5.7 Safeguarding - Provider Concerns

Provider Concerns refer to issues that affect a group of people, for example adults living in a care setting. Where safeguarding concerns are raised about an individual these should be progressed under Section 42 enquiry (See procedures). The outcome of any individual Section 42 enquiry related to a provider where there is a Provider Concerns process in place, should be fed back to the Provider Concerns process.

The Provider Concerns process should only be invoked where there are patterns of safeguarding and care quality concerns that indicate that the provider has not made any changes to reduce the number of incidents surrounding the same or similar situations and there is concern that the provider is unable to provide care and support in a safe environment that respects the human rights of people in receipt of that care.

5.7.1 Organisational Abuse

Organisational abuse (or organisational safeguarding) is a broad concept and is not just applicable to high profile cases, for example Winterbourne. It is an umbrella term defined as, ‘the mistreatment or abuse or neglect of an adult at risk by a regime or individuals within settings and services that adults at risk live in or use, that violate the person’s dignity, resulting in lack of respect for their human rights.’ (Care and Support statutory guidance, 2014)

Organisational abuse occurs when the routines, systems and regimes of an institution result in poor or inadequate standards of care and poor practice which affects the whole setting and denies, restricts or curtails the dignity, privacy, choice, independence or fulfilment of adults at risk. Organisational abuse can occur in any setting providing health and social care. A number of inquiries into care in residential settings have highlighted that Organisational abuse is most likely to occur when staff:

• Receive little support from management;
•  Are inadequately trained; 
• Are poorly supervised and poorly supported in their work; and
•  Receive inadequate guidance.

Early identification

Hull University (Early Indicators of Concern in Residential and Nursing Homes for Older People 2012) identified over ninety individual indicators or warning signs for concern. A summary of factors which can increase the likelihood of abuse occurring within provider settings are drawn from these indicators:

• Management and leadership
• Staff skills, knowledge and practice
• Residents’ behaviours and wellbeing 
• The service resisting the involvement of external people and isolating individuals
• The way services are planned and delivered
• The quality of basic care and the environment

Where there is proof or suspicion of organisational abuse, for example the abuse and neglect highlighted in the Winterbourne View report; or omission to provide care and support that puts adults at risk, action will be channelled through the Provider Concerns process.

Principles

• The safety and wellbeing of adults using the service is paramount;
• Strong partnerships that acknowledge the expertise of others; 
• Openness and transparency to achieve positive outcomes; 
• Joint accountability for risk between commissioners, safeguarding leads, providers, the police, the Local Authority, the CCG and other stakeholders who may be involved; 
• Prudent targeted use of resources;
• Information shared responsibly between all agencies, including the provider; 
• Co-operation between agencies; 
• Natural justice.

How concerns are addressed depends on level of risk and the impact on people using the service. There are no hard and fast rules and each case should be considered on its own merit. The process can challenge capacity of one service/organisation therefore it is important that there is a shared approach, breaking down barriers between services and organisations to provide a joined up approach.

5.7.2 Roles and Responsibilities

Host Authority – The Local Authority and CCGs in the area where abuse or neglect has occurred.

The host authority is responsible for:

• Liaising with the regulator if any concerns are identified about a registered Provider. 
• Determining if any other authorities are making placements, alerting them and liaising with them over the issues in question/under investigation. 
• Co-ordinating action under safeguarding and has the overall responsibility to ensure that appropriate action is taken.
• Ensuring that advocacy arrangements are in place where needed and care management responsibilities are clearly defined and agreed with placing authorities.
• Ensuring that there is appropriate management of processes (e.g a Chair and administration of meetings, clear audit trail of agreements, identification of leads for particular actions and timescales. 
• Taking on the lead commissioner role in relation to monitoring the quality of the service provision.

Placing Authority – The Local Authority (or CCG) that has commissioned the service for adults delivered by a provider where there are Provider Concerns.

The placing authority is responsible for:

• Duty of care to people it has placed that their needs continue to be met.
• Contribute to safeguarding activities as requested by the host authority, and maintain overall responsibility for the individual they have placed
• Ensure that the Provider, in service specifications, has arrangements in place for safeguarding. 
• The placement continues to meet the adult’s needs 
• Undertaking specific mental capacity assessments, or best interest decisions for adults they have placed 
• Reviewing the contract specification, monitoring the service provided and negotiating changes to the care plan in a robust and timely way 
• All usual care management responsibilities 
• Assessments under the Deprivation of Liberty Safeguards 
• Keeping the host authority informed of any changes in individual needs and/or service provision.

The Care Quality Commission (CQC)

The CQC acts independently and is a valued partner in the process of information sharing and working to tackle areas of concern. Their expertise in working with providers and standard setting may support safeguarding processes.

The CQC have the authority to take appropriate enforcement action where providers are found to be slipping, but have not yet breached the requirement. This supports CQC’s approach to inspection and enforcement which is based less around compliance of set outcomes, and instead focuses on five key questions about care:

• Is it safe? 
• Is it effective? 
• Is it responsive? 
• Is it caring? 
• Is it well-led?

Where there has been a recent inspection it may be helpful for providers to share pre-publicised reports, to support the principle of openness and transparency. In some instances providers may be addressing issues identified by inspections and adult safeguarding and it makes sense to address both through agreed joint processes.

Lead Agency

The lead agency will be responsible for chairing and co-ordinating the enquiry. The Chair in this instance takes on the responsibilities of a safeguarding manager. The co-ordinator is the appointed member of staff who co-ordinates and undertakes actions and is responsible for documenting and recording. The chair should be a person of seniority with adult safeguarding experience including commissioners.

Local Authority

In most cases, the Local Authority will lead on safeguarding action in consultation with partners and in particular Regulators. The principle on who is best to lead on an enquiry should always be determined by the issue, who the lead commissioner is and the knowledge and expertise required.

CCG

The CCG may also lead on the enquiry, especially where the concern is about health provision, as their clinical knowledge and expertise is likely to be needed.

Police

As with all criminal matters the police are the leads and must be consulted about any additional proposed action.

Front line workers

Throughout the safeguarding processes a number of tasks and actions will be identified. The table below are suggested roles, although action should always be determined on a case by case basis and the best qualified person to assess or assure the issue assigned. A system whereby professional knowledge and skills complement each other is the most effective way to safeguard people.

Adults who use services/advocates/ carers

As with Section 42 enquiries it is essential that adults using the service are spoken to; encouraged and supported to raise complaints and concerns, questioning when care is not provided according to care plans; or care is not delivered when expected; or care is not provided with dignity and respect. Where there are patterns of complaints and concerns these may indicate poor quality service or a safeguarding concern.

Differentiating between poor care and potential safeguarding issues

Poor care

• A one-off medication error (although this could of course have had very serious consequences) 
• An incident of under-staffing, resulting in a person’s incontinence pad being unchanged all day 
• Poor quality, unappetising food 
• One missed visit by a Care Worker from a Home Care Agency

Potential causes for concern

• A series of medication errors 
• An increase in the number of visits to A&E, especially if the same injuries happen more than once 
• Changes in the behaviour and demeanour of adults with care and support needs
• Nutritionally inadequate food
• Signs of neglect such as clothes being dirty
• Repeated missed visits by a Home Care Agency
• An increase in the number of complaints received about the service
• An increase in the use of agency or bank staff
• A pattern of missed GP or dental appointments
• An unusually high or unusually low number of safeguarding concerns.

There should be careful analysis to understand what intentional and unintentional harm is. However, where there is unintentional harm due to lack of guidance for staff this may also constitute organisational abuse.

Care Governance Boards

Sharing information on quality and safeguarding, strengthening the relationship and knowledge sources from commissioning, safeguarding, CQC, CCG and front line practitioners assists in driving up standards. Formal mechanisms for sharing information between agencies are helpful to determine risk levels and the most proportionate response. The purpose of such mechanisms is to ensure both soft and hard intelligence s brought together in an effective and cohesive manner to facilitate timely action.

Most Local Authorities have implemented a formal information sharing meeting, with key partners from the CQC and the CCG. These Care Governance Boards have the ability to:

• Reduce the need for safeguarding under Provider Concerns procedures through early warning systems 
• Enhance the standards of care and support by sharing early warning signs with providers
• Target resources effectively to reduce duplication
• Support prevention strategies 
• Support continuous service improvements.

Establishing Care Governance Boards will be locally determined. Please refer to your local team for advice.

The illustration below represents the core organisations concerned with care governance and the information they may hold. Other organisations that might be involved may includ, South Central Ambulance Service, local HealthWatch and Community Nursing Services.

Liaising and Reporting to the Police

Information arising from these meetings should always be provided to the police where there is an indication of possible crime. It may also be prudent to have police presence at such meetings so that they can make an early assessment. Local protocols will determine how information is shared with the police.