What is a Safeguarding Adult Review (SAR)?
According to Part One Section 44 of the Care Act 2014 Safeguarding Adult Boards (i.e. Cambridgeshire and Peterborough Safeguarding Adult Partnership Board) must undertake a Safeguarding Adult Review (SAR) when:
- An adult in its area with care and support needs (i.e. an adult at risk) has died as a result of abuse or neglect whether this was known or suspected before the adult died and there is concern that partner agencies could have worked more effectively to protect the adult.
- An adult in its area with care and support needs (i.e. an adult at risk) has not died, but the SAB knows or suspects that the adult has experienced serious abuse or neglect and there is concern that partner agencies could have worked more effectively to protect the adult.
The purpose of a Safeguarding Adults Review is to learn the lessons about how professionals and organisations work together, and to consider how the learning can be used to improve practice for others in the future.
(Adapted and Taken from Care Act 2014 and Cambridgeshire and Peterborough Safeguarding Adult Partnership Board Website)
The SAR Audit
The review focused on SARs completed locally between 2019 to 2021 identifying case factors and ‘professional practice themes’. Both the Peterborough and Cambridgeshire electronic recording systems were accessed during November 2021 to December 2021 and either full SARs or their executive summaries, published from 2019 were located.
In total ten safeguarding adult reviews (SAR) were completed between 2019 – 2021. The thematic SAR review report written in 2020 examined ten SAR’s over a period of eight years (2022-2018) whilst this report analyses the same amount of SARs but over a two year period (2019-2021) which is an increase overall of 78% of completed SARs. During 2019 – 2021, 50% of SAR referrals came from health agencies and 25% from police and 25% from adult social care.
60% of the adults at risk had a variety of mental health issues closely followed by 50% of cases where the adult had physical health issues. 40% of the adults at risk experienced domestic violence that included coercive control either from their partners or from close family members. 40% of cases were also deemed to be adults at risk who were neglecting themselves and displaying variety of behaviours including hoarding and alcohol misuse. Other impacting factors included their families not engaging with support, the subject of the SAR making what was deemed as unwise decisions and adults potentially having learning difficulties.
The local findings are similar to the national research on SARs in relation to case factors. In the 2020 national SAR report ‘self-neglect’ was prevalent in 45% of SARs that researchers reviewed whilst physical health issues were found in 19% of the cases (Preston-Shoot et al, 2020,p13).
In 30% of the cases we reviewed, the following good practice was identified; (i) the completion of mental capacity assessments, to ascertain whether or not an adult at risk had capacity to undertake certain decisions and (ii) proactive multi-agency support was recorded as being given to the adult at risk for the provision and support of care needs.
20% of the cases reviewed there were other ‘good areas of professional practice’ noted and these included:
- Professionals being able to effectively challenge either family members or other professionals on what was being stated in relation to the adult at risk
- Professionals holding multi-agency meetings to discuss complex cases and working together jointly to work with the adult at risk in order to support and safeguard them
- Professionals using an Advocate to support the adult at risks understanding
- Professionals and agencies making good safeguarding referrals and, in some cases, including photographic evidence or the clutter scale tool to evidence hoarding behaviours and the situation of the living home environment
- Agencies and professionals effectively communicating with each other to safeguard the adult at risk
- Agencies and professionals ensuring that the adult at risk’s medical needs were supported and catered for
The top good practice themes identified in Preston-Shoot et al (2020) national SAR report included themes similar to our local findings of responding to health needs, attending to mental capacity and safeguarding (Preston Shoot et al (2020), p73).
Professional Practice Areas to Improve On
In 70% of cases professionals did not share information in relation to safeguarding the adult at risk. In 60% of cases professionals failed to record events on case records. In half of the sample of cases (50%) practitioners,
- In half the sample of cases (50%) did not undertake assessments and risk assessments for evidencing and supporting planned work on areas such as the adult at risk’s potential learning disabilities, family carers and the impact of alcohol on the adult at risk’s ability to function both mentally and physically
- Undertaking mental capacity assessments was deemed as good practice in 30% of the SAR cases. However, in 50% of the other SAR cases examined professionals did not undertake a mental capacity assessment, when the adult at risk may have had difficulties with their capacity to understand what was happening and ability to make important decisions
- In 50% of the SARs practitioners did not formulate a plan of action in terms of managing risk, multi-agency working and having a contingency plan in case the risks for the adult at risk changed
- In 50% of SARs practitioners failed to communicate either with other professionals working with the adult at risk or with family members
Additionally, even though, in 30 % of cases making a safeguarding referral was deemed as good practice in 50% of the other SAR cases, within the sample, professionals failed to make a safeguarding referral for the adult at risk
Improvement of Practice
In the previous thematic review, that we carried out in 2020, 100% of cases had the lack of recording as a factor and this has decreased to 70% of cases in this review. Not completing assessments was found in 100% of cases in the previous review and this has decreased to 50% of SARs in this review. Failing to work together was found in 80% of cases in the last thematic review and this has decreased to 30% within this review. This is evidence of improvement of practice in these areas.
The top themes found within the national research for improved practice, included attention to mental capacity, undertaking risk assessments, information sharing, safeguarding, working with carers and addressing health needs (Preston-Shoot, 2020, p73- 75). Some of the findings from this local thematic review mirror the national findings in that information sharing, mental capacity, safeguarding and completion of assessments were identified in the majority of the SAR sample as areas where safeguarding practice needed to improve.
Safeguarding Partnership Board Training – https://safeguardingcambspeterborough.org.uk/availabletraining/
Virtual Briefings, Briefings and Training Resources – http://www.safeguardingcambspeterborough.org.uk/availabletraining/
Safeguarding Adult Reviews – http://www.safeguardingcambspeterborough.org.uk/adults-board/about-the-adults-board/sars/
Multi-Agency Policies and Procedures – Cambridgeshire and Peterborough Safeguarding Adults Policies, Procedures and Practice Guidance | Cambridgeshire and Peterborough Safeguarding Partnership Board (safeguardingcambspeterborough.org.uk)
Cambridgeshire and Peterborough Safeguarding Children Partnership Board (2020) Thematic Review of the Professional Themes found within Safeguarding Adult Reviews from 2011 – 2018. CPSAPB
Cambridgeshire and Peterborough Safeguarding Children Partnership Board (2020) Thematic Review of the Professional Themes found within Safeguarding Adult Reviews (SARs) and SAR Action Plans from 2015 – 2019. CPSAPB
Care Act 2014. London: HMSO
Preston-Shoot.M., Braye.S.,Preston.O., Allen.K., and Spreadbury.K., (2020). Analysis of safeguarding adult reviews April 2017- March 2019: Findings for a sector-led improvement. Local Government Association