Safeguarding adults in care homes

Why the committee made the recommendations

These recommendations are based on:

Overall, the committee's confidence in the research evidence was low. The main issues with the evidence were that the included studies provided only limited data and reported research conducted in a range of settings, making it difficult to determine whether each finding was directly relevant to care home contexts. There were also concerns regarding the methods used in some of the included studies, for example their recruitment processes and how they considered the wider research context.

The committee also reviewed existing non-NICE UK health and social care guidance. There were uncertainties around the methods used to develop much of this guidance. However, the committee found the guidance to be highly relevant as a source of evidence to support their work, and used it to inform the recommendations, alongside their own expertise and experience. The guidance highlighted some of the challenges faced by individuals and organisations when there is no clear safeguarding procedure. This has implications for:

The committee were keen to highlight the obligations of individuals (including visitors) and organisations, to ensure that everyone knows what to do when a safeguarding concern arises. The committee made a recommendation on ensuring that the safeguarding policy is accessible, easy to find and understand because safeguarding is everyone's responsibility, and people with little experience of safeguarding (such as visitors) may need to read it.

While having policies and procedures in place is important, care homes and care home providers can have problems ensuring that staff follow these. The committee believed it was important to have systems in place to make sure policies and procedures are followed. They made recommendations on how these systems should be used to record and share information.

How the recommendations might affect practice

Care homes should already have a safeguarding policy and procedure, and the recommendations reflect statutory requirements. However, some care homes may need to change their policy and procedure so that they fully comply with these recommendations. This may involve extra work for care home managers. Care homes may need to update their systems to ensure that safeguarding concerns (and patterns of concerns) can be monitored. Care home staff may also need training to improve their understanding of safeguarding policy and procedure, and to show them how to preserve evidence from reported safeguarding concerns.

Return to recommendations

Why the committee made the recommendations

The committee used qualitative themes from research evidence on identifying abuse and neglect to make the recommendations. There were several issues with this evidence. The main concern was relevance, as it was not always clear whether the data reported came from research conducted in a care home setting. There were also concerns regarding the methods used in some of the studies, for example in relation to their recruitment and data analysis processes.

The committee also reviewed existing non-NICE UK health and social care guidance, and legislation and care law about whistleblowing. There were uncertainties around the methods used to develop much of this guidance. However, the committee found the guidance to be highly relevant as a source of evidence to support their work, and used it to inform the recommendations. The guidance highlighted the challenges associated with whistleblowing and the impact whistleblowing can have on care homes, staff and volunteers. The committee felt that this was an important area, and built on the evidence using their own expertise. Good whistleblowing policies are important and help support a culture in which staff feel able to report concerns.

Based on their own knowledge, the committee decided to emphasise the legal protections for whistleblowers. This is because whistleblowers are vulnerable to victimisation.

How the recommendations might affect practice

Care homes may need to revise and update their whistleblowing policy and procedure. They may also need to do more to promote more positive attitudes about whistleblowing among staff, and to encourage an open culture to help staff feel more confident raising concerns. In turn, this should help reduce the under-reporting of safeguarding concerns. There may be a cost for care homes who choose to provide external whistleblowing services, which is why the committee only ask care homes to consider using this service.

Return to recommendations

Why the committee made the recommendations

Qualitative themes were identified from the research evidence, covering the challenges associated with governance, roles and responsibilities, and lines of communication. There were a number of issues that limited how the committee could use the findings. The main issues were the adequacy of the data and the relevance of the evidence, as it was not always clear whether data had been collected in a care home setting.

In addition, there were concerns about methods used in some of the studies, for example in relation to data analysis processes and how the researchers took account of ethical issues.

The evidence did, however, highlight the uncertainties and misunderstandings surrounding the roles, responsibilities and accountabilities for safeguarding within care homes and care home providers. The committee agreed that this is a crucial area and they built on the evidence with their own expertise.

How the recommendations might affect practice

Care homes will need to ensure they implement relevant, up-to-date policies and procedures. This should only require minor changes to current practice because it is already a statutory requirement.

Return to recommendations

Why the committee made the recommendations

The committee agreed that it is important to reiterate the responsibilities of local authorities, clinical commissioning groups and other public sector commissioners, because they can use contract monitoring and other statutory monitoring processes to ensure that care homes are meeting their safeguarding responsibilities.

The committee also wanted to emphasise the important role of commissioners in working with care homes. Commissioners can help care homes implement lessons from Safeguarding Adults Reviews and ensure that good safeguarding records are maintained.

How the recommendations might affect practice

Local authorities, clinical commissioning groups and other commissioners should already be monitoring safeguarding in care homes as part of contract management, so this should not represent a significant change in practice. Commissioners may need to do more to promote good communication and working relationships with care homes, but this could be achieved without additional resources.

Return to recommendations

Why the committee made the recommendations

The committee made the recommendations based on a limited amount of qualitative evidence on the roles and responsibilities of Safeguarding Adults Boards. There were a number of concerns with this evidence, around:

The evidence highlighted the challenges associated with partnership working, and the difficulties in communicating with care homes. The evidence also indicated that there may sometimes be confusion around:

How the recommendations might affect practice

There is wide variation in the way Safeguarding Adults Boards operate and communicate. The recommendations should lead to greater consistency. Safeguarding Adults Boards should not need additional resources, but some will need to change the way they work. If they are not already doing so, they will need to promote a positive culture and encourage greater collaboration between their members and partner organisations, especially care homes.

Return to recommendations

Why the committee made the recommendations

Quantitative and qualitative data were available on training in the care sector, but the committee's confidence in this evidence was low. For the quantitative data, this was mostly because of the use of non-randomised trials and imprecision in effect estimates. For qualitative findings there was a shortage of evidence, with only limited data from a small number of studies. In addition, there were issues with the relevance of the qualitative data, because some studies may have been conducted outside of care homes, and some findings may not have been specifically related to safeguarding.

As a result of the limitations of the evidence, the committee also used their own expertise, and their knowledge of statutory guidance requirements, to make a recommendation. They believed this is important because good-quality training can have a big impact on safeguarding practice and the safety and wellbeing of care home residents.

The evidence highlighted the need for basic training for all staff employed by or contracted to work within the care home, to make sure they have a good understanding of what safeguarding is, how it is everyone's responsibility and how it might relate to their job within the care home.

Mandatory training is required to fulfil section 14.225 of the Care and support statutory guidance 2020, and each organisation is responsible for ensuring that staff receive effective training. This includes ensuring that agency staff have the necessary training. The committee discussed whether it is possible to specify how soon new staff should have mandatory safeguarding training. Although there was no evidence on this the committee agreed it would be helpful to specify that this should take place within 6 weeks of starting work. This is in line with standards that already exist, such as Adult Safeguarding: Roles and competencies for Health Care Staff 2018, but there is still inconsistent practice in this area. Evidence suggested that improvements in safeguarding practice were not always maintained in the longer-term, and the committee agreed that it was important to run refresher training if needed.

How the recommendation might affect practice

Care Quality Commission standards cover basic safeguarding training for all staff (CQC: Regulation 13 - Safeguarding service users from abuse and improper treatment and CQC: Safeguarding Adults - Roles and responsibilities in health and care services) so this is not a new requirement and is unlikely to lead to significant resource implications. However, the content of training may vary across care homes, and some care homes may need to adapt their training programmes to make sure that safeguarding forms part of all new employee inductions within 6 weeks of starting work. Training programmes may also need to be adapted so that staff have protected time to ensure they fully understand the actions they need to take if they ever have a safeguarding concern.

There may also be minor resource implications associated with improved safeguarding practice. For example, if staff have a better understanding of abuse and neglect, they may raise more concerns and there may be an increase in safeguarding referrals and enquiries.

Return to recommendations

Why the committee made the recommendations

The strength of the evidence was limited, but the committee made recommendations in areas where the evidence aligned with their own experience and expertise.

The committee had low confidence in the quantitative outcomes, because of concerns about bias (as most studies were not randomised) and imprecision in effect estimates. They were also concerned about the short follow-up periods the studies used.

There were also issues with the qualitative evidence. This was mainly due to the relevance of the data, because it was not always clear whether findings related specifically to safeguarding. There were also concerns regarding the adequacy of data, as most of the themes in the evidence were based on limited data.

The evidence suggested that in some care homes, training only covers a basic understanding of adult protection policies and procedures, which staff may not then know how to apply in their daily work. To address this and ensure that staff have a more thorough understanding of safeguarding, the committee specified the different areas that need to be covered in training programmes for all staff.

How the recommendations might affect practice

Care homes may need to change their safeguarding training programmes to make sure they cover the areas included in this guideline. They may need to make training programmes applicable to the daily practice and responsibilities of staff and particularly to safeguarding in the care home environment. Care homes will need to make sure that specific safeguarding concepts and terminology is clearly understood by all staff, regardless of literacy levels or language skills, and this may require some additional resources.

Return to recommendations

Why the committee made the recommendations

There was quantitative and qualitative evidence available, but the committee had limited confidence in this.

The quantitative evidence had issues with bias (as most studies were not randomised) and imprecision in effect estimates. In addition, the studies only used short-term follow-up periods.

There were issues with the relevance of the qualitative data, as it was not always clear whether findings related specifically to safeguarding. There were also concerns regarding adequacy, as most themes were based on limited data.

Because of the limitations with the evidence, the committee also used their expertise when making recommendations on further training.

Evidence on training suggested that improvements in safeguarding practice were not always maintained in the longer-term, and that there should be opportunities for further and more advanced learning. As a result, the committee agreed that it is important to emphasise that training should not be a one-off event. Their recommendations included advice about further training that may be beneficial for some staff. More detailed information on safeguarding training and the competencies that different staff need is covered in Adult Safeguarding: Roles and competencies for Health Care Staff 2018. Because of this, the committee did not make recommendations about who should have further training or when this should happen.

How the recommendations might affect practice

Ensuring that care home staff can regularly take part in safeguarding training may lead to an increase in resource use, particularly if care homes choose to use external organisations to deliver these programmes. However, increased costs will be justified given the improvements in safeguarding practice that are likely to occur.

There may be an increase in the number of requests for training. There may also be cost implications if practitioners need training of their own in order to conduct training for staff. In addition, some staff posts may need to be backfilled while training takes place. However, any additional costs may be justified by the improvements in staff knowledge, competence and confidence, which will provide better quality of care for residents.

Return to recommendations

Why the committee made the recommendations

There was only limited evidence that focused specifically on safeguarding training in the care sector. There was no evidence comparing the effectiveness of different modes of training (for example e-learning programmes compared with group sessions). The committee provided anecdotal evidence of concerns about the efficacy of e-learning, in particular when there is no opportunity for discussion and human interaction. They agreed that further research is needed to evaluate the most effective modes of training, and to clarify whether e-learning training can meet best practice standards. To address this, the committee made a research recommendation to look at the effectiveness, cost effectiveness and acceptability of e-learning safeguarding training, compared with face-to-face training.

There was some limited economic evidence on training. This evidence did not demonstrate any differences in costs or effectiveness between 2 different programmes. An economic analysis showed that face-to-face training could be cost-effective relative to e-learning, under certain assumptions. Other evidence that was available highlighted the positive outcomes achieved with some training methods (such as case studies and examples), and the challenges associated with other types of training (such as e-learning). The committee supported this evidence with their own expertise.

The recommendations should help care home managers identify the most appropriate training methods for their staff, which will improve care home practice.

How the recommendations might affect practice

There is some variation across the UK in the way care homes conduct training, although the contracts that providers have with local authorities will tend to encourage best practice and standardisation.

There may be an increase in the number of requests for training. There may also be cost implications if practitioners need training of their own in order to conduct training for staff, or if external organisations are used to deliver training. However, any additional costs will be justified by the improvements in staff knowledge, competence and confidence, which will provide better quality of care for care home residents.

Return to recommendations

Why the committee made the recommendations

Although there was some quantitative evidence on the effectiveness of safeguarding training, there were concerns with this evidence. The main concerns were around bias (as most studies were not randomised) and imprecision in effect estimates. There were also concerns regarding the short-term follow-up periods used by the studies.

The qualitative evidence also had problems. There was a lack of detail regarding study methodology, making quality assessment difficult. The committee had concerns about the adequacy of the findings, which were based on 'thin' data. And it was unclear whether the data related specifically to safeguarding.

Because of the shortage of good-quality evidence, the committee made recommendations partly based on their own expertise and experience.

Despite the limitations of the evidence, the qualitative data indicated that training can improve staff safeguarding skills. This was also reflected in the qualitative evidence, which indicated that practitioners recognised the value of safeguarding training. However, this evidence also suggested that managers may be unwilling to implement learning from training programmes or make changes to care home procedures, which may negate any benefits associated with training. To address this, the committee made a recommendation on how managers should encourage staff to complete training.

The evidence on training only included short-term measurements of effectiveness. To address this potential issue, the committee made a recommendation on assessing how well training is working and whether it is being used to improve practice. For example, care home managers could assess this through follow-up conversations with staff, and by evaluating changes immediately after training and at further longer-term follow-up.

How the recommendations might affect practice

Care home managers may need to re-assess how they engage with safeguarding training. They will need to find ways to identify positive changes from training, and implement these across the care home. This may mean that managers have to place greater emphasis on reflective practice and shared learning among staff. The structure of staff supervision sessions may need to be changed, to ensure that positive learning is acknowledged and reinforced.

Return to recommendations

Why the committee made the recommendations

Some qualitative evidence was available, but the committee had limited confidence in it. This was mostly due to issues with:

As a result, the committee drew on their own expertise to supplement the evidence and make recommendations.

The evidence indicated that care home managers can play a key role in influencing the attitudes of their staff and colleagues towards training. Some staff may also need more support to benefit from training. Staff may not benefit from training if managers are unable or unwilling to allow staff to implement what they have learned within the care home and share their experience with other members of staff.

How the recommendations might affect practice

Managers will need to make sure their safeguarding knowledge is up to date. This has been a legal requirement for some time so should not represent a change in practice.

There is variation in how much care home managers do to encourage other staff to learn more about safeguarding. The recommendations will help standardise practice, and ensure that managers promote safeguarding training and learning in care homes.

Return to recommendations

Why the committee made the recommendations

There was a good amount of qualitative evidence on identifying abuse and neglect in care homes, and the barriers and facilitators to this. In particular, the evidence looked at the concept of whistleblowing and the reasons why care home staff may be reluctant to report concerns (for example, fear of losing their job).

There were some problems with this evidence. There were issues with the methods used by some studies, such as their recruitment strategies and data analysis processes. Some of the included research was not conducted in care home settings, so there were concerns about how relevant it was. And some of the studies provided limited data, which led to issues with the overall adequacy of the data.

The committee therefore drew on their own experiences when drafting recommendations, with the aim of helping managers to increase staff confidence in identifying and raising safeguarding concerns.

How the recommendations might affect practice

Reflective supervision is already a key feature of broader social work, but the extent to which it takes place in care homes is extremely varied. These recommendations will help standardise the use of reflective supervision. Care home managers may need to do more to support staff who are reluctant to raise concerns.

Return to recommendations

Why the committee made the recommendations

There was a good amount of qualitative evidence on the barriers and facilitators to identifying abuse and neglect in care homes. There were concerns with:

This research did not specifically evaluate the impact that care home culture can have on staff willingness to report safeguarding concerns. However, the committee agreed that the culture of a particular care home (and the role played by managers in shaping this) is a key factor in enabling and encouraging care home staff to report safeguarding concerns.

The committee suggested 'safeguarding champions' as a way to provide more informal support for people worried about the impact of raising concerns. This is in addition to the formal and mandatory role of a safeguarding lead.

The evidence also included data on how to reduce the risk or incidence of abuse and neglect by learning from past safeguarding issues in the care home. The committee agreed that this should be encouraged at all levels, to help create a care home culture where safeguarding is central and transparency is established. The committee also wanted care homes to reflect on and learn from Safeguarding Adults Reviews.

The committee recommended that care homes should ask for feedback from residents and families to find out what they thought about the way that safeguarding issues were addressed and managed in the home. It is important that this is used routinely to help improve safeguarding practices.

Staff are encouraged to watch out for changes in the mood and behaviour of residents, because many indicators of abuse and neglect are quite subtle physical or emotional changes or traits.

How the recommendations might affect practice

Some care homes have a positive, open culture, in which staff and others are supported to reflect on, identify and report safeguarding concerns. For care homes where this is not the case, care home managers and care home providers will need to make major changes in leadership style. Additional resources should not be needed for care homes to appoint safeguarding champions, because the champions are expected to be existing staff members.

Creating a culture in which everyone can learn from safeguarding concerns should not represent a significant change. However, it will bring care homes in line with best practice, particularly in terms of supervision and continuing professional development.

Return to recommendations

Why the committee made the recommendations

Qualitative evidence indicated that multi-agency working and learning can help to improve safeguarding practice. There were issues with this evidence (mainly with the methods used for recruitment and data analysis processes, and the limited adequacy and relevance of the data), but it did align well with the committee's own experience.

The recommendation covering staff apprehensions about external oversight was made because the committee are aware that staff can feel criticised and undermined by people delivering training (especially people from external agencies). The effectiveness of training and learning with other organisations is likely to be improved if positive relationships are established.

The committee made a recommendation on sharing information from Safeguarding Adults Boards with care home staff because they thought it could improve accountability, and help staff understand the responsibilities of other practitioners and organisations in relation to safeguarding.

How the recommendations might affect practice

In some care homes, staff already have the opportunity to share good practice and challenge poor practice. However, it is not uncommon for staff to work in a climate of suspicion and defensiveness. These recommendations encourage openness about lessons learned across agencies, and emphasise the factors that might help care homes to make their culture more positive.

Managers will need to give staff time for these discussions to take place, and will need time themselves to promote the reflective and transparent approach to safeguarding.

Return to recommendations

Why the committee made the recommendations

Qualitative evidence suggested that recording actions or preventative measures and sharing these with colleagues can help staff to safeguard residents more effectively. Although there were concerns about this evidence (mainly regarding the adequacy and relevance of the data), the committee also drew on their own expertise to make the recommendations. In their experience, the way that safeguarding records are used and reviewed can play a key role in embedding learning and improving safeguarding practice.

How the recommendations might affect practice

Standards of documentation and record-keeping within care homes vary widely, so these recommendations are expected to help standardise practice.

Return to recommendations

Why the committee made the recommendations

There was no research evidence about the indicators that should alert people to abuse and neglect in care homes. Instead, the committee based these recommendations on a review of existing non-NICE UK health and social care guidance (see the context and evidence review C for details of the guidance). There were uncertainties around the methods used to develop much of this guidance. However, the committee found the guidance to be highly relevant as a source of evidence to support their work, and used it to make recommendations, alongside their own expertise and experience.

Most of the indicators are adapted from the guidance the committee reviewed, and others were added by the committee based on their knowledge and expertise.

The aim of these recommendations is to help people better understand when a safeguarding referral should be made and when a referral should not be made. The committee felt that some indicators are more serious or urgent than others. This is because, in their experience, those indicators represented a higher likelihood of abuse and neglect. To reflect this, the indicators are split into 2 categories ('consider' and 'suspect'), with different actions based on the likelihood of abuse or neglect. The 'suspect' indicators need to be reported to a safeguarding lead and referred to the local authority.

Some of the indicators of neglect may also be indicators of self-neglect. The guidance the committee reviewed made little mention of this. Based on this lack of coverage the committee felt it was important to make a research recommendation on self-neglect in care homes. They also included a consensus-based recommendation on self-neglect as they agreed that this issue is especially important, because self-neglect in care homes raises questions about the balance between individual choice and the home's duty of care. It also affects the safety, health and wellbeing of other residents, staff and visitors, and can lead to false allegations of abuse and neglect against staff and care homes.

Medication misuse can be a sign of neglect or physical abuse, so the committee included slightly different indicators in both sections.

The committee agreed that indicators of sexual abuse are particularly important because residents may feel embarrassed and ashamed, and therefore reluctant to tell someone and because care homes need to uphold the rights of residents to engage in sexual activity in line with their mental capacity to consent. Care home staff need to be able to recognise these indicators and act upon them.

All types of abuse involve some level of psychological abuse, and psychological abuse may be a sign that other forms of abuse are also happening. Psychological abuse affects the safety, health and wellbeing of other residents, staff and visitors.

Recommendations on financial and material abuse are needed because, while staff are often experienced at recognising other types of abuse, they may find it more difficult to recognise certain types of financial and material abuse.

Discriminatory abuse is important to highlight because it may be difficult to recognise, and may also involve other types of abuse or neglect. It affects the safety, health and wellbeing of residents, because their care may not meet their needs.

How the recommendations might affect practice

The recommendations are based on existing non-NICE UK guidance, so staff should be familiar with the indicators in this guideline. Some, such as being denied freedom of movement, are also enshrined in law (for example the Human Rights Act, Article 5: right to liberty and security).

Care homes may need to do more to help their staff understand these indicators. But doing so will help care homes manage safeguarding issues more proactively, and deal with early warning signs of potential neglect.

Acting early may improve the quality and safety of care and support for residents. The recommendations may also help to reduce the number of section 42 enquiries involving the care home, local authority and others.

Return to recommendations

Why the committee made the recommendations

No directly relevant research evidence was identified on what to do if abuse or neglect is suspected. Instead, the committee used existing non-NICE UK health and social care guidance on recognising and reporting abuse and neglect in care homes. There were uncertainties around the methods used to develop much of this guidance. However, the committee found the guidance to be highly relevant as a source of evidence to support their work and used it to inform recommendations on:

The existing guidance did not cover all the areas that the committee thought were important, so they also used their own knowledge and expertise when agreeing the recommendations.

Return to recommendations

Why the committee made the recommendations

There was no research evidence identified in this area. Instead, the committee used existing non-NICE UK health and social care guidance about information gathering when abuse or neglect is suspected. There were uncertainties around the methods used to develop much of this guidance. However, the committee found the guidance to be highly relevant as a source of evidence to support their work, and used it to inform the recommendations, alongside their own expertise and experience. The guidance highlighted the importance of writing down carefully what the person discloses using their own words, but not interviewing them, and encouraging the resident to preserve any physical evidence if a crime may have been committed.

How the recommendations might affect practice

Inconsistent or poor-quality records could impact on future enquiries. To ensure staff understand how to gather and record information correctly, care homes and care home providers may need to provide extra training.

Return to recommendations

Why the committee made the recommendations

There was no research evidence identified on confidentiality and suspected abuse and neglect. Instead, the committee used existing non-NICE UK health and social care guidance on recognising and reporting abuse and neglect in care homes. There were uncertainties around the methods used to develop much of this guidance. However, the committee found the guidance to be highly relevant as a source of evidence to support their work, and used it to inform the recommendations.

When the existing guidance did not cover all the areas the committee thought were important they also used their own expertise and experience to make the recommendations.

The committee used their experience and expertise to make the recommendation on reporting suspected abuse and neglect, and who to contact if the problems are with the management of the care home. The committee felt it was important to be clear that if you suspect abuse and neglect you must tell someone in a responsible and accountable position about this.

How the recommendations might affect practice

There may be uncertainty within care homes around confidentiality, and when to share information. Care homes may need to provide staff with training on the importance of sharing information and the potential risks of not doing this correctly. There may be an impact on staff time and resources. But this would be outweighed by the benefits of making staff aware of who to share concerns with, which should increase the speed of responses to safeguarding.

Return to recommendations

Why the committee made the recommendations

There was no research evidence identified on safeguarding leads. Instead, the committee reviewed existing non-NICE UK sector guidance on recognising and reporting abuse and neglect in care homes. There were uncertainties around the methods used to develop much of this guidance. However, the committee found the guidance to be highly relevant as a source of evidence to support their work, and used it to inform the recommendations, alongside their own expertise and experience.

The committee emphasised the importance of asking the resident at risk what they would like to happen next, to ensure that the response to safeguarding was in line with the principles of Making Safeguarding Personal. They also agreed that care homes should build good relationships with local authorities, seeking advice if needed, in order to better judge when referrals should be made.

How the recommendations might affect practice

Care homes will have to check that their safeguarding leads have the relevant skills and competencies to assess and act on concerns. If they do not, training may be needed. Care homes may also have to change the way they work with the local authority, to ensure they have a good relationship and can seek advice and support when needed. The implications for care home resources should not be significant, and some of the ways of working suggested may already be in place in some or most care homes.

Return to recommendations

Why the committee made the recommendations

The committee used evidence from a number of sources to make recommendations specifically for local authorities. These included qualitative themes from research evidence on progressing safeguarding concerns and information needs, and existing non-NICE UK health and social care guidance on recognising and reporting abuse and neglect in care homes.

The committee had low confidence in the qualitative evidence about this issue. The main limitations were:

There were also methodological concerns regarding some of the studies, for example in relation to recruitment strategies and data analysis processes.

The committee also reviewed existing health and social care guidance. There were uncertainties around the methods used to develop much of this guidance. However, the committee found the guidance to be highly relevant as a source of evidence to support their work, and used it to inform the recommendations. The committee also used their own expertise and experience to make recommendations. In addition, they linked the recommendations to Care Act statutory requirements for local authorities. The committee emphasised what care homes find most important when they make a safeguarding referral to a local authority, and at the beginning of a section 42 enquiry.

The evidence highlighted the value that care homes place on local authorities as a key source of support and transparent advice. To reflect this, the recommendations emphasise how local authorities should work with other organisations and support care homes to promote best practice.

Local authorities also use guidance on section 42 enquiries from the Association of Directors of Adult Social Services and the Local Government Association. This guideline aims to complement these other sources of guidance, rather than duplicate them.

How the recommendations might affect practice

Existing relationships between care homes and local authorities may vary. Depending on how well local authorities already work with other organisations, they may need to do more to develop good ongoing relationships about safeguarding with care homes and to promote multi-agency working. More resources may be needed for a multi-agency approach to safeguarding, but it should improve the quality and safety of care and support.

Return to recommendations

Why the committee made the recommendations

The committee used qualitative themes from research evidence on responding to and managing safeguarding concerns in care homes, and support and information needs for everyone involved in safeguarding concerns in care homes.

The evidence showed that residents benefit when they are involved and kept informed throughout the safeguarding process. The evidence also emphasised the value that residents place on support from family, friends or advocates in helping them achieve their desired outcomes. However, the committee had some concerns about the quality of the data, which had some methodological limitations as well as questionable relevance (it was not always clear whether findings related specifically to care home settings).

The committee therefore also used the Making Safeguarding Personal framework and the Care Act 2014. These sources highlight the importance of involving people fully as possible in decisions and giving them the information and support they need to participate.

The evidence matched the committee's experience of practice. They agreed that involving people in decision making will help them achieve the outcomes they want, and make it more likely that they will receive safe and effective care after the enquiry ends. Although the committee were able to draw on their own knowledge and experience, they felt that the gap in the evidence indicated that a research recommendation was needed about the views of care home residents in relation to their experiences of safeguarding enquiries. Getting the views of residents will ensure that their needs are understood and that subsequent care can be person-centred and outcomes-focused.

The committee recognised that there should be a clear difference and understanding of the roles of the practitioners and independent advocate involved in safeguarding. Although the practitioner might be acting in the best interest of the person, they may be operating within the constraints of their role. It is only the independent advocate who acts according to instruction from the person.

Residents will often need emotional and practical support while an enquiry is taking place. In addition, they may need this support to continue afterwards, and their needs should be reassessed after the enquiry.

How the recommendations might affect practice

Organisations may need to do more to involve people at risk and their independent advocates in safeguarding enquiries. Implementing the recommendations may involve minor changes to existing practice.

The recommendations could also lead to greater demand for support (for example, speech and language therapists) from people at risk. This may have cost implications, but access to support is a statutory right under the Care Act 2014 and is part of the Making Safeguarding Personal framework.

There is variation in how support is currently provided. Some organisations will need to review how they provide support. This may have resource implications for care homes, who will be responsible for ensuring that support is available in the short and long term and that it is tailored to each person's needs.

Return to recommendations

Why the committee made the recommendations

A small amount of qualitative evidence provided findings relating to the information and support that care home staff need during safeguarding enquiries. However, there were concerns with the adequacy of this data, limitations arising from the data analysis processes used in the studies, and issues with selection bias.

Despite the limitations of the evidence, the committee recognised that this is a crucial issue, in particular for staff who are subject to a safeguarding enquiry. The committee used their own expertise to support the evidence and make recommendations.

The recommendations should reduce the potential psychological and emotional distress on affected staff. They should also encourage staff to report safeguarding problems in the future, as it would be clear to them that everyone would receive support regardless of their involvement.

How the recommendations might affect practice

Some care home providers already fund access to employee assistance programmes, so would not significantly need to change practice. There could be cost implications for care home providers that do not have employee assistance programmes, unless alternative programmes or funding are available for staff already. The committee did not believe that holding return-to-work meetings would be a substantial change in practice. These meetings already commonly occur, so they may just need more emphasis on guidance and support for the affected member of staff.

Care homes do not currently nominate people to provide support to staff accused of abuse or neglect. However, as this can be an existing member of staff, the committee were confident that there would be no significant resource impact.

Return to recommendations

Why the committee made the recommendations

There was a small amount of qualitative evidence relating to the information and support needs of care home staff during a safeguarding enquiry. There were concerns around the adequacy of the data, issues with the methods used to analyse the data, and problems with how the study authors addressed potential bias. Despite these limitations, the committee agreed on the importance of support for care home staff, and built on the evidence with their own expertise. These recommendations are important because:

How the recommendations might affect practice

During a safeguarding enquiry, care home managers will need to allocate time to hold discussions with staff and direct them to external information and advice. Managers will also need time to provide one-on-one support to anxious staff, and to make changes to policies, processes and training in response to the outcome of safeguarding enquiries.

In many care homes, managers already do all of this. However, in care homes where this is not the case, managers will need to spend more time supporting staff and learning from safeguarding enquiries.

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Why the committee made the recommendations

There was a small amount of qualitative evidence about the impact of safeguarding enquiries on care homes and the support that care homes, managers and staff need. There were concerns regarding the adequacy and relevance of the data, as it was not clear whether all of the findings were from a care home context. The committee built on this evidence with their own expertise.

The committee made these recommendations because the business impact of safeguarding enquiries is often overlooked, but can be detrimental to care homes. There can be a financial impact, as well as problems with staff recruitment and retention. The recommendations should help reduce these risks. In addition, improved information sharing and trust between care homes and local authorities will help to reduce the stress of the enquiry process.

How the recommendations might affect practice

Local authorities will need to identify a single point of contact for care homes, which in some cases will be a change in practice. Local authorities may also need to learn more about the reputational risks to care homes and effects on staff morale when they are involved in safeguarding enquiries. Finally, local authorities will need to offer feedback and practical support to care homes.

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Why the committee made the recommendations

There was a small amount of qualitative evidence on effective multi-agency working, and on responding to and managing safeguarding concerns. This evidence had various problems:

However, the committee recognised the importance of these issues and were able to build on this evidence using their own expertise.

The evidence suggested that some people felt excluded from important safeguarding meetings. While this is sometimes justifiable, the committee wanted to reduce suspicion about possible bias and increase transparency and collaboration by ensuring that people are always given an explanation and a chance to contribute in another way.

Safeguarding meetings should be opportunities for different organisations to share information and discuss the needs of adults at risk. Because of the multiple organisations involved and the complexity of the process, communication is important, so the committee made recommendations to ensure that everyone involved is kept informed about the process.

No evidence was identified on the management of safeguarding concerns. Because of the lack of evidence, and the potential variation in practice across the country, the committee made a research recommendation on the effectiveness and cost effectiveness of the different approaches to investigating safeguarding concerns.

How the recommendations might affect practice

There is currently wide variation in what is communicated during safeguarding enquiries and how clear the outcomes are. These recommendations should lead to greater consistency and higher standards, by ensuring that everyone affected by the safeguarding enquiry is kept informed.

The recommendations do not require specific additional resources, but the chairs of meetings may need to take greater care in their documentation and communication.

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Why the committee made the recommendations

No research evidence was identified about the indicators that should alert people to organisational abuse and neglect in care homes. Instead, the committee based these recommendations on a review of non-NICE UK health and social care guidance, (see evidence review C for details of this guidance). There were uncertainties around the methods used to develop much of this guidance. However, the committee found the guidance to be highly relevant as a source of evidence to support their work, and used it to make recommendations, alongside their own expertise and experience.

Most of the indicators are based on a synthesis of findings from the review of health and social care guidance documents, and others were agreed by the committee based on their experience.

The aim of these recommendations is to help people better understand when a safeguarding referral should be made and when a referral should not be made. The committee felt that some indicators would warrant more urgent or more significant action than others. This is because, in their experience, those indicators represented a higher likelihood of organisational abuse and neglect. To reflect this, the indicators are split into 2 categories ('consider' and 'suspect'), with different actions based on the likelihood of abuse or neglect. The committee particularly wanted to emphasise the key role of local authorities in relation to organisational abuse or neglect. This is true for their proactive role (monitoring care standards locally), and in their responsibility for starting and running section 42 enquiries (including large-scale enquiries when needed).

A wide range of people are involved in enquiries into organisational abuse and neglect. The committee agreed, based on their own expertise and experience, that local authorities needed to plan ahead for the support that these people might need (this would be especially important for large-scale enquiries). This is so that the support is in place at the right time during the enquiry.

Organisational abuse is distinct from other types of abuse or neglect because it is generally not directly caused by individual action or inaction. Instead, it is more likely to be a cumulative consequence of how services are managed, led and funded. Abuse and neglect are more likely to happen when staff are poorly trained, poorly supervised, unsupported by management, and when the care home has a culture that does not promote openness and good communication. Therefore, the committee made recommendations focusing on these issues.

Organisational abuse and neglect both involve some level of psychological or medical and physical abuse, and may be a sign that other types of abuse and neglect are also happening.

How the recommendations might affect practice

The recommendations are based on a review of existing guidance, so staff should be familiar with the indicators referred to in this guideline.

Care homes may need to do more to help staff, residents and visitors understand these indicators. However, doing so will help care homes manage safeguarding issues more proactively, and deal with early warning signs of potential organisational abuse and neglect. Acting early may help to reduce the number of section 42 enquiries involving the care home. The recommendations may also improve the safety and quality of care and support for care home staff, residents and visitors.

Care homes may also need to change their recruitment processes, to ensure that applicants are suitable and have been properly vetted.

Staff may also need more training and support, to ensure that they understand their duty of care and to improve their confidence in identifying and reporting potential organisational abuse and neglect.

Identifying organisational abuse and neglect is likely to have other benefits for the care home, in reducing staff turnover and staff absences. This should in turn improve the safety, health and wellbeing of care home residents.

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Why the committee made the recommendations

Although evidence on implementing learning in care homes was available, this did not focus specifically on using findings from past safeguarding referrals and enquiries in the care home. However, the committee agreed that these findings can be a key source of learning material for care home providers, and they regularly use information from Safeguarding Adults Reviews in their own work. As a result, they felt that it was important to make specific recommendations on this, to ensure that this learning is more widely promoted. The recommendations are for care home managers and local agencies, to ensure that organisations can implement this at the local level.

Given the limited evidence about the use of Safeguarding Adults Reviews, the committee made a research recommendation to identify how the findings from these reviews affect practice in care homes. This includes:

The committee agreed that this research is important to identify how care homes understand Safeguarding Adults Reviews and what they learn from them. If the research allows care homes to better utilise these reviews to improve practice, the safety and wellbeing of care home residents will improve.

How the recommendations might affect practice

Managers may need to dedicate time specifically to collating data and sharing findings with staff. However, this is unlikely to take a significant amount of time, as there should already be systems in place to record and share this information.

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