Agenda item
Adult B Safeguarding Adult Review (SAR): Update on Action Plan and Progress with Recommendations
This report will place the process of commissioning, conducting, publishing and disseminating the findings of the Adult B SAR within the national legal and policy context. This report will also outline local arrangements for commissioning, contract monitoring and quality assurance of care and support arrangements, for collaboration between the local authority, CCG and service providers, and for adult safeguarding. The report will also provide an update on the Adult B SAR itself, with specific reference to how the recommendations have been taken forward and how Adult B herself has been safeguarded.
Minutes:
The Chair opened the discussion by inviting Professor Michael Preston-Shoot (Independent Chair of Brent Safeguarding Adults Board) to introduce the item which provided the Committee with an update on the action plan and progress with recommendations relating to the Adult B Safeguarding Case Review.
Professor Preston-Shoot stated that Adult B’s case was an unsettling example, indicative of wider, nationwide issues in social care and conveyed his deep regret of the failure and inadequacy demonstrated by services in relation to Adult B. Nevertheless, he expressed confidence that the report had provided reassurance by drawing upon and disseminating both locally and nationally the lessons learnt. Members’ attention was drawn to the recommendations in the report and the specific changes which had resulted from these in relation to people with learning disabilities and their respective family carers. In particular, Helen Woodland (Operational Director, Social Care) highlighted the review of residential and nursing care provision through commissioning services, which had enabled the Council to have a more holistic view of patients and the quality of care provided to them. Councillor Harbi Farah, Lead Member for Adult Social Care added that the report had been brought to his attention and commended Professor Preston-Shoot and Phil Porter (Strategic Director, Community Wellbeing) for their leadership and commitment to the learning process.
In welcoming the report, the Committee raised a number of questions/lines of enquiries in the subsequent discussion.
Members questioned the lack of knowledge and professional curiosity in Adult B’s circumstances at the time of the incident and sought further clarification about the prevention measures undertaken since then by the Council to ensure that mistakes were not repeated.
Professor Preston-Shoot stated that lack of knowledge and professional curiosity was not an isolated, Brent specific problem and was not unusual for services to be experiencing difficulties in recording/following up the chronology of patients they were working with. He explained that the lack of professional curiosity seen in Adult B’s case was partly due to changes in care management following the introduction of the Care Act 2014 as well as systemic issues with information sharing between GPs and providers. Furthermore, insufficient emphasis was placed on making safeguarding personal, which had to be rectified within all levels of care. Whilst a challenge task, the expectation was that every time a person moved, their personal information, including any social and GP records, should follow them, gradually leading to the situation where the individual held the information themselves, with each interaction should be added to the record and updated.
Helen Woodland (Operational Director, Social Care) stated that a key part in transforming care, was the development of supported living, which would allow the Council to design care around the individual and ensure full transition and communication between services. Within the context of Adult B’s case, Ms Woodland also noted that the communication issues experienced by some individuals which had highlighted the need for further work with providers was required to ensure the patients’ needs were understood and met. The Committee was informed of a new initiative in the form of a Communications Passport, which would accompany individuals and assist them when accessing care but also allow emergency services to better understand their needs/communicate better.
Phil Porter (Strategic Director, Community Wellbeing) added that in addition to the structure of the services, existing cultural issues and the level of staff’s diligence when carrying out duties should also be considered and addressed going forward.
Discussions moved with the Committee seeking further clarification on the Council’s practices in setting a digital infrastructure to allow information sharing between services. Professor Preston-Shoot explained that information sharing was a widespread problem across the whole health economy and despite steps being undertaken to address existing barriers, it was not as widely established as it should. Whilst physical copies of patients records did exist, the challenge remained in terms of the range of systems operated by different organisations and how they interacted with each other. Duncan Ambrose (Assistant Director, Brent CCG) advised that a potential solution to the problem which was actively promoted was the Whole Systems Integrated Care software which was being used by some organisations and enabled frontline practitioners to safely access and share information, which had been drawn from various databases.
Phil Porter explained that the challenge of information sharing should not be underestimated. Whilst welcoming the use of data sharing software and the communication passport initiative, he stressed the importance of ensuring that core information was included with the Council continuously working with frontline social workers to ensure the records were consistently maintained.
Responding to members’ questions on the type and effectiveness of the current monitoring system, Helen Woodland advised that the Council had designated teams in place responsible for monitoring not only providers but also the care recipients. She further explained the process of annual reviews, stating that this was an entitlement to every patient. Annual reviews were traditionally carried out by either reviewing all individuals in a given cohort or on an individual basis through the community review team. However, multiple reviews due to complex conditions had seen an increase due to the increasing complexity of patients’ conditions and it was not uncommon for ad hoc annual review requests of care arrangements to be made by patients. In the year to date the Council had carried out more than 7000 reviews.
In welcoming Ms Woodland’s comments, Professor Preston-Shoot reminded members that the above approach was fairly new and was a direct result of the recommendations made in the Adult B report. He added that the Brent Safeguarding Adults Board (SAB) had taken an active interest in the commissioning and contract monitoring arrangements towards providers, resulting in the establishment of a fully functioning establishments and providers’ concerns working group which was monitoring any issues and served as a mechanism of holding the Care Quality Commission to account. The work of the group itself was subject to regular review, with a discussion planned for the next Board meeting in July 2019.
Members queried what the real life impact of cuts on services had been and what was being done to make council services more efficient. It was explained that despite continuous cuts in services, the care which Adult B currently received was significantly cheaper. Helen Woodland asserted that it was important to consider what represented actual value for money alongside continuous austerity measures and in so doing ensure that the commissioned services delivered what was needed by the patients. She explained that a key aim of the Council’s transforming care agenda had been to review the cohort of people with learning disabilities and consider what the best possible provision for them that needs to be commissioned in future was. The cohort was fairly static in terms of numbers, allowing the Council to plan effectively in the long term. A priority of adult social care was also the effective use of day care centres subject to necessary remodelling, alongside working with carers and young people to establish what support was required and commissioning a suitable service accordingly.
A key line of enquiry pursued by the Committee revolved around the role of staff, their recruitment and level of accountability they had. Referencing Section 1 of the Care Act 2014, Professor Preston-Shoot stated that it was important to be mindful of the statutory guidance which set out a general definition of wellbeing. The overall aim was to get as close as possible to delivering patient’s wellbeing, while also taking into account available resources and offsetting these against the needs of the individual/family members. In terms of staffing, the Committee was informed that every time a care package was commissioned, the services were responsible for establishing that the staff had the required knowledge and skills to deliver what was needed. Following Adult B’s case, there had been a greater emphasis in ensuring that robust staff checks were embedded at the forefront of the council policies.
Phil Porter assured the Committee of the importance of recruiting the right people to the right roles and ensure they offered the appropriate level of supported required by individuals. Following Adult B’s case, the Council had adopted a new approach and was seeking to develop a different, more strategic partnership stance in its relationship with providers. Members were informed that the approach was already in place but it would take time before its true impact could be established.
In response to members concerns about quality of care from private providers and whether there was an intention to bring more care services back “in house”, Helen Woodland stated that there were a number of very good private providers which have been working well in partnership with the Council. The Committee was reassured that the current schemes had been performing well, drawing upon staff’s expertise and sharing of knowledge in delivering personalised care. In term of bringing more services under the control of the Council, Helen Woodland stated that there were a number of “in house” services provided by the Council, including a learning disability care home and a private financing scheme (PFI) already in operation. However, members were advised that bringing all services back in house may not be the most effective option, with no immediate plans set out to do this in the near future.
Referencing the issue of training and professional curiosity as well as the number of outside providers who may be intermittent to provision of care, the Committee enquired about the Council’s approach in ensuring mistakes from Adult B’s case were not repeated. In noting the need for further regulation, members further questioned the robustness of contract monitoring practices in ensuring that services were held to the highest possible standards.
Professor Preston-Shoot stated that whilst no guarantees could be given, the Brent SAB could seek assurance from agencies that appropriate training be provided for every aspect of the workforce or if necessary, seek to utilise its own resources in doing so. He also noted that a key to avoiding mistakes was ensuring adequate supervision and developing a culture amongst staff of escalating concerns outside of their direct line management. An overarching point was made that there was a national issue that needed to be argued in terms of revamping the training provided for social care staff and pursuing the development of a national accredited system.
In terms of contract monitoring, the Committee heard that a new system was already in place, with a report on details of it to be presented at the Brent SAB meeting in July 2019. Members were also asked to note the frequency of the reviews, which allowed to identify and manage notifications of concerns received accordingly. In addition, members were informed of a recent external audit, which would form part of a wider peer review currently under way. A further approach was to seek to hold the Care Quality Commission (CQC) to account to ensure their decisions were based on evidence in relation to particular providers.
The meeting continued with the Chair inviting Councillor Neil Nerva (committee member, in capacity of an observer for the meeting) to make a contribution to the discussion. Cllr Nerva expressed his concerns from the findings of the report and noted the need to seek further assurance from the CQC in ensuring the adequate provision of continuous service. In his presentation, he sought clarification on the review target for people with learning disabilities as well as a feedback on the risks identified from the Adult B report in terms of patients with complex care needs.
Helen Woodland informed members that there was no specific target for people with learning disabilities but the annual overall target of 84% had been achieved and would be increasing year on year. She clarified that the term “review” was being used loosely and in fact the process involved a much more detailed investigation, on a case by case and depending on the individuals’ circumstances. Reviews also looked at what an individual wanted to achieve as well as into their care plan, any risk factors and respective mitigation measures. In addition, she pointed out that partnerships with providers and people who provide care also played an integral part. It was explained that as a result of Adult B’s case, conversations about identifying complex cases which would benefit from ongoing social care involvement were now taking place and were factored in the priorities within the adult social care transformation for next year.
In addition, Michael Preston-Shoot stated that a number of other opportunities had been explored. These included the raising of the issues/lessons from Adult B’s case at the National Safeguarding Adults Boards Chair’s Network and sharing with commissioning services and providers as well as a project for the Local Government Association under way, focusing on how to make safeguarding personal, the outcome of which would be known in early autumn of 2019.
Members questioned the training structure for frontline staff and what their knowledge of safeguarding and raising concerns was. It was felt that accreditation was not limited to training alone and demanded that more be done through existing commissioning policies. The Committee was assured that the Council was working closely with care homes and looking at the issues they were experiencing in order to provide appropriate training. However, it was explained that provision of training was national problem, resulting in lack of specific structures and in turn posting significant challenges in pursuing further accreditation.
Michael Preston-Shoot stated that social workers, GPs, nurses all needed to be registered to practice which guaranteed some a certain status. In addition, care packages were legally required to meet individual’s needs and Brent had proven successfully in defending its care packages in court on a number of occasions. However, he stated that an opportunity to register social workers had been missed, resulting in lack of adequate regulation and filtering when recruiting for social works. He further stated that more onus was needed to ensure that the Council was satisfied with the provider’s requisite knowledge/skills and existence of appropriate procedures in place to guarantee individuals’ protection.
Spotlighting on the content of the report, members questioned the limited references made to care management services as well as their absence from the meeting. The Committee was informed of the difficulties experienced in trying to engage the care providers fully in the serious case review process, their reluctance to accept scrutiny and further learning and the concerns by the Council and Board as a consequence. A judgement call therefore had to made in preparation of the report to the degree in which the provider voice was required, taking into account their general level of defensiveness.
Further referencing the recommendations in the report, members expressed concerns about the lack of advocacy in Adult B’s case and how the council was engaging with parents and carers. They further questioned the lack of uniformity in the training received by advocates as well as the lack of necessary language skills. Helen Woodland that there were three key elements to this – how were family members involved; how are people who can’t advocate for themselves supported; and how are they supported to advise services of their needs/wishes. The complexity of the process would require a robust assessment and plan which looked at the wider network, strengths and skills of the individual. In some instances, the Council would also consider seeking the help of an independent advocate to help decide what is best for the individual. Where applicable, details of advocates and family/friends network would also be recorded on the Communications Passport. In reminding members and officers of the importance of meeting the obligations set out in the Care act 2014, Michael Preston-Shoot added that the Brent SAB had looked at a number of referrals with an element of advocacy, highlighting the invaluable role many of them had played.
The Committee was assured that qualification and training standards regarding advocacy were in place. Nevertheless, due to the diverse community in Brent the Council also commissioned a translation service to help advocates in their work when needed. It was explained that there had been difficulties recruiting frontline care staff who spoke certain languages such as Gujarati and that needed to be considered through workforce development in the long term. A further service to assist advocates with assessments was also commissioned and regularly used. No specific numbers could be given to people with advocates but officers agreed to report back to members with more information.
Discussion moved on with the Committee welcoming the Communications Passport scheme and seeking further details on the timescale for progressing it. Officers advised that the scheme was part of a wider review. The Communication Passport would be in addition to the care support plans to which all individuals were entitled to and would be determined following appropriate assessment. Reviews were rolling and started from the date when a person came into the service.
Spotlighting on the recommendations in the report, the Committee enquired about their progress and monitoring. Michael Preston-Shoot confirmed that all recommendations set out in the report had been referred to the relevant Council department. He confirmed that recommendations 1 and 2 had already been completed and recommendation 3 was ongoing, as part of a wider transformation initiative. In relation to recommendation 4 which focused on the new commissioning arrangements, he explained that serious case reviews were now fully included within the arrangements for commissioning and contract monitoring so recommendation 4 was both completed and ongoing.
It was explained that reviews didn’t end with action plans and were expected to be regularly revisited and discussed at future meetings. Actions from serious case reviews and lessons were disseminated in a range of ways to ensure they are given sufficient prominence. The review processes included ensuring that every partner agency knew how to make referrals to case review group. Set within the structure of the Brent SAB, a case review group would discuss and review cases, the meetings of which were minuted and attended by a legal representative. In addition, progress updates on the report had been announced via newsletters and the annual SAB report had included an account of the number of cases received and decisions made.
Whilst the report did not identify any additional elements that required routine reporting, Michael Preston-Shoot stated that if there were reasons to believe that care packages were not delivered on, then necessary actions would be taken. Committee members were assured of the continuous work between the Council and care providers to ensure standards were maintained, evident through the Council’s combined approach and existence of an Establishment and Provider Concerns working group.
Finally, the Committee questioned the methods used by the Council in holding providers to account and minimise further cases like Adult B from happening in future. Whilst no specifics could be given, Members were assured that the concerns resulting from Adult B’s case had been identified and the Council was no longer contracting with the care provider. The Chair of the Brent SAB added that whilst cases like Adult B’s were shocking, reviews should be welcomed and seen as a tool for identifying lessons to be learned and revealing good/bad practice. It was noted that where potential concerns could arise from were cases of repeat referrals as these would be seen as indicative of the existence of systemic issues in Brent. In addition to reporting concerns directly to the Chair of the Brent SAB, members were advised of the possibility to seek, where appropriate, legal action. A further argument could also be made as to whether or not the law could be extended to include individual members of staff as a way of holding them to account.
On behalf of the Community and Wellbeing Scrutiny Committee, the Chair asked the Chair of the Brent SAB to pass Adult B and Adult B’s mother their best wishes. In conclusion of the meeting, the Chair thanked officers for their contributions to the meeting and invited members to make recommendations.
RESOLVED:
- That the Cabinet undertakes to take forward and monitor progress of the Communication Passports Scheme
- That the Cabinet be asked to make representations with regards to providers and their robustness and accreditation of training; and further liaison with the CQC in this area.
Supporting documents:
- Safeguarding Adult Review - Covering Report, item 4. PDF 125 KB
- Brent Safeguarding Adults Board - SAR Report, item 4. PDF 518 KB