ACS Independent Adult Safeguarding Investigations

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Case Study – Advanced Clinical Solutions
Independent Adult Safeguarding Investigations
Background
Advanced Clinical Solutions Ltd (ACS) has supported and continues to support the health and
social care sector for a number of years as an independent clinical resource in relation to adult
safeguarding concerns raised and the subsequent clinical quality improvements.
Our lead clinical consultants working within the sector are Ian Whitehouse (RGN MA) and Josie
Winter (BSc MSc). Both of whom have professional clinical backgrounds in healthcare and
nursing, along with several years’ experience in quality improvement and clinical leadership.
A combination of investigative work, root cause analysis, focused clinical service audits, action
planning for improvement and upskilling of staff, by delivery of training has been utilised by ACS
for this project.
Section 1: The Challenge
In summer 2018, ACS were instructed by a private healthcare provider, as independent
investigators into a large number of safeguarding concerns that had been raised to the local
authority adult safeguarding team, from a variety of sources dating back spring 2018.
Due to staffing vacancies, time restraints, lack of internal resources and a number of other
factors the additional workload and the level of detail required for the investigations had become
unmanageable for the staff that were currently in-situ.
ACS had been instructed as an independent clinical resource, due to the nature of the
safeguarding concerns being raised to the local authority adult safeguarding team, which were
predominately nursing and clinical in focus. Under the Care Act 2014 (Section 42) each local
authority must make enquiries, or cause others to do so, if it believes an adult is experiencing,
or is at risk of, abuse or neglect. The enquiry should establish whether any actions need to be
taken to prevent or stop abuse or neglect, and if so, by whom

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ACS began to review the Section 42 enquiry terms of reference and case files laid out by the
Adult Safeguarding Team. At this point there were, a significant number of (section 42)
enquiries raised, and many were outstanding and needed to be investigated and reported back
to the adult safeguarding team. During the initial 2-month investigative period, the count of
safeguarding investigations rose. ACS investigated and reported on a considerable number
(section 42 & safeguarding enquiries) over the entire project period.
Section 2: Our Approach
For all safeguarding investigations, ACS utilise a cause-and-effect root cause analysis and
quality improvement methodology. This particular method helps to identify many possible
causes for an effect or issue and sorts ideas into useful categories and is one of the basic
quality tools. Cause and effect are widely used in the healthcare sector and can be easily
adapted to use a variety of themes as a focus to assist with determining the root causes of any
concerns raised. A number of evidence sources were explored and synthesized throughout the
investigative work including:
Direct observations
Staff interviews
Relative interviews
Documentation reviews including but not limited to
• Organisation policies and procedures
• Care plans and notes
• Risk assessments
• Audits
• Staff rota’s
• Medication administration records
• Staff training and competence records
• CQC evidence files
Clinical Evidence Reviews (e.g. NICE Quality Standards, RCN Guidance)
After completion of all investigations and reports, ACS embarked on an analysis of all
concerns raised and their potential contributory factors across the board. A number of
trends and patterns emerged.
The following factors although not exhaustive, persistently featured as contributory factors.

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1) Training, Education & Staff Development
2) Documentation & Record Keeping
3) Communication
4) Leadership, Management & Culture
5) Clinical Effectiveness & Clinical Quality Assurance
Section 3: Our Solutions
This section provides the details related to quality improvement phase which commenced after
the initial investigative period. A series of improvement interventions were made based on the
findings from all safeguarding enquiries.
1. Personal Development Surgeries (for RGN’s)
ACS ran a series of personal development surgeries for all nursing staff. A self-assessment of
competence and personal / professional development survey was developed.
Nursing staff were invited to discuss and asses their own competence levels that would be used
to gauge a baseline assessment for any future improvements. The objectives of these sessions
were to:
a) Directly address the training, development and education contributory factors
established during the safeguarding investigations
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2
NE GLE C T ORGA NIS A T IONA L P H Y S IC A L F INA NC IA L
TYPES OF ABUSE FEATURED

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b) Understand potential gaps in clinical knowledge and skills of nursing staff
c) Discuss any potential training and education that would be of benefit to all care
and nursing staff
d) Understand what barriers (if any) that impacted the quality of care being given
The overall outcomes of the sessions showed a mixed result throughout the staff, with the more
established personnel being much more confident than the newer staff. It became apparent that
there was a knowledge skills gap in certain key clinical areas such as:
- Safeguarding
- End of Life
- Records and Record keeping
- Risk assessment tools
- Accident/Incident reporting
- Pressure sore and falls prevention.
2. COMPETENCE ASSESMENTS
A significant proportion of the safeguarding concerns raised were in relation to
medicines management and nutrition / hydration needs.
ACS nurses re-assessed competence of all staff who were directly involved with
medicines management/administration and staff who were directly involved with
supporting service users with nutrition and hydration care. A selection of up to date
clinical practice guidelines and internal evidence sources were used to identify the
correct competence assessment factors.
3. POLICY & PROCEDURE UPDATES
ACS also conducted a number of minor revisions and updates to the organisations clinical
policies and procedures. The following changes were made where necessary:
- Adding new or clearer definitions to increase staff understanding of the policy scope
- Clarifying certain points of the initial policy where needed
- Rearranging the policy information for a better, more reader friendly flow
- Making changes and updating any attached clinical procedures
- Attaching a new procedures and care bundles where necessary to aid in the policies
implementation
- Adding up to date and current guidance and clinical evidence sources.

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4. Mandatory Training / Clinical Skills Refresh for all staff
Based on the outcomes of the personal development surgeries it was thought to be beneficial to
run a mandatory training/clinical skill refresh initiative for all staff, regardless of their tenure
within the organisation. Every staff member was invited to attend a 3-day intensive face to face
training course. This course covered 6 core sessions (Roles & Responsibilities, Safeguarding
Adults, Infection Prevention & Control, Mental Capacity Act/DoLs, Equality & Diversity and the
importance of good hydration and nutrition). A training programme was devised and
implemented by ACS.
Each cohort number was kept small (approx. 6-8 per session), with a mix of staffing groups in
attendance. This allowed time for extensive interactions between the ACS trainers and staff,
and also allowed staff to get more assistance with individual needs as the skill mix and
knowledge base was wide-ranging.
Smaller groups also offered more opportunities for the ACS trainers to focus on individual
queries and provide positive criticism and suggestion for real time improvements. Having a mix
of staff groups proved invaluable as a realisation and appreciation for holistic team working and
the importance of each role began to emerge. These sessions also directly improved internal
communication and was often a mutual talking point for all staff.
ACS ran sessions weekly over a consecutive 3-day period for 5 months. Staff were scheduled
into the sessions, away from their normal working duties and the management team received
feedback on each staff member after every cohort.
105
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86
59
4
21
C ONC E RNS
RAISE D
S E C T ION 42
DUT Y NOT
T RIGGE RE D
S E C T ION 42
DUT Y
T RIGGE RE D
S E C T ION 42S
C OMP LE T E D
S E C T ION 42S
W IT H P OLIC E
DE C IS ION NOT
MADE Y E T
Figure 2: Analysis of Section 42-LOCAL AUTHORITY DATA

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A total of 85 staff were trained for all core sessions. In conjunction with the 6 core sessions, a
number of supplementary clinically focused training session were run by ACS, specifically
designed to upskill RGN’s and senior staff.
These workshops aligned to the Section 42 enquiry actions and were geared towards the
nurse’s personal development plans conducted previously
The clinically focused sessions included Pressure Area Care, Sepsis Awareness, NEWS2-
Patient Deterioration, Infection Prevention & Control Champions Course (covering catheter
care, UTI’s, antibiotic stewardship and other key IPC issues) End of Life & Safe Use of T34
Syringe Driver.
5. Clinical Audits
Running alongside the intensive training programme, ACS conducted a series of 9 in-depth
clinical audits which aligned to key issues identified in the clinical effectiveness contributory
factors. These clinical focused audits took a deeper look into practices around continence and
catheter care, end of life care, tissue viability, medicines management and falls prevention to
name a few.
Clinical audits make up a crucial element of any clinical improvement programme, and it was
recognised that having a well-managed and evidence-based clinical audit programme, the
organisation could start to build a robust internal quality assurance programme, which could be
used in future CQC inspections as evidence of applying better standards to clinical care and a
way of addressing many of the issues raised within the section 42 enquiries
A suite clinical audit tools developed by ACS was utilised and analysis of data was undertaken
using excel. Raosoft.com was used to calculate a meaningful and appropriate sample size for
the audit data collection.All clinical audits performed provided a baseline assessment and were
aligned to several regulatory and best practice sources such as:
- CQC key lines of enquiry and fundamental standards.
- NMC Code: Professional standards of practice and behaviour for nurses, midwives and
nursing associates.
- The 6C’s : Care, Compassion, Competence, Communication, Courage and
Commitment (which underpin the compassion in practice strategy set out by NHS
England/Department of Health & Social Care)
- Up to date clinical evidence bases such as NICE Quality Standards.
All clinical audit outcomes were compiled into a manageable action plan with a scheduled
timetable for improvements. This was passed onto the nursing and management staff to action
and implement accordingly.

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transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without
the prior written permission of the publisher.
Section 4: Summary
We have provided an overview of our approach and involvement in this clinical quality
improvement project. The aspects of this project from our perspective ,that need most emphasis
are, the trust placed in ACS by the healthcare provider to conduct the independent
investigations of all concerns raised, the dramatic improvement, focus and investment given to
improving staff knowledge and practices from the organisation and the introduction of clinical
audit as a quality improvement and governance tool.
‘All of the quality improvement activity undertook by ACS has had a direct impact on the
number of subsequent safeguarding concerns being raised for a notable period of time.
Our work has also contributed to the organisation being taken out of special measures
and the organisation has had their embargo lifted’.
The facts and
recommendations
given can serve as
a guide to
whomever has a
vested interest in
safeguarding and
the quality of care
given to service
users within the
sector.
Our goal is to disseminate quality improvement information that is most useful and that may be
of benefit to other programs. ACS is an organisation that champions knowledge sharing and
learning, and we would kindly ask that you share this case study to inform other quality
improvement programs and educators within the sector about the initiatives undertook.
To contact the team for impartial, non-judgmental support please call 01633 415 427 or
email info@advancedclinicalsolution.co.uk

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Copyright © 2019 Advanced Clinical Solutions Ltd All rights reserved. No part of this publication may be reproduced, distributed, or
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