Large Scale Enquiry (Safeguarding Adults) Procedure

Flowchart

1. Introduction

This document describes the procedure for conducting a Large Scale Enquiry (LSE) and should be read alongside the Cambridgeshire and Peterborough Multi-Agency Adult Safeguarding Procedures.

The purpose of the procedure is to ensure a consistent and proportionate response when serious, non-compliance of minimum care standards are raised about a provider, both domiciliary and residential, that has or is likely to result in a number of adults being abused

This may come to light as a result of:

• An enquiry into individual concerns reveals wider issues about a provider.
• Information from Contracts/CQC indicate a systemic concern about a provider

The decision to hold a Large Scale Enquiry lies with the Service Director.

The criteria for instigating a Large Scale Enquiry are:

1. Accumulated complaints about the same service by people accessing the service, their families or members of the public, which amounts to serious safeguarding concerns;
2. Serious concerns of a safeguarding nature following several visits or individual reviews in the service;
3. Serious concerns of a safeguarding nature following contract compliance reviews of the service;
4. Reports of serious safeguarding concerns from other professional services / organisations involved in the service;
5. Serious concerns as a result of whistleblowing;
6. Serious concerns following a Safeguarding Adults planning meeting or enquiry.

This includes concerns relating to NHS and privately funded establishments as well as those contracted by the Local Authority.

During the course of a Large Scale Enquiry, ordinary adult safeguarding processes will continue in parallel to ensure individual adults identified as at risk are safeguarded.

2. References

• Peterborough and Cambridgeshire Safeguarding Adults Multi-Agency Policy and Procedures;
• Human Rights Act 1998
• The Care Act 2014
• Data Protection Act 1998
• The Mental Capacity Act 2005
• Safeguarding Vulnerable Group’s Act 2006

3. Escalation Procedure

There are a number of escalation routes for concerns that appear to meet the threshold for a Large Scale Enquiry, and these are specific to the following service areas:

• Adult Social Care Operations
• Commissioning and Contracts
• Quality Assurance and Safeguarding

Escalation process within Adult Social Care:

At this stage, the relevant operational Team Managers should ensure that the request to escalate the concern is entered as a case note on the Adult Social Care record of every adult at risk involved in the safeguarding concern.

NB Relevant operational team managers should also ensure that the decision whether to proceed with an LSE or not is also recorded as a case note.

The Head of Safeguarding is available for advice and guidance at any stage.

Irrespective of where the initial decision to escalate is taken, the authority for initiating an LSE rests with the Service Director for Adults and Safeguarding but not without first consulting the Head of Safeguarding.

If the concern relates to a service commissioned exclusively by a Clinical Commissioning Group (CCG) then the decision to implement the Large Scale Enquiry procedure must be made in conjunction with the Safeguarding Lead of the relevant CCG.

The Service Director Adults and Safeguarding may decide on a different course of action, or request further investigation and information gathering before making a final decision.

Once sufficient information is available, the Service Director for Adults and Safeguarding will make a decision within one working day.

4. Procedure for Initiating a Large Scale Enquiry

The decision to initiate the LSE procedure should be communicated, by the Head of Safeguarding or delegated as appropriate to:

• Service Director, Adult Social Care
• Head of Social Care Commissioning/Contracts
• Peterborough Safeguarding Adults Board
• Cambridgeshire Safeguarding Adults Board
• Safeguarding Adults Lead for the CCG (if relevant)
• Cambridgeshire Police
• Care Quality Commission (CQC)
• S/U Family
• Operational Heads of Service

Once the decision has been made to initiate the LSE procedure, the following actions should be taken promptly and overseen by the Head of Safeguarding:

1. Immediate actions to ensure adults are adequately safeguarded
2. Securing of records
3. Appointment of an LSE Chair
4. Report to DMT/CCG/Safeguarding Adults Board as appropriate – this should be ongoing throughout the course of the LSE

Appointment of the LSE Chair

The Chair of the LSE will be the Head of Safeguarding or a nominated other.

The key responsibilities of the Chair are to:

• Arrange an LSE meeting;
• Secure appropriate membership and representation at all LSE meetings;
• Consider the appropriateness and timing of provider involvement;
• Ensure the highest level of confidentiality and appropriate information sharing;
• Maintain explicit records of decision-making;
• Promote best practice levels of multi-agency working;
• Securing of records;
• Ensure the needs of adults at risk are placed at the centre of the enquiry;
• Keep the Departmental Management Team (DMT) updated on progress.
• Ensure SU family and SU wishes are considered and individual Safeguarding Enquiries continue.

5. Large Scale Enquiry Initial Meeting

It is imperative that a meeting be held with all relevant agencies at the earliest opportunity and within five working days of the decision to progress to an LSE.

It is expected that the LSE meeting is an actual meeting rather than simply phone or email contact. An aide memoire can be found in Appendix B.

Attendance

Core:

• The Head of Safeguarding for the Local Authority
• Safeguarding Adults manager for the Local Authority
• Cambridgeshire and Peterborough Clinical Commissioning Group (CCG) Safeguarding Lead Nurse (when applicable)
• Cambridgeshire Police
• Care Quality Commission (CQC)
• Contracts representative for the Local Authority

As appropriate:

• Representatives of other commissioners of the service
• Legal representative from the Local Authority
• Manager from the care management team
• The professional raising the concerns
• Contract Manager from the Local Authority
• Primary Care Team
• Community Health representative
• Probation
• Advocacy services / IMCA service
• Other investigating teams /authorities
• Service providers

The Chair is responsible for ensuring that partner and provider agencies have an appropriate level of seniority in attendance, and that their attendance at LSE meetings is consistent. Large scale providers should assign the area/regional manager; smaller providers the registered manager; voluntary sector the chairperson of the trust or management committee.

The CCG must be involved in all cases where the alleged victim is fully or part funded by health. If an individual’s care is commissioned by an NHS health provider that agency will be responsible for ensuring that the individual’s care arrangements are reviewed and will be responsible for taking the appropriate contractual actions as appropriate.

Purpose of the Meeting

The LSE meeting will need to consider:

1. The immediate safety of all adults at risk – this may include taking action to suspend or relocate staff;
2. The need for alternative accommodation or care provision for a number of individuals;
3. Other organisations that may need to be involved – such as CQC, other local authorities, other CCGs;
4. How best to co-ordinate the enquiry – who has overall responsibility for co- ordination;
5. Roles and responsibilities of each agency and individuals involved, ensuring that all are aware of how their contribution to the enquiry fits into the overall multi-agency process;
6. Who needs to be notified of the enquiry, whose responsibility it is and the method for doing so – those who may need to be notified include legal services, elected members, NHS England, adults who may be at risk and their family/carers/representatives;
7. The degree of involvement with/from the referrer/whistleblower;
8. Resource allocation – the number of investigators needed, facilities for conducting interviews, funding for relocating individuals at risk, etc.;
9. How to support the adults at risk and their family/carers/representatives through the enquiry process;
10. How to support staff throughout the enquiry process;
11. How media enquiries will be dealt with;
12. Timescales and framework for ensuring all actions are completed.

An aide memoire can be found in Appendix B.

The outcome of the LSE meeting will be a Large Scale Enquiry Action Plan.

The Head of Safeguarding will be assigned the responsibility of leading the coordination and monitoring of the LSE Action Plan, which will include the monitoring and dissemination of a significant volume of information. Allocating time for planning and analysis of the information gathered is an essential part of the ongoing process that takes place outside of the LSE meetings. How this is managed is at the discretion of the Head of Safeguarding but resource considerations and support to the Head of Safeguarding must be addressed at the initial LSE meeting.

The Large Scale Enquiry should commence within one working day of the initial LSE meeting.

Communication Strategy

The Chair can expect the level of media interest in a large scale enquiry to be high. A clear multi-agency communications strategy should therefore be in place and reviewed throughout the course of the LSE. PCC/CCC standard practice regarding the handling of media needs to be followed at all times, as guided by the Communications Team.

Key actions for the Chair:

• Identify a lead for communication/media statements – with all statements approved by the Chair prior to issue;
• Consider whether to deploy joint or single agency statements, or a mix of both;
• Ensure sufficient resource to focus on liaison with relatives and significant others, dependent upon context of the case – written communications, hosting of meetings, nominated points of contact.

Investigative Strands

Where institutional concerns are indicated or suspected, the Chair should consider the adoption of three investigative strands and assign roles and responsibilities for these within the LSE Action Plan:

Specific Individuals

• Investigation into the concerns/allegations relating to particular individuals;
• Identifying any service deficits that may contribute to the occurrence of these concerns/allegations.

Other Service Users

• Identifying which other service users, if any, are at risk;
• Service user reviews – where the need is indicated.

Service Issues

Assessment of the service provider’s systems and processes including:

• Policies, procedures and processes
• Culture, including staff knowledge, attitudes and practice
• Leadership and management oversight

When conducting an LSE action from the plan, a range of methods will be considered:

• Observations
• Written materials
• Conversations

Guidance on these methods can be found in Appendix C.

Health partners should be considered best placed to carry out some investigatory aspects as they will have the expertise to evaluate evidence of a medical nature which may be pertinent to the investigation. Such distinct roles will be clearly defined at the LSE meeting.

Any requirements will be specified in the LSE Action Plan and/or within an agreed service improvement plan.

Throughout the course of the LSE, relevant documentation must be attached to the files of adults at risk. Case records of affected individuals must be kept up-to-date, personal safeguarding plans created, reassessment of needs undertaken, best interest decisions clearly recorded, and so on, as required.

It is the responsibility of the relevant team managers in ASC Operations to ensure this with oversight from the relevant Head of Service.

Service user reviews should be considered as a protective measure, as their purpose is to ensure that a services user’s needs are being met. They also form part of the enquiry process and will serve to identify risks to service users, deficits in service provision and, potentially, incidents of abuse. Findings from service user reviews should inform any ongoing individual safeguarding enquiries as well as the LSE.

Any requirement for service user reviews will be included in the LSE Action Plan.

Where placements are commissioned by other local authorities, responsibility for those service user reviews lies with the commissioning local authority, which will need to be notified accordingly. It should be agreed at the LSE meeting how other local authorities will be involved/informed of the concerns. However, it is expected that the individual safeguarding enquires for those individuals will be led by PCC/CCC unless agreed otherwise.

Any requirement for service user reviews will be included in the LSE Action Plan.

A request must be submitted to the service provider asking them to provide a list of all service users, self-funders included, alongside details of their commissioning authorities.

Any requirement will be included in the LSE Action Plan.

6. Large Scale Enquiry Review Meetings

The Chair should convene a first review meeting within 28 days of the enquiry commencing. Further LSE review meetings will be arranged at any time during the process, as required. The purpose of LSE review meetings is to:

• Provide feedback on the different strands of investigation;
• Plan further actions;
• Evaluate progress of previously agreed actions;
• Evaluate ongoing risk.

It is the responsibility of the LSE Chair to convene review meetings and ensure appropriate and consistent attendance.

The aide memoire in Appendix B should also be followed at these meetings.

7. Large Scale Enquiry Closure and De-escalation

A final LSE closure meeting must take place to ensure:

• There is consensus that the LSE has achieved its agreed outcomes and actions;
• Appropriate mechanisms are in place if required to manage individual agency actions which do not require the oversight of the LSE;
• An agreed threshold for escalation should the risks or issues reoccur;
• An evaluation of whether the criteria has been met for a Safeguarding Adults Review in line with the SAB Policies and Procedures;
• Plans are in place to provide a final communication to the Corporate Director, Service Director and Safeguarding Adults Board as a minimum.

8. Debrief

The LSE Chair will consider inviting all involved agencies to participate in a review of the enquiry process. The purpose of the debrief is to identify the lessons learned and good practice of the LSE with recommendations for future inter-agency learning including policy, procedure and practice guidance.

9. Storage of Large Scale Enquiry Documentation

Access by affected agencies, personnel and adults at risk/their families may be requested at any time.

The Head of Safeguarding and Quality Assurance will securely store the Large Scale Enquiry documentation and maintain a record of all LSEs for future profiling, background information and monitoring.

Appendix A – Large Scale Enquiry Terms of Reference

1. To accept collective responsibility for the LSE for its duration
2. To ensure empowerment of Service Users in decision making and informed consent with access to independent advocacy as appropriate
3. To ensure proportionate intervention with the least intrusive response appropriate to the risks presented
4. To risk manage the enquiry at a strategic level and to provide clear instruction and actions regarding the conduct of the enquiry
5. To receive reports and information, monitor progress, identify further areas for improvement and develop action plans as appropriate.
6. To ensure the enquiry in relation to each individual agency is effectively coordinated and delivers its action plan.
7. To act as a conduit of communications for all partner agencies at a local and national level
8. To ensure resources, knowledge and expertise are available to conduct and support the Investigation
9. To ensure appropriate and consistent representation to the meetings
10. To ensure transparency and clear lines of accountability in the conduct of the enquiry
11. To openly challenge partners unwilling to actively participate in the enquiry and escalate the concern within partners own agencies as detailed in the Multi-Agency Safeguarding Adults Policy and Procedures
12. To participate in the de-escalation process and recommendations to the Peterborough Safeguarding Adults Board in relation to future inter-agency learning including policy, procedure and practice guidance if appropriate.

Appendix B – Aide Memoire for Large Scale Enquiry Meetings

1. Introductions, reminders of need to know confidentiality issues
2. Brief synopsis of concerns raised, and who is involved / implicated
3. Mental capacity of people accessing the service, in terms of decisions regarding their care
4. What are the risks, who do they impact upon, likely outcome without intervention?
5. What, if any, action has been taken to minimise risks?
6. Are there any criminal proceedings to be considered?
7. Are there any regulatory requirements / enforcements?
8. Regulation and contractual history of service
9. Contractual / legal implications
10. Abilities and co-operation of the service provider to highlight concerns and take effective remedial action
11. Details of funding arrangements / responsibilities
12. Immediate known health and social care needs of people accessing the service
13. Previous independent support offered by advocacy / IMCA
14. Family or relevant other supports
15. Are there appropriate risk, health and care management plans in place to safeguard people with care and support needs?
16. Need for further enquiry
17. Need for remedial contractual actions, e.g. suspension of new placements
18. Immediate actions required with timescales
19. Agree roles and responsibilities for completing and monitoring agreed actions
20. Agree communications strategy
21. Agree date of follow up meeting

Appendix C Investigative Methods

Observations

• Culture of the home. Is it warm, open and inviting?
• Environment – cleanliness, smell, state of repair, fixtures and fittings
• Noise
• Locks on doors – toilets
• Staff – numbers, visibility, quality and style of interaction (particularly at meal times)
• Arrival at the home – reception at the home, signing-in book
• Service users – where are they in relation to the time of day, are they being engaged,
• Activities – quality of activities
• Demeanour of staff and residents

Written Materials

• Policies and procedures – are they being embedded/followed
• Service user records – regular reviews, up-to-date care plan, communication records
• Person centred care records
• Quality of care records – recording
• Up to date records
• Accessible to staff
• Fluid/diet charts – are they being completed
• Medication charts – are there errors/gaps in recording/missed medications
• Analysis of complaints
• Analysis of reported incidents
• Analysis of reported safeguarding concerns
• Readily available information – accessible complaints procedures, statement of purpose
• Appropriate language
• Quality of recordings – legible, easy to find
• Staff rotas
• Staff training

Conversations

• Interviews – with staff, service users, families
• Ask what is it like to work/live here?
• Ask what would you change to improve what it is like to work/live here?
• Advocacy – awareness and application
• Training questions – staff understanding of MCA, safeguarding and dignity in care