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.


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.


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.


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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