Improving governance, policy and practice in adult safeguarding and in self-neglect
Submitting InstitutionUniversity of Sussex
Unit of AssessmentSocial Work and Social Policy
Summary Impact TypeLegal
Research Subject Area(s)
Medical and Health Sciences: Public Health and Health Services
Studies In Human Society: Policy and Administration
Summary of the impact
The research has had significant impact in three key areas:
- shaping the Care Bill 2013: it influenced the Law Commission's
recommendations on legal reform and directly shaped key elements of the
- stimulating changes to the governance arrangements of Safeguarding
Adults Boards (SABs): it produced a benchmarking template for SABs,
informed guidance to Directors, and led to strengthened SAB governance
- influencing procedures, practice and workforce development strategies
in self-neglect work: supporting new multi-agency procedures in
localities, and providing an evidence base that has improved capacity
assessment and approaches to intervention, to the benefit of
Braye and Orr's research into adult safeguarding was commissioned from
Sussex by the Department of Health (DH) — executed by Sussex with a
contribution from the University of Bedfordshire, 1 December 2009 to 31
May 2010. It comprised two studies: first, effective governance for
Safeguarding Adults Boards (SABs) and, second, self-neglect within
safeguarding arrangements. Braye has been Professor of Social Work at
Sussex since 1 April 2005; Orr was initially a Research Fellow (February
2010) and became a Lecturer on 18 July 2011.
• Effective governance for SABs
The significance of adult safeguarding is increasingly recognised; the UK
Study of Abuse and Neglect of Older People Prevalence Survey Report
(O'Keefe et al. 2007) estimates that 4 per cent of over-65s are
subjected to abuse and neglect each year. Existing guidance (No Secrets,
DH, 2000) encouraged but did not require the establishment of multi-agency
SABs. Our study explored the strategic goals, structures, membership,
networks, functions and accountability of SABs and made recommendations to
government on SAB governance arrangements. It gathered data from a
systematic literature review, 5 workshops with senior managers and
safeguarding specialists, 5 key informant interviews, and detailed
documentation from 47 Boards. It revealed the diversity of practice
between boards and identified barriers to effective SAB governance. We
developed a benchmarking template from these findings, providing detailed
standards for SAB performance review. We also recommended legislating for
statutory SABs in order to facilitate participation and commitment by
different agencies, and to set consistent standards.
Because safeguarding's remit currently only covers actions or omissions
by a third party, it is often unclear where risk from self-neglect
fits; health and social-care workers thus lack clarity on assessment and
intervention pathways. These cases are frequently complex, involving
ethical dilemmas between promoting autonomy and fulfilling a duty of care.
Our research systematically reviewed the international literature and drew
on the above-mentioned interviews and workshops (plus a practitioner
workshop) to determine how self-neglect practice could be improved. It
found that SABs mostly excluded self-neglect from their remit,
highlighting the need for alternative multi-agency processes. The findings
illustrated the diversity of contributing factors to self-neglect, and
showed that the complex nature of the capacity for autonomous
decision-making is not always adequately addressed in practice. Our
research evidence provided guidance on effective assessment and
intervention, multi-agency information-sharing and risk management.
Findings from both studies were presented through a range of media,
including SCIE reports [see Section 3, R1, R2], journal articles [R3, R4]
and online videos feeding live, online, webinars (e.g. https://knowledgehub.local.gov.uk/group/adultsafeguardingcommunityofpractice/forum/-/message_boards/message/6943054).
have stimulated overwhelming interest; the researchers have delivered 16
invited national conference plenaries and 5 international conference
papers (2 invited), and participated by invitation in 4 DH expert panels
and 17 policy/practice development workshops, involving approximately 45
local authorities and their interagency safeguarding networks.
The high profile which this work gained led to a sector skills council
Skills for Care (SfC) research commission for Sussex to investigate
social-care workforce-development needs on self-neglect (Braye and Orr, 15
January 2013 to 30 April 2013) [R5], a national consultation by SfC (https://www.surveymonkey.com/s/sfc_self_neglect),
and a further DH research commission from Sussex to identify best practice
in self-neglect, including the first-ever England study of service-users'
perspectives (Braye and Orr, 1 March 2013 to 30 November 2013).
References to the research
This report was peer-reviewed at the Department of Health and was further
quality-assured by the Social Care Institute for Excellence before
This report was peer-reviewed at the Department of Health and was further
quality-assured by the Social Care Institute for Excellence before
R3 Braye, S., Orr, D. and Preston-Shoot, M. (2012) `The governance
of adult safeguarding: findings from research', Journal of Adult
Protection, 14(2): 55-72.
This peer-reviewed journal article was awarded `Outstanding Paper of the
Year' in the Emerald Publishing Group Literati Awards for Excellence 2013.
R4 Braye, S., Orr, D. and Preston-Shoot, M. (2011)
`Conceptualising and responding to self-neglect: challenges for adult
safeguarding', Journal of Adult Protection, 13(4): 182-93.
This peer-reviewed journal article was awarded `Highly Commended Paper of
the Year' in the Emerald Publishing Group Literati Awards for Excellence
Outputs can be supplied by the University on request.
Details of the impact
• Shaping the Care Bill
The Care Bill, currently passing through Parliament, is a significant
part of `the most comprehensive overhaul since 1948 [of the] care and
support system' (http://caringforourfuture.dh.gov.uk/).
Our research findings influenced policy debate and directly shaped key
elements of this legislation.
Our governance report argued that making SABs a legal requirement would
help to improve safeguarding governance. DH accepted the recommendation,
announcing in May 2011 that establishing a SAB would become a legal
requirement for all local authorities in England. The research evidence on
the value of such legislation was given as the grounds for this decision,
with our then-unpublished report cited [see Section 5, C1]. Our
recommendation also influenced the Law Commission's review of
adult-social-care law, which called for statutory boards [C2, C3]. Our
research also evaluated Board configurations, exploring different models
without specifying any single one for universal adoption. DH has said that
this `played a major part in informing our thinking' on how prescriptive
the legislation should be about SAB membership and chairing arrangements,
leading them to allow a strong degree of flexibility to reflect local
circumstances [C4]. The overview of current Board practices was used by DH
in evaluating the feasibility of the SAB reform proposals, informing and
being directly cited in the impact assessments accompanying the Care Bill
Our self-neglect report led the Law Commission to recommend that
self-neglect should be expressly included within the new duty on local
authorities to investigate cases of abuse and neglect [C2]. The government
accepted the need to address self-neglect and will do so in the linked
Code of Practice, in direct response to the issues highlighted by the
• Stimulating changes to the governance arrangements of SABs
The research has also had wide impact on local governance arrangements.
The template developed in our governance report to benchmark best practice
in safeguarding governance was itself used by the DH in setting principles
against which SABs are required to assess their arrangements [C1]. The
template was used by chairs of 30 SABs to benchmark their arrangements in
two national events on 15 February 2011 and 22 February 2011, organised by
the Local Government Association and the Association of Directors of Adult
Social Services (ADASS) [C7]. Four SABs invited the researchers to work
directly with their whole board. In Camden, for example, the research
served as the basis for a review of SAB arrangements and led to the
restructuring of sub-groups (January 2013), the adoption of independent
chairing arrangements (April 2013) and revision of the communications
strategy (July 2013) [C7, C8]. In Oxfordshire, the research-based workshop
on 8 June 2012 `helped the board to consider its structure', `helped
tremendously in establishing greater clarity about the role of the board'
and `directly influenced the business plan' and future priorities [C9].
The governance report informed the ADASS Adult Safeguarding Network in
preparing guidance for all Directors of local authorities in England and
was directly cited in that document [C10].
• Influencing procedures, practice and workforce development
strategies in self-neglect work
Some authorities participating in development workshops on self-neglect
[see Section 2] reported subsequently changing their systems or practices.
For example, an event for the Camden SAB on 21 June 2012 highlighted gaps
in services and inter-agency systems and facilitated the identification of
solutions. Camden have since trialled and established a `high-risk panel'
to manage self-neglect cases which, with 35 referrals by July 2013, `has
been very successful in building networks and reducing risk' [C7, C8].
High-risk panels have also been established by Brighton and Hove, East
Sussex and West Sussex, accompanied by a tiered, multi-agency training
strategy on self-neglect, with content shaped by the research: `The
published research has been particularly informative in shaping the need
for successful learning intervention' [C7]. West Sussex drew on the
research in developing its own guidance to staff [C11]. Wirral NHS
Foundation Trust changed its approach to mental-capacity assessment as a
result of our findings [C7]. The national organisation Research in
Practice for Adults included in its current work-plan the development of a
practice tool based on our research, to support evidence-informed practice
by its local authority members [C7].
We have ensured, too, that the research implications are addressed at
individual practitioner level. Every practice development event involves
action planning for personal and organisational change. Social workers,
health professionals, team leaders and safeguarding leads in many
localities have set targets for their own personal practice development,
in locations as diverse as Brighton and Hove, Buckinghamshire, East
Sussex, Liverpool, Merton, Middlesbrough, Milton Keynes, Oxfordshire,
Reading, Sutton and York. The research has been described by the DH, as a
result of the expert seminars they have run, as `exceptionally
Finally, benefits for service-users are emerging; one example is from a
hospital-based safeguarding lead:
I just wanted to let you know that your presentation ... may already be
having an impact on people who are self-neglecting. I had a call yesterday
about an elderly couple who are living in very unsafe surroundings and are
really struggling, but have declined all interventions. I have asked
social services to review their decision about (mental) capacity and have
directed them to your research findings. I am hopeful that they will now
at least engage in a conversation about how we help to minimise the risks
to this very vulnerable couple [C7].
Sources to corroborate the impact
C1 DH (2011) Statement of Government Policy on Adult
Safeguarding. London: Department of Health: `Research commissioned
by the Department of Health has shown that specific legislation for
statutory Safeguarding Adults Boards would help to hold agencies
accountable in ways which guidance, differentially binding on the
partners, has not so far been able to do' (p. 5). http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_126748
C2 Law Commission (2011) Adult Social Care, LC326. London:
Law Commission, (Rec. 44, p. 136; Rec, 39, p. 133; Rec. 7, p. 38):
`[The] research played an important role in our final recommendations'
C3 Chief Executive, Law Commission: `Braye was able to secure the
early release of the research reports in order to inform our review of
adult social care. This work led us to recommend that the new duty on a
local authority to investigate cases of abuse and neglect should apply
expressly to cases of self-neglect. The Government has taken this
recommendation into account in the resulting Care Bill, which was
introduced into Parliament earlier this year. Whilst the Bill does not
include an express reference to self-neglect, the Government has agreed to
clarify this matter in the code of practice, which is due to be published
C4 Senior Policy Manager, Adult Safeguarding, Department of
Health: `The research was particularly helpful in informing how
prescriptive the legislation should be... Government has reflected this by
prescribing (minimally) about the form, opting for small core statutory
membership and allowing a lot of local flexibility to reflect local
circumstances. What the legislation does emphasise is the need for
accountability and transparency of Boards, including to the local
community and for the Boards to concentrate on improving outcomes rather
than focusing on procedure and processes. The research played a major part
in informing our thinking on this'.
C5 Department of Health, External Relations Directorate: `I found
your research very helpful in supplementing our strategic view of the
current range of local safeguarding board arrangements, and our
discussions on the matter were also incredibly helpful. I remain extremely
grateful for the time you offered to support this work and I do believe I
was able to produce better documentation to support the development of
policy as a result of your research'.
C6 DH (2013) Care and Support Legal Reform: Impact Assessment.
London: Department of Health (para. 5.10, p. 43; para. 5.17, p. 44).
`Your work was directly cited in the impact assessments that
accompanied the social care bill (ref.69)' [C5].
C7 Departmental record of impact feedback from a range of
stakeholders, available for audit.
C8 Safeguarding Development Officer, Camden Housing and Adult
Social Care: `Sussex's safeguarding governance research was invaluable,
offering depth of analysis, breadth of coverage, and an insight into what
other Boards were doing and were finding to be effective. Without the
safeguarding governance research we would have had very little to draw
C9 Independent Chair of Safeguarding Adults Boards,
Oxfordshire/Hounslow: `Your influence was particularly important when the
board moved on to consider its priorities, and your engagement in the
discussion, calling on your research findings, provided depth to our
C10 ADASS (2013) Safeguarding Adults: Advice and Guidance to
Directors of Adult Social Services. `Current research has shown that
Safeguarding Adults Boards are variable in their structure and
effectiveness, for example see The governance of adult safeguarding:
findings from research into Safeguarding Adults Boards. However,
while there is not a magical template, there are clear principles that
make for a high performing Board' (p. 11):
C11 West Sussex County Council (2013) Self-Neglect and Social
Care Intervention: Adults' Services Policy. `The literature study
reviewed definitions of self-neglect and trends in how self-neglect was
conceptualised in research as well as considering the interface with adult
safeguarding, and reviewing the evidence relating to professional
interventions. In total, over 3,000 papers published since 2000 were
screened and 160 papers were reviewed in greater detail' (p.7). http://www.westsussex.gov.uk/idoc.ashx?docid=20379951-7931-45c2-9685e70360fe5d3e&version=-1.