Complex cases audit - learning briefing
Overview
This briefing summarises the findings and learning outcomes of a SAB multi-agency audit of complex safeguarding cases.
We encourage staff in all SAB partner agencies working with adults with care and support needs to read the briefing and discuss it in your team meetings.
Background to the audit
The Performance, Quality and Audit subgroup undertakes themed multi-agency audits on behalf of the East Sussex Safeguarding Adults Board. In November 2018, it conducted an audit of complex safeguarding cases.
The audit group had representatives from:
- East Sussex Adult Social Care and Health
- Sussex Police
- East Sussex CCGs
- Sussex Partnership NHS Foundation Trust (SPFT)
- East Sussex Healthcare NHS Trust (ESHT)
- National Probation Service
- Eastbourne Borough Council
- Change Grow Live (CGL)
- BHT/Fulfilling Lives
- Kent Surrey and Sussex Community Rehabilitation Company (KSS CRC).
Focus of the audit
The audit assessed how partner agencies work together to manage complex safeguarding cases. It looked at the effectiveness of approaches to adults:
- with complex and multiple support needs, including high risk factors, such as substance misuse and mental health issues
- who self-neglect
- who may lack capacity
- who practitioners may find challenging to engage.
In each case, the audit considered agencies’ responses and assessed effectiveness in the following areas:
- risk assessment
- safeguarding planning and intervention
- multi-agency working including information sharing
- multi-agency working
- professional knowledge and professional curiosity
- management oversight and supervision
- making safeguarding personal
Cases the audit looked at
Case A - a woman with schizophrenia and complex support needs, including alcohol misuse and self-neglect.
Case B - a male carer at risk from abuse from a close relative with serious mental health issues.
Case C - a woman with physical health support needs and at risk due to self-neglect, substance misuse and domestic abuse.
Case D - a man with complex and multiple support needs. These included physical disability and issues around substance misuse, self-neglect and exploitation.
Case E - a woman with a learning disability at risk of sexual and financial exploitation.
The audit findings and recommendations
The audit identified strengths and examples of good practice and some areas for improvement and development.
What was done well
- Effective multi-agency working and information sharing in several cases including good use of multi-disciplinary team meetings.
- The application of Making Safeguarding Personal in several cases.
- Good use of the self-neglect procedures in one case.
- Professional curiosity demonstrated and exploration of alternative options including legal avenues, to reduce risk.
- Some cases demonstrated good knowledge and application of the Sussex Safeguarding Adults Policy and Procedures by the agencies involved.
- Consideration and application of the Human Rights and Mental Capacity Act principles.
- Persistence, patience and flexible approach by practitioners when working with adults who at times appear to be difficult to engage.
What could be improved
The audit highlighted these areas for improvement:
- Communication between agencies could have been better in some cases. For example, sharing meeting minutes and communication with Primary Care agencies.
- The importance of communication and involving family members in complex cases.
- Agencies would find it helpful to have a specific risk assessment template to use with the self-neglect policy and procedures.
- Third sector organisations may not be aware of avenues to challenge decisions within safeguarding processes, for example the Sussex escalation and resolution protocol.
- There were some issues with how safeguarding concerns and enquiries are identified and recorded.
- Feedback to referring agencies on safeguarding concerns and subsequent actions could be more consistent.
- The benefits of improved joint working between agencies working with adults who may be difficult to engage.
The audit group developed an action plan to address the areas for improvement and development.
The subgroup will monitor progress in implementing the action plan.
The importance of communication
The audit highlighted the importance of effective communication between agencies working together in complex safeguarding cases.
- Think about who needs to be involved in multi-agency meetings and plans. It is especially important to consider how GP practices can contribute to the process and what information they need or can provide.
- When circulating notes of meetings and agreed actions, make sure you include agencies who were not present at the meeting but who need to know what you agreed.
- Think about family members and friends. Talk to the adult concerned – who do they want to be involved?
- Provide feedback to those who raise safeguarding concerns. Keep them informed throughout the process and let them know the outcome.
Resolving problems
All professionals should feel able to challenge decision making. This is their right and responsibility, to promote the best multi-agency safeguarding adults and mental capacity practice.
The Sussex escalation and resolution protocol explains how to manage disagreements between different agencies or professionals about safeguarding or making decisions about mental capacity. It emphasises the importance of working together effectively and cooperating to resolve disagreements as quickly as possible.
The Sussex information sharing guide and protocol sets out an agreed set of principles and standards about sharing confidential and sensitive personal data.
Making safeguarding personal
The audit reinforced the importance of Making Safeguarding Personal and ensuring that we learn from feedback from adults who are the subject of safeguarding enquiries.
One of the cases audited involved a female with multiple and complex support needs. These included a history of abusive relationships, self-neglect, substance misuse, self-harm and offending behaviour.
One of the main challenges in this case was the adult’s chaotic lifestyle and her suspicion of agencies.
Despite this, staff in the agency supporting her used flexibility and persistence to maintain contact. They met with her to ask her about her experience of the safeguarding process. She provided valuable feedback about how adults with complex needs, including substance misuse, can be better supported by services on their release from prison.
Working with adults who may be difficult to engage
In line with Making Safeguarding Personal, it is important to promote a person’s choice and control whilst recognising the statutory obligations to protect people from the risk of abuse or neglect and harm.
We can achieve effective engagement by applying key principles of respect, equality, partnership, social inclusion and empowerment. Practitioners should understand the complexity of the person’s background. They should show compassion about how this has led to their current circumstances.
Key principles
- Who is best placed to work with and build a trusting relationship with the adult? Who else can support with this, such as a family member, advocate, other professional?
- Find the right tone. It is important to be honest about potential consequences, while being non-judgemental and separating the person from the behaviour.
- Progress at the adult’s pace. Allow conversations to take place over a period of time and focus on finding out what motivates them.
- Ensure that the adult receives information about practical options for support in a format they can understand. Check whether they understand these options and the consequence of their choices.
- If there is doubt about a person’s mental capacity, complete a decision-specific capacity assessment.
- Develop a plan which clearly sets out options and agreed actions. It is important to offer choices and respect the person’s judgement.
- Ensure the person is involved as much as possible, for example making sure they are invited to meetings.
- It's important that front-line practitioners can access effective supervision and training within their organisation.
Professional curiosity
One of the cases audited involved a woman with a learning disability who was at risk of sexual and financial exploitation. There was generally a good multi-agency response to reduce risk. However in this case the audit group felt there was one occasion when a health professional should have demonstrated greater professional curiosity.
Having a conversation with the adult | Sussex safeguarding adults policy and procedures has useful guidance on how to talk to an adult who may be at risk from abuse.
- Always speak to the adult in a private place where they are likely to feel safe.
- Use open questions to gain an understanding of the situation, the person’s wishes and what actions may need to be taken. Do not ask leading questions or make enquiries inappropriately.
- If something has happened, get the adult’s views on what took place and what they want done about it.
- Give them information in an accessible format about:
- advice, support and different options that may be available to them
- the safeguarding adults procedures and how these could help to make them safer
- responsibilities of people working with adults to share information where there may be concerns of abuse or neglect.
- Support the adult to ask questions about issues of confidentiality.
- Consider any advocacy support needs.
- Explain what will happen next, and how they will be kept informed and supported
Guidance on raising safeguarding concerns
The Sussex safeguarding adults policy and procedure has guidance on raising concerns about abuse and neglect. This helps build confidence and consistency in deciding when an issue is a safeguarding concern.
The guidance helps staff across all agencies consider risk and potential safeguarding concerns involving adults with care and support needs. It ensures staff report safeguarding concerns when appropriate and the response to reports is consistent.
Use this and your own agency’s safeguarding policy and procedures.
