Large Scale Enquiries

When there is a safeguarding concern about an individual, the focus of a safeguarding enquiry will be on what has happened to that person, their safety and wellbeing, on their desired outcomes and what actions will be needed to support that person to be safe. 

If there are concerns that more than one person is experiencing abuse or neglect within the same service or setting, then this process should be followed for each person. 

As such each individual safeguarding enquiry will need to result in its own safeguarding plan and outcome discussion / meeting. This is important to ensure that each individual person’s needs, desired outcomes, circumstances and personal safety are considered in their own right. 

Where there are safeguarding concerns for more than one person within the same service or setting, then a Large Scale Enquiry may be additionally required. However, this will only be appropriate where the nature of the various individual enquiries, when considered together, potentially indicate organisational abuse. 

As a Large Scale Enquiry is an additional enquiry, it should only be followed where there is a potential benefit to safeguarding people within that service or setting. The need for a Large Scale Enquiry may be identified at any time, for example, whilst other enquiries are being undertaken or at their conclusion. 

The Large Scale Enquiry will need to draw upon the findings of each individual safeguarding enquiry undertaken, and undertake additional enquiries and actions as required in order to respond to the concerns of organisational abuse. 

For further information, Section 6.5 provides illustrated case examples of when a Large Scale Enquiry is required and when one is not.

Involvement at the Planning Meeting/Outcome Meeting should be limited to those who need to know and can contribute to the decision making process. This may include an appropriate representative of any organisation that has a specific role in: 

• undertaking enquiries in relation to abuse or neglect 
• assessing the risk 
• developing or carrying out the safeguarding plan 
• undertaking related enquiries e.g. criminal, regulatory 
• taking other actions in relation to the organisation alleged to have caused harm 

In all cases where the Large Scale Enquiry is being considered involving a regulated service provider, the following must be informed and invited to Planning Meetings and Outcome Meetings (and be offered copies of minutes irrespective of attendance):  

• Care Quality Commission 
• Contracting/Commissioning authorities 

Where Large Scale Enquiry is undertaken in relation to an NHS Trust, the Trust should ensure its Chief Executive Officer and the Executive Officer for Safeguarding within the CCG are be notified and involved/kept informed as requested. Similarly, where Large Scale Enquiry involves a Leeds City Council Adults & Health ‘in-house service’, the Director of Adult Social Care must be notified, and involved/kept informed as requested.

The person at risk, and their relatives as appropriate, should be fully involved within individual safeguarding enquiries relating to them as set out in the Leeds MultiAgency Safeguarding Adults Policy and Procedures. 

The focus of the Large Scale Enquiry will however be on the collective issues and themes from a number of individual enquiries. For reasons of privacy and confidentiality, or the need to plan an enquiry, it may often not be appropriate for the person at risk or their relatives to attend a Large Scale Enquiries Planning Meeting/Outcome Meeting. 

The Large Scale Enquiry however should be informed by the views of those at risk and their representatives. As such the Safeguarding Coordinator/Outcome Meeting Chair will need to consider how the views of the adult at risk and their relatives can be most appropriately included. These will often have already been raised within individual enquiries and some, may wish to offer further views in relation to the large scale enquiry being undertaken. 

Those individuals safeguarded through individual safeguarding enquiries should be offered feedback in relation to actions taken and decisions reached within the Large Scale Enquiry. Any implications for the person’s own care must be discussed and agreed with the individuals concerned.

It is important that the service provider is involved as fully as possible in safeguarding concerns involving their service. 

Depending on the size of the organisation and the nature of the concerns, the individuals implicated, the appropriate representative for Planning Meetings/Outcome Meetings might be for example, the manager, the owner or the regional/company director. It is important that the representative is appropriately senior to respond on behalf of the organisation to the service level nature of the concerns. 

Where the given representative is directly implicated (or attendance may prejudice the planning of an enquiry) it may not be appropriate for them to be present at the Planning Meeting. If this is the case, an alternative manager should be provided with an opportunity to attend to represent the service, for example, a regional manager. Communication with and involvement of the organisation must be maintained as fully as is possible. 

The service provider's organisation should have the opportunity to respond to any concerns raised by the Large Scale Enquiry, and to be able to review the Formal Report and comment on its findings, as set out within the Leeds Multi-Agency Safeguarding Adults Policy and Procedures. 

An appropriate representative of the service provider must be invited to attend the Outcome Meeting.

Where a person at risk is placed in a service by non-Leeds placing authorities, then those placing authorities should also be invited to the Planning Meeting/Outcome Meeting. 

The ADASS (2016) Out-of-Area Safeguarding Adults Arrangements: Guidance for Inter-Authority Safeguarding Adults Enquiry and Protection Arrangements establishes how authorities should work together in these circumstances. Key principles of this guidance are summarised in Section 6.2.

The local authority will appoint a Safeguarding Coordinator for the Large Scale Enquiry, who will need to determine how the enquiry is undertaken. 

As Large Scale Enquiries involve situations where there are serious multiple concerns or repeated instances of abuse or neglect and/or where managers/senior managers may be implicated within the organisation's practices, it will usually be appropriate for this to be undertaken by the local authority so as to achieve the safe outcomes required from the Large Scale Enquiry. 

Where undertaken by the local authority, the Large Scale Enquiry will often be undertaken by the person who acted as Safeguarding Coordinator for the individual enquiries; with a more senior manager adopting the role of the Safeguarding Coordinator for the Large Scale Enquiry. This has the benefits of ensuring the person undertaking the enquiry has a good knowledge and understanding of the individual safeguarding concerns.

There may be occasions however where a provider organisation undertakes the Large Scale Enquiry, this could be appropriate where the designated person is independent of the organisational concerns, and is well placed to achieve the safe outcomes required from the Large Scale Enquiry.

Individual safeguarding enquiries will focus on the person’s individual safeguarding needs. 

The Large Scale Enquiry will need to assess the risk to individuals within the service and consider the need for additional arrangements in relation to specific individuals and/or service users more generally. Service wide actions may include staff guidance, reviews of policies and procedures, reviews of staffing numbers, immediate training needs amongst others. 

Where there are proposed changes to individual service users/patients care plans they will need to be consulted/informed appropriately before changes are made. 

Additional service improvements may be separately required by Contracting/ commissioning authorities and the Care Quality Commission (CQC) that continue outside of the safeguarding adults procedures.

Where a Large Scale Enquiry has been undertaken, an Outcome Meeting, chaired by an appropriate manager in the local authority, will always be required. 

Enquiries undertaken in relation to particular individuals should be completed and the respective Outcome Discussions or Outcome Meetings held prior to the Large Scale Enquiry Outcome Meeting wherever possible. This will enable the findings to inform the Large Scale Enquiry Report and Outcome Meeting.

There may be circumstances where there is a need to inform wider service user/patients of the nature of the concerns and the actions being taken to respond to these. This will be particularly relevant where there are widespread concerns, and where clear communication will help to reassure wider service users/patients and their representatives of actions being taken. Such communications will usually be undertaken by the service provider, who will be best place to respond to individual concerns of their service users/patients.

As part of undertaking a Large Scale Enquiry it may become apparent that there are service users/patients, who do not require the support of the multi-agency safeguarding procedures, but who nonetheless would benefit from a review of their needs. 

The need for such reviews of individual service users/patients' needs and provision may therefore also be required, alongside or subsequent to the Large Scale Enquiry. It is important that the service user/patient, their relatives or representatives are appropriately involved in such reviews. 

Where placements are commissioned by non-Leeds Commissioning authorities, the undertaking of reviews will be the responsibility of the relevant commissioning authority.

Safeguarding Coordinators, and their line management, including Chief Executive Officer (NHS) or Director (Adult Social Care) and the relevant communications/media team must be informed of any media interest as soon as possible. Under no circumstances should Safeguarding Coordinators or those undertaking enquiries give a comment or interview to the press.

There may be circumstances where the findings from individual enquiries and Large Scale Enquiries, indicate potential offences. Whilst concerns may relate to offences committed by individuals; they may also be committed by services/organisations, by virtue of how their arrangements are managed or organised. For example: 

• Ill treatment and Wilful neglect: provider offence 
• Corporate Manslaughter and Corporate Homicide Act 2007 

Where there are such concerns, the police should be contacted for advice.

The Care and Support statutory guidance describes Organisational abuse as: 

Including neglect and poor care practice within an institution or specific care setting such as a hospital or care home, for example, or in relation to care provided in one’s own home. This may range from one-off incidents to on-going ill-treatment. It can be through neglect or poor professional practice as a result of the structure, policies, processes and practices within an organisation. 

Where a large scale enquiry is being undertaken, many different forms of abuse or neglect may be evidenced within the individual safeguarding enquiries being undertaken. The overarching large scale enquiry will be able to consider these individual enquiries together, to identify underlying factors that maintain the risk of abuse and neglect (see Illustrative Examples, Section 6.5). 

The following guidance can inform professional judgements and decision making as to whether organisational abuse is a presenting concern: 

As organisational abuse or neglect arises as a result of the structure, policies, processes and practices within an organisation, it may be evidenced by certain characteristics: 

• It is widespread within the setting (e.g. the abusive/neglectful practice is not confined to the practice of a single staff member) 
• It is evidenced by repeated instances of abuse or neglect 
• it is generally accepted that these things happen 
• It is sanctioned – it is encouraged or condoned by line managers 
• The absence of effective monitoring or management oversight by managers has allowed the practice to occur. 
• There are environmental factors (e.g. unsuitable buildings, lack of equipment, many temporary staff) that adversely affect the quality of care. 
• It is systemic e.g. factors such as a lack of training, poor operational procedures, poor supervision and management all significantly contribute to the development of organisationally abusive practice. 

It is not necessary for each of these characteristics to be present. However, the presence of one or more characteristic increases the likelihood that organisational abuse is taking place. Please note: organisational abuse may also be indicated by a number of adversely affected service users. However, it could occur in relation to a single service user. 

The assessment of possible organisational abuse will need to be based upon professional judgement, with consideration of all the individual circumstances. This should include consideration of the actual or potential impact on the wellbeing individuals concerned; as well as the underlying causes of any abuse and neglect.

Sometimes local authorities will need to work together to respond to safeguarding concerns. This is most common when abuse or neglect occurs in one local authority area, but the person receives services funded/commissioned by another. 

The ‘ADASS (2016): Out of area safeguarding arrangements’ highlights the needs for authorities to work together and outlines respective responsibilities. 

Key general principles are summarised below: 

The safeguarding adults procedures of the host authority (i.e. the local authority in the area where the abuse occurred) will be followed. This means that, the host authority: 

• will fulfil the role of the Safeguarding Coordinator 
• will maintain effective communication with the placing authority 
• may need to undertake immediate make safe arrangements, but wherever possible this should be in consultation with the placing authority 

Placing authorities (the local authority or NHS body responsible for commissioning care and support services for that person): 

• will contribute to the safeguarding response as required 
• have overall responsibility for assessing and providing for the care and support needs of the person at risk 
• will ensure, through contracting arrangements and in-service specifications, that the provider has arrangements in place for protecting adults at risk of harm. 

If the person is a self-funder and there is no placing authority involved in commissioning care and support services, the host authority has the duty to act under the multi-agency policy and procedures regardless of the area from which the person originated. 

If a person experiences abuse whilst in another local authority area from where they live, for a very short period, for example whilst on holiday, the statutory duty lies with the host authority. However, there may need to be agreement between the host and placing agency as who is the most appropriate to undertake enquiries in relation to the concerns. 

The full ADASS Guidance includes more information about the arrangements required in such situations.

The Care Quality Commission (CQC) is the independent regulator of all health and adult social care services in England, including those provided by the NHS, local authorities, private companies and voluntary organisations. 

The Commission makes sure health and social care services provide people with safe, effective, compassionate, high-quality care and it encourages care services to improve.

The role of the CQC 

Includes: 

• Registering and monitoring of care providers. (Link to CQC website here) 
• Inspecting and rating services (Link to CQC website here) 
• Taking action to protect people who use services (Link to CQC website here) 

Fundamental standards 

All service providers registered with the CQC are expected to meet fundamental standards, below which care should never fall. These 17 standards include: 

• Safeguarding from abuse: You must not suffer any form of abuse or improper treatment while receiving care. 
• Duty of Candour: The provider of your care must be open and transparent with you about your care and treatment. Should something go wrong, they must tell you what has happened, provide support and apologise. Regulation 20: Duty of Candour: Care Quality Commission 

For more information about all the fundamental standards (Link to CQC website here): 

Statement on CQC’s role and responsibilities for safeguarding children and adults 

The CQC states sets out a range of roles and responsibilities in relation to safeguarding. These include: 

• Supporting the local authority’s lead role in conducting enquiries or investigations regarding safeguarding children and adults. We do this by cooperating with them and sharing information where appropriate from our regulatory and monitoring activity. We assist the police in a similar way. 
• Holding providers to account by taking regulatory action to ensure that they rectify any shortfalls in their arrangements to safeguard children and adults, and that that they maintain improvements. This includes requiring providers to produce action plans, taking enforcement action to remedy breaches of fundamental standards, and taking action against unregistered provider 

To access the full document is available on the CQC webpage: here

Commissioning authorities will have required standards for services and systems in place for monitoring, inspection and for supporting service providers to achieve improved standards. 

In the event that safeguarding concerns emerge, these roles and responsibilities will be continuous with the safeguarding process, however liaison with the Safeguarding Coordinator will be required to ensure that responses are coordinated and information shared appropriately. 

Depending on the circumstances, commissioning authorities may support the safeguarding enquiry process by: 

• Advising on past service performance issues and agreed actions to address concerns 
• Advising on expected standards and identifying areas where the service provider has not met their contractual requirements 
• Undertaking a review of systems or records. 
• Obtaining from the service provider all relevant policies and procedures 
• Inspecting areas of organisational practice 
• Requiring evidence of improved/agreed practice 
• Identifying the need for service improvement plans 

Service improvements may be required by the commissioning authority to achieve required standards of service provision. The nature of such plans will be determined by the commissioning authority, and may continue irrespective of the safeguarding adults procedures. 

The decision to suspend or end any suspension of placements with a service provider will be made by each individual commissioning authority in accordance with the criteria and agreed processes as set out in their own suspension policy. The decision may be informed by the safeguarding process, but will be made outside of the multi-agency safeguarding adults procedures.

During April and May, there were 4 safeguarding concerns raised for residents in X, a small Care Home in Leeds.

In April, Mrs A’s daughter reported an incident when her mother fell whilst being supported to dress herself, causing an injury to her hand. The service provider was asked to undertake an enquiry, who found that the care plan was not being followed. The safeguarding plan recognise the need for the new member of staff in question to be given more training. 

Later in April, the care home reported that a member of staff reported a colleague under stress shouting at a resident Mrs B. The service provider was asked to undertake an enquiry, who found that the staff member was very apologetic. The resident was given support and the care home recognised the need for the new member of staff in question to be given more training and support to understand their role. 

In May, Mr. C experienced an injury whilst being hoisted. There was enquiry determined that Mr A’s care plans were regularly not being followed. Care Home X reviewed the care plan and put in place regular checks to make sure this was being followed. 

Later in May, a safeguarding concern was raised for Mrs. D by a District Nurse in relation to her pressure ulcers. The nurse was concerned that advice provided and care plans were not being followed. An enquiry was undertaken for Mrs. D in relation to her safety and wellbeing. 

As a result of these concerns, the Safeguarding Coordinator convened a Planning Meeting to consider the need for a Large Scale Enquiry. There were repeated concerns around neglect, care planning and training within a short space of time. Those attending the Planning Meeting felt the concerns potentially indicated organisational abuse, in that each incident appeared to be caused by wider organisational issues. 

The Large Scale Enquiry considered the issue of organisational abuse. The findings of the Enquiries for Mrs A, Mrs B, Mr C and Mrs D were collated. Further information was sought from the service provider and others about care planning, induction, supervision and training. A separate Large Scale Enquiry, Formal Report was written. 

The Outcome Meeting for the Large Scale Enquiry included the service provider, and the Commissioning/Contracts Team. Those present felt that the lack of management oversight, care planning, and training issues were resulting in the various incidents of abuse. The safeguarding plan focused on measures to improve these issues for all residents, the relevant commissioning teams agreed to monitor these improvements through their own performance framework. 

Mrs A, Mrs B, Mr C and Mrs D were provided with feedback on the conclusions of the Large Scale Enquiry and the actions being taken. 

Comment: 

There was an individual Safeguarding Enquiry about the individual circumstances of Mrs A, Mrs B, Mr C and Mrs D. Each Safeguarding enquiry resulted in its own Outcome discussion/meeting. Each individual person’s desired outcome and safeguarding planning needs were considered. 

There was an additional Large Scale Enquiry due to the concerns of organisational abuse, and concerns that the individual safeguarding plans would not prevent abuse from reoccurring. The Large Scale Enquiry collated relevant information from each individual enquiry, and the subsequent Outcome Meeting explored the need for additional service level safeguarding arrangements.

Example One: Single Enquiry, with service wide concerns 

Mr E receives care support from domiciliary care service Y. A safeguarding concern was raised for Mr E following an injury sustained whilst being hoisted at home by a paid carer. An enquiry was undertaken, during which it was identified that his care plan was not adequate, and that training and record keeping was poor. There were no other safeguarding concerns raised in relation to this service provider, however similar practices were being followed for other clients. The Outcome Meeting was concerned as to the potential risk to other residents, with similar needs. 

The service provider agreed to review all of Mr E’s care plans, and those of any other person using these kinds of hoists, provided specific training to staff and introduced new measures to monitor effective recording. The service provider confirmed to the Safeguarding Coordinator when these actions were complete. 

Comment: 

A Large Scale Enquiry is not required. There were service wide concerns, but a Large Scale Enquiry would only be required where necessary to bring together more than one individual enquiry, to consider organisational abuse concerns. 

Example 2: Multiple Enquiries, without service wide concerns 

Between April and May, in day service Z, there were 3 safeguarding concerns raised for service users. 

During April, the day service reported that Mrs F had complained that a male service user with dementia had made sexual comments and touched her chest, and was distressed by her experience. An Enquiry was undertaken by the service provider which supported her account of events. This behaviour was not a previously known risk. Support was provided to Mrs F and the care plans for the male resident were reviewed to prevent the risk of reoccurrence. 

During April, the day service reported concerns that a new member of staff had made racist comments to a service user. This staff member had been suspended. A safeguarding enquiry was undertaken and the day service is in the process of following their disciplinary process. 

During May, the day service raises a safeguarding concern, that a service user is being financially abused by a relative. A Safeguarding Enquiry was undertaken and day service and local authority worked together to put safeguards in place. 

Comment: 

A Large Scale Enquiry is not required. Although there have been several safeguarding concerns involving the same service, there is no indication that organisational abuse is an underlying cause. The risk to each individual has been addressed through their individual safeguarding plans.