Annual report for 2022-23

Professionals and volunteers across our partnership aim to work collaboratively to prevent and reduce harm to adults at risk in the borough.

The SAB seeks to support this work by ensuring that all residents and people who work with adults at risk in H&F are able to recognise potential abuse or neglect, and know how to respond.

We also play a role in gathering assurance that adult safeguarding arrangements are effective, and that we work within the principles of Making Safeguarding Personal by putting the person at the centre of everything we do. 

The local picture

The SAB seeks to make use of data to ensure that we are making evidence-based decisions and understand how abuse and neglect impact on H&F residents.

We have produced a focused report which contains an overview of the demographic of our borough and information about how adults at risk of harm are protected from abuse or neglect through the use of section 42 safeguarding enquiries.

What we’ve been working on

Our focus in the last year has been on revitalising the work of the SAB, re-establishing our purpose, and ensuring we are evidence-based.

Key to this work has been the creation of our new Quality in Practice subgroup, led by Helena Peros (H&F Designated Professional Safeguarding Adults, North West London NHS ICB) with co-chair Kay Carpenter (Manager of ASC Safeguarding Hub).

This group was established to gain a strategic overview of safeguarding adult activity across the partnership and promote best practice and learning. This group has already made an impact by reviewing the SAB’s use of local data and developing a survey to better understand the views of operational staff in the borough.

The group has also reviewed the SAB’s compliance with the Care Act statutory guidance, and this has highlighted the need to develop a local framework for responding to allegations against Persons in Positions of Trust. A task and finish group has been established to address this with hopes to conclude this piece of work by September 2023.

Our Safeguarding Adults Case Review Group has also developed over the past year and is now better established and structured, thanks to the leadership of Lisa Redfern (Strategic Director, Adult Social Care) and Parminder Sahota (Director of Safeguarding, West London NHS Trust) who co-chair the group. This has involved a review of our terms of reference and the development of new checklists based on the Safeguarding Adults Review Quality Markers.

Two Safeguarding Adults Reviews were commissioned in 2022-23, the first in the borough (see below) and the group has helped to ensure we take a proactive approach to learning from this process.

We have also started to think about how we capture the learning from non-statutory reviews, creating a 7-minute briefing based on learning from a local case that centred on domestic abuse. The group has also developed two guides to support those involved in SARs, with one aimed at family, friends and carers and another aimed at professionals.

Safeguarding Adults Reviews: Information for family, friends and carers

Safeguarding Adults Reviews: Information for professionals

The High-Risk Panel, established in 2018-19, has also continued to operate with leadership from Lloyd Palmer (H&F Borough Commander LFB) and Christopher Nicklin (Assistant Director for Quality, Safety and Performance, Adult Social Care).

The panel has seen an increase in the number of referrals and has supported decision making in a range of complex cases. The majority of the cases heard at this panel relate to issues around hoarding and fire risk.

However, there is recognition that this panel may have a role in other types of self-neglect cases which have reached a level of high risk, for instance where a person may be neglecting their health to the extent that it presents a risk to their vital interests.

The SAB intends to review the remit of this group in 2023-24, which will include consideration of panel membership to ensure that we have the right people at the table to make informed decisions.

Individual agencies have also been working hard to improve the way we engage with adults at risk in the borough, ensuring we are outcome focused and working in a person-centred way.

Safeguarding Adults Reviews

Under the Care Act 2014, the SAB is responsible for the coordination of Safeguarding Adults Reviews (SARs).

These independent reviews are commissioned where there has been an incident of serious harm or death involving an adult at risk, and focus on capturing learning. They set out to establish what may have gone wrong and to identify where agencies or individuals could have acted differently or worked better together.

In 2022-23 the H&F SAB concluded its first SAR and we are now working to implement the recommendations locally.

Alison

Alison was in her late fifties and lived with her civil partner. Alison had a long history of substance misuse, and her drug use was considered as a significant contributory factor in her multiple health issues. Alison was also a smoker and smoked around twenty cigarettes a day.

A SAR was commissioned following Alison’s death in December 2021 as a result of a fire in her own home. 
There were a number of agencies who had regular contact with Alison, whilst others struggled to maintain engagement with Alison, who would decline offers of support. This review sought to understand how professionals are able to balance risk with a person’s right to choice and autonomy.

The review also considered the response taken to two previous fatal fires in the borough, which has led to the creation of a local action plan.

What have we learnt?

Importance of multi-agency working

The review has placed a spotlight on the importance of effective multi-agency working. Multi-agency communication is key to reducing the risks for any case and avoiding silo-working. Having an awareness of what other partners can provide to mitigate risks also helps us to plan and share risks.

Improving understanding of fire risk and our responses

This process has also highlighted gaps in understanding of how we assess fire risk, with some training provisions not being sufficient to cover fire risk in the home. In addition, more work is needed to ensure that we have robust risk assessments and that practitioners have an understanding of what they can do to mitigate any identified risk.

Consideration of mental capacity

Whilst Alison was deemed to have the capacity to make decisions in relation to her care and support needs, the review has led to reflection on how we understand fluctuating capacity and executive functioning. This is particularly pertinent when a person is known to be living with addiction.

Read the Safeguarding Adults Review for Alison

What will we do in response?

Partners within the H&F SAB partnership have taken a proactive approach to learning from this review, with a number of initiatives already put in place.

Multi-agency working

The H&F SAB partnership is committed to strengthening the way in which we work together to protect adults at risk. An example of this work is improved links between the London Fire Brigade and other partner agencies including H&F Adult Social Care and H&F Housing, where there now better relationships in terms of fire safety multi-agency approaches.

The concept of 'Making Every Contact Count' has been introduced as part of this initiative, and this seeks to ensures that all professionals make every possible use of the contact had with vulnerable people in our communities, offering education and advice and, where appropriate, making referrals to partner agencies where wider specific support needs can be offered.

In April 2023, the London Fire Brigade introduced a new system for conducting Home Fire Safety Visits. This will allow them to prioritise the most vulnerable by using new risk categories. Locally, the LFB are seeking to host multi-agency sessions to offer further support and advice around the application of the new process.

The LFB are also considering how they can respond to the recommendations that LFB take a new leading role within multi-agency meeting and mental capacity assessments relating to fire risk, with discussions on how this will look in practice.

Risk assessment and response

The care provider involved in Alison’s care has done a great deal of work to improve responses to home fire safety, including the creation of a new, more robust risk assessment tool. This work has been supported by the work of LBH&F commissioning services, who have included fire safety as a standing item in monthly contract monitoring. Commissioners have also sought to strengthen communication links with the LFB, with regular updates and training opportunities shared with all known providers registered in the borough.

Adult Social Care has also included a new prompt within their case records database (Mosaic) to complete Person-Centred Fire Risk Assessments with a clearer escalation process. The local authority has also committed to consideration of Personal Protective Equipment to mitigate fire risk, with funds being allocated for this purpose.

These efforts are supported by the London Fire Brigade, who have been delivering multi-agency training to local partners focused person-centred fire risk assessment.

The Central London Community Healthcare NHS Trust has also responded to the learning by dip sampling records of patients who are bedbound or had reduced mobility, to see if a checklist has been completed and LFB home safety visit requested.

Awareness

We have also created an action plan in response to the recommendations within the report in order to monitor partner responses, and with a view to take collective action in areas such as raising awareness of home fire safety and promoting expected best practice in multi-agency working.

An example of this within partner organisations is the work of the Central London Community Healthcare NHS Trust, who has sought to raise awareness of fire safety through the development of posters, sticks and banner pens, and a specific page within internal intranet safeguarding pages to create a specific page with QR code for staff to easily access resources and information on fire safety.

‘Fire safety in care settings’ awareness has also been added to the CLCH statutory and mandatory training resource, and the team plan to expand on this by hosting lunch and learn webinars and including fire safety as a topic at the CLCH safeguarding conference planned for September 2023.

Other healthcare providers, such as Imperial College London NHS Trust, have also been working with frontline staff to promote the importance of fire prevention, whilst

The West London NHS Trust has also launched a new self-neglect toolkit which provides practitioners with specialist assessment tools and escalation options.

Another important area we need to consider is legal literacy, particularly when working with someone who may have fluctuating capacity. This includes the promotion of different methods and pathways that can be used to manage risk, as well as consideration of case law and inherent jurisdiction. This will be a focus for the SAB as we seek to embed the learning from this SAR.

SARs expected to be concluded in 2023-24

The H&F SAB are now in the final stages of our second SAR. This SAR focuses on the death of a man who lived with a number of physical and mental health issues, and substance misuse. He had also experienced homelessness and had been previously detained in prison.

Initial learning from this SAR centres on:

• the importance of multi-agency working and effective communication
• how we assess the mental capacity of people who use alcohol and, or substances
• how we engage with adults at risk who are difficult to engage

Some of this learning will overlap with what we have learned from Alison’s case. We continue to consider how we can take a proactive to this learning.

What’s next

Our new strategy for 2023-24 focuses on preventative safeguarding practice and learning from practice, with 3 priority areas.

Effective systems and processes

We will use an evidence-based approach to develop our responses to potential abuse and neglect and areas of complexity.

Creating a culture of learning

We will promote continuous improvement in safeguarding practice by learning from experience and supporting workforce development.

Communication and partnership

We will work seek to build active partnerships and expand our network.

This work will consider how we share learning from SARs and other review processes widely across the partnership, with a clear methodology for reviewing the impact on practice. We also want to explore how we expand our reach beyond the immediate SAB membership, by engaging with the local voluntary and community sector and raising awareness in H&F communities on how to spot signs of potential abuse and neglect and seek support.

Self-neglect has also been identified as an important area for us in H&F, and this also links to our plans to review the understanding and application of the Mental Capacity Act by H&F practitioners and promote a deeper understanding of how this legislation can be applied in practice.

We also want to focus on promoting the importance of multi-agency working in safeguarding adults at risk, showcasing best practice in the borough as we do so.

Throughout all of this work, our aim is to keep those we seek to protect at the centre of what we do. We want to do more to capture the voice of service users and understand how abuse and neglect affects our communities.

To learn more about what we aim to achieve next year, please see our strategic plan for 2023-24.