Safeguarding Adults Reviews

What is a Safeguarding Adults Review (SAR)?

A SAR is a statutory multi-agency learning process that reviews cases where:

1. an adult with care and support needs has
2. died (including suicide) or come to serious harm as a result of abuse and/or neglect, including self-neglect (whether known or suspected)
3. and there is a concern about the way in which local professionals or agencies worked together to safeguard the adult at risk.

In these circumstances, a review is mandatory. Safeguarding Adults Boards (SABs) are responsible for commissioning a SAR in order to consider what agencies and individuals could have done differently to prevent harm or death.

Serious abuse and/or neglect means where the person would have died but for intervention, or where they have experienced permanent harm or reduced capacity or quality of life. The impact of abuse and neglect can include fear, shame, trauma, suicidal ideation, self-neglect, mental health and/or acute hospital admission, substance misuse, poverty and homelessness. The person does not need to have been in receipt of services as a result of their care and support needs.

SABs may also commission reviews in any other situations involving adults with care and support needs . Such reviews are discretionary. SARs may also be commissioned to explore examples of good practice in order to identify lessons for future cases.

Why do a Safeguarding Adults Review?

A SAR should be a transparent and non-blaming procedure which aims to learn from the incident, rather than investigate it. The SAR is used to establish what learning can be achieved from the case about the way in which local professionals and agencies work together to safeguard vulnerable adults. This will include:

• Reviewing how effective procedures within, and across, agencies are
• Informing and improving local multi-agency working
• Developing good practice actions from the learning
• To prepare a report about the incident and findings which includes recommendations for future action, to changing policies and working practices
• The Safeguarding Adults Board has a duty for ensuring that lessons learned are applied to future cases.

What is the Safeguarding Adults Review process?

• Once a decision to commission a SAR has been made, SAB partners can decide on the methodology to be used – the approach adopted should be proportionate to the scale and complexity of the case.
• The statutory guidance recommends that the SAR should be completed within a reasonable time period and, in any event, within 6 months of initiating it, unless there are good reasons otherwise.
• If the individual is still alive, their involvement should be sough and advocacy provided if they require support to participate – the statutory guidance requires early discussions with the individual, family and friends to agree how they wish to be involved, with their expectations managed appropriately and sensitively. Practitioners should also be fully involved in reviews.
• The statutory guidance advises that terms of reference should be published and openly available, and that SARs should reflect the six adult safeguarding principles (see our webpage on Safeguarding Adults at Risk).
• SABs may decide whether or not to publish SAR reports and/or executive summaries and/or seven-minute briefings (short documents which identify the key points of learnings derived from the findings and recommendations in a SAR).
• SABs must also provide detail in annual reports of the SARs that have been commissioned or completed, the lessons learned, and the actions taken to implement recommendations.

How can I request a Safeguarding Adults Review?

Every local authority has a SAB which is hosted within the Adult Social Care function in the Council. There should be information on the local authority or SAB website about how to raise safeguarding concerns, and how you can refer a case to be considered for a SAR.

What happens if a case does not fit the criteria for a Safeguarding Adults Review?

The SAB may decide that a case does not meet the criteria for a SAR. However there are many other effective ways in which the death of someone who is homeless can be used to instigate change and improve practice.

Internal reviews

A senior member of staff in an organisation can review all contacts they had with the person in order to identify opportunities where improvements can be made to policies and procedures. An internal review, once complete, should have clear actions and expected outcomes with a timescale in which these will be achieved. Key things to consider are:

• What resources are available to clients and how effective are they?
• Is there potential to adapt existing resources to meet new needs?
• Is communication between team members, between teams and between agencies effective? Could this change to improve outcomes?
• Do informal conversations need to happen in a formal setting and/or be recorded so everyone is clear on what is happening with a client or situation?
• Are staff aware of the roles and remits within their own and other agencies?
• Have people had the training they need to safeguard the people they work with?
• Can the client access help and advice when they need it?

Multi-agency reviews

If the SAB are not going to conduct an official SAR, they or a senior member of another organisation can invite agencies involved with the client to attend a multi-agency review to consider the questions posed above, and to discuss potential recommendations.

Learning from Safeguarding Adults Reviews: good practice

Direct practice with individuals experiencing homelessness

• A person-centred approach that comprises proactive, rather than reactive engagement, and a detailed exploration of the person’s wishes, feeling, views, experiences, needs and desired outcomes.
• A combination of concerned and authoritative professional curiosity, characterised by gentle persistence, skilled questioning, conveyed empathy and relationship building skills.
• Early and sustained intervention, including supporting people to engage with services and assertive outreach.
• When faced with service refusal, there should be a full exploration of what may appear a ‘lifestyle choice’, with detailed discussion of what might lie behind a person’s refusal to engage e.g., experiences of trauma.
• Comprehensive risk assessments are advised, especially in situations of service refusal and/or non-engagement, using recognised indicators to focus work on prevention and mitigation.
• Where possible, involvement of family and friends in assessments and care planning but also, where appropriate, exploration of family dynamics, including the cared-for and care-giver relationship.
• Thorough mental health and mental capacity assessments: assumptions should not be made about people’s capacity to be in control of their own care and support; nor should assumptions be made that apparently unwise decisions are indicative of a lack of mental capacity.
• Careful preparation at the point of transition, e.g., hospital & prison discharge, end of probation orders etc.
• Use of advocacy where this might assist a person to engage with assessments, service provision and treatment.
• Thorough social care assessments, care plans and regular reviews.

Team around the person

• Inter-agency communication and collaboration, working together, coordinated by a lead agency and key worker in the community to act as the continuity and coordinator of contact, with named people to whom referrals can be made.
• A comprehensive approach to information-sharing, so that all agencies involved possess the full, rather than partial picture.
• Detailed referrals where one agency is requesting the assistance of another in order to meet a person’s needs.
• Multi-agency meetings that pool information and assessments of risk, mental health and mental capacity to agree a risk management plan.
• Use of policies and procedures for working with adults who self-neglect and/or demonstrate complex needs associated with multiple exclusion homelessness, with specific pathways for coordinating services to address such risks and needs.
• Use of the duty to enquire (Section 42, Care Act 2014) where this would assist in coordinating the multiagency effort.
• Evaluation of the relevance of diverse legal options to assist with case management.
• Clear, up-to-date and thorough recording of assessments, reviews and decision-making; recording should include details of unmet needs.

Organisational support for members of the team around the person

• Supervision and support that promote reflection and critical analysis of the approach being taken to each case, especially when working with people who are hard to engage, and exhibit challenging behaviour.
• Access to specialist legal, mental capacity, mental health and safeguarding advice.
• Audit decision-making about referrals of adult safeguarding concerns.
• Case oversight, including comprehensive commissioning and contract monitoring of service providers.
• Joint commissioning of providers of health, social care and housing following review of gaps, informed by feedback from people with lived experience and frontline practitioners.
• Agreed indicators of risk that are formulated into a risk assessment template that will guide assessments and planning.
• Attention to workforce development, including training, and workplace issues, such as staffing levels, organisational cultures and thresholds.
• Promote trauma-informed practice and recognition of the interface between homelessness and self-neglect.

Governance

SABs should:

• Ensure that multi-agency agreements are concluded and then implemented with respect to working with high risk individuals. This will include the operation of MAPPA, MARAC, MASH and other complex case or multi-agency panel arrangements.
• Develop, disseminate and audit the impact of policies and procedures regarding homelessness, ensuring that they contain explicit references to, and pathways into adult safeguarding.
• Review the interface between housing/homelessness and adult social care, mental health, and adult safeguarding, and include housing in multi-agency policies and procedures.
• Establish a system to review the deaths of people experiencing homelessness and/or as a result of alcohol/drug use where the SAR criteria are not met.
• Work with Community Safety Partnerships, Health and Wellbeing Boards and partnership arrangements for safeguarding children and young people, to coordinate governance, namely strategic leadership, and oversight of the development and review of policies, procedures and practice.
• Provide or arrange for the provision of workshops on practice and the management of practice with adults who experience homelessness, including a focus on self-neglect, trauma-informed and strength-based approaches, substance use and dual diagnosis.
• Audit the impact of the recommendations from completed SA