Safeguarding Adults A framework to facilitate multiagency decision

Safeguarding Adults A framework to facilitate multi-agency decision making in a strategy meeting (Dorena Hughes & Di Galpin) www. bournemouth. ac. uk

Safeguarding Adults • CQC/CSCI Inspections • From January 2008 to August 2009, sixty-six councils had been inspected and thirty-seven reports were available at the time of writing. www. bournemouth. ac. uk 2

Safeguarding Adults • CQC ratings for these councils Safeguarding Adults activity are as follows 1 = Excellent 12 = Good 20 = Adequate 4 = Poor www. bournemouth. ac. uk 3

Safeguarding Adults • The figures suggest sixty-five percent of councils were rated as poor or adequate whilst thirty five percent were rated as good or excellent. • Of those rated as poor or adequate seventy five percent had issues concerning strategy meetings identified within the report. www. bournemouth. ac. uk 4

Safeguarding Adults Findings suggest: • Plans developed from strategy meetings lacked detail and were not holistic or outcome focused (CSCI, 2008 a) • There were variations in clarity of decision making (CSCI, 2008 b) www. bournemouth. ac. uk 5

Safeguarding Adults • Strategy meetings were not routinely undertaken (CSCI, 2008 c; 2008 i) • Strategy meetings did not take place in line with agency policy and procedures (CSCI, 2008 d) • There was unacceptable and potentially unsafe inconsistency in approaches to multi-agency meetings and decision making responsibility (CSCI, 2008 e) www. bournemouth. ac. uk 6

Safeguarding Adults • Varied practice led to uncoordinated investigations (CQC, 2009 c) • Protection planning needed to be sharper about specific actions required to protect someone from abuse (CSCI, 2008 f) • Lack of clarity about who should be invited to a strategy meeting, leading to inconsistency in strategy meeting participation from other agencies (CSCI, 2008 g) www. bournemouth. ac. uk 7

Safeguarding Adults • Multi-agency decision making unclear leading to investigation processes becoming muddled (CSCI, 2008 g) • Records of meetings was poor and protection plans did not explicitly set out the risk assessment process and actions did not specify responsibilities, timescales and implementation processes (CSCI, 2008 i) www. bournemouth. ac. uk 8

Safeguarding Adults • Strategy meetings resulted in task lists rather than clear plans where timescales and accountability were clearly set out (CQC, 2009 a) • Attendance at strategy meetings by medical staff and police was variable (CQC, 2009 b) www. bournemouth. ac. uk 9

Practice Framework • Aim to be efficient and effective, as a minimum standard. Efficiency and effectiveness requires professionals to a) respond appropriately and professionally in a timely manner to Safeguard Adults in vulnerable circumstances and b) ensure adults are not left at risk. www. bournemouth. ac. uk 10

Practice Framework Effective outcomes for a strategy meeting require: • Achieving outcomes which support the views of service users and their carers • Multi-agency information sharing and decisionmaking www. bournemouth. ac. uk 11

Practice Framework • Working in partnership with service users, carers and other agencies to assess and manage risks • Reaching agreement on an action plan for the investigation or ongoing monitoring www. bournemouth. ac. uk 12

Practice Framework • Compliance with multi-agency policy and procedures • Adherence to professional codes of practices for all agencies involved. www. bournemouth. ac. uk 13

Practice Framework Achieving efficient outcomes for a strategy meeting will require: • Attendance and input from all agencies involved in the individual’s care • A coordinated investigation process which does not compromise a successful outcome www. bournemouth. ac. uk 14

Practice Framework Meeting agreed timescales to allow agencies to meet their own organisation’s responsibilities and protocols. www. bournemouth. ac. uk 15

Practice Framework • The Harvard Business model (2006) offers simplicity in approach to help support the complexity of practice. • This decision-making model suggests achieving a quality decision relies on having a good process in place to begin with. www. bournemouth. ac. uk 16

Practice Framework The model identifies five key steps as being crucial to decision-making: • • • Establish context Frame the issue Generate alternatives Evaluate alternatives Choice of best option www. bournemouth. ac. uk 17

Practice Framework In addition, a sixth step is required to facilitate for future stages of an investigation • Action planning www. bournemouth. ac. uk 18

Practice Framework • Establishing context • Step one sets the scene for a ‘decision-friendly’ environment within the strategy meeting, central to this is ensuring a strategy meeting is called and the right people attend the meeting. www. bournemouth. ac. uk 19

Practice Framework • The consequences of not using strategy meetings to Safeguard Adults is made clear in the serious case review in respect of TS, a 43 year old woman who died on the 12 th March 2007 after being Practice Framework admitted to hospital on the 1 st March 2007. (she had a history of alcohol abuse and had a stroke) www. bournemouth. ac. uk 20

Practice Framework • whilst many professionals had been involved with TS, i. e. police, health and social care, for several years, they did not use the procedures available to them to safeguard TS • The SCR suggested www. bournemouth. ac. uk 21

Practice Framework a strategy meeting • ‘… may well have resulted in a more holistic and coordinated approach being taken, involving all relevant agencies’ (Cornwall Safeguarding Adults Board, 2008, p 6) www. bournemouth. ac. uk 22

Practice Framework Of equal importance is to ensure the right people attend • In your experience who is usually invited And • Who actually attends? www. bournemouth. ac. uk 23

Practice Framework • The SCR in respect of TS is clear on who should be invited stating • ‘It is recommended that agencies calling a multiagency meeting in respect of a potentially vulnerable adult extend the invitation to all agencies whose expertise may provide a contribution to the outcome regardless of the agency’s prior or current involvement with the client and that all agencies have a responsibility to ensure they are represented. ’ (Cornwall Safeguarding Adults Board, 2008, p 6) www. bournemouth. ac. uk 24

Practice Framework Service Users/Carer/Advocate? • Pros • Cons www. bournemouth. ac. uk 25

Practice Framework • one needs to balance this decision in the knowledge that focusing primarily on protection of service users, and excluding them from meetings, can lead to a paternalistic approach and contribute to the disempowerment of service users (Cambridge & Parkes, 2004). www. bournemouth. ac. uk 26

Practice Framework • it is important not only for the right people to be invited but also that all agencies make a commitment to giving adult protection a priority. Sometimes at strategy meetings, key people are not present. For example, anecdotal evidence suggests GPs and Police are frequently unable to attend, findings from CQC support this (2009 b). www. bournemouth. ac. uk 27

Practice Framework • To improve multi-agency attendance the lead for adult protection within partner agencies could be invited as this may assist the process as some professional groups have less knowledge of adult abuse, investigation procedures and their responsibility within the process www. bournemouth. ac. uk 28

Practice Framework • One might reflect at this point on the case of Steven Hoskins (Flynn, 2007) and the multitude of agencies involved in this case and their apparent lack of understanding regarding roles and responsibilities in protecting Steven. www. bournemouth. ac. uk 29

Practice Framework • In establishing context, participants are required to attend with an open mind and be prepared to be challenged on preconceived ideas about the outcome. • Problems can occur if people are ‘dichotomous’ in their thinking (Fook, 2002), rigid or polarised, seeing individuals as either vulnerable to abuse or as a perpetrator of abuse www. bournemouth. ac. uk 30

Practice Framework • Steven Hoskins: Flynn (2007) suggest at the heart of the tragedy was the fact that Steven was not seen or experienced as a vulnerable adult, instead he was seen as an instigator of problems. www. bournemouth. ac. uk 31

Practice Framework A decision-friendly environment for a strategy meeting will require statements about and a commitment to: • Confidentiality • Anti-oppressive and Anti-discriminatory Practice • Dignity and respect for service users, carers and professionals contributing to the meeting. www. bournemouth. ac. uk 32

Practice Framework Framing the issue • This model recognises the need to be clear about defining the problem/issue in order to arrive at the best possible solution. • This is a crucial stage in adult protection decisionmaking and one often lost during the information sharing process across agencies as attendees often fail to separate the key issues in their own minds www. bournemouth. ac. uk 33

Practice Framework • JK was a 76 -year-old women who lived alone with her three dogs in rented accommodation provide by a housing association. She was reluctant to leave the home. JK had a number of health issues and there were concerns about the poor state of hygiene in the house. A number of professionals worked with JK over a sustained number of years. JK was discovered dead in her home on the 13 th November 2008 by a profession involved in her care. www. bournemouth. ac. uk 34

Practice Framework • ‘JK was not apparently neglected or forgotten by the services around her. She did not allow this to happen. Nor were they unaware of aspects of her self-neglect or vulnerability. However, they got confused about choice and risk. In the light of her clear and articulate resistance to receive help to change her situation they lost the ability to work in anything but a reactive way. ’ (Cornwall & Isles of Scilly Safeguarding Adults Board, 2009, p 5) www. bournemouth. ac. uk 35

Practice Framework • Dalgliesh and Hollows (2008) identify the unknowns, in terms of knowledge of abuse or policy and procedure, along with an inability to interpret information in the context of assessing risk as obstacles to effective risk assessment in child protection • might this also be true of adult protection? www. bournemouth. ac. uk 36

Practice Framework Questions that could be asked to clarify the ‘unknowns’ to ensure an accurate framing of the issues include; • What has happened, i. e. what are the allegations or concerns? • What is known about the individual/ perpetrator? www. bournemouth. ac. uk 37

Practice Framework • What information can I contribute to clarify the issue? • What is unknown and what do I need to know either to support the individual or alleged perpetrator to carry out my own role and responsibilities within the multi-agency investigation procedures? www. bournemouth. ac. uk 38

Framing the issue and Mental Capacity ‘The issue of mental capacity and the ability of an individual to consent to acts that may be Practice Framework considered abusive by professionals can be central in deciding if abuse has occurred and in determining action to be taken. ’ (Galpin & Parker, 2007, p 7) www. bournemouth. ac. uk 39

Practice Framework • If an individual is assessed as lacking mental capacity, in these specific circumstances, consideration will need to be given to who should be involved in making a ‘best interest’ decision and the Court of Protection’s power under the Mental Capacity Act 2005 to make declarations as to the lawfulness of certain acts done in relation to individual lacking mental capacity www. bournemouth. ac. uk 40

Practice Framework • However, assessing an individual as having mental capacity should not be viewed as a reason for organisations and professionals to withdraw from the process. www. bournemouth. ac. uk 41

Practice Framework The SCR suggests everyone involved was clear JK had the mental capacity to make decisions and this had implications for practice stating • ‘As a consequence, for months if not years the accepted pattern of care and support offered to her came to be reactive, dealing with the immediate concerns she raised and then withdrawing. There was a lack of multi-agency discussion about JK’s situation and ownership of how to address the choices she was making. ’ (Cornwall & Isles of Scilly Safeguarding Adults Board, 2009, p 5) www. bournemouth. ac. uk 42

Practice Framework • Munby J reminds us the High Courts jurisdiction is available in relation to a vulnerable adult (Arden Davies, 2008), even if not incapacitated by mental disorder or mental illness www. bournemouth. ac. uk 43

Practice Framework • suggesting in this context that it is lawful for a local authority to enforce living arrangements if the individual is believed to be either ‘(i) under constraint or (ii) subject to coercion or undue influence or (iii) for some other reason deprived of the capacity to make the relevant decision, or disabled from making a free choice’ (A Local Authority v MA, NA and SA (2006) 1 FLR 867). www. bournemouth. ac. uk 44

Practice Framework • Mental Capacity and individuals perceptions of their situation • How do they perceive the situation? www. bournemouth. ac. uk 45

Practice Framework • Choice? • However, this does not mean the process should automatically stop as individuals may require additional support to make choices. www. bournemouth. ac. uk 46

Practice Framework • ‘There was no one identified from the range of people surrounding her who sought to work with her about her choices. This is skilled work. It is not about organising and delivering services or medication. Without someone in the team surrounding JK working with her perspective, all interventions became essentially service driven. ’ (Cornwall & Isles of Scilly Safeguarding Adults Board, 2009, p 5) www. bournemouth. ac. uk 47

Practice Framework • Fear may also prevent individuals, who are otherwise deemed to possess mental capacity, from engaging with professionals to address issues of abuse • Fiona & Francecca Pilkington www. bournemouth. ac. uk 48

Practice Framework The Assistant Chief Constable suggested at the inquest into their deaths that • ‘it was difficult to bring prosecutions against the gang because it was not what the family wanted’ The Independent, 18 th Sept 2009 www. bournemouth. ac. uk 49

Practice Framework • The coroner stated “This was a woman who may have been terrified , who might have been vulnerable and not the best person to make the decision about a prosecution under the circumstances” The Independent, 18/09/2009 www. bournemouth. ac. uk 50

Practice Framework • What can we learn from this? • Consideration needs to be given to wider issues in terms of mental capacity to • identify factors that influence individuals in making decisions about protection so that • professionals can develop support that assists in enabling people to make choices that could bring about positive change. www. bournemouth. ac. uk 51

Practice Framework Clarity in framing the issue • Care is needed at this stage not to state as fact concerns, which may have causes other than those defined in terms of Safeguarding Adults • Discussion can become confused about what is alleged, what can be evidenced and what further information is required. www. bournemouth. ac. uk 52

Practice Framework • In these types of case scenario the meeting may become more concerned with what each agency could or should actually do; to the point where a meeting might be brought to a close on the basis that there is nothing anyone can. www. bournemouth. ac. uk 53

Practice Framework • Facts giving serious concern need to be substantiated. This process can identify gaps in information, this is important because where there is a lack of information and an element of uncertainty professional reactions could become over or under exaggerated. www. bournemouth. ac. uk 54

Practice Framework • It is necessary to clearly identify, from the information available, what is known, what is uncertain and what questions need to be asked before either chairing a strategy meeting or attending one. www. bournemouth. ac. uk 55

Practice Framework • The consequences of professionals not preparing adequately can result in confused thinking leading to difficulties in formulating a plan of action and unhelpful outcomes for the adult in vulnerable circumstances (CSCI, 2008 g). www. bournemouth. ac. uk 56

Practice Framework • The Harvard model makes it clear that the way people frame problems can exert power over the options recognised at a later stage • Think Sutton & Merton/Cornwall Inquiries and the power of health professionals in those settings www. bournemouth. ac. uk 57

Practice Framework • Think NPSA – Sexual Assault/Abuse • One explanation for this is that responses to abuse within a medical model of practice serves to link abuse to mental illness by blaming allegations on individual pathology which then helps keep abusers invisible (Humphreys & Thiara, 2003; Corrigan & Penn, 1997). www. bournemouth. ac. uk 58

Practice Framework • Therefore, careful questioning would be required to understand what might underpin comments made when attempting to clarify issues. www. bournemouth. ac. uk 59

Practice Framework Generating alternatives • The model works on the basis that without alternatives there can be no genuine decision. www. bournemouth. ac. uk 60

Practice Framework • This is the stage at which professionals, usually from a variety of services with a wide range of knowledge, skills, and responsibilities, work together to identify all the options available for resolving the issue www. bournemouth. ac. uk 61

Practice Framework • Statham (2004) points out that a multi-professional team will be working from different codes of practice and priorities and that these requirements are likely to be firmly embedded in their practice than in multi-agency working www. bournemouth. ac. uk 62

Practice Framework • This appears to be true of the Steven Hoskin case (Flynn, 2007). Partner agencies had a limited understanding of their role and responsibilities within the adult protection investigation www. bournemouth. ac. uk 63

Practice Framework • Also in the case of JK, a referral to another agency was seen to meet their responsibilities in terms of safeguarding by passing the problem on to another agency (Cornwall & Isles of Scilly Safeguarding Adults Board, 2009) • The generation of alternatives will be restricted if the process does not successfully complete stages one and two www. bournemouth. ac. uk 64

Practice Framework • A strategy meeting also requires direct leadership, making it very clear what is expected of attendees, rather than a participative style that just seeks the views of a multi-agency group (Mullins, 2007). www. bournemouth. ac. uk 65

Practice Framework • By drawing attention to the wider context, in terms of policy and legislation, and individual responsibilities within the process, attendees waiting for another agency to take on support and investigation activities will need to be encouraged to participate. www. bournemouth. ac. uk 66

• The Harvard model lends itself to ensuring that all agencies have contributed at every stage of the process. www. bournemouth. ac. uk 67

• It is important, again, to note that when the service user is absent from a strategy meeting this increases the likelihood that professionals will negotiate their own interests first rather than those of the service user and carer (Payne, 2000). www. bournemouth. ac. uk 68

Evaluation of alternatives • The goal at this stage is to keep in focus the issues as framed at the beginning and to ensure that all attendees understand the options in order to weigh up the pros and cons of each. www. bournemouth. ac. uk 69

• The evaluation of options should be underpinned by observance of professional values and ethics and a commitment to legal and human rights. • It is also important to assess the risks of each option for service users, carers and any professionals involved in the investigation. www. bournemouth. ac. uk 70

Choosing the best alternative • The Harvard model stresses the importance of not making a decision without full consideration being given to all the available options; www. bournemouth. ac. uk 71

• including the impact, that each will have on the service user and carer for example. A choice of appropriate action needs to consider risks, taking the least restrictive option so as not to infringe on human rights and individual autonomy, but also to offer protection. www. bournemouth. ac. uk 72

• Arguably, autonomy and protection are not mutually exclusive, but practitioners need to grasp how they relate to one another (Galpin & Parker, 2007). www. bournemouth. ac. uk 73

Action Planning An action plan would require as a minimum explicit recording of • Timescales • Roles and Responsibilities of each professional group • The proposed action(s) • Identified lead to review/monitor progress www. bournemouth. ac. uk 74

What next? How might you develop effective and efficient multi-agency decision making in a strategy meeting? Can any of these approaches be used to develop practice elsewhere? www. bournemouth. ac. uk 75

• Final Thought The ‘Peter Principle’ (1967) by Laurence Peter Why does history keep repeating itself……. . because nobody ever listens Are we going to listening, and more importantly can we going to learn from past mistakes? www. bournemouth. ac. uk 76