Performance Activity
There continues to be an increase in safeguarding concerns reported to the Local Authority: from 1270 in 2021/2022 to 2500 in 2022/23, representing an increase of 97%. Analysis of safeguarding concerns evidence that this increase was due to improved recording on the adult social care recording system and changes to local safeguarding processes.
There was a minimal decrease in the number of safeguarding concerns received in 2024/25 with a total of 2471, a 1% decrease compared with the previous year. Notwithstanding, from 2021/2022 to 2024/2025 the overall increase in the number of safeguarding concerns received is 95%. The volume is increasing as a result of changes to recording practices that are now more aligned with other local authorities that share similar demographics.
There exists a debate regarding whether a rise in safeguarding concerns is positive or negative. Generally, a rise indicates that safeguarding training and awareness raising is having an impact on the number of safeguarding concerns received. This means that the Safeguarding Adults Board is meeting its core objective in ensuring that safeguarding truly is everybody’s business, as more people are aware of what adult safeguarding is, and how to report safeguarding concerns.
Section 42 and other enquiries
Section 42 and discretionary safeguarding enquiries (commonly referred to as “other” safeguarding enquiries) have seen a smaller increase; from 680 in 2022/2023 to 1273 in 2024/25, although this is not insignificant, representing a percentage increase of 87%. In 2023/24, safeguarding enquiries accounted for 41% of all adult safeguarding concerns received, this increased to 52% in 2024/25.
Consistent with trends identified over the last four years, Neglect and Acts of Omission and Physical Abuse continue to be the most reported categories of abuse in Section 42 and discretionary adult safeguarding enquiries, accounting for 47% of concluded cases in 2024/2025 (Neglect and Acts of Omission 28%, Physical Abuse 19%). Neglect encompasses many factors, including failing to provide access to appropriate health, social care or educational services, ignoring medical or physical care needs and withholding the necessities of life such as medication, adequate nutrition and heating. It is important to note that this trend is not unique to Cheshire West and Chester and is reflected in regional and national data trends, including those local authorities that are most similar to Cheshire West and Chester in terms of demographics. Physical abuse encompasses hitting, slapping, pushing, kicking, misuse of medication, restraint or inappropriate sanctions. In 2024/2025, Psychological abuse (also known as Emotional abuse) was the third most reported category of abuse, accounting for 14% of safeguarding enquiries concluded within the year. Psychological abuse encompasses emotional abuse, threats of harm or abandonment, deprivation of contact, humiliation, blaming, controlling, intimidation, coercion, harassment, verbal abuse, isolation or withdrawal from services or support networks. This is consistent with trends identified in the previous year. More than one category of abuse can be reported for each safeguarding concern or enquiry.
The most reported location of abuse is the individual’s own home, recorded in 52% of concluded safeguarding enquiries. This is consistent with trends identified over the last four years. A slight increase in abuse reported in a person’s own home has been noted, from 44% of concluded safeguarding enquiries in 2021/2022 to 52% of concluded safeguarding enquiries in 2024/2025. This is consistent with regional and national trends. Care homes were the second most reported location of abuse in 2024/2025, accounting for 30% of concluded safeguarding enquiries which is consistent with regional and national trends. More adults are receiving services in their own home, and there are increasing numbers of people being cared for in residential and nursing care homes which might explain the reasons why a person’s own home and care homes are the most reported locations of abuse. For the first time in the last four years, there has been a very small number of reported incidents taking place in services in the community, accounting for 1% of concluded safeguarding enquiries. Community services include community centres, day care centres, leisure centres, libraries, schools, GP surgeries and dental surgeries.
Making safeguarding personal
Making Safeguarding Personal is about having conversations with people about how to respond in safeguarding situations in a way that enhances involvement, choice and control as well as improving quality of life, wellbeing and safety. The Care Act 2014 advocates a person-centred rather than process driven approach to safeguarding. The individual or their representative are asked their wishes as part of the safeguarding enquiry. The number of people who expressed their wishes at the outset of the safeguarding enquiry was 76%, which is a 3% decrease when compared with the previous year. Of these, 95% had their outcome fully or partially achieved, a 1% decrease when compared with the previous year. 493 people were asked how satisfied they were with the safeguarding process, an increase of 4% compared with the previous year. 474 people (96%) said that they were satisfied with the safeguarding process which is consistent with trends identified over the last two years. Making Safeguarding Personal is central to the support provided by the Safeguarding Adults Board Partnership.
Cohort of gender and age
Females continue to account for the highest ratio of clients subject to Section 42 and discretionary enquiries, although the proportion has decreased slightly this year, from 63% in 2022/2023 to 57% in 2024/25. The most reported age group continues to be working age individuals aged 18-64 (35%) which is consistent with the previous two years, although represents a 1% decrease in percentage terms. The second most reported age group in 2024/2025 is adults aged 75-84 which is consistent with the previous year.
Findings from audits
Cheshire West and Chester Safeguarding Adults Board undertook an audit to understand more regarding use of the Cheshire West and Chester Safeguarding Adults Board self-neglect policy, procedure, and toolkit; barriers to working with people experiencing self-neglect; what is working well; and what can be done to improve practice. Discretionary safeguarding enquiries and safeguarding enquiries undertaken under section 42 of the Care Act 2014 where self-neglect was recorded increased by 290% between 2021-22 and 2023-24. An increase in self-neglect is also reflected nationally in referrals for Safeguarding Adults Reviews under section 44 of the Care Act 2014.
Overarching themes
- Differing professional opinions regarding an individual’s mental capacity or the circumstances in which a mental capacity assessment would be undertaken.
- A general lack of longer-term, specific interventions for people experiencing self-neglect, as the majority of offers of intervention is time limited.
- Lack of time was a concern for professionals. This underpins the other emerging themes as professionals reported that individuals with comorbidities such as poor mental health or use of drugs and alcohol often required more time to build up relationships and professionals also felt that they needed more time to understand situations which are frequently highly complex. Several people who experience self-neglect having experienced earlier life trauma. Time and a sensitive approach are required to understand a person’s history, to gain their trust and to build a positive working relationship.
- Linked with theme number three, operational professionals discussed that front line practice was increasingly busy and cases were increasingly complex. The ability to respond to cases in a timely way or to provider longer-term support is impacted by resources, the main issue being the number of staff and their existing caseloads.
- Professionals discussed that a specific, multi-agency team for people experiencing self-neglect and hoarding would be of immense benefit; not only to professionals but to people experiencing self-neglect and hoarding, as this would enable longer-term intervention and the time required to build professionals relationships.
- Multi-agency communication, specifically knowing the correct professional(s) to contact, being in possession of up-to-date and accurate contact details and access to external systems to enable information to be shared in a timely manner and to reduce duplication.
There are common themes with regional and national Safeguarding Adult Review (SAR) recommendations: effective multi-agency communication, mental capacity, resource implications and a lack of tailored support. A number of these themes are also reflected in local SARs, including those that have been undertaken in Cheshire West and Chester.
Overarching recommendations
- Cheshire West and Chester Safeguarding Adults Board to undertake a multi-agency audit with the theme of mental capacity, to formulate recommendations from this audit and to use these recommendations to positively impact multi-agency practice.
- Enabling professionals to have sufficient time to build a relationship with individuals experiencing self-neglect and/or hoarding.
- The provision of longer-term interventions, specifically for adults experiencing self-neglect and/or hoarding, as opposed to time-limited interventions.
- Cheshire West and Chester local authority and Safeguarding Adults Board partners to consider implementation of a multi-agency specialist team to support adults experiencing self-neglect and hoarding.
- Cheshire West and Chester Safeguarding Adults Board partners to discuss how each organisation’s communication systems and processes could be used more effectively to reduce duplication and ensure better multi-agency communication and information sharing within and between agencies.
- Cheshire West and Chester Safeguarding Adults Board to relaunch the self-neglect policy, procedure, and toolkit during Adult Safeguarding Week 2024 (18 - 22 November 2024) to raise awareness of the toolkit with partners and encourage use of the self-neglect policy, procedure, and toolkit.
Professional understanding and application of the Mental Capacity Act 2005 is a common theme in recommendations from Safeguarding Adults Reviews. In May 2024, the second National Analysis of Safeguarding Adults Reviews was published by the Local Government Association (LGA). This study analysed the findings of 652 SARs completed over a 4-year period, drawing out common learning themes. The most commonly noted practice shortcomings included shortcomings in mental capacity assessment, which was found in 58% of cases analysed. Findings on the wider systemic factors that impact upon direct practice highlight a lack of relevant guidance for practitioners. Mental Capacity Act policies were identified as a specific area where relevant guidance was lacking. The Mental Capacity Act 2005 was an overarching theme throughout two Safeguarding Adults Reviews commissioned by Cheshire West and Chester Safeguarding Adults Board under s.44 Care Act 2014. Furthermore, the Mental Capacity Act 2005 was identified as the top training priority across all sectors responding to a training survey facilitated by Cheshire West and Chester Safeguarding Adults Board and Cheshire West and Chester Safeguarding Children Partnership. For this reason, Cheshire West and Chester Safeguarding Adults Board undertook an audit to understand more about professionals’ understanding and application of the Mental Capacity Act 2005.
Audits were completed by Cheshire West and Chester Council, Cheshire Constabulary, Cheshire and Wirral Partnership NHS Foundation Trust, Mid Cheshire Hospitals NHS Foundation Trust, Countess of Chester Hospital NHS Foundation Trust, Cheshire and Merseyside Integrated Care Board and Weaver Vale Housing Trust.
Overarching themes
- Lack of formal Mental Capacity Act assessment
- Lack of decision-specific Mental Capacity Act assessment
- Mental Capacity assessments to include executive capacity
- The individual not provided with the relevant information, meaning that the Mental Capacity Act assessment does not stand up to legal scrutiny
- Lack of Best Interest decisions recorded, or lack of involvement of the person
- Lack of referrals to statutory advocacy services
- Multi-agency information sharing needs to improve, specifically around hospital discharge
- Need to ensure that the person’s voice is central to the assessment, and to include the views of family carers as appropriate
- To improve practitioner confidence in completing Mental Capacity Act assessments, working with Best Interests, case recording and making advocacy referrals