Policies and procedures
The following safeguarding policies have been either produced or revised to keep people informed of what they are expected to do:
- Self-Neglect Policy, Procedure and Toolkit
- Quality Assurance Framework
- Safeguarding Adults Review (SAR) Procedure
- Seldom Heard Guidance
Safeguarding Adult Review (SAR)
Safeguarding Adult Reviews are a multi-agency process that considers whether serious harm experienced by an adult at risk of abuse or neglect could have been predicted or prevented. The purpose of Safeguarding Adult Reviews is set out in the statutory guidance (Section 44) within the Care Act 2014. The reviews seek to ‘promote effective learning and improvement action to prevent future deaths or serious harm occurring again.’ The aim is that lessons can be learned from the case and for those lessons to be applied to future cases to prevent similar harm re-occurring. The purpose of a Safeguarding Adult Review is not to hold any individual or organisation to account as other processes exist for that purpose.
During this period the Safeguarding Adult Review panel received five referrals of which three met the criteria for a SAR. Themes included self neglect, mental capacity and harmful use of alcohol.
We published two reports during this period, which can be found on our Safeguarding Adult Reviews page. Case one was around quality of care provided to the individual in the community and to support their discharges from hospital. Case two looked at the ways in which services respond to adults experiencing hoarding, the response to potential coercive and controlling behaviour, how services work with people who are seldom heard, and how professionals work with the Mental Capacity Act and take account of executive functioning.
Review one:
Norfolk’s Safeguarding Adults Board Safeguarding Adult Review for Joanna, Jon and Ben who were three young adults who died at Cawston Park Hospital within a 27-month period between April 2018 and July 2020. It raised critical questions and learning – not just for Norfolk but nationally, about the care and protection of a group of our most vulnerable adults with learning disabilities and complex needs, placed in private hospitals.
Review two:
David (pseudonym) was at the time of the incident a 17-year-old autistic young man, who was a looked after child under a section 20 agreement. He had been known to Special Educational Needs Services (SEND) and Neuro Disability Services since he was five years old. David was also known to Mental Health Services and in 2016, was placed under a section two and subsequently a section three of the Mental Health Act. At the time of the incident on 4 August 2019, David was living in a bespoke semi-independent care placement where he received 2:1 care. On the day of the incident, David was allowed independent leave between 12pm and 4pm and he informed the care staff that he was going to a local shopping centre. That afternoon David went to a public building in central London and was involved in a serious incident on a young child. The victim sustained life changing injuries requiring hospital care. The victim was not previously known to David.