Making safeguarding personal and professional curiosity should be central to practice to support safeguarding both carers and the person they care for.
The following case study is taken from a Safeguarding Adults Review and is shared here as an example for discussion and learning, with some observations on lessons taken from the review and some questions to prompt reflection on your practice:
Bill and Mary
Bill was an 86-year-old man diagnosed with vascular dementia and other co-morbidities. Bill lived with Mary, his wife and main carer. Bill was dependent on Mary to provide support for all activities of daily living. He required the assistance of two people and the use of mobility equipment for all transfers. Because of his cognitive impairment, it was difficult for Bill to communicate his own views and wishes. Bill was dependent on Mary to maintain communication with the different agencies involved in his life.
A package of care was set up by the Council, to support Bill to live at home with Mary. The package of care was for one carer to support Mary and Bill with transfers and a weekly visit to a day centre. Mary was hesitant to accept this support as she felt that they could manage. The professionals involved disagreed. Although Bill was assessed as lacking capacity to make decisions with regard to his needs, there was no formal ‘best interest’ decision made. Professionals continued to give weight to Mary’s views and wishes regarding Bill’s support, even though they did not agree that they were in Bill’s best interests. Follow up visits from professionals highlighted concerns about how they were coping and there were concerns regarding Mary’s memory. Mary cancelled the home care services. Bill’s daughter was present at one of the visits and highlighted concerns about Mary’s ability to care for Bill and that she was increasingly concerned that decisions in Bill’s best interests were not being made, with Mary’s wishes were being allowed to take precedence. Opportunities to raise safeguarding concerns were missed and Bill continued to be supported under the care management pathway.
During a six-month period, Bill’s health deteriorated, and a safeguarding enquiry began, as the concerns about Mary’s ability and decision making to supporting Bill continued to escalate. Home care was reintroduced, despite Mary’s reluctance. Bill’s attendance at the day centre was sporadic. Bill was admitted to hospital after a home visit from his GP and was diagnosed with pneumonia, sepsis and four pressure sores (including 1 at Grade 4). Concerns had been previously raised with regards to pressure care and visits had been undertaken by District Nurses. Bill passed away two days later. A safeguarding concern was raised but this did not go onto an enquiry, as it was the opinion of a manager that Mary had not intentionally neglected Bill and that Mary had needed an assessment in her own right.
Lessons learned
Making Safeguarding Personal: Approaches to adult safeguarding should be person-led and outcome-focused. The Care Act 2014 emphasises a personalised approach to adult safeguarding that is led by the individual, not by the process. It is vital that the adult feels that they are the focus, and they have control over the process. In this case:
Bill’s views and wishes were missing; Making Safeguarding Personal principles were not applied.
Disproportionate weight was given to Mary’s views and wishes. Mary’s wish to care for Bill, whilst well-meaning, may have had unintended consequences such as his assessed needs not being met.
Professional Curiosity/Challenge: Practitioners need support to understand the competing needs of the cared for person and carer and how these interact when a carer may have needs of their own.
Practitioners did not appear to understand the appropriate intervention to apply when a carer has needs of their own – i.e. carers assessment/assessment of need.
Advocacy: Independent Advocates support people to understand their rights under the Care Act 2014, and to be fully involved in a local authority assessment, care review, care and support planning or safeguarding process.
It would have been appropriate to consider appointing an independent advocate for Bill for both his needs assessment and the open safeguarding enquiry.
Safeguarding process: There was a conflict that was not addressed satisfactorily i.e. Mary was named as the person alleged to have caused harm but was also consulted as Bill’s representative as part of the safeguarding enquiry
- Bill’s daughter was not informed about open safeguarding concerns, although she may have been suitable to contact to act as his representative.
- There was a lack of effective planning around the safeguarding enquiry. Effective plans come from multiagency working with clear delineation between the roles and tasks of each profession, as part of that plan.
- There was no wider consultation regarding Mental Capacity or Best Interest decisions with Bill’s extended family.
- Application of the Mental Capacity Act (MCA) was not consistent. There was no record of a MCA assessment for specific decisions.
The learning from this case for all practitioners is presented here as a series of questions.
Case study 1: Questions for future practice: to consider, discuss with your team and inform training plans
- Are you confident in your practice to effectively challenge family members who you believe may not be making decisions that are in the best interests for the individual you are working with?
- How do you ensure that advocacy is considered and implemented, according to the Care Act requirements in your work?
- Are you clear on how to escalate concerns, if in your professional opinion, risks have not been dealt with adequately?
- Are you confident in the application of the Mental Capacity Act in your practice?
- Are you confident and encouraged to always apply Making Safeguarding Personal principles and professional curiosity in your practice?