Lincolnshire Safeguarding Adults Board Annual Report

Independent chair's introduction

As the independent chair of the Lincolnshire Safeguarding Adults Board (LSAB), I invite you to consider our annual report for 2022-2023.

The board, with our partners, agreed on the strategic priority areas in our strategic plan.  To do this, we undertook:

  • a joint needs assessment
  • analysis of the Lincolnshire annual safeguarding return

As you will see in this report, the partners are progressing significant pieces of adult safeguarding work in line with our strategic priorities.

One of the most exciting developments of this year has been the creation of our Keeping people safe prevention strategy 2023-2026. This strategy will help guide the prevention activities of the LSAB partnership, including:

  • promoting individual wellbeing
  • help keep people safe by preventing safeguarding risks from escalating

It aims to do this by working collaboratively with:

  • other statutory partnerships
  • organisations
  • communities
  • families
  • carers

The delivery of the strategy depends on the commitment of the whole partnership.  It is a testament to the strength of our partnership that senior leaders from various sectors are leading work on prevention priority areas.

I would like to express my gratitude to the LSAB staff.  They work tirelessly to coordinate and support the board’s work.  Their work allows us to meet our statutory requirements and move towards achieving our strategic priorities.

Richard Proctor
Lincolnshire Safeguarding Adults Board
Independent Chair

Strategic priorities and key updates

Our overarching priority from 2022 to 2025 is prevention and early intervention.

The areas of work we intend to focus on over the coming years can be defined into three areas:

  • making safeguarding personal
  • learning and shaping future practice
  • safeguarding effectiveness

Find out more about adult safeguarding on our website.

Key updates

Throughout 2022-2023, the board enjoyed the full support from all partner agencies, those that are statutory:

  • local authority
  • integrated care board
  • police

and those that we welcome as partners, such as:

  • all seven district councils
  • agencies from the voluntary sector
  • all emergency services
  • care provider representation

The collaborative work undertaken by all partners is far greater than the sum of its parts.  It creates:

  • a very positive culture of challenge
  • some new and innovative service models
  • very strong safeguarding teams

Some key pieces of work undertaken during 2022-2023 include:

Prevention and early intervention

A focus on keeping people safe by mitigating safeguarding risks before they escalate. Priority areas for focus will include:

  • further improvement in the quality and safety of residential and nursing care
  • preventing and or limiting the impact of pressure sores (across NHS and independent sector providers)
  • tackling the domestic abuse of older adults - including joint working with the other three statutory boards
  • preventing financial abuse (includes an opportunity for joint working with the other three strategic boards)
  • safeguarding adults with complex needs by piloting phase two of the team around the adult (TAA) approach

Work undertaken in 2022 and 2023 on prevention and early intervention includes:

  • Prevention strategy: we have updated our previous prevention strategy and developed a strategy for 2023-2026. Key areas of focus include:
    • further improvement in the quality and safety of residential and nursing care
    • preventing the impact of pressure sores
    • tackling domestic abuse of older adults
    • preventing financial abuse
    • safeguarding adults with complex needs by piloting phase two of team around the adult
  • We are working closely with the newly formed Lincolnshire domestic abuse partnership to combat elder abuse.  A current key focus is on domestic abuse in older adults.

Learning and shaping future practice

We will ensure that the learning from all our reviews and assurance activities is shared and embedded within partner agencies.  The aim is to reduce the risk of repeat incidents or causes of harm. Key areas of focus will include:

  • trailing innovative approaches to safeguarding adult reviews (SARs)
  • completing assurance activities to inform the continuous improvement of safeguarding practice across all partners
  • identifying themes and trends to drive training and awareness input locally and nationally, for example, professional curiosity and mental capacity
  • build on our ability to evaluate that system-wide change has taken place as a result of the learning
  • supporting all stakeholders to improve the quality and impact of their safeguarding activity to improve the outcomes for adults who are abused
  • establish a constant cycle of learning and improvement at a local and national level

Safeguarding effectiveness

The board must work effectively.  To do this, we ensure the effective operation and continuous improvement of the governance, scrutiny and business.

Key areas of focus will include:

  • To develop a flexible and effective communications and engagement strategy.  This will include a review of the LSAB information and advice offered.
  • Ensuring our quality assurance process is robust.  We will:
    • identify any challenges, share best practices and hear the voice of the service user
    • incorporate the completion of the local assurance framework by LSAB partners
  • Ensuring an effective risk and issues management process and the board’s policy and procedures, including a review of the LSAB’s risk register.
  • Data collection and analysis to ensure our work is always based on evidence. This will include developing an enhanced assurance dashboard for the LSAB executive.
  • Develop a service user and community engagement plan to help us embed our co-production ambitions further.
  • Lincolnshire Assurance and Assessment Framework (LAAF) is a self-assessment audit. 15 LSAB organisations took part, rating their effectiveness in a number of adult safeguarding areas. This LAAF saw a tailored assessment for care home and domiciliary providers and a peer moderation element. Overall, most responses to the safeguarding standards were rated as effective.
  • Quality assurance programme: LSAB plans to replace the LAAF with a quality assurance approach of peer-to-peer site visits in 2024.

Making safeguarding personal (MSP)

Ensuring all LSAB partners can consistently evidence an MSP approach to safeguarding practice. In particular:

  • partners can evidence that they have spoken to the person at risk before raising a safeguarding adult concern
  • that all partners will encourage the person at risk (or their advocate) to confirm what outcomes they wish to be achieved
  • that we will seek to achieve the outcomes expressed in a personalised way
  • that partners will work together to keep people safe and prevent safeguarding risks from escalating
  • implementation of the LSAB MSP action plan

Trauma-informed practice

As a result of the learning from TAA phase 2, we have begun a working group with:

  • Lincolnshire Domestic Abuse Partnership (LDAP)
  • Lincolnshire Safeguarding Children Partnership (LSCP)

The aim is to deliver a consistent approach to trauma-informed practice across the partnerships.

Transitional safeguarding

We are collaborating with LSCP to develop a joint protocol on this area of safeguarding.

Policies and guidance

During the reporting period, we published our:

  • reviewed policy and procedures
  • first person in a position of trust protocol
  • professional curiosity resource pack

We continue to work on our quality incident form to support care homes and domiciliary providers.

Self-neglect and hoarding

We are currently:

  • reviewing our self-neglect protocol
  • working closely with colleagues from public health on the hoarding protocol

Team around the adult (TAA) – Phase 2

We have set up a task and finish group with the Mental Health, Learning Disability and Autism Group (MHLDA).  The group was established in April 2022 to progress a second phase of the TAA initiative.  It operates under the oversight of the LSAB prevention strategy.

The existing TAA remains unchanged and runs alongside Phase 2. To support the task and finish group in developing recommendations for improvement, we established a multi-agency audit group (MAAG).  The MAAG comprises representatives from:

  • police
  • adult care (LPFT and LCC)
  • housing (district councils or framework housing)
  • LPFT
  • LCHS
  • VCSE sector

Since July 2022, the group have been auditing the activity of 40 individuals who presented most often to each of the four agencies.  Ten each from the:

  • police
  • LPFT crisis team
  • district councils
  • LCC emergency duty team

There has been a great commitment to these meetings.  Information is shared and attendees actively participate.  This fosters open discussions, professional curiosity, and constructive challenges.

The MAAG work together with the task and finish group. Each has a specific role:

  • MAAG focus on what the person’s situation is and how they were being supported
  • the task and finish group considers these findings to help determine priorities for change, improvement, and implementation

The audit will establish if the individual’s needs have been met.  If they haven’t, the TAA will support the coordination and development of a multi-agency support plan.  The aim is to empower the person to maintain their safety and wellbeing in the long term.

From the audits to date, the task and finish group have identified a need for coordinated and multi-agency access.  This access is required for multi-agency trauma informed practice training and resources.  We have agreed to develop this in Lincolnshire alongside the other statutory boards.

Feedback and learning have been shared as part of the self-neglect protocol review.  This includes the emerging findings associated with a frequent perception of ‘non-engagement’ and ‘individuals not being ready for support’.

The final MAAG is scheduled for Tuesday 31 October 2023.  By then, activity relating to 35 individuals will have been audited. The task and finish group will review the findings in their entirety.  They will then consider and agree on the next steps and further recommendations for improvement.

Reviews and learning

We will ensure that the learning from all our reviews and assurance activities is shared.  It will be embedded within partner agencies to reduce the risk of repeat incidents or causes of harm.

Safeguarding Adults Boards (SAB) have a statutory duty to undertake safeguarding adult reviews when:

"...an adult in its area dies as a result of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked more effectively to protect the adult."

A SAR may be needed even if an adult has not died.  If the SAB knows or suspects that an adult has experienced serious abuse or neglect, they must arrange a SAR. 

The review aims to identify learning that can be used to improve outcomes for others.  The review is not to find fault and apportion blame.

The Significant Incident Review Group for Adults (SIRGA) is a subgroup of the LSAB.  Under the Care Act 2014 it is responsible for safeguarding adult reviews (SARs).

SIRGA manages the process of recommending and commissioning SARs.  They also ensure multi-agency partnerships and individual agencies have addressed recommendations and associated actions. Throughout 2022 and into 2023, the board has:

  • Progressed one safeguarding adult review – SAR Anthony.  This review is expected to be completed and published by late Autumn 2023.  The group has worked together on all proposed recommendations, ensuring that key learning is cascaded in a timely way.
  • Received and considered five significant incident notifications. When looked at further, they did not meet the criteria for a safeguarding adults review.  In two notifications, learning identified from single agency processes was presented and discussed at a subsequent SIRGA meeting.

All published reports, executive summaries and learning bulletins are on the LSAB website.

Ongoing SAR – Anthony

Lincolnshire Community Health Services NHS Trust made a referral in February 2022 following the death of a man in his sixties in hospital. The male was part of a family where there were complex dynamics.  He was believed to have a learning difficulty, and there were concerns about the conditions within his home, which he owned, and around self-neglect.

The notification was discussed at the SIRGA meeting, where it was decided that the criteria for a SAR had been met.

Information gathering from partners has taken place.  As the SAR has progressed, the group has worked together to:

  • identify emerging themes and agreed recommendations
  • ensure that key learning is cascaded in a timely way throughout the review process

The report has been written and is expected to be published in the late autumn of 2023.

What we learned

The learning that emerged from this review highlighted the importance of:

  • identification and escalation of safeguarding concerns
  • professional curiosity
  • practitioners’ knowledge of executive functioning
  • the multiagency response to self-neglect
  • discharge planning

There was good practice identified in relation to:

  • professional tenacity of professionals in ensuring Anthony received the care needed
  • the practice of some professionals in undertaking assessments of capacity

What we have done

  • learning has been taken forward through a reflective partnership event, applying the learning from the review to the self-neglect protocol
  • the process of the review to date has been quality assured using the Lincolnshire SAR policy and toolkit, including SCIE quality markers

What we will do

  • deliver a learning event to cascade the learning from this review and the wider body of knowledge of research and practice
  • development of an “easy read” version of the report
  • development of a learning bulletin
  • reflect the learning from the review in the professional curiosity resource pack
  • reflect the findings of the review of the Lincolnshire self-neglect strategy and our strategic plan
  • share a range of learning materials around executive functioning

How we will know this has impacted on practice

  • peer review and site visits as part of the new assurance framework will provide quantitative evaluation
  • include patient stories that reflect the key areas of learning as a standing agenda item at SIRGA meetings to provide a qualitative evaluation
  • scrutinise individual agency audit feedback

Learning from SARs – a thematic approach

Throughout 2020 and 2021, three notifications were submitted to SIRGA for consideration as a SAR.  Two were additionally submitted to the Lincolnshire Domestic Abuse Partnership (LDAP) for consideration for a domestic homicide review (DHR).

Although none of the cases met the statutory criteria for an SAR or DHR, similarities in cases were noted.  It was agreed that a joint thematic non-statutory review would be undertaken. The joint thematic review was completed in the period 2022 to 2023.

The learning

The learning emerging from this review highlighted the importance of:

  • raising professional awareness of the completion of DASH risk assessments when professionals fail to engage service users
  • considering whole households in assessment practice
  • consideration of how disability may impact on engagement
  • responding effectively to individuals with complex needs, including those who lack executive function capacity
  • professional curiosity

What we have we done

  • SAB has asked each agency for evidence of how the learning has been taken forward in relation to awareness raising related to DASH risk assessment and assessment practice.
  • The learning through the thematic review has been developed into an action plan. There are agreed actions and their progress is monitored at each monthly SIRGA meeting.
  • Based on the review, a learning bulletin has been developed and circulated across the partnership.
  • SIRGA has developed a pool of learning and development material on executive functioning.
  • LDAP has commissioned a “tool kit” which will:
    • support practitioners when working with domestic abuse and those living with dementia or cognitive impairments
    • be shared across the partnership

What more we will do

  • develop a seven-minute briefing to promote the professional curiosity resource pack
  • review the complex needs section in the policies and procedures

How we will know the learning has impacted on practice

  • peer review and site visits as part of the new assurance framework will provide quantitative evaluation
  • include patient stories that reflect the key areas of learning as a standing agenda item at the meetings

SAR recommendations

All SARs commissioned by the LSAB include recommendations from the independent reviewing author. These recommendations charge the LSAB and its partners with improving systems to try and prevent similar significant issues from occurring in the future.

SIRGA monitors the recommendations until they are completed, and the impact on the service users’ experience is assessed through the SAB assurance framework.

SARs in rapid time learning and development

The SARs in rapid time is a training programme funded by DHSC and delivered by SCIE.

The training focuses on a model for completing safeguarding adult reviews in rapid time.  It also offers a process and tools to support SABs in producing learning of practical value for ongoing improvement work. Several SAB and SIRGA members have attended the training.  The approach is included in the updated Lincolnshire safeguarding adults review policy and toolkit.

SAR quality markers

The SAR quality markers are a tool to support people involved in commissioning, conducting and quality-assuring SARs to know what good looks like. Covering the whole process, they provide a consistent and robust approach to SARs.

The quality markers are based on:

  • statutory requirements
  • established principles of effective reviews
  • incident investigations
  • practice experience
  • ethical considerations

The SAR quality markers assume the principles of MSP, as well as the six principles of safeguarding that underpin all adult safeguarding work:

  • empowerment
  • prevention
  • proportionate
  • protection
  • partnership
  • accountable

These principles, therefore, permeate the quality markers explicitly and implicitly. The Lincolnshire safeguarding adults review policy and toolkit has been updated to reflect the revised SCIE quality markers.

Analysis of safeguarding adults reviews

This report was commissioned by the Care and Health Improvement Programme (CHIP).  It presents the findings of the first national thematic analysis of published and unpublished SARs in England since the implementation of section 44 of the Care Act 2014.

When published in 2021, LSAB conducted a benchmarking exercise against the report’s proposed sector-led improvement priorities. LSAB continues to use this resource to support the SAR process’s ongoing improvement.