Safeguarding Adults Thresholds Guidance Update

1. Safeguarding Adults Thresholds Guidance Update

2. Accessing the Thresholds guidance • The safeguarding thresholds guidance has been completely updated • The guidance can be accessed through the Safeguarding Adults Multi-Agency Policy and Procedures (MAPP) on the following link and must be used in conjunction with the MAPP http://www.llradultsafeguarding.co.uk/thresholds/ • All staff should ensure they are signed up for automatic MAPP updates on the following link http://www.llradultsafeguarding.co.uk/home/register/

3. What has changed? • Divided into 10 types of abuse as defined in the Care Act Guidance • Additions to several areas including Modern Slavery and Domestic Abuse • Simplification with only Lower Level and Higher Level concerns • Clarity around arrangements for Self-Neglect • Subsections within Neglect to make this easier to use • Links to all main safeguarding policy and guidance-so the guidance should be used electronically

4. This is what it looks like

5. How will the Thresholds Guidance help you? • Assists the local authorities in making consistent decision around potential safeguarding referrals (in consultation with their manager) • Enables agencies to understand how these decisions are made. • Aids defensible decision making-helps define where a safeguarding enquiry is required and also where alternative routes could be used to address any risks • It does not cover every situation and does not replace professional judgement; if you are worried about something which does not ‘fit’ in the thresholds always discuss with your manager

6. Defensible Decision Making • Defensible decision making – this means recording a clear rationale for all the decisions made and the discussions that led to the decisions, including why you are not referring to the Local Authority • This involves negotiating and balancing issues of risk and safety to identify what is acceptable for everyone concerned (the individual and others including the community) on a case by case basis • Making Safeguarding Personal – taking into account the views, wishes, preferences and outcomes for the adult. Keeping the adult at the centre of any discussions and working in partnership with the adult, families and partner agencies

7. Case Studies Exercise Use the Thresholds Guidance to identify: • Whether the referral meets the threshold for further safeguarding enquiry • How the referral could be addressed • The type of abuse.

8. Case Study 1 You have received a referral about Mr Janes. He is currently in hospital after cutting his wrists and taking an overdose of medication. He was found by his wife. Due to the overdose Mr Janes had taken, there is concern this may have caused some permanent brain damage, and further tests are being undertaken. There is a history of domestic abuse between Mr and Mrs Janes, where Mr Janes has been the perpetrator. Mr Janes also has a history of alcohol abuse and depression, and is known to mental health services. Mrs Janes states she does not now want Mr Janes to return home, as they have 3 children who Mrs Janes says have witnessed the domestic abuse, and she feels are also at risk from their father. However Mrs Janes feels that Mr Janes is likely to self-harm again if she were to separate from him, and therefore she does not feel she can ask him to leave the family home when he is discharged. Mr Janes is likely to require significant support when he is discharged from hospital, and he has no other family who would be prepared to provide this support.

9. Case Study 2 An anonymous whistleblowing referral is received via CQC. The whistle-blower makes the following statements: • Management are falsifying staffing rotas to show that they have enough carers on duty during the night shift. • They have witnessed residents being left wet/soiled due to a lack of staff and this has resulted in pressure ulcers to some residents as well as causing distress. The whistleblower has provided names of these residents. • Normally 1 carer and 1 nurse on duty but last week 2 agency staff had to come to work as no one else was at work. • They were working without any permanent staff.

10. Case Study 3 A referral is received from a family friend of Susan. She states Susan has a learning disability, is aged 70 and is living with a male and female who are in a relationship. The referrer states that the couple have been financially abusing Susan for many years, and that she has also been sexually abused by the male. The referrer states that Susan has to complete all the domestic tasks and receives no pay for this. She states that they move house on a regular basis and they also sub let. The referrer said they are preparing to move again to a house where Susan will not have a bedroom and has been told to purchase a couch. The referrer states that Susan looks disheveled and is often hungry. The referrer states that Susan feels she is unable to live alone as she cannot manage her finances and bills. She has said she does want to talk to professionals as she is afraid of this couple, and has become isolated from her family members so they will not support her.

11. Case Study 4 Mr K lives in a warden aided property and has visits twice a day from a care agency to help him with his personal care and meals. Mr K is a wheelchair user and has a diagnosis of depression. Over the years he has spent time being treated as an inpatient for acute, suicidal episodes. You visit Mr K and he tells you that he has a carer called J who is his key worker who he likes. Mr K tells you that he and J have “a laugh together” and “joke about”. Whilst you are at the property, J arrives and you hear him call Mr K a “Nutter”. When you question this Mr K looked uncomfortable but laughs in response and tells you that he doesn’t mind. You ask Mr K how he is getting on and in the course of conversation he tells you that J puts his medication in a top cupboard as “as not like I can reach it, can I?” and he goes on to say that when he asks J not to put it there J says “I don’t‘ want to be the one accused if you end up in a mental hospital?”. Mr K tells you that he likes J and does doesn’t want to upset him.

12. Responses to Case Studies • Case 1 There is clearly potentially high risk around domestic abuse within this situation, however it is not clear that a safeguarding adults enquiry is required, as there is currently no indication that Mrs Janes has any needs for care and support and as a result is unable to protect herself from abuse-but this would need to be established. There is also no immediate risk around on-going domestic abuse given Mr Janes is in hospital. There is clear risk to the children within this situation if Mr Janes returns home and also the Trilogy of Risk is present (MH needs, substance misuse and domestic abuse-see link in Domestic Abuse section of the Thresholds Guidance), and therefore a referral is required to Children’s Services. If it is established that Mrs Janes does not have needs for care and support and therefore safeguarding adults thresholds are not met and no other support required from the LA, then a referral to UAVA/DASH risk assessment (see link in Thresholds Guidance under the Domestic Abuse section) should be discussed with her for on-going support around Domestic Abuse. Mr Janes’ support needs and risk of self-harm on discharge from hospital also need to be carefully considered.

13. Responses to Case Studies • Case 2 There are a mix of potential safeguarding concerns and issues for Contracts/CQC as regulator in this referral. The initial main safeguarding issue is the identified residents who have allegedly developed pressure sores/have been distressed as a result of inadequate personal care. This meets the following criteria in the Neglect-Providing Care and Managing Risk sections, indicating that further safeguarding enquiry should be considered: • Reoccurring events resulting in harm e.g. hunger, thirst, distress, implications for health, such as soreness, constipation or loss of dignity and self-confidence malnutrition, tissue viability, choking or any other deterioration in health, or distress • Reoccurring events resulting in harm e.g. hunger, thirst, distress, implications for health, such as soreness, constipation or loss of dignity and self-confidence malnutrition, tissue viability, choking or any other deterioration in health, or distress • The adult has not been formally assessed/advice not sought with respect to pressure area management or plan exists but is not followed resulting in harm e.g. avoidable tissue damage A Strategy Meeting should be convened with Contracts Team and if possible CQC to consider immediate risk and plan how the enquiry will be undertaken.

14. Responses to Case Studies • Case 3 This referral indicates alleged Modern Slavery (it does not appear to be domestic abuse as there is no indication that Susan has an intimate relationship with this couple). From the information referred, it appears that Susan may have needs for care and support and may be unable to protect herself from abuse. The referral meets the following criteria of the Modern Slavery section of the Thresholds Guidance, indicating that further safeguarding adults enquiry needs to be considered • Appearing frightened or hesitant to talk to professionals and fearful of law enforcers • Appears to be working long hours for little or no pay, or unsure about what their pay arrangements are • May look malnourished or unkempt, anxious/agitated or appear withdrawn and neglected. An urgent strategy discussion or meeting with the Police is required to plan how the enquiry will be undertaken without increasing the risk to Susan.

15. Responses to Case Studies • Case 4 Discriminatory Abuse? • direct discrimination - treating someone with a protected characteristic less favourably than others • Recurrent taunts, associated with diversity, causing harm e.g. emotional distress, loss of confidence, intimidation, loss of dignity Neglect and Acts of Omission? • There is a clear breach of “duty of care” and professional practice resulting in harm Psychological? • Humiliation

16. Regional and National Developments • East Midlands Safeguarding Network are developing a regional thresholds tool which is based on the Leicester, Leicestershire and Rutland model. • Following this, work is planned for the end of November via the Local Government Association to look at this becoming a National Decision Making Tool (threshold document).