarding Children and Adults Partnership together with a summary report detailing the concerns, actions, risk management, outcomes and the effectiveness of safeguarding. Assurances should be made that adults and carers know how to raise any further concerns. It may also be helpful to agree a reviewing and escalation process

Appendix 1: Provider Concern Process Escalation Flowchart

Click here to view Provider Concern Process Flowchart

1. Introduction

Safeguarding concerns can be raised regarding adults within any care setting. Where safeguarding concerns are raised about an individual these should be progressed via a Section 42 Enquiry (see Stage 2: Enquiry) where they meet the criteria as set out in the Care Act, Section 18.

Provider concerns refer to issues that affect a group of people who receive care from a Local Authority commissioned care provider. The outcome of any individual Section 42 Enquiry related to such a care provider should be fed back through this Provider Concerns process. The Provider Concerns process should only be invoked where there are patterns of safeguarding concerns that indicate that the provider has not made any changes to reduce the number of incidents surrounding the same or similar situations and there is concern that the provider is unable to provide care and support in a safe environment that respects the human rights of people in receipt of that care.

2. Organisational Abuse

Organisational abuse (or organisational safeguarding) is a broad concept and is not just applicable to high profile cases, for example Winterbourne View. It is an umbrella term defined as, ‘the mistreatment or abuse or neglect of an adult at risk by a regime or individual’s within settings and services that adults at risk live in or use, that violate the person’s dignity, resulting in lack of respect for their human rights.’

Organisational abuse occurs when the routines, systems and regimes of an institution result in poor or inadequate standards of care and poor practice which affects the whole setting and denies, restricts or curtails the dignity, privacy, choice, independence or fulfilment of adults. Organisational abuse can occur in any setting providing health and social care. A number of inquiries into care in residential settings have highlighted that organisational abuse is most likely to occur when staff:

• receive little support from management;
• are inadequately trained;
• are poorly supervised and poorly supported in their work; and
• receive inadequate guidance.

3. Early Identification

Hull University (Abuse in Care Project, 2012) identified over 90 individual indicators or warning signs for concern. A summary of factors which can increase the likelihood of abuse occurring within provider settings are drawn from these indicators:

• management and leadership;
• staff skills, knowledge and practice;
• residents’ behaviours and wellbeing;
• the service resisting the involvement of external people and isolating individuals;
• the way services are planned and delivered;
• the quality of basic care and the environment.

Where there is proof or suspicion of organisational abuse by omission, for example the abuse and neglect highlighted in the Winterbourne View and the Old Deanery reports, or omission to provide care and support that puts adults at risk of or experiencing abuse or neglect, action will be channelled through this Provider Concerns process.

4. Principles

The following principles apply to the Provider Concerns process:

• the safety and wellbeing of adults using the service is paramount;
• strong partnerships that acknowledge the expertise of others;
• openness and transparency to achieve positive outcomes;
• joint accountability for risk between commissioners, safeguarding leads, providers, the police, the local authority, the ICB and other stakeholders who may be involved;
• prudent targeted use of resources;
• information is shared responsibly between all agencies, including the provider;
• cooperation between agencies;
• natural justice.

How concerns are addressed depends on level of risk and the impact on people using the service. There are no hard and fast rules, and each case should be considered on its own merit. The process can challenge capacity of one service /organisation therefore it is important that there is a shared approach, breaking down barriers between services and organisations to provide a joined up, one team approach.

5. What is a Provider Concern?

The provider concerns process can relate to both contracted providers and non-commissioned providers. We have to acknowledge the difference between individual safeguarding concerns, assessment and investigations within a provider setting to that of concerns impacting on a larger group of individuals within that setting.

Additionally we must recognise the difference between issues that would be dealt with through normal contract management processes and what should be escalated under the Provider Concern Process and could ultimately constitute organisational abuse.

6. The Provider Concerns Process

The South Tyneside Safeguarding Children and Adults Partnership sets out a range of circumstances as to when the process should apply.  Provided below are some working examples:

• a number of safeguarding concerns raised for similar issues, within a few months of each other in respect of individuals who are receiving care from the same provider;
• a combined number of safeguarding concerns across a set of group homes owned by the same organisation;
• inappropriate recruitment processes or staffing levels;
• lack of, or unsuitable care plans.

In order to clarify these matters further we need to consider and establish what the working threshold level is for applying the provider concerns process. This is best achieved through the assessment of risk and is something which we will look at in more detail in the sections to follow.

6.1 Provider Concerns Threshold Level

At times it is difficult to decide whether or not a provider should go into provider concerns. Consideration should be given to the associated risk. Appendix 1, Provider Concern Process Flowchart and Appendix 2, Provider Concerns Threshold Table provide a summary and demonstrate combined threshold levels, as an indication as to how concerns should be managed.

It is important to view each situation on a case by case basis, collating inter-agency intelligence and utilising specific risk assessment processes. Risk can and should be considered at various stages of the process.  The risk assessment tool can be used to compile information to help decide whether a provider should go into serious concerns or it can be use throughout the process to monitor and mitigate risk. The risk assessment will cover safeguarding considerations and compliance information; it will also include a specific risk analysis of the provider and the current situation.

It is best to collate multi-agency information and gain an agreement as to the risks involved and whether to take the matter forward through the provider concerns process. It may be beneficial to use this to evidence the level of concern prior to initial decision making. It must be acknowledged that the collection of information must not delay initial conversations.

Where concerns are growing but not yet serious and time allows the provider intelligence meeting can be used, alternatively a decision from a responsible officer is required. If at this point the responsible officer feels matters are still unclear then the case should go into provider concerns and the decision taken at the initial meeting.

7. Roles and Responsibilities

7.1 Host authority

The local authority in the area where abuse or neglect has occurred is the host authority.

The host authority is responsible for:

• liaising with the regulator if any concerns are identified about a registered provider;
• determining if any other authorities are making placements, alerting them and liaising with them over the issues in question / under investigation;
• coordinating action under safeguarding and has the overall responsibility to ensure that appropriate action is taken and monitoring the quality of the service provided;
• ensuring that advocacy arrangements are in place where needed, and care management responsibilities are clearly defined and agreed with placing authorities;
• ensuring that there is a chair and administration of meetings, and provides a clear audit trail of agreements, responsible leads for particular actions and timescales;
• taking on the lead commissioner role in relation to monitoring the quality of the service provision.

7.2 Placing authority

The local authority that has commissioned the service for an individual/s delivered by a provider where there is a provider concern.

The placing authority is responsible for:

• duty of care to people it has placed that their needs continue to be met;
• contribute to safeguarding activities as requested by the host authority, and maintain overall responsibility for the individual they have placed;
• ensure that the provider, in service specifications, has arrangements in place for safeguarding;
• the placement continues to meet the individual’s needs;
• undertaking specific mental capacity assessments, or best interest decisions for, individuals they have placed;
• reviewing the contract specification, monitoring the service provided and negotiating changes to the care plan in a robust and timely way;
• all usual care management responsibilities;
• assessments under the Deprivation of Liberty Safeguards;
• keeping the host authority informed of any changes in individual needs and/or service provision.

7.3 Care Quality Commission

The Care Quality Commission (CQC)  acts independently. It is a valued partner in the process of information sharing and working to tackle areas of concern. Its expertise in working with providers and standard setting may support safeguarding processes. The CQC has the authority to take appropriate enforcement action where providers are found to be slipping, but have not yet breached the requirement. This supports the CQC’s approach to inspection and enforcement which is based less around compliance of set outcomes, and instead focuses on five key questions about care, the Fundamental Standards:

• Is it safe?
• Is it effective?
• Is it responsive?
• Is it caring?
• Is it well led?

Where there has been a recent inspection it may be helpful for providers to share pre-publicised reports, to support the principle of openness and transparency. In some instances providers may be addressing issues identified by inspections and adult safeguarding and it makes sense to address both through agreed joint processes.

7.4 Local authority

In most cases, the local authority will lead on safeguarding action in consultation with partners and in particular regulators. The principle on who is best to lead on an enquiry should always be determined by the issue, who the lead commissioner is and the knowledge and expertise required.

7.5 North East and North Cumbria Integrated Care Board

The Integrated Care Board (ICB) should be informed where there are a number of individual safeguarding concerns regarding people within a health commissioned service.  The ICB will progress these concerns through the Quality Review process.

7.6 Police

As with all criminal matters the police are the leads and must be consulted about any additional proposed action.

7.7 Frontline workers

Throughout the safeguarding processes a number of tasks and actions will be identified. The table below contains suggested roles, although action should always be determined on a case by case basis and the best qualified person to assess or assure the issue assigned. A system whereby professional knowledge and skills complement each other is the most effective way to safeguard people.

Agency / individual	Tasks
Social workers / managers Care managers Reviewing officers Contract monitoring officers Commissioners	Review care plans and risk assessments Analyse staff rotas Check incident / accident reports Review policy and procedures   Mental capacity and DoLS audits
Nurses Occupational therapists Physiotherapists Behavioural therapists Pharmacists	Infection control Review nursing and treatment plans Manual handling assessments Safety and use of equipment e.g. hoists Falls policies and strategies to reduce falls Medicine management
General Practitioners	Primary health care Raising safeguarding concerns
Northumbria Police Service, Community Safety Unit	Criminal investigations Wilful neglect Provide expertise on investigative practice Crime prevention visits
Legal services	Advice where there are legal challenges to safeguarding or contractual matters Advice on decommissioning decisions
Adults who use services	Raising concerns and complaints Monitoring improvements
Advocates Family / friends / visitors	Supported decision making Consulted on best interest decisions Raising concerns, monitoring improvements

8. Defining Roles, Responsibilities and Process

Various numbers of professionals and agencies may be involved with individuals and their care provider, all in a position to identify potential serious concerns. We will look at the key groups of professionals involved at a local level, how they interact with the process and consider how they operate to safeguard individuals, improve the quality of service delivery provided in our Borough and identify potential serious concerns.

Practitioners from all social work teams are in a key position to monitor the care environment across all types of contracted provision, assess the quality and delivery of provider care plans, provide early notification to quality and commissioning officers in relation to compliance and quality  issues or report safeguarding concerns.

Practitioners (from all teams) are responsible for ensuring that provider care plans and the actual delivery of care addresses the needs established during the assessment and are in accordance with the social care/health support plan.  Re-assessments must be conducted jointly with the care provider and changes to provision must be reflected in both the revised social care support plan and the provider care plan.

Where care planning and delivery is failing practitioners should raise the issues with the care provider.  Practitioners are responsible for reporting any identified safeguarding issues and engaging appropriately with the ongoing process. Where issues are related to contract compliance or quality concerns the practitioner must inform the commissioning team as appropriate and work with them accordingly.

Line managers and / or Assistant Team Managers must be informed of arising issues. In turn they make the initial decision as to whether these issues should be shared through the multi-agency monthly provider intelligence meeting, or should be progressed immediately to the Provider Concern Process.

The Let’s Talk Team (see Local Contacts) manage all safeguarding concerns and capture the information presented through the initial contact. This in turn is forwarded on to the relevant Adult Social Care Manager who is responsible for investigating concerns raised in relation to adults at risk. Within the first 24 hours, the duty manager evaluates the situation and decides whether to progress through the recognised safeguarding processes. Any safeguarding alerts that include a provider as an alleged perpetrator will be progressed via the Safeguarding Team.

The Let’s Talk Team play a crucial role in collating and interpreting information from various sources to build up a picture of what is happening across our contracted care providers. Working in conjunction with key partners they take a preventative approach, working to support and educate providers thus stopping issues escalating into what would be considered as serious provider concerns. Where the threshold for provider concerns has been reached the safeguarding team form a part of the multi-agency response.

9. Adults who use Services / Carers / Advocates

As with Section 42 enquiries it is essential that adults using the service are spoken to, and encouraged and supported to:

• tell us what outcomes they want
• raise complaints and concerns;
• questioning when care is not provided according to care plans;
• care is not delivered when expected; or
• care is not provided with dignity and respect.

Where there are patterns of complaints and concerns these may indicate poor quality service or a safeguarding concern.

10. Differentiating between Poor Care and Potential Safeguarding Issues

10.1 Poor care

Poor care, includes instances of:

• a one-off medication error (although this could have had very serious consequences);
• an incident of under-staffing, resulting in a person’s incontinence pad being unchanged all day;
• poor quality, unappetising food;
• one missed visit by a care worker from a home care agency.

10.2 Potential causes for concern

Potential causes for concern, include instances of:

• a series of medication errors;
• an increase in the number of visits to A&E, especially if the same injuries happen more than once;
• changes in the behaviour and demeanour of adults with care and support needs;
• nutritionally inadequate food;
• signs of neglect such as clothes being dirty;
• repeated missed visits by a home care agency;
• an increase in the number of complaints received about the service;
• an increase in the use of agency or bank staff;
• a pattern of missed GP or dental appointments;
• an unusually high or unusually low number of safeguarding alerts.

There should be careful analysis to understand what is intentional and unintentional harm. However, where there is unintentional harm due to lack of guidance for staff this may also constitute organisational abuse.

 Appendix 1: Provider Concerns Process Flowchart

Click here to view Provider Concern Process Flowchart

Appendix 2: Provider Concerns Threshold Table

Click here to view Provider Concerns Process

Appendix 3: Provider Intelligence Meeting (Domiciliary Care and Care Homes)

Sharing information on quality and safeguarding, strengthening the relationship and knowledge sources from commissioning, safeguarding, CQC, ICB and front line practitioners assists in driving up standards. Formal mechanisms for sharing information between agencies are helpful to determine risk levels and the most proportionate response. The purpose of such mechanisms is to ensure both soft and hard intelligence, available agencies is brought together in an effective and cohesive manner to facilitate timely action.

South Tyneside local authority has implemented a formal intelligence meeting, with key partners from the CQC and the ICB. The ‘Provider Intelligence Meeting’ has the ability to:

• reduce the need for safeguarding under Provider Concerns procedures;
• enhance the standards of care and support by sharing early warning signs with providers;
• target resources effectively to reduce duplication;
• support prevention strategies;
• support continuous service improvements.

3.1 Liaising and reporting to the police 

Information arising from these meetings should always be provided to the police where there is an indication of possible crime. It may also be prudent to have police presence at such meetings, so that they can make an early assessment. Local protocols will determine how information is shared with the police.