The Four Stage Approach - Stage Two: Enquiries

1. Safeguarding 'Enquiry' is not just Another Word for 'Investigation'

A safeguarding enquiry can encompass a range of required activities (for example) from conversations with people, to changes in care and support, to changes in systems or processes, to repairing or maintaining key relationships, to the accessing of social justice & recovery etc. An enquiry can also encompass different types of investigations: for example: criminal, regulatory or personnel related. An assessment of risk will be necessary in all cases.

Our safeguarding terminology needs to shift to supporting adults at risk: and concerns being raised 'in relation to' or 'in respect of' adult abuse or neglect - and not be used 'against' a person or organisation. This is important.

2. Planning Discussions or Planning Meetings

All enquiries need to be planned and coordinated. No agency should undertake enquiries prior to a planning discussion or meeting unless it is necessary for the immediate protection of the adult or others.

Planning can be undertaken as a series of telephone conversations, or meetings with relevant people and agencies. In some cases, the complexity or seriousness of the situation will indicate that more formalised planning is required. The urgency of a response should be proportionate to the seriousness of the concerns raised, and the level of risk. The AST will decide on whether a meeting, discussion or range of discussions is the most appropriate and proportionate response.

Proportionality is important – as holding meetings takes up time, office space, minute taking etc. – and may not be the best use of limited resources. The involvement of the adult (vulnerable) at risk is particularly vital, so all consideration needs to be given to how to optimise inclusion and empowerment of the person most affected by the concern. Not all people at risk will like to attend a planning meeting, or discuss personal aspects with (sometimes multiple) people who they have never met.

These adult safeguarding procedures allow for flexibility and creativity – and remove the restrictions of a linear process to be followed.

Consideration of the risks to others needs to be factored into all decisions about adult safeguarding. With this in mind, the AST and others need to give due regard to what information should be discussed with the individual affected, and what information should be discussed and managed separately to the individual's active involvement. This should be pre-planned and the individual be advised beforehand. For example: a meeting may take place in two or more parts.

These procedures are not process-driven – and exiting the enquiry is permissible when more proportionate alternatives are properly identified and put into place. Outcomes may be met through a variety of ways and risks can addressed through alternative measures. Proper advice will be given to people about the options available to them. All decisions MUST be recorded and communicated. The AST may seek to appoint an enquiry officer as part of the planning process.

3. Records from the Planning Stage

The AST will oversee the completion and the dissemination of the planning (stage) record. These records will be sufficiently and proportionately detailed including actions – dependent on the complexity of the case, and contribution of multi-agency partners. We aspire to provide summary minutes and do not promote the use of verbatim minutes.

Adults (vulnerable) at risk who do not attend a planning meeting (for example) should still receive or be offered a copy of notes for their record – providing that copies of this do not raise risk factors to the person or others (e.g. domestic abuse, familial abuse in same household).

4. Enquiries Explained

The purpose of the safeguarding enquiry is to establish with the individual and/or their representatives what action is needed in relation to the situation, and to establish who should take such action. The enquiry could range from a conversation with the adult or their representative or advocate (for example, if they lack capacity or have substantial difficulty in understanding the enquiry) right through to a much more formal multi-agency plan or course of action.

The AST retains the responsibility to ensure that enquiries are properly managed and concluded in line with the six principles of safeguarding below:

The person at risk should always be involved at the earliest appropriate opportunity in the enquiry, unless there are exceptional circumstances that would increase the risk of abuse. If the person has substantial difficulty in being involved, and where there is no one appropriate to support them, then the AST should arrange for an independent advocate to represent them, facilitating their involvement, where possible.

The organisation or person carrying out the enquiry will need appropriate support from the AST to manage the work to the desired standard. The person carrying out the enquiry will need to be appropriately skilled, using professional curiosity and have the sufficient resources to manage the required work objectively, working in partnership with other agencies to protect the adult at risk. The AST hold the statutory responsibility to carry out enquires with the support of other agencies that have a duty to work in partnership with AST. Specialist, such as the safeguarding doctor and other professionals maybe called upon to assist with the enquiry. Important to remember the zone of professional opinions that may contribute to identifying lessons learnt.

Those undertaking enquiries require appropriate sensitivity and skill to ensure minimal distress to the person. Personal and family relationships within community settings can prove both difficult to assess and complex regarding intervention. The dynamics of personal relationships can be challenging to judge and rebalance. For example, a person may make a choice to remain in a relationship that causes them emotional distress or financial harm, if they prefer to prioritise maintaining the relationship.

The focus of an enquiry should fully involve and reflect the person at risk's wishes wherever possible, as stated by them or by their representative or advocate. Whilst work with the person may (at times) require the input of a social worker, other aspects of enquiries may be best undertaken by others with more appropriate skills and knowledge. For example, healthcare professionals for clinical evaluation and input. (It is important not to conflate a safeguarding enquiry with an assessment of needs – an assessment of needs may form part of an enquiry, but the two functions are distinctly different).

Some enquiries may require a range of staff to play their part. Someone well known to the person may be able to engage with them more positively, so professionals from a range of agencies should be considered dependent on the nature of the concern. The AST will respectfully request the assistance of any other organisation they consider appropriate to safeguarding individuals and in return MUST receive cooperation from multi-agency partners in carrying out any required safeguarding interventions.

Whilst the AST are the lead agency with responsibility for coordinating adult safeguarding arrangements, all the members of the SB should designate a lead officer. Other agencies should also consider the benefits of having a lead for adult safeguarding. Disputes to these arrangements will follow the agreed format (see the Safeguarding Board Resolving Professional Differences/Escalation Policy); however, it is expected that cooperation prevails and that disagreements are managed with courtesy and professionalism, and are kept away from clients and their private networks.

5. Initial Safeguarding Visits (Pre or Part of an Enquiry)

An initial safeguarding visit is a critical element of risk assessment and opportunity to work with the adult (vulnerable) at risk in an empowering way. The visit can take place either pre or as part of an enquiry. Ideally this would be within 48 hours of receiving the referral or more urgently if risks necessitate.

The Police must be consulted prior to making a visit where a crime may be indicated. Joint visits may be appropriate in certain circumstances. The visit is an opportunity to inform on aspects of safety as well as establish rapport with the person at risk, ensuring that their voice is heard and that their desired outcomes are explored.

Visits can be conducted by any relevant partner, or by more than one person – or by agencies working collectively (as appropriate, and sensitive to the unique needs of the person). In some circumstances visits will not be possible, or may heighten risk factors – therefore planning is essential. All reasons and rationales should be appropriately recorded. In some instances, a visit may be possible by meeting with the person at risk in a neutral location or safe place. In some cases - for example where the person at risk raises a concern themselves – then a visit may not be required or when there is sufficiently detailed information gathered as part of the concern being raised). These decisions should be appropriately recorded.

If a person at risk requests the assistance or presence of a trusted friend during this or any meeting, it is good practice to ensure the person is properly supported. During the visit the practitioner leading the enquiry will ask the person for their own account of any situations highlighted in the safeguarding concern, (subject to consultation with the Police in cases of suspected crime) and to assess any risk of abuse they may be facing. This is the prime opportunity to explore the person's wishes and expectations of the outcome.

Explain what will happen next and check that they are in agreement. The practitioner may also:

• Assess the person's capacity to make informed choices about actions that could be taken to decrease any risk of abuse;
• Establish whether they give consent (if able to) for the procedures to be implemented and to information being shared with partner organisations; in line with the principles of the island of Man freedom of information Act 2015 and the Isle of Man data protection Act 2018;
• Any sharing of information needs to be on a “needs to know basis” to protect the adult at risk and in sharing information complaint with the aforementioned legislation and the Caldicott Principles;
• Establish their wishes for family members and/or informal carers to be informed or involved and whether they wish them to be included in any safeguarding meeting or next steps;
• Advise that consent can be overridden if (for example) a partner organisation needs to interview employees or other people as part of their duty to carry out an enquiry, or a criminal matter requires police attention;
• Inform the person (and their family/supporters) of their rights to make formal complaints and/or take other action;
• Gain information about actions needed to address communication, assistance and physical access needs;
• Establish and clarify what the allegations of abuse are and obtain any necessary evidence;
• Assess the presenting risks and agree protection arrangements;
• Give information about the input that partner organisations could make to the risk assessment and to any safeguarding plan;
• Consider immediate needs for care and support or specialist input and advice;
• Consider if an offence has been committed and if so evidence will need to be secured.

6. Our Approach to Enquiries

Enquiries can range from non-complex single agency interventions to multi-agency complex enquiries. The key questions in choosing the right method of enquiry, is dependent on:

• What outcome does the adult want?
• How can enquiries be assessed as successful in achieving outcomes?
• What prevention measures need to be in place?
• How can risk be reduced? Risk to the adult, public interest, risk to others reduced.

The specific objectives of an enquiry into abuse or neglect are also to, where necessary:

• Establish facts; using evidenced bases practice, free of subject opinion;
• Have professional curiosity, using specialist opinions where necessary to support the enquiry;
• Ascertain the adult's views, wishes and desired outcomes; considering capacity issues and the aforementioned issues of consent, control and coercion. Irrespective of the client has capacity to consent, they should continue to be involved and any decisions made, Including public interest, should weight up and balance, but work to the adults “best interests”, involving the patient representative / where possible advocate (but not the PATCH) in line with Mental capacity policy and the concepts of “reasonable and proportionate” to aid the enquiry;
• Protect the adult from abuse or neglect, in accordance with their wishes;( please see the aforementioned capacity issues about control and coercion);
• Assess the needs of the adult for protection, support and redress, and how these might be met; it is everyone responsibility to protect adults, and any plan needs to be reasonable and proportion, where appropriate identifying learning to help others contribute to the protection of adults;
• Make decisions that’s are reasonable and proportionate as to what action should be taken with regard to the person or organisation thought to be the cause of concern/ risk;
• Enable the adult to participate in the achieve resolution and recovery; and promote their safety;
• Add measures, and identify learning where appropriate that contributes to protection of others from abuse or neglect.

Identifying the primary source of risk may assist in deciding what the most appropriate and proportionate response to the individual enquiry might be. There are no hard and fast rules and judgement will need to be made about what type of enquiry and actions are right for each particular situation.

An enquiry report will be requested – which will be completed by the enquiry officer and will need to be sufficiently & proportionately detailed. Adults should receive or be offered a copy of their report – providing that copies of this do not raise risk factors to the person (e.g. domestic abuse, familial abuse in same household).

7. Exceptions and Disagreements

There will be instances where professionals may disagree on whether action is required or on the appropriate level of intervention. Professional challenge and professional curiosity are encouraged, providing that they are constructive and do not interfere with appropriate action being taken. Disagreements will be duly noted in case notes and meeting minutes. It is essential that any disagreements are resolved professionally through constructive dialogue and a willingness to consider other points of view. No agency should unilaterally withdraw their involvement – where in doing so endangers adults at risk, or partner agencies, or others.

See the Safeguarding Board Resolving Professional Differences/Escalation Policy.

8. Refusals by Adults at Risk

The undertaking of an enquiry is not dependent on the consent of the adult once it has been established that they are at risk of abuse. Additionally, there is a duty of care to undertake an assessment of the adult's care and support needs despite their refusal in cases where:

1. They lack capacity to refuse the assessment and it would be in their best interests; or
2. The adult is experiencing, or at risk of abuse, neglect or self-neglect.

In cases where the adult does not wish to co-operate with an enquiry or rejects any proposed safeguarding measures there will need to be an attempt to negotiate and seek to identify areas of possible agreement (recording these discussions is important).
Decisions and their rationale must be recorded.

For cases where there remains a high level of significant complexity the AST can apply for (case specific) legal advice from the Attorney General Chambers.

ADASS 'duty to carry out safeguarding adult enquiries' advice note (2019):
Making Safeguarding Personal does not mean 'walking away' if a person declines safeguarding support. That is not the end of the matter.
Empowerment must be balanced for example, with a Duty of Care and the principles of the Human Rights Act (1998). People must not simply be abandoned in situations where, for example, there is significant risk and support is declined and/or coercion is a factor.

See Myths & Realities of Making Safeguarding Personal for further information.

9. Lines of Enquiry

The focus of a safeguarding enquiry should be on the impact and repercussions for the adult (our previous Policy & Procedures focused on whether the abuse is substantiated or not).

The purpose of an enquiry is to establish the facts to an extent that decisions and plans for the adult's wellbeing and protection can be fully informed and take account of the context of the situation. The Planning Discussion will have determined the scope of the safeguarding enquiry and any parallel type(s) of investigation that may be required, e.g. criminal investigations, disciplinary processes etc.

Safeguarding enquiries are undertaken in accordance with the SPB Multi-agency Adult Safeguarding Policy & Procedures which do not have any statutory powers to compel, enforce or sanction. Where this becomes necessary this will be the responsibility of those agencies that do have the relevant powers (e.g. arrest, prosecute, discipline, terminate employment etc.)

10. Linking Different Types of Enquiry

There are a number of different types of enquiries. It is important to ensure that where there is more than one enquiry that information is dovetailed to avoid delays, to avoid interviewing staff more than once and to avoid making people repeat their story.

Other processes, including police investigations, the MASM policy can continue alongside the safeguarding enquiry. Where there are HR processes to consider, it is important to ensure an open and transparent approach with staff, and that they are provided with the appropriate support, including any appropriate trade union representation. The remit and authority of organisations need to be clear when considering how different types of investigations might support safeguarding enquiries.

MASM: Each organisation should have their own policy and procedure regarding how allegations against staff will be managed, which should be compatible with the safeguarding boards MASM policy. This will have clear guidelines and timescales set out to support practitioners in what steps to take when an allegation about a member of staff or a volunteer is made. All agencies, third and private sector services should hold their safeguarding responsibilities set out in the Safeguarding Act 2018 when working collaboratively through the MASM process and should at all times cooperate and promote the welfare of children and vulnerable adults.

The protection and promotion of overall wellbeing of the adult is the prime focus of adult safeguarding enquiries. Fundamental to any safeguarding enquiry is a spirit of professional curiosity whereby there must be a genuine inquisitive interest in the narratives and facts that are presented and also the ability to question information and objectively evaluate it rather than optimistically accept accounts at face value.

The undertaking of enquiries should be tailored to the individual needs and circumstances of the adult. Involvements must be lawful and take account of the express consent of the adult at risk. In situations where there may be coercion or undue influence safeguarding staff should seek to undertake any interviews in a way that prevents the source of risk from directly or indirectly intervening. This may require the involvement of more than one worker.

11. Protective Issues to be Considered as Part of a Safeguarding Enquiry

12. Enquiries May Involve

Enquiries may involve:

• Holding single or multiple conversations with the person at risk;
• Identifying and revisiting the person's desired outcomes;
• Assessing and reviewing capacity throughout;
• Medical examinations (with consent);
• Reviewing documents such as incident reports, logs, accounts, medical information, statements etc.
• Interviewing witnesses, the person at risk, or the person alleged to have caused harm, etc.
• * Carrying out observations and assessing risk;
• Assessing needs and levels of support – including carers' needs;
• Receiving and reviewing information from other partners and agencies;
• Investigations carried out by others, for example, employers - (SI's) Serious Incidents, (RCA's) Root Cause Analysis;
• Police-led investigations carried out alongside other supportive functions for example, Adult Social Care;
• Specialist input;
• Regulatory input and decisions.

(N.B. this is not an exhaustive list).

13. Interviews with People who are Believed to be a Potential Source of Risk

It is important that the principles of natural justice are applied and that as far as is practically possible any person who is a potential source of risk is given details of the allegations against him/her and also the opportunity to respond to allegations of abuse and/or neglect. (Information sharing between partners and planning is imperative to avoid increasing the risks to a person or subjecting them to increased victimisation).

If the potential source of risk also has care and support needs, consideration should be given to their needs and they should be offered any assessment or support that they may require. In the interests of independence and objectivity separate workers should be allocated to support both individuals.

It is not appropriate to invite any person named or directly implicated as a source of risk to a safeguarding planning meeting or outcomes meeting under these procedures.

14. Photography

Photographs should only be taken in accordance with organisational policy and by an authorised person. Consent should be sought from the person before any photograph is taken. The person's dignity must be preserved at all times and there must be clear evidential or clinical reasons for the use of photography.

The purpose of photographic evidence will be to demonstrate the harm that has occurred to the adult with a view to presenting this to a court or for regulatory or disciplinary processes. In some cases (e.g. pressure areas) photography will be required for clinical care reasons and such photographs may also be admissible as evidence where they indicate neglect or ill treatment. Whenever photographic evidence of injuries has been obtained it must be accompanied by medical opinion - to provide expert interpretation of the images.

When the purpose of the photographs is to provide evidence for a criminal investigation, the photographer will be a member of the Police service and will have received appropriate training. If the photographs are being taken for clinical purposes, then they must be taken by staff that are suitably trained. If photographs are being used for purposes of sharing risks around hoarding (in a person's household) – then the person's express consent must still be gained.

It is not appropriate for staff and volunteers to take photographs of injuries or persons on their mobile phones or other personal devices. Similarly requesting a family member or third party to undertake such photography is to be discouraged. Photographs are personal data and should be kept securely, and be subject to an agency's own retention procedures. Any photographs taken should be appropriate and with consent. Where photographs are taken this could potentially be seized as evidence by the police.

Where a person lacks capacity to consent to photographs being taken and used, then the principles of Best Interest Decision Making still apply.

15. Medical Assessment

Medical assessment is likely to be required in cases involving:

Medical assessments can only be made by registered medical practitioners.