NYSAB

Stage 3 – Safeguarding Response

6.1 Safeguarding Response
6.2 Risk Assessment
6.3 Role of the Local Authority
6.4 Criminal Investigations
6.5 Ill Treatment and Wilful Neglect
6.6 Desired Outcomes for the Adult
6.7 Considering How Best to Help the Adult at Risk
6.8 Points to Consider
6.9 Objectives (of the conversation to determine the safeguarding response)
6.10 Desired Outcomes Identified by the Adult
6.11 Planning an Enquiry as part of the Safeguarding Response
6.12 Communication and Actions
6.13 Support Networks
6.14 Types of Safeguarding Enquiries
6.15 Linking Different Types of Enquiries
6.16 Action against the Person(s) Alleged to have Caused Harm
6.17 Support for People who are Alleged to have Caused Harm
6.18 Feedback to People who are Alleged to have Caused Harm
6.19 Care and Support Provider Duties
6.20 Local Authority Duties – Cross Border Arrangements
6.21 Providers Undertaking the Enquiry
6.22 Provider Duties to the Person Alleged to have Caused Harm
6.23 Disciplinary Investigations and Referrals to the Disclosure and Barring Service (DBS)
6.24 Providers and Duty of Candour
6.25 Organisational Enquiries
6.26 Enquiry Reports
6.27 Standards and Analysis

7.1 Safeguarding Response

Some safeguarding enquiries require more work and a relatively small number of cases require in depth and sometimes complex enquiries which may involve families, Police, employers etc. All enquiries should establish what action needs to be taken to prevent or stop abuse or neglect.

The safeguarding objectives are to agree what the adult or their representative wants to happen (the outcomes), identify any risks, and agree the actions necessary to manage those risks in terms of removing or reducing them.

The safeguarding response should be seen as a tool kit of options to proportionately manage any risk posed to the adult.

Where an enquiry involves an identifiable adult, local authorities should aim to provide a swift and personalised safeguarding response, involving the adult in the decision making process, as far as possible.

Where the adult has significant difficulties understanding or making decisions, appropriate family or friends can act as a representative, or where no such person is available or appropriate an advocate must be used.

A personalised safeguarding response may involve a face to face meeting(s) with the adult/ representative to agree the desired outcomes and whether these have been achieved or not.

The local authority should record the information received, the views and wishes ascertained, the decisions taken, and the reasons for them and any advice and information given.

A personalised enquiry is aimed at achieving the desired outcome(s) as determined by the adult, their representative or through a best interest decision.

Enquiries are normally finalised by determining if there are no further actions to be taken, or if those actions taken have removed or reduced the risk and if a risk remains, what on-going work will try and continue to manage the risk.

Outcomes will also involve a determination by the adult or representative if the enquiry work has fully, partially or not achieved their desired outcomes.

Again such outcome determinations can range from a conversation between the Enquiry Officer and the adult/representative through to a multi-agency outcomes meeting. Multi-agency meetings will only be required where there is a need to manage on-going risk.

ACTIONS AND DECISIONS UNDER SECTION 42 ENQUIRIES

Action	a) Identify Enquiry Lead/Officer b) Clarify the adults desired outcomes c) Plan the Enquiry d) Identify links to other procedures in progress e) Undertake agreed action(s) f) Update/agree the safeguarding plan g) Agree communication(s) h) Agree outcomes for the person(s) alleged to have caused harm, if relevant i) Evaluation by the adult/advocate j) Explore recovery and resilience	Safeguarding Co-ordinator Adult / Advocate Enquiry Lead Officer
Decisions	a) What type of enquiry is appropriate and proportionate b) Who should lead and who should contribute c) Does the Enquiry Report (where required) meet standards d) Is it necessary for the Enquiry to be taken over by the Local Authority e) Whether to close the Enquiry down f) Action(s) for the adult g) Actions for the person alleged to have caused harm	Safeguarding Co-ordinator / delegated Enquiry Lead Officer in consultation with the adult and others

The Care Act provides no legal framework for deciding on a balance of probabilities if abuse has occurred, but in some circumstances factual information is likely to be known which may result in some sort of action being taken, for example by the Police, the employer, or a referral being made to a professional body .

7.2 Risk Assessment

It is important when considering the enquiry to approach reports of incidents or allegations with an open mind. In considering how to respond the following factors need to be considered:

The adult’s need for care and support;
The adult’s risk of abuse or neglect;
The adult’s ability to keep themselves safe or the ability of their networks to increase the support they offer;
The impact on the adult;
The frequency;
The severity;
Their wishes;
The possible impact on important relationships;
The potential increasing risk to the adult;
The risk of repeated or increasingly serious acts involving children, or another adult or abuse or neglect;
The responsibility of the person or organisation that has caused the abuse or neglect;
Research evidence to support any intervention;
Consider need for a safeguarding plan (see Stage 4).

Whilst it is important to focus on the risk(s) to the adult concerned, it is equally important to consider the potential risk to others, including children or other adults at risk.

Sometimes actions are required that relate to the safety of others irrespective of the adult’s wishes.

7.3 Role of the Local Authority

The local authority should decide very early on in responding to the concern, who is the best person/organisation to lead on the enquiry. The local authority retains the responsibility for ensuring that the enquiry is referred to the right place and is acted upon.

If the local authority has asked someone else to make enquiries, it is able to challenge the organisation/individual making the enquiry if it considers that the response and/or outcome are unsatisfactory. In exceptional cases, the local authority may undertake an additional enquiry, for example, if the original enquiry fails to address the safeguarding concern(s).

The degree of involvement of the local authority will vary from case-to-case, but at a minimum must involve decision making about how the enquiry will be carried out, oversight of the enquiry, decision making at the conclusion of the enquiry about what actions are required to reduce risk. This must also include ensuring data collection is carried out, and quality assurance of the enquiry report has been undertaken.

This decision on how the enquiry is progressed will vary with each local authority. Some authorities may place the decision making in the hands of specialist Social Workers working in Safeguarding Teams with oversight and closure by a Manager. Other local authorities may have different structures and only allow Managers acting as their Safeguarding Co-ordinators, to be their decision makers.

Refer to local operational guidance in your local area.

7.4 Criminal Investigations

Although the local authority has the lead role in making enquiries or requesting others to do so, where criminal activity is suspected, early involvement of the Police is essential.

Police investigations should be coordinated with the local authority who may support other actions, but should always be Police led.

7.5 Ill Treatment and Wilful Neglect

The Police will determine whether there should be criminal investigations where there is ill treatment and wilful neglect. There are a number of possible offences which may apply, including the specific offences mentioned below.

Section 44 of the Mental Capacity Act 2005 makes it a specific criminal offence to wilfully ill-treat or neglect a person who lacks capacity.

Section 127 of the Mental Health Act 1983 creates an offence in relation to staff employed in hospitals or mental health nursing homes where there is ill-treatment or wilful neglect.

Sections 20 to 25 of the Criminal Justice and Courts Act 2015 relate to offences by care workers and care providers.

7.6 Desired Outcome(s) for the Adult

Where the enquiry is not quickly and proportionately finalised and it involves an identifiable adult, the adult should experience the safeguarding process as empowering and supportive.

It is essential to establish from the outset what the adult wants to happen now, and what their desired outcome(s) is in order to make the enquiry personal to their wishes and situation. This should be seen as a series of conversations to determine their desired outcome(s), and to continue to check that these remain the same, throughout the enquiry.

Desired outcomes are those changes that the adult at risk wants to achieve from the support they receive, such as feeling safer at home, access to community facilities, restricted or no contact with certain individuals or pursuing the matter through the criminal justice system.

It is vital that the views of the adult are sought and recorded. Sometimes the adult may have unrealistic expectations of what can be achieved through the safeguarding enquiry, and the adult should be supported to understand from the outset if, and how their desired outcome(s) can be met.

Their wishes and desired outcome(s) are important in determining the appropriate and proportionate response to the concern(s) raised. Sometimes action(s) are required without the adult’s consent as described in Section 3.5.

The support needs of the adult should be considered and provided to enable them to contribute their views and wishes. This will include, but not be limited to support with communication needs. Where a person needs support or representation this will often be provided by a friend or relative.

However, where the person lacks mental capacity, or has a ‘substantial difficulty’ in being involved in the enquiry, and they have no one other than those acting in a professional capacity to support them, an independent advocate will be required.

7.7 Considering How Best to Help the Adult at Risk

7.8 Points to Consider:

The pace of conversations;
Whether the presenting issue identifies the risk to the adult’s safety, or whether there are additional risks to be considered;
Wider understanding and assessment of the adult’s overall wellbeing.

The adult should be aware at the end of any conversation what action will be taken, and provided with contact details for key people. Some local authorities have prepared written information to be left with the adult/representative for reference.

7.9 Objectives (of the conversation to determine the safeguarding response)

Seek consent from the adult to undertake a safeguarding enquiry;

Establish the facts (avoiding leading questions);
Ascertain the adult’s views and wishes and preferred outcomes;
Assess the needs of the adult for protection, support and redress, and how these might be met;
Protect the person from the abuse and neglect, in accordance with the wishes of the adult where possible;
Enable the adult to achieve resolution where possible.

Enquiries need to be handled in a sensitive and skilled way to ensure minimal distress to the adult. Where information is already known people should not have to tell their story again, this does not prevent clarification being sought where necessary.

There is a skill involved in eliciting information and asking the right questions, to ascertain what the concern is, how it impacts on the adult, what action they would find acceptable and the level of associated risk. Whilst it is essential to put the adult at ease, and to build up a rapport, the objectives of an enquiry should focus the conversation with the agreed objectives and actions to be taken to remove or minimise risk clearly recorded.

7.10 Desired Outcomes Identified by the Adult

The desired outcome by the adult should be clarified and confirmed by the conversation(s), to:

Ensure that the outcome is achievable;
Manage any expectations that the adult may have and;
Give focus to the enquiry.

Staff should support adults to think in terms of realistic outcomes, but should not restrict or unduly influence the outcome that the adult would like. Outcomes should make a difference to risk, and at the same time satisfy the adult’s desire for justice and enhance their wellbeing.

The adult’s views, wishes and desired outcomes may change throughout the course of the enquiry process. There should be an on-going dialogue and conversation with the adult to ensure their views and wishes are checked as the process continues, and enquiries re-planned should the adult change their views.

Talking through an enquiry may result in resolving it. If not, the duties under Section 42 continue. If the adult has capacity and expresses a clear and informed wish not to pursue the matter further, the local authority should consider whether it is appropriate to close the enquiry.

It should consider whether it still has reasonable cause to suspect that the adult is at risk and whether further enquiries are necessary before deciding if further action should be taken. The adult’s consent is not required to take further steps, where appropriate, but the local authority must bear in mind the importance of respecting the adult’s own views. Refer to 3.5. of the policy.

This decision will be made by the local authority by checking with the adult and consulting with relevant partners and their advocate.

7.11 Planning an Enquiry as part of the Safeguarding Response

All enquiries need to be planned and coordinated and key people identified. No agency should undertake an enquiry prior to a planning discussion or meeting, unless it is necessary for the protection of the adult or others; however, a planning meeting could be just a discussion of the case between the manager or the adult and the Enquiry Officer.

Dependent upon the complexity of an enquiry the Enquiry Officer/Safeguarding Co-ordinator may wish to convene a multi-agency planning meeting.

Enquiries are proportionate to the particular situation. The circumstances of each individual case determine the scope and who leads it. Enquiries should be outcome focused, and best suit the particular circumstances to achieve the outcomes for the adult.

There is a statutory duty of co-operation and in most cases there will be an expectation that an enquiry will be made as requested. The statutory duty does not apply if co-operation would be incompatible with an organisation’s own duties, or would have an adverse effect on its own functions.

If an organisation declines to undertake an enquiry or if the enquiry is not done, local escalation procedures should be followed. The key consideration of the safety and wellbeing of the adult must not be compromised in the course of any discussions or escalation, and it is important to emphasise that the duty to co-operate is mutual.

When planning an enquiry, a review should be made of:

The adult’s mental capacity to understand the type of enquiry, the outcomes and the effect on their safety now and in the future;
Whether consent has been sought;
Whether an advocate or other support is needed;
The level and impact of risk of abuse and neglect;
The adults’ desired outcome;
The adults own strengths and support networks.

7.12 Communication and Actions

It may be helpful to agree the best way to keep the adult and relevant parties informed. Where the enquiry is more complex and requires a number of actions that may be taken by others to support the outcome, it may be appropriate for a planning meeting to be held. Where enquiries are simple single agency enquiries, it may not be necessary to hold a meeting. Action should never be put on hold, due to the logistics of arranging meetings. Proportionality should be the guiding principle.

If the adult wishes to participate in a meeting with relevant partners, one should be convened. If the adult does not have the capacity to attend, then an advocate should represent their views. If it is appropriate consideration should be given to notifying Commissioners.

GOOD PRACTICE GUIDE INVOLVING THE ADULT IN SAFEGUARDING MEETINGS

Effective involvement of the adult and/or their representative in safeguarding meetings requires professionals to be creative and to think in a person-centered way.

a) How should the adult be involved?

b) Preparation with the adult

c) Where is the best place to hold the meeting?

d) How long should the meeting last?

e) Timing of the meeting?

f) Agenda

g) Who should chair?

h) Agreement by all parties to equality

i) Communication needs

j) Access

Co-operation between organisations to achieve outcomes is essential and that actions are coordinated to ensure the safety of the adult is paramount. Information sharing should comply with all legislative requirements and be timely.

Where one agency is unable to progress matters further, for example a criminal investigation may be completed but not necessarily achieve the adult’s desired outcome (e.g. criminal conviction), the local authority in consultation with the adult and others will/may decide whether further action is needed and if so, what action is needed.

7.13 Support Networks

The strengths of the adult at risk should always be considered. Mapping out with the adult, and identifying their strengths and that of their personal network may reduce risks sufficiently so that people feel safe without the need to take matters further.

Risk should be assessed and managed at the beginning of the enquiry and regularly reviewed throughout the enquiry.

7.14 Types of Safeguarding Enquiries

A range of options can be found at the Local Government Association website for Making Safeguarding Personal.

Enquiries can range from non-complex single agency interventions to multi-agency complex enquiries. The key questions in choosing the right type of enquiry, is dependent on:

What outcome does the adult want?
How can enquiries be assessed as successful in achieving outcomes?
What prevention measures need to be in place?
How can risk be reduced?

Identifying the primary source of risk may assist in deciding what the most appropriate and proportionate response to the individual enquiry might be. There are no hard and fast rules and judgement will need to be made about what type of enquiry and actions are right for each particular situation.

GOOD PRACTICE GUIDE

Types of Enquiries	Who Might Lead
Criminal (including assault, theft, fraud, hate crime, domestic abuse and abuse or wilful neglect)	Police
Domestic abuse (serious risk of harm)	Police coordinate the MARAC process
Anti-social behaviour (e.g. harassment, nuisance by neighbours)	Community Safety services/local Policing (e.g. Safer Neighbourhood Teams).
Breach of tenancy agreement (e.g. harassment, nuisance by neighbours)	Landlord/ Registered Social Landlord/ Housing Trust/ Community Safety Services
Bogus callers, rogue traders, and fraud and scams	Trading Standards / Police
Complaint regarding failure of service provision (including neglect of provision of care and failure to protect one service user from the actions of another)	Manager/ Proprietor of service/ Complaints department Ombudsman (if unresolved through Complaints procedure)
Breach of contract to provide care and support	Service Commissioner (e.g. Local Authority, NHS CCG)
Fitness of registered service provider	CQC
Serious Incident (SI) in NHS settings	Root Cause Analysis investigation by relevant NHS Provider
Unresolved serious complaint in health care setting	CQC, Health Service Ombudsman
Breach of rights of person detained under the MCA 2005 Deprivation of Liberty Safeguards (DoLs)	CQC, Local Authority, OPG/ Court of Protection
Breach of terms of employment/disciplinary procedures	Employer
Breach of professional code of conduct	Professional Regulatory Body
Breach of health and safety legislation and regulations	HSE / CQC / Local Authority
Misuse of enduring or lasting power of attorney or misconduct of a court-appointed deputy	Office of the Public Guardian(OPG)/ Court of Protection/ Police
Inappropriate person making decisions about the care and wellbeing of an adult who does not have mental capacity to make decisions about their safety and which are not in their best interests	OPG/Court of Protection
Misuse of Appointeeship or agency	Department of Work and Pensions (DWP)
Safeguarding Adults Review (SAR) (Care Act Section 44)	Local Safeguarding Adult Board

Choosing the right type of enquiry, is dependent on:

What outcome does the adult want?
How can enquiries be assessed as successful in achieving outcomes?
What prevention measures need to be in place?
How can risk be reduced?

7.15 Linking Different Types of Enquiries

There are a number of different types of enquiries. It is important to ensure that where there is more than one enquiry that information is dovetailed to avoid delays, interviewing staff more than once, making people repeat their story.

Other processes including Police investigations can continue alongside the safeguarding adults’ enquiry.

Where there are HR processes to consider, the employer will need to follow their own HR advice to comply with Employment law.

The completion of any Police or employer investigation may be all that is needed to achieve the adult’s desired outcome(s) and the enquiry can be exited accordingly.

7.16 Action against the Person(s) Alleged to have Caused Harm

7.17 Support for People who are Alleged to have Caused Harm

Where the person alleged to have caused harm is also an adult who has care and support needs, organisations should consider what support and actions may help them not to abuse others. For example, enquiries may indicate that abuse was caused because the adult’s needs were not met and therefore a review of their needs should be made.

Where the person alleged to have caused harm is a carer, consideration should be given to whether they are themselves in need of care and support.

Checks might be made whether staff were provided with the right training, supervision and support. Whilst this does not condone deliberate intentions of abuse, prevention strategies to reduce the risk of it occurring again to the adult or other people should be considered.

People who are known perpetrators of domestic violence may benefit from

Domestic Abuse Prevention Programmes.

When considering action for people who abuse, prevention and action to safeguard adults should work in tandem.

7.18 Feedback to People who are Alleged to have Caused Harm

An evaluation should be carried out as to whether it is safe to share information about the safeguarding concern with the person allegedly responsible. The adult should give their informed consent before sharing information with the person allegedly responsible. However, where the sharing of information to prevent harm is necessary, lack of consent to information sharing can be overridden.

7.19 Care and Support Provider Duties

The Care Act Statutory guidance (2016) is clear where abuse or neglect is carried out by employees or in a regulated setting such as a care home or hospital or college, the first responsibility to act must be with the employing organisation as provider of the service. Social workers or counsellors may need to be involved in order to support the adult to recover.

Care Act Statutory guidance (2016) states that the provider has duties as both a service provider and as an employer. Duties include:

Dealing with employment/disciplinary issues;
Protecting the adult;
Incident investigation;
Assuring regulators and commissioners;
Preventing recurrent risk, and risk to others;
Reporting concerns.

Where an employer is aware of abuse or neglect in their organisation, they are under a duty to address this and protect the adult from harm and as soon as possible inform the local authority, CQC and CCG where the latter is a commissioner.

7.20 Local Authority Duties – Cross Border Arrangements

It is recognised that there is increased risk and complexity associated with adults whose care and support arrangements cross local authority boundaries. Such circumstances arise when the funding/commissioning responsibility lies with an authority in one area and where concerns about potential abuse and/or exploitation arise in another area. This can include social care and health commissioners. For some service providers such as mental health or learning disability services this may involve both local and regional specialised commissioning teams,

(ADASS Guidance “Out of Area Safeguarding Adults Placements”) should be read in conjunction with this section of the policy and procedures, for further detailed guidance on the respective roles of the host authority, placing authority and service provider at each stage of the safeguarding process.

The host authority is defined in the above guidance as “the local authority in the area where the alleged abuse occurred and which therefore has the S.42 duty to make enquiries or cause them to be made whether or not the host authority is commissioning the care and support services for the adult.”

The placing authority is defined as the local authority or NHS Body that is responsible for commissioning care and support services for an individual involved in a safeguarding adult’s enquiry.

Once a safeguarding concern has been raised with the host authority it is their responsibility to lead the initial response to the concern in consultation with the placing authority.

The host authority must always seek to inform all placing authorities as soon as possible of any allegations involving one or more of their service users as either a person who has experienced the alleged abuse or the person who has caused the alleged abuse.

Providers should also supply the contact details of placing authorities responsible for the adults involved in the enquiry, so that the host authority can liaise with the placing authorities. They should also provide information on adults who are funding their own care. If the information is not provided, the host authority may refer to the Safeguarding Adults Board procedure on Section 45 of the Care Act, which places a duty on individuals and organisations to supply relevant information required to safeguard adults.

The host authority may well be reassured by the employer’s response to the concern, so that no further action is required and in most cases a telephone call(s) completes the Section 42 enquiry. However, a local authority would have to satisfy itself that an employer’s response has been sufficient to deal with the safeguarding concern and if not, to undertake any enquiry of its own and any appropriate follow up action (for example, referral to CQC, professional regulators).

7.21 Providers Undertaking the Enquiry

The Care Act guidance states the employer should investigate any concern (and provide any additional support that the adult may need) unless there is a compelling reason why it is inappropriate or unsafe to do so. For example due to a conflict of interest on the part of the employer, for example

A family-run business where organisational abuse is alleged, or where the manger or owner is implicated;
Concerns having been raised about non effective past enquiries or serious multiple concerns; or
A matter that requires investigation by the Police.

In such cases it may be better for an external person to be appointed to investigate. Anyone undertaking such enquiries should have received appropriate training.

The provider may have duties as an employer and as a service provider of care and support services. Where the provider is making the enquiry, they should be mindful of the requirement to fully involve the adult and in particular to ask them (or their representative or advocate) what they want as an outcome following the raising of the safeguarding concern.

The circumstances where an external person would be required are set out in local protocols where local authorities have delegated duties to providers to undertake “trusted enquiries.” (see local guidance for details).

In such situations the local authority, in its lead and coordinating role, should assure itself that the enquiry and any action taken satisfies its duty under Section 42. In this role if the local authority has asked someone else to make enquiries, it is able to challenge the body making the enquiry if it considers that the process and/or outcome is unsatisfactory.

7.22 Provider Duties to the Person Alleged to have Caused Harm

Employers who are also providers or commissioners of care and support not only have a duty to the adult, but also a responsibility to take action in relation to the employee when allegations of abuse are made against them.

Employers should ensure that their disciplinary procedures are compatible with the responsibility to protect adults at risk of abuse and neglect.

In addition refer to Section2.18 Person in a Position of Trust.

7.23 Disciplinary Investigations and Referrals to the Disclosure and Barring Service (DBS)

A disciplinary investigation and potentially a hearing may result in the employer taking informal or formal measures which may include dismissal and possibly referral to the DBS.

If someone is removed by either being dismissed or redeployed to a non-regulated activity from their role providing regulated activity following a safeguarding incident, or a person leaves their role (resignation or retirement) to avoid a disciplinary hearing following a safeguarding incident and the employer, voluntary organisation feel they would have dismissed the person based on the information they hold, the regulated activity provider has a legal duty to refer to the DBS.

The fact that a person tenders his or her resignation, or ceases to provide their services, must not prevent an allegation being followed up in accordance with the provider’s disciplinary procedures. It is important to reach a conclusion in all cases on allegations bearing on the safety of adults at risk.

It may not be possible to apply disciplinary sanctions if a person’s period of notice has expired before the process is complete, but it is important to reach and record a conclusion where possible.

The statutory guidance is clear that the standard of proof for prosecution is ‘beyond all reasonable doubt’. The standard of proof for internal disciplinary procedures and for discretionary barring consideration by the DBS and the Vetting and Barring Board is usually the civil standard of ‘on the balance of probabilities’. This means that when criminal procedures are concluded without action being taken this does not automatically mean that the regulatory or disciplinary procedures should cease or not be considered. In any event there is a legal duty to make a safeguarding referral to DBS if a person is dismissed or removed from their role due to harm to a child or vulnerable adult.

If an agency or personnel supplier has provided the person, then the legal duty sits on that agency to refer to the DBS. A personnel supplier may be an employment agency, employment business or an educational establishment. Refer to DBS referral instructions: Personnel suppliers for more detailed guidance.

The Safeguarding Vulnerable Groups Act (2006) places a legal duty on regulated activity providers and personnel suppliers to refer any person to the (DBS) who has:

Harmed or poses a risk of harm to a child or vulnerable adult;
Satisfied the harm test;
Received a caution or conviction for a relevant offence.

In circumstances where these actions are not undertaken then the local authority can make such a referral.

7.24 Providers and Duty of Candour

Providers of Health and Social Care must note the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 20

The intention of this regulation is to ensure that providers are open and transparent with people who use services and other ‘relevant persons’ (people acting lawfully on their behalf) in general in relation to care and treatment. It also sets out some specific requirements that providers must follow when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, providing truthful information, and an apology when things go wrong.

The regulation applies to registered persons when they are carrying out a regulated activity.

CQC can prosecute for a breach of parts 20(2) (a) and 20(3) of this regulation and can move directly to prosecution without first serving a Warning Notice. Additionally, the CQC may also take other regulatory action. See the offences section of this guidance for more detail. Refer to www.cqc.org.uk for more detailed information for all providers.

7.25 Organisational Enquiries

The Care Act guidance of March 2016 sets out the criteria for Organisational Abuse. It includes neglect and poor care practice within a care and support setting which may include a registered setting, supported living, community setting (e.g. care home), family placement, adult’s own home or hospital. It may range from one off incidents to on-going ill treatment. It can be through neglect or poor professional practice as a result of the structure, policies, processes and practice within an organisation.

The difference with this type of enquiry is that it may not just be about a concern around the care/treatment of one individual, but may be a series of concerns or potential concerns about more than one individual within an organisational setting, caused by poor practice.

An example of this would be a series of medication errors by the same provider which requires a more in depth response than a phone call. It would involve the provider, placing authority, and may involve families or an advocate for the adult.

Such an enquiry will be looking at the medicine management process to ensure that the cause of the multiple errors was identified and corrected. The purpose of the enquiry is to work with the provider to achieve the organisational outcomes determined at the outset.

Each local authority area has its own mechanism and protocol for responding to organisational safeguarding concerns, which may indicate that an organisational safeguarding enquiry is required. These concerns are likely to be complex and require a more strategic response.

Principles of respect, transparency, and an open culture around safeguarding should be encouraged. Organisational enquiries should reflect best practice around partnership working to ensure effective and responsive actions are undertaken in a timely way to ensure the best outcome for the adult.

In addition, each local authority area will have their own mechanisms and procedures which reflect their local approaches to working with providers which include the duty upon the local authority to respond to market failure.

7.26 Enquiry Reports

In some cases it may be necessary for a report to be collated and drawn up by the Enquiry Officer.

In some more complex enquiries, there may be a number of actions taken by staff from different organisations that support the enquiry. Where there are such contributions from other agencies/staff, these should be forwarded within agreed formats and timeframes, so that there is one comprehensive report that includes all sources of information.

An enquiry report is likely to be needed only in cases where there is on-going risk and the report is required to aid decision making on continuing risk management action.

Reports need to be concise, factual and accurate. Reports should be drafted and discussed with the adult/advocate. Reports need to address general and specific personalised issues. They should cover:

Views of the adult;
Whether the adults desired outcome(s) were achieved;
Identified risk and actions taken to manage them;
Whether any further action(s) is required and if so by whom;
Who supported the adult and if this is an on-going requirement for support;
Views of the person alleged to have caused harm and their response to any allegations made.

In some enquiries, there will be a disciplinary investigation. The disciplinary investigation is the responsibility of the employer and whilst linked, it remains a separate procedure to the safeguarding enquiry, the focus of which is to help the adult develop resilience and recover from the abuse. It is not appropriate to have sight of any disciplinary investigation report but it could be recorded that the employer had taken appropriate action under disciplinary procedures.

Agencies are responsible for carrying out the recommendations which might be included in future safeguarding plans. Recommendations should be taken forward monitored, and reviewed.

7.27 Standards and Analysis

The Report should be evaluated so that it meets the standards above, and analysed to assess whether there are gaps or contradictions and that information has been triangulated, i.e. is the report evidence based, and is there sufficient corroboration to draw conclusions.

The Report should be discussed with the adult or their representative, who may have a view about whether it has been completed to a satisfactory standard. The adult or their representative must consent before the report can be shared with others. Any enquiry report completed and presented as part of any outcome meeting must be fair and balanced to comply with the principles of natural justice.

The local authority should decide if the enquiry is completed to a satisfactory standard. In reaching this decision, the Local Authority may wish to consult partner organisations involved in the enquiry.

If another organisation has led on the enquiry, the local authority may decide that a further enquiry should be undertaken by the local authority. The exception to this is where there is a criminal investigation and in this case, the local authority should consider if any other enquiry is needed that will not compromise action taken by the Police.

Section 6: Stage 3 – Safeguarding Response