Principles for a Referral to Implement the Learning And

Contents Page

Introduction 3

Principles for a Referral to implement the Learning and

Improvement Framework 5

Objective of the Review 6

Initiation of the Case Reviews 8

Learning and Improvement Reviews 10

Who should be involved in the reviews and timescales 14

Shared learning and Implementation 16

Case Review threshold flowchart 18

Safeguarding Adult Review Forms 19

1.  Introduction

Tameside Adult Safeguarding Partnership Board encourages learning from practice to safeguard adults at risk of abuse. The framework aims to collate the findings and lessons from the full range of case reviews (from statutory Safeguarding Adult Reviews and, to case reviews below the thresholds of a Safeguarding Adult Review).

The framework will enable Tameside Adult Safeguarding Partnership Board (TASPB) to be clear about:-

·  what needs to be learnt,

·  where services and practice require improvement,

·  And how any programme of action will lead to sustainable improvements.

This document provides TASPB with guidance on:

·  the principles to be applied in response to the Care Act regarding Safeguarding Adult Reviews

·  Objective of the reviews

·  the principle outcomes any learning and improvement process should achieve;

·  the framework which outlines the different types of case reviews;

·  the thresholds for conducting the different types of reviews;

Principles for a Referral to implement the Learning and Improvement Framework

2.  Principles for a Referral to implement the Learning and Improvement Framework

Care Act criteria for conducting a Safeguarding adult Review:-

Safeguarding adults reviewsE+W

This section has no associated Explanatory Notes

A SAB must arrange for there to be a review of a case involving an adult in its area with needs for care and support (whether or not the local authority has been meeting any of those needs) if—

(a)  there is reasonable cause for concern about how the SAB, members of it or other persons with relevant functions worked together to safeguard the adult, and

(b)  condition 1 or 2 is met.

(2) Condition 1 is met if—

(a)  the adult has died, and

(b)  the SAB knows or suspects that the death resulted from abuse or neglect (whether or not it knew about or suspected the abuse or neglect before the adult died).

(3) Condition 2 is met if—

(a)  the adult is still alive, and

(b)  the SAB knows or suspects that the adult has experienced serious abuse or neglect.

(4) An SAB may arrange for there to be a review of any other case involving an adult in its area

with needs for care and support (whether or not the local authority has been meeting any of those needs).

(5) Each member of the SAB must co-operate in and contribute to the carrying out of a review under this section with a view to —

(a)  identifying the lessons to be learnt from the adult's case, and

(b)  applying those lessons to future cases.

OBJECTIVE OF THE REVIEW

3.  Objective of the Review

TASPB are primarily concerned with applying the most appropriate approach to promote effective learning to prevent future deaths or significant harm in the future.

The Review is not an opportunity to hold any individual or organisation to account. TASPB will seek to determine what organisations and individuals could have done differently to prevent death or Safeguarding abuse or neglect.

Reviews should encourage learning and participation. TASPB want to ensure maximum benefit is achieved through the SAR and want individuals to experience a safe and trusted process, where honest, transparency and sharing of information is embolden.

No one model will be applicable to all cases. TASPB will determine at a local level the most suitable method.

Safeguarding Adult principles

The following six safeguarding principles are defined in the Care Act and the reviews should reflect these:

Empowerment – Personalisation and the presumption of person-led decisions and informed consent.

Prevention – It is better to take action before harm occurs.

Proportionality The least intrusive response appropriate to the risk presented

Protection – Support and representation for those in greatest need.

Partnership – Local solutions through services working with their communities. Communities have a part to play in preventing, detecting and reporting neglect and abuse.

Accountability – Accountability and transparency in delivering safeguarding.

In the context of these principles TASPB will conduct reviews applying:

·  A culture of continuous learning and improvement, promoting the well-being and empowerment of adults, promoting good practice and focusing on opportunities to apply what works

·  A proportionate response

INITIATION OF CASE REVIEWS AND QUORACY

4.  Initiation of Case Reviews

·  TASPB Safeguarding Adult Co-ordinator will receive the relevant written information from Partner Organisations that indicates a Case Review maybe required.(appendix 1)

·  The Safeguarding Adult Co-ordinator will notify the Chair of the TASPB Learning and Accountability Principle Sub Group.

·  The Chair of this group will decide if an Extraordinary Meeting of the TASPB Learning and Accountability sub group is required to discuss options for Case Reviews or if the case can wait for discussion at the next scheduled TASPB Learning and Accountability Principle Sub Group meeting.

·  The TASPB Learning and Accountability sub group will determine the most suitable process to use in deciding if a case meets the criteria for a case review.

·  For cases that are considered for Safeguarding adult reviews, the final decision if a case meets the Safeguarding adult review criteria will rest with TASPB Independent Chair. Decisions on whether to initiate a Safeguarding adult review should be normally made within one month of TASPB being notified of the incident triggering the threshold.

5.  Quoracy:

Extraordinary Meeting of the TASPB Learning and Accountability Principle Group requires a minimum of one representative from each of the Statutory Partners as defined in the Care Act:-

Local Authority

Clinical Commissioning Group

Greater Manchester Police

LEARNING AND IMPROVEMENT REVIEWS

Cases which meet the SAR threshold

Cases which do not meet the SAR threshold

6.  Learning and Improvement Review formats

·  Cases which meet SAR threshold

Safeguarding Adult Review (SAR)

TASPB must arrange for there to be a review of a case involving an adult in its area with needs for care and support (whether or not the local authority has been meeting any of those needs) if—

·  there is reasonable cause for concern about how TASPB, members of it

or other persons with relevant functions worked together to safeguard

the adult,

·  and the adult has died, and TASPB knows or suspects that the death resulted from abuse or neglect (whether or not it knew about or suspected the abuse or neglect before the adult died).

·  or TASPB knows or suspects that the adult has experienced Safeguarding abuse or neglect.

·  or TASPB Chair does not consider the Safeguarding Adult Review threshold to have been met, but peer challenge on Safeguarding Adult Reviews would suggest that initiation of a Safeguarding Adult Review may be prudent.

·  Safeguarding Adult Review (relates to themes)

This methodology seeks to target review activity in a proportionate way based on the specific circumstances of the case. A SAR relating to themes should be considered in the following circumstances

Safeguarding Adult Reviews where TASPB consider it is proportionate to use themed Review methodology. This may include cases where:

·  the scope for learning is focussed on an area of practice or issues which have already been recently identified and agencies are in the process of, or recently implemented a programme of action;

·  in exceptional circumstances, if the case is largely historical in nature and it is not practicable or desirable to undertake a SAR regarding an individual

·  Links with other Reviews

TASPB will consider how the review process with other relevant investigations such as Domestic Homicide Review (DHR) can dovetail at the beginning of the review and how duplication can be avoided. Any review will need to take in account of a Coroners Inquiry and criminal investigations to ensure that relevant information can be shared without incurring significant delay in the review process. It will be the responsibility of the Chair of the review to ensure contact is made to minimise avoidable duplication.

·  Joint Borough Safeguarding Adult Reviews

Safeguarding Adult Reviews held jointly with other Boroughs will adopt the learning and improvement framework of the Borough hosting the review. Learning for TASPB from these reviews will be facilitated by the TASPB Learning and Accountability Principle.

·  Cases which do not meet the SAR threshold

·  Multi-Agency Reviews (MAR)

Multi-agency reviews are reviews of all cases falling below the SAR threshold.

Cases can involve incidents where an adult has been harmed and there are concerns about multi-agency practice.

TASPB recommends the following criteria to follow in select cases for a multi-agency review:

·  An adult is harmed through abuse/neglect and the case gives rise to concerns about the way in which local professionals and services worked together to safeguard the adult that could lead to significant and new learning that improves multi-agency communication, procedures, policy and/or practice.

Where a case gives rise to concern about learning already identified in previous case reviews, TASPB should review, outside of the multi-agency review process, how that learning is being embedded and query why the learning has not been sustained.

·  Individual Agency Reviews (IAR)

Where a case is considered for a Safeguarding adult review or multi-agency review but does not meet the criteria as practice requiring further analysis and learning is limited to a single agency, the Learning and Accountability Principle Group may recommend an Individual Agency Review. It is an expectation that lessons learnt would be shared with TASPB.

·  TASPB Proportionate Review (TPR) of Safeguarding Enquiries and dissemination of learning

On occasions cases that meet the Safeguarding Adult Review criteria may have identified the learning and actions via the outcomes of the enquiry. In these instances the Learning and Accountability Principle Group will recommend to TASPB that a Safeguarding Adult Review is not necessary as work would be duplicated.

The Learning and Accountability Principle Group will recommend sharing best practice with Partner Organisations.

In response to the learning of these enquiries, the Safeguarding Plan for the enquiry will be used to inform a formal action plan for TASPB.

The TASPB Safeguarding Adult Team will co-ordinate the sharing of information to update this action plan and the Learning and Accountability Principle Group will assure TASPB that these actions have been completed.

Themes and trends from the learning of this enquiry will be identified by the Learning and Accountability Principle Group. This learning will be shared with the Continual Improvement Principle Group to consider options for dissemination of this learning and sharing of best practice.

Who should be involved in the review and what are the timescales?

7.  Who should be involved in the Review?

The Learning and Accountability principle group will agree who needs to be involved in the relevant reviews.

It is an expectation that those undertaking the reviews will have appropriate skills and experience which should include:-

·  strong leadership and ability to motivate others

·  expert facilitation skills and ability to handle multiple perspectives, sensitive and complex group dynamics

·  collaborate problem solving experience and knowledge of participative approaches

·  good analytical skills and ability to manage qualitative data

·  safeguarding knowledge

·  inclined to promote an open, reflective learning culture

Professionals should be invited to contribute their perspectives and encouraged to be fully engaged in the review.

Early discussions should take place with the Adult, family and friends to agree how they wish to be involved. It may be appropriate to involve an advocate for the Adult.

8.  Timescales

TASPB will aim for a completion of a SAR within six months, unless there are good reasons for a longer period being required.

Learning and Accountability Principle Group will agree timescales for reviews which are not SAR and these will be proportionate to the nature of the review.

Sharing Learning and Implementation of the Framework

9.  Sharing learning

Integral to the success of this framework will be the sharing of learning on a wide area basis to ensure transparency, accountability and consistent improvement to practice. TASPB will publish, where practicable, the outcomes of case reviews and multi-professional discussion forums which do not meet Safeguarding Adult Review thresholds. TASPB will make recommendations to the Learning and Accountability and the Continual Improvement Group Principle as appropriate.

TASPB will include the findings and actions from any SAR in its Annual Report.

10. Implementation

A period of consultation and reflection should be undertaken in order to ensure the Framework is implemented successfully. It is recommended the process is reviewed in 12 months.

SAFEGUARDING ADULT REVIEW FORMS

·  Cases should be referred to the TASPB Learning and Accountability Principle for consideration via the relevant TASPB Lead if an adult at risk of abuse or neglect has died or been seriously harmed and abuse or neglect are believed to have been a factor. Greater Manchester Police will refer via the Serious Case Review Unit.

·  This form should be completed by any professional who has become aware of a case where the above criteria is met and will be submitted by the relevant TASPB Lead or the GMP Serious Case Review Unit

·  All information provided should adhere to information sharing protocols and have due regard to the Mental Capacity Act and Best Interest Decision protocols.

·  Please note there is a statutory duty in Section 45 of the Care Act 2014 for agencies to share relevant personal data with the Safeguarding Adults Board.