Around 155 Safeguarding Adults Reviews (SARs) have been commissioned or conducted in the two years following the implementation of the Care Act 2014. The Act states that SARs should promote 'effective learning and improvement action to prevent future deaths or serious harm occurring again' (14.164). But is there a consensus about what makes an effective SAR? In this webinar, Professor Jill Manthorpe discusses what we know as a result of her extensive work in this area. Aimed at: Safeguarding leads, Safeguarding Adults Board Chairs, Safeguarding Adults Board managers, Safeguarding Adults Reviews lead reviewers, multi-agency members of Safeguarding Adults Boards.

1. What makes for an effective
Safeguarding Adult Review?
Jill.Manthorpe@kcl.ac.uk
stephen.martineau@kcl.ac.uk

2. High profile … not just social care
but most Serious Case
Reviews/Safeguarding Adult
Reviews are local

3. ‘New’ world of Safeguarding
Adult Reviews
A Safeguarding Adults Board
must arrange for there to be a
review of any case in which
(a) an adult in the SAB’s area
with needs for care and support
(whether or not the local
authority was meeting any of
those needs) was, or the SAB
suspects that the adult was,
experiencing abuse or neglect,
and (my emphasis)
(b) the adult dies or there is
reasonable cause for concern
about how the SAB, a member
of it or some other person
involved in the adult’s case
acted.

4. SCR to SAR
› What we took with us to
the new world of SARs?
› We have been analysing
adult SCRs for over a
decade
› Today focus on perceived
effectiveness
› Let’s start with overall
ideas
Knowledge of the past is
the key to the future…

5. Differences? What’s in a name?
› Care Act placed
safeguarding on a
statutory basis
› Care Act duty to co-
operate for SAB members
› Interest rising?
› Still huge discretion
locally but timing may not
be of your choosing
› And other forms of review
remain…

6. Old news? Are Children’s SCRs
on the wane? (2016)
› (Govt. will change law to) set up independent National
Panel to be responsible for commissioning and
publishing national reviews and investigate the most
serious and/or complex cases relating to children in
circumstances which the Panel considers will lead to
national learning;
› Require Local Safeguarding Children Boards (and their
successors) to carry out and publish lessons from
local reviews into cases which relate to a child/ren in
the local area and which are likely to lead (at least) to
local learning.
› Important for Joint SABs but also for wider climate
› https://www.gov.uk/government/uploads/system/upl
oads/attachment_data/file/526330/Government_resp
onse_to_Alan_Wood_review.pdf

7. Stop press news 1 - June 2017
Draft Domestic Violence and
Abuse Bill to:
› Establish a domestic
violence and abuse
commissioner
› Set out a legal definition
of domestic abuse
› New domestic abuse civil
prevention and protection
order regime
› Changes to Domestic
Homicide Reviews?

8. Stop Press news 2
A draft Patient Safety Bill
› To “instil greater public
confidence in the
provision of healthcare
services in England”
› Govt. will set up a
Health Service Safety
Investigation Body “to
conduct independent
and impartial
investigations into
patient safety risks”.

9. Back to SARs - Key questions –
for Boards or Sub-Committees
What is the concern?
› How far back to go (eg
chronology)?
› Review personnel – who?
› Agreeing remit, timescale,
venue, resources…
› Think early + often about how
to be assured that
recommendations are put into
action (if possible) …
› Review afterwards – whether
through sub-committee or
other system

10. SAB to Sub-Committee?
Who commissions & devises SAR
Terms of Reference?
› Delegation?
› Key task - SCREENING
› Decisions
− What type of Review? (if any)
− Defining methods
− Budget?
− Roles at start or end
− When to start?
− Managing relations
− Keep going with recommendations +
implementations
− Would a protocol/toolkit be helpful?

11. Avoiding reinventing the wheel
For example, information for families
and carers from Rochdale
https://www.rbsab.org/UserFiles/Doc
s/22Safeguarding%20Adults%20Revi
ew%20-
%20Information%20for%20Families.
pdf

12. Managing risks of overlaps
(eg re care homes)
› ‘Incidents’ or ‘whole home’
investigations?
› Overlap with disciplinary
cases, court cases,
coroners’ courts,
commissioning decisions,
domestic homicide reviews
(not much in care homes),
CQC activities, clinical
governance, professional
regulators…
› How to manage that?

13. An early SAR – effectiveness in terms of
messages to practitioners + managers?
THE CLOSURE OF
OXFORD GRANGE CARE
HOME
SAFEGUARDING
ADULTS: LESSONS
LEARNED REPORT
Kirklees Council 2015
Wider lessons (in our view)
› Being on top of care plans
and reviews of care home
residents
› Planning for a hypothetical
local closure
› Potential for turnaround?
When can it work? when
not?

14. Agencies’ Responsibilities
› Duty to co-operate
› Knowing the Terms of
Reference (TOR) (& shaping)
› Authoring/arranging
Independent Management
Reviews – chronologies, or
similar
› Supporting residents & families
& staff
› Organisational memory – time
lapses, org + personnel changes

15. SARs – towards the end of the review
› Opportunity to contribute to
ideas for recommendations
› Support/communications for
staff – can be long time after
‘event’
› Support/communications for
other residents and families
› Support for reviewer(s)
› Managing reputation and
communications
› Rebuilding and learning

16. Examples of effectiveness efforts
› One/two page summary
› Special briefings
› 7 min. summaries
› Use of Family Statements
› Easy Read Response
Review & Action Plan
› Explicit SMART
recommendations
› Public message
26 June 2017
This 1 hour briefing will
provide practitioners and
their managers with an
overview of the learning
from the Adult B
Safeguarding Adult Review.
Key themes include the
importance of Care Act and
Mental Capacity
assessments, the role of
family members,
recognising &
understanding problem of
alcohol misuse and early
identification of a lead
professional or agency in
safeguarding cases

17. My suggestions -
› Read SARs of interest/relevance
› Establish who would do what ie
compile the chronology, attend
interview or workshop
› Ensure response to
recommendations
› Communication – how & when to
inform staff, families, users,
Councillors, Board, what is
happening
› Potential for closure and catharsis
(+ useful outcomes can come forth)
› Multi-level effectiveness – on their
own or joined up (probably not just
one purpose) – debate and
capture

18. New analyses of SCRs
Thanks for your help with
different analyses of
› Pressure ulcers in care homes
(in press JAP) & home
acquired
› Dementia focus
› Care Homes
› Learning disabilities
› New – mental health problems
› Other researchers – self-
neglect, housing, London
SARs, Repository.
Please contact us for copies if
you cannot locate

19. QUESTIONS AND
COMMENTS

20. This presentation presents independent
research funded by the Department of Health
(DH). The views expressed in
this presentation are those of the authors and
not necessarily those of the DH.
Any questions?
Thanks for listening

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