Multiple Exclusion Homelessness: A Safeguarding Toolkit for Practitioners

Multiple Exclusion Homelessness

A Safeguarding Toolkit for Practitioners

Citation: Ornelas, B., Bateman, F., Meakin, A., Cornes, M., Pritchard-Jones, L. (2023).

Multiple Exclusion Homelessness: A safeguarding toolkit for practitioners. Stoke-on-Trent: Expert Citizens CIC.

Foreword

The Care Act 2014 was intended to reduce anomalies in access to social care where particular groups of people were treated differently. For the first time, this new legislation also put adult safeguarding on a statutory footing.

Increasingly, new opportunities for interdisciplinary social care interventions are now being recognised through the research literature. This is of particular benefit to people experiencing multiple exclusion homelessness who may previously have been overlooked.

One example is that the legislation now places self-neglect within the purview of adult safeguarding. In the context of multiple exclusion homelessness, this emphasises the need for those involved in adult protection to explore the complex interplay between needs, potential risks, and people’s ability to self protect.

Research shows that people experiencing multiple exclusion homelessness often have hidden vulnerabilities. This includes problems stemming from childhood trauma, acquired brain injuries, chronic mental and physical ill-health, limited mobility, and severe addiction.

Recent research in relation to Safeguarding Adult Reviews where homelessness was a factor recognised that agencies may have missed opportunities to protect adults at risk. Themes included a lack of leadership and coordination between agencies, challenges in performing and interpreting assessments, a lack of suitable accommodation provision, poor hospital discharge arrangements, and missed opportunities sometimes through a lack of professional curiosity or normalisation of risk.

Our intention with this toolkit is to provide practitioners with a helpful resource to aid fact-finding and decision-making in the context of adults experiencing multiple exclusion homelessness to avoid these pitfalls.

Ultimately, our best hopes for the toolkit are that it is an aid to communication and multidisciplinary working across sector boundaries which improves contextual safeguarding for this marginalised group.

Introduction

Homelessness and the causes of homelessness are complex. The term encompass people sleeping rough, single homeless people living in emergency and temporary supported accommodation; statutorily homeless households who are seeking housing assistance from local authorities; and ‘hidden homelessness’ (e.g. ‘sofa surfing’).

The rise in our homeless population raises significant challenges for agencies seeking to offer preventative support and interventions to meet complex needs. This tool has been developed to support practitioners from across statutory, charity and third sector organisations to bring together information in a manner that facilitates lawful decision making and leads to effective interventions that uphold the core principles of safeguarding, including the aspiration to empower an adult at risk to protect themselves.

The focus of this tool is to improve multi-agency support for individuals who have an appearance of need for care and support and are experiencing multiple exclusion homelessness (MEH).

This is characterize as:

‘People who have been ‘homeless’ (including experience of temporary/unsuitable accommodation as well as sleeping rough) and have also experienced one or more of the following additional domains of deep social exclusion –‘institutional care’ (prison, local authority care, psychiatric hospitals or wards); ‘substance misuse’ (drug problems, alcohol problems, abuse of solvents, glue or gas); or participation in ‘street culture activities’ (begging, street drinking, ‘survival’ shoplifting or sex work).’

Fitzpatrick, et al., 2011: 502-503.

Most adults experiencing MEH face significant increased risk of serious abuse, exploitation and neglect as well as an escalation of their health and care needs and a reduction to their life expectancy.1

Safeguarding Adult Reviews (SARs) undertaken in relation to ‘rough sleeper deaths’2 recognised opportunities to improve multiagency practice required a shift in culture to protect against professional preconceptions often applied to people with MEH backgrounds or, conversely the normalisation of a high level of risk. Both were found to negatively impacts on safeguarding decision making and related assessment process.

This tool is not intended to be used to replace local or national guidance, rather it will direct practitioners from across the sectors to relevant materials to assist agencies objectively ascertain needs for accommodation based support, recognise common risks associated with care and support needs taking into account risks associated with MEH and weigh up available multi-agency risk management pathways to identify what action is needed and by whom to reduce or remove foreseeable risk in accordance with the legal framework.

‘Vulnerability’ is a subjective term and used in different context within numerous statutory legal frameworks to help professionals from the police and criminal justice organisations, housing, social care, public health, and medical professionals define when duties may arise to provide advice, information or intervene to protect or carry out assessment and care/ treatment planning functions. The legislative framework to support those with an appearance of care and support needs and experiencing MEH is complex, but designed to ensure that agencies with statutory responsibilities carry out their functions in partnership to protect the adult’s human rights.3 This includes a duty for public sector services4 (including social care, housing5 and health authorities) and service providers to make reasonable adjustments for disability or any relevant protected characteristic so as to uphold the principles of equality of opportunity and protection from discrimination.

This toolkit draws on three key questions which practitioners are encouraged to use throughout the completion of this toolkit:

• Have you somewhere safe to stay tonight, can you get the help you need to meet your basic needs there? (See section 3, pages 26 and 27).

• Do you understand why I am concerned about the level of risk to your well-being? (see section 1, pages 5,7 and 8).

• What help do you need now to protect you and how should partner agencies work together?

1 Detailed more comprehensively in https://www.bmj.com/ content/360/bmj.k902/rr and https://www.mungos.org/wpcontent/uploads/2018/06/Dying-on-the-Streets-Report.pdf). The difference in life expectancy- the mean age at death was 44 years for men and 42 years for women between 2013-17, compared to 76 (men) and 81 (women) in the general population. ONS,2018.

2 Safeguarding, homelessness and rough sleeping. An analysis of Safeguarding Adults Reviews’ Stephen Martineau, Michelle Cornes, Jill Manthorpe, Bruno Ornelas, James Fuller, Kings College University, 2019.

3 See: https://www.ageuk.org.uk/globalassets/age-uk/blocks/ promo/ourrightsourvoices_toolkit.pdf

4 See: https://www.equalityhumanrights.com/en/advice-andguidance?who=public-sector

5 See: https://www.equalityhumanrights.com/en/publicationdownload/housing-and-disabled-people-toolkit-local-authoritiesengland

THINGS TO CONSIDER

Making Safeguarding Personal

Section 1

The adults’ needs and the risks that they face

Learning for Safeguarding Adults Reviews identified key barriers to effective early intervention or responses to safeguarding concerns for those experiencing multiple exclusion homelessness includes:1

• Failure to recognise care and support needs

• A lack of parity given to concerns raised by housing practitioners or those working in homelessness services, resulting often in their exclusion from decision making

The purpose of this section is not to duplicate other risk management processes (e.g. MARAC) or statutory assessment processes owed in respect of housing, health or social care law.

The duty to safeguard an adult at risk is not a ‘gateway’ to assessment, but rather a separate duty. So it is possible for a safeguarding enquiry to run in parallel with an assessment and other risk management process. It is important, however, to show that this is necessary and proportionate given the adult’s circumstances.

Applying making safeguarding personal’ principles does not mean partner agencies are absolved of their duty of care if an adult says they do not want an enquiry to be undertaken under s42 Care Act.

Please complete all relevant sections so as to clearly demonstrate why you reasonably believe the adult is in need of care and support and that, because of those needs, the adult is unable to protect themselves from the risk of abuse or neglect.

This is part 1 and 3 of the 3 stage test.

Remember that it is well established that multiple exclusion homelessness and rough sleeping puts people at increased level of physical assault and neglect. Nonetheless, it is still necessary to identify the person’s current care and support needs and how these impact on their ability to protect themselves from abuse and neglect, including self-neglect, as well as foreseeable risks.

Asking the question ‘do you understand why I am concerned about the level of risk to your well-being?’ enables you to properly explore the adult’s capacity to understand the objective risk the adult faces.

Local Authority practitioners must also be mindful of the definition of organisational abuse and of relevant enduring duties to assess (s11(2) Care Act 2014) if there is a risk of abuse and neglect, irrespective of the person s capacity to refuse support.

1 See: Martineau, S. J., Cornes, M., Manthorpe, J., Ornelas, B., & Fuller, J. (2019). Safeguarding, homelessness and rough sleeping: An analysis of Safeguarding Adults Reviews. London: NIHR Policy Research Unit in Health and Social Care Workforce, The Policy Institute, King's College London. https://doi.org/10.18742/pub01-006

Ability to manage and self protect

It is important to carefully set out the adult’s ability to manage across all health and social care domains of need. This is to understand how this impacts on their to recognise and respond to reduce the risk of abuse and neglect.

Domains of need

Practitioners must be mindful of how they ask adults may feel stigmatised by their circumstances, reluctant to acknowledge any inability to meet basic needs, or have become reliant on informal support. In relation to informal support, practitioners should also me mindful that these relationships may be complex and also include exploitative, coercive, or controlling behaviours. Nonetheless, the adult may feel dependent on such informal support which may influence their response.

Cognitive Impairment

Who is best placed to lead?

What is the level of concern?

Severe harm

Moderate harm

Low harm

Minimal harm

THINGS TO CONSIDER

Does the adult require some supervision, prompting and/or assistance with basic care needs and daily living activities?

Do they have an awareness of their basic needs or risks?

Can they make choices appropriate to needs — do they need assistance — and, without this, would the be at some risk of harm, neglect, or health deterioration?

This will usually be lead by a GP, but access to social care cannot be restricted based on their ability to be involved or wider cognitive ability.

Executive Decision Making

This involves whether the adult understands the reasons for concern and the level of risk to their wellbeing. It is important to explain this in a manner the adult can understand, using all the relevant information, and in a safe environment. This will make it possible to assess whether they have understood, retained, and weighed up the information as part of a capacitated free decision.

THINGS TO CONSIDER

Even if the adult can say they understand what they need to do to keep safe, if there is evidence that they can t take that action, e.g. because of recent past behaviours, this should be set out here and included in the chronology in section 2.

Include the attempts that have been made to support them to understand the: current level of risk type of risk impact of risk

Who is best placed to lead?

What is the level of concern?

Local protocols on selfneglect may set out powers and processes for multi agency risk management.

External Factors Impairing Informed Decision-making

There may be concerns about impaired decision-making. Please explain what it is that leads you to have these concerns. Make reference to what is known about the behavioural patterns and impact of coercive, controlling and grooming activities. There are links in the reference section of this toolkit to further reading to support you.

Who is best placed to lead?

What is the level of concern?

THINGS TO CONSIDER

It is important to consider if the adult is under any undue influence from a person in a position of trust (see local safeguarding policies) or duress. This is particularly important in contextualised safeguarding; e.g. cuckooing.

Causing someone to fear bodily harm, acting in a way to intimidate, harass or using repeated or continuous controlling or coercive behaviours that have a serious effect on the victim are criminal offences.

Police may have powers if there is reasonable suspicion of coercion or duress.

Psychological and Emotional Health

Please use this section to set out information you may have on the adult’s emotional and psychological health. Include why you think this might impede their ability to recognise and respond to abuse, exploitation or neglect. Be aware of the tendency to ‘normalise risk’ and guard against potential confirmation bias; e.g. by making an assumption that behaviours are associated with lifestyle choices.

THINGS TO CONSIDER

Practitioners should be aware of the duties to make reasonable adjustments under the Equality Act 2010 (s.20). Is there evidence of mood disturbance, hallucinations or anxiety symptoms, or periods of distress?

How do these impact on their health and/or wellbeing?

The ability of the adult to respond to prompts, distraction and/or reassurance.

Who is best placed to lead?

What is the level of concern?

Typically, a GP or health professional will lead. But, this may also trigger a duty to assess for social care (see s.9 of the Care Act).

Physical Health (including skin viability)

Who is best placed to lead?

Identify whether a person’s physical health renders them unable to manage daily activities. Describe whether any physical health needs identified also prevent the person from recognising or responding to abuse exploitation or neglect. Physical health needs will often trigger assessment duties which, combined with risk of abuse or neglect, may necessitate parallel enquiries including safeguarding. Severe harm

What is the level of concern?

THINGS TO CONSIDER

Does the adult have a condition as a result of either physical, mental, sensory, learning, or cognitive disabilities or illnesses, substance misuse, or brain injury?

Is there a heightenedrisk or infection and/or skin breakdown which requires preventative intervention?

How frequentlyis this needed?

Is treatment successful or are there persistent concerns?

Do they need to be looked after and wouldit be reasonably practicable to provide support without accommodation?

Health lead on diagnosis and treatment (inc. district nursing) butmay also trigger a duty to assess and allocate provision if there is an urgent need for social care (s9 and s19(3)of the Care Act).

Medication and Treatment Needs

A clinician will determine any medication and treatment needs. It may be useful to set out what additional support, including informal support, the person relies on. If relevant, set out risks associated with self-medication, including through substance misuse, and the adult’s ability to recognise and respond to this risk. This may require consideration of whether their capacity fluctuates.

THINGS TO CONSIDER

This includes substance misuse or dependency issues, inc. current use, treatmentoptionsavailable and whether the adult is in agreement to accept support orengagement with harm minimisation strategies.

If receiving treatmentor medications, does the adult require supervision, administration of, and/or prompting?

Consider if the adult isin pain.

Is this predicable and/or associated with certain activities of daily living?

Does pain orother symptomshave an impact on the provision of care?

Who is best placed to lead?

What is the level of concern?

GP and health services would determine necessary support (see s.3 NHS Act 2006)

Challenging Behaviour

Who is best placed to lead?

This may include a current or past history of harm to people or property. Remember that assessment and safeguarding interventions should be carried out in such a way as to ensure the safety and wellbeing of staff and other adults at risk. This includes in any accommodation. Practitioners should make reasonable adjustments if behaviours result from cognitive impairment, psychological, or mental ill-health. Severe harm

What is the level of concern?

THINGS TO CONSIDER

This includes butis not limited to aggression, violence or passive nonaggressive behaviour, severe disinhibition, intractable noisinessor restlessness, resistance to necessary care and treatment, severe fluctuationsin mental state, inappropriate interference with others, identified high risk of suicide or serious self harm.

Detail anyincidents that establish whether: a predictable pattern behaviour ismanageable there isa risk of harm to self, others, or property

Where a health need, this may require psychological input who may also identify what, if any, reasonable adjustmentsare needed to access services.

Access to food is an essential component of wellbeing and this may be made more difficult by street living. Please detail here any specific requirements the adult may have due to care and support needs. Also explore whether dependency on others for food results in the adult being at greater risk of exploitation, neglect or abuse.

THINGS TO CONSIDER

Does the adult need supervision, prompting with meals, or help to cook or shop and is this because of a physical, cognitive, or mental impairment?

Does the adult need feeding and/or a special diet?

Who is best placed to lead?

These can be social care or health needs triggering a duty to assess.

What is the level of concern?

Severe harm

Moderate harm

Low harm

Minimal harm

Maintaining Personal Care and Toileting

Maintaining personal care is likely to be more difficult because of homelessness and street living. Please detail here any specific requirements the adult may have due to care and support needs. Also explore whether dependency on others for assistance, or their presentation, results in the adult being at greater risk of exploitation, neglect or abuse.

THINGS TO CONSIDER

Who is best placed to lead?

What is the level of concern?

Severe harm

Moderate harm

Minimal harm

Is the adult continent? Are they able to wash, dress, wash their clothes without assistance, or does it take a long time or cause significant pain, distress or anxiety, or endanger the health or safety of the adult or others.

These can be social care or health needs triggering a duty to assess.

Mobility

In the context of mobility, please detail here any specific requirements the adult may have due to care and support needs. Also explore whether dependency on others for assistance, or their presentation, results in the adult being at greater risk of exploitation, neglect or abuse. Include whether they are less able to get to a place of safety if subject to abuse or neglect.

THINGS TO CONSIDER

Is the adult able to weight bear?

Do they need assistance and/or require mobility equipment for daily living or require assistance to get safely round any accommodation or access community facilities?

Who is best placed to lead?

These can be social care or health needs triggering a duty to assess.

What is the level of concern?

Severe harm

Moderate harm

Low harm

Minimal harm

Communication

In the context of communications, please detail here any specific requirements the adult may have due to care and support needs. Also explore whether dependency on others for assistance, or their presentation, results in the adult being at greater risk of exploitation, neglect or abuse. Include whether they are less able to get or ask for help effectively if subject to abuse or neglect.

Who is best placed to lead?

What is the level of concern?

THINGS TO CONSIDER

Does the adult need assistance to communicate their needs?

Is special effort needed to ensure accurate interpretation of needs, or is additional support needed either visually, through touch, or with hearing?

Do they need an interpreter and/or advocate?

This could be because of a sensory impairment, deteriorating cognitive function, an acquired brain injury or because English is not their first language.

These can be social care or health needs triggering a duty to assess.

A current or past history of accommodation breakdown due to rent arrears or breach of ‘house rules’, hoarding behaviours, etc., will need to be considered to ensure that staff can understand whether any care and accommodation offer puts in place support to reduce future risk. Practitioners should be mindful to make reasonable adjustments where there are known or suspected impairments resulting from cognitive function, psychological, or mental ill-health.

THINGS TO CONSIDER

Detail any accessibility issues.

Detail any matters of concern re public health, for example, infestations of vermin or filthiness.

Whether there is evidence of problematic hoarding. See the clutter index.

Whether there is evidence of exploitation, e.g. cuckooing.

Reasonable adjustments may include relaxing restrictions on eligibility for on going support if behaviours are as a result of a cognitive impairment, psychological, or mental ill health.

Who is best placed to lead?

What is the level of concern?

Severe harm

Consider whether there is an appearance of need for care and support sufficient to trigger social care assessment duties.

Minimal harm

1. See: https://hoardingdisordersuk.org/research-and-resources/clutter-image-ratings/

Developing and Maintaining Family or Other Relationships

Please consider duties to consult with the adult at risk, principles of safe enquiry and Making Safeguarding Personal. Detail within this section the insight the adult has into the risks posed by the relationships and what actions might mitigate risks whilst respecting their wishes. This is particularly the case where this is to maintain important relationships.

THINGS TO CONSIDER

Is there a risk arising from domestic abuse?

Stalking

Violence or the threat of violence

Destruction of property

Isolation from friends, family or other potential networks of support

Preventing or controlling access to money, personal items, food, transportation

See the ADASS guide on safeguarding and domestic abuse. Who is best placed to lead?

What is the level of concern?

2. See: https://www.adass.org.uk/adult

Police powers (s17(1) PACE Act) requires reasonable concern of serious bodily injury or risk to life and limb

THINGS TO CONSIDER

Are they at risk of social isolation, co dependency issues or exploitation risk? E.g.

Modern slavery

Sexual exploitation

Financial exploitation

Emotional coercion

Cuckooing

Stalking

Engagement in Work, Employment, or Volunteering

Experiencing multiple exclusion homelessness may itself provide a practical barrier to engaging in work or volunteering, but it is important to set out within this section information that would give reasonable cause to suspect this adult is at risk of certain types of abuse or exploitation associated with work type activities, such as modern day slavery, including sexual exploitation.

Who is best placed to lead?

What is the level of concern?

Consider whether there is an appearance of need for care and support sufficient to trigger social care assessment duties.

Severe harm

Moderate harm

Low harm

Minimal harm

Managing Finances

Inability to manage finances is not of itself an outcome of the Care Act eligibility regulations. But, it may indicate a risk of abuse or neglect. It could also impact on the adult’s ability to meet their own care and support needs without help.

Who is best placed to lead?

What is the level of concern?

Severe harm

Moderate harm

Low harm

Minimal harm

THINGS TO CONSIDER

Can they access and manage their own finances?

Is there a risk or previous experience of financial exploitation?

Have they access to sufficient means to buy essentials, e.g. Food Clothing

Inability to manage finances is not of itself an outcome of the Care Act eligibility regulations. But, it may indicate a risk of abuse or neglect. It could also impact on the adults ability to meet their own care and support needs without help.

SUMMARY AND CONCLUSIONS

The adult’s needs, the risks they face, and their insight into both must be documented objectively in order to protect against normalisation of risk or, conversely, a lack of professional curiosity or disregard of concerns raised because recipient believes the referrer is emotionally driven.

THINGS TO CONSIDER

Tools and guidance on risk assessment (e.g. the Activity Worksheet ) can assist practitioners from any background to plan conversations with the adult.

This would be to ascertain specific risks, the person s level of vulnerability and identify if other agencies might already be (or should be) involved in assessing risk.

1 See: https://www.local.gov.uk/our-support/our-improvement-offer/care-andhealth-improvement/making-safeguarding-personal/working-risk

2 See: http://www.homelesspalliativecare.com/wp-content/uploads/2018/09/ Identfying-clients-of-concern.pdf

3 See: http://westminsterhhcp.org/Resources(4)/ Autism_Homelessness_Toolkit.pdf

4 See: https://www.thedtgroup.org/brain-injury/for-professionals/resources/thebrain-injury-needs-indicator-bini

5 See: https://www.homeless.org.uk/our-work/resources/mental-health-andwellbeing-toolkit

RESOURCES

Other useful toolkits:

• Autism and Homelessness toolkit3

• Brain Injury Needs Indicator4

• Mental Health screening tool5

• Physical Health screening tool6

• Homelessness and Pregnancy7

• Care Act Toolkit8

• Risk assessment tool9

• Clutter rating index10

• Domestic abuse11

It is also difficult to assess a person’s capacity as they are not in one place for long and often experience fluctuating capacity or external pressure (e.g. coercion) that impairs ‘truly informed decision which impacts directly on health and survival’ – see Hayden J’s judgment on the use of the High Court’s Inherent Jurisdiction to safeguard an adult at risk in Southend on Sea Borough Council v Meyers [2019].

In SL v Westminster [2013] the Supreme Court confirmed that where the needs for care and support is not available otherwise than through the provision of accommodation (i.e. affected both by the nature and location of accommodation) it would be for the local authority to provide under their social care duties (if the person was ineligible under the Housing Act).

Given the evidence that rough sleepers are at an increased level of risk of physical assault and neglect, any safeguarding concern requires a proactive investigative response which demonstrates consideration of Human Rights Act 1998 obligations, including the right to life (article 2, ECHR), the absolute prohibition on torture, inhuman and degrading treatment (article 3, ECHR) and the qualified duties to protect liberty (art.5, ECHR) and respect private and family life (article 8, ECHR).

6 See: https://www.qni.org.uk/resources/guidance-health-assessment-tool-2015/

7 See: https://www.mungos.org/publication/homeless-pregnancy-toolkit/

8 See: https://www.voicesofstoke.org.uk/care-act-toolkit/

9 See: https://www.local.gov.uk/sites/default/files/documents/1%29%20Solihull% 20SG%20risk%20screening%20tool.pdf

10 See: https://www.london-fire.gov.uk/media/1608/clutter-image-ratings.pdf

11 See: https://www.adass.org.uk/adassmedia/stories/Adult%20safeguarding% 20and%20domestic%20abuse%20April%202013.pdf

THINGS TO CONSIDER

Interventions should concentrate on getting the right response at the earliest opportunity.

Key to this for practitioners, particularly in frontline provision (housing professionals, social care, GP s, district nurses, carers), identifying signs of abuse, understanding principles of safe enquiry and knowing how to report and secure preventative support for an adult at risk.

Professional curiosity is an essential component of the s42 duty and practitioners own professional standards.

Section 2 Chronology of events

Most recent six months

Begin at month one with the most recent events and work backwards to month six.

Practitioners seeking to raise safeguarding concerns will find it helpful to put together a chronology for the person. This should summarise previous interventions succinctly.

For example, hospital admissions, periods of homelessness, or other incidents such as missing persons reports, neglect or abuse suffered, etc.

THINGS TO CONSIDER

An effective chronology can help to identify risks, patterns, or issues in an adults life.

1 MONTH

It can help to get a better understanding of the immediate or cumulative impact of events.

It helps to make links between the past and present to assist with understanding the importance of historic information upon what is happening in the adult s life now.

It can draw attention to seemingly unrelated events or information.

An accurate chronology can assist the process of assessment, care planning, and review.

DESCRIPTION OF SIGNIFICANT EVENTS 6 2 3 4 5

A significant event is anything that has a positive or negative impact on the adult.

It does not have to happen directly to the adult but can be any change in circumstances or events that have or may have consequences for the adult.

This template is provided for convenience. It does not replace any agencies own recording systems or requirements. It is intended as an aid to help practitioners in getting a better understanding.

IMPACT SOURCE OF EVIDENCE

AGENCY CONTACT

THINGS TO CONSIDER

Identify what is significant enough to include in the context of the safeguarding concern

Key dates

Facts rather than opinions

Agency involvement or interaction

Key professional interventions

Key actions

Assessments carried out

Transitions and changes of circumstance; e.g. homelessness

Incidents, accidents, assaults, etc., where harm or risk of harm

Source of evidence or further information

THINGS TO CONSIDER

Chronology of events

Longer term view

Many people who are at risk of or are experiencing long term homelessness have been exposed to trauma.

Trauma is prevalent in the narrative of many people’s pathway to homelessness. Research has shown that people who are homeless are likely to have experienced some form of trauma, often in childhood.1

85% of those in touch with criminal justice, substance misuse and homelessness services have experienced trauma as children.2

The purpose of this section is to describe how a person’s view of the world may be informed by any significant or traumatic events.

DESCRIPTION OF SIGNIFICANT EVENTS

Trauma can occur at a particular time and place, and can be shortlived, such as serious accident, sudden loss of parent or a single sexual assault. AND/OR

Adulthood

Adolescence

Trauma can refer to events which are typically chronic, begin in early childhood and occur within family or social environments. They are usually repetitive and prolonged, involve direct or indirect (witnessing) harm or neglect by caregivers or other entrusted adults in an environment where escape is impossible. Traumatic experiences often leave people feeling unsafe and distrustful of others. Creating a sense of physical and emotional safety is an essential first step to building effective helping relationships.

Childhood

Summary of observations

Professional judgement is required to decide whether particular circumstances or events are significant for a specific individual. Use this section to summarise and draw attention to more pertinent facts whilst taking into account your own professional judgement.

1 E.Sundin and T. Baguley, 2015: Prevalence of childhood abuse among people who are homeless in Western countries: a systematic review and meta-analysis. In: Social Psychiatry and Psychiatric Epidemiology February 2015, Volume 50, Issue 2, pp 183–194

2 Lankelly Chase Foundation, 2015: Hard Edges: Mapping severe and multiple disadvantage, England, accessed at: http://lankellychase.org.uk/wp-content/ uploads/2015/07/Hard-Edges-Mapping-SMD-2015.pdf

THINGS TO CONSIDER

Chronologies should NOT be repeats of case notes, be time consuming to compile, or overly detailed

When adding evidence to case chronologies consider its relationship and relevance to previous information

Practice and research has shown that multiagency chronologies can be extremely important in identifying critical events and patterns in the lives of adults at risk and can assist professionals in decision making

THINGS TO CONSIDER

Principles of safe enquiry include:

Section 3

Immediate risks

This section concerns itself with understanding whether there are any immediate risks to the adult that require an urgent intervention to prevent harm; e.g.

• Provision of accommodation

• Interventions to remove risk from a 3rd party

• Reconnecting an adult with care and support needs to existing family or statutory support

Practitioners must act on concerns and actively gather information until satisfied there is no reasonable cause to suspect the three part test set out in s42(1) Care Act is met.

Practitioners are permitted to share information, but must record their rationale for believing this was necessary and proportionate to do so in order to support the duty to conduct a safeguarding enquiry.

This will be a matter of professional judgment, but it is important to remember:

• The adult may give permission for disclosure

• The law provides exceptions to obtaining consent, if it is necessary to meet a legal obligation, public task or for vital interests, including safeguarding

Be free from potential interruptions in a safe place

Never ask in front of a partner, friend or child

• Most safeguarding local policies and procedures will have an information sharing agreement that confirm powers to share and set out how agencies working within the partnership can resolve a dispute

Consider if the person requires an advocate, e.g. due to a lack of capacity

Please set out all immediate risks to the adult that require an urgent intervention to prevent or reduce harm. Be explicit about the type, level, pattern of abuse or neglect. Set out if it is likely that, without timely intervention, the adult will experience actual bodily harm or intense physical or mental suffering.

The Local Authority and statutory partners will have legal powers to provide immediate support even whilst they carry out enquiries or complete assessments if, without this, there would be a breach of the adult’s human rights.

Interventions should concentrate on getting the right response at the earliest opportunity.

Consider if an interpreter is required, only use an approved professional

Document the persons responses being mindful of information security and confidentiality

A person’s ‘ordinary residence’ or ‘local connection’ is only relevant after the person has been assessed as eligible for accommodation and/or social care support. It does not prevent a local authority from carrying out an assessment of need, providing advice and information, and providing services. Nor does it prevent urgent provision as there are powers to provide this under s19(3) Care Act 2014 and s188 Housing Act 1996.

Key to this for practitioners, particularly in frontline provision identifying signs of abuse, is understanding principles of safe enquiry and knowing how to report and secure preventative support for an adult at risk

Section 4 covers the protection planning in more detail.

Somewhere safe to stay tonight

Type here

Who is best placed to lead?

Type here

What is the level of concern?

Severe harm

Moderate harm

Low harm

Minimal harm

THINGS TO CONSIDER

Is the person at immediate risk of harm?

If yes, can the risk be removed through immediate action? e.g.

Interventions, potentially police action, to remove risk from a third party

Reconnecting an adult with existing family or statutory support

Is suitable accommodation needed to protect the adult at risk and, if so, what type?

Does the adult understand why you are concerned about the risk to their wellbeing?

THINGS TO CONSIDER

Section 4 Protection planning

Research (including Safeguarding Adult Reviews) highlights how important it is to ascertain early who is best placed to take a lead on co-ordinating multi-agency risk assessment. Any information gathering process must also take into account procedural safeguards written into statutory duties, in particular set out the steps taken to:

• consult with the adult and their carer(s)

• the role of advocacy

• written reasons for decisions

Where a protection plan is required [s42(2) Care Act 2014] professionals must consider whether they have legal authority to enact that plan. The plan must meet relevant partners’ statutory duties either by reducing risk of harm or by demonstrating further action would be unnecessary or would be a disproportionate interference with human rights.

Transitions, whether involving hospital and prison discharges, or young people leaving care, for example, are opportunities to put the right support in place.

•Abuse: physical,discriminatoryandorganisationalabuse

•Neglect: includingactsofomission,self-neglect,self-harmandriskof suicide

•Exploitation: sexual,psychological,financialormaterialabuse,including moderndayslavery,coercionorcontrollingbehaviours Type

Transitions are just one example of the central criticality of comprehensive risk assessments and mitigation planning.

Indicators

Risk assessment templates may be useful here, for example that focus on the person, the individual s immediate environment and wider networks.

Equally, police and ambulance crews may witness that homeless people are experiencing abuse and exploitation.

•Observations: Gatherallrelevantdataforthepurposeofsense makingandintegratingeventstocometoanoverallpicturetoinform riskmanagementplanning(utilisationofpracticetoolsincluding assessmentsmentionedelsewherehereinmaybeuseful)

•Whoisatrisk: Doestheconcernaffectchildren,orotheradultsat risk?

•Recurrence: Hastherebeenrepeatallegations?

There are two adult safeguarding responses required. Namely meeting the immediate need for protection and triggering a multi agency response to coordinate a longer term plan to address health and social care needs.

Level

•Criminality: Ifproven,wouldthisconstituteacriminaloffense?

•Relationship: Isthereacurrentorpastrelationshipoftrust,commercialorcontractualrelationship,familialorintimaterelationshipbetween theadultandtheallegedperpetrator?

This highlights the importance of clear referral pathways and safeguarding literacy.

•Insight: Whatunderstandingdoestheadulthaveintothelevelofrisk, dotheyunderstandwhypractitionershaveconcerns?

•Capacity: Isthereanyevidenceofincapacity,coercion,undueinfluenceorduress?

•Desiresandwishes: Whatoutcomesmattertotheadultandwillthis reduce/removerisk?

Preparatory checklist

As the person raising the concern, have you identified the facts / circumstances that gave rise to a ‘reasonable cause to suspect’ the adult:

• Has a current need for care and support? 1 

• Is at risk of abuse and/or neglect?

• Is unable to protect themselves?

If you can tick the above three elements, based on the information you have, there is sufficient information for consideration of the duty under s.42 of the Care Act. Therefore, staff conducting the screening or triage must record:

• What added information gathering took place? 

• Did you seek the views of the adult at risk? 2 

• Consideration of duty to appoint an advocate? 3 

• Did you address immediate risks (section 3)? 

• Whether there’s a need to preserve evidence? 4 

• Referrals for statutory assessments made? 

• Confirmation referrals received? 

• Confirmation referrals actioned? 

• Ascertain if already subject to risk management? 5 

• Ascertain if there are statutory referrals required? 6 

• Do these circumstances trigger a duty under s.42? 7 

THINGS TO CONSIDER

Whether or not the Authority is meeting any of those needs (see s.42(1) of the Care Act). It is expected that the views, wishes, and desired outcomes of the adult at risk are sought, unless there are reasonable grounds to believe that doing so would place them at further risk of harm.

Use where an individual would have substantial difficulty with one or more of the following (1) understanding relevant information; (2) retaining that information; (3) using or weighing that information as part of the process of being involved; (4) communicating the individuals views, wishes, or feelings (whether by talking, using sign language, or any other means)

Police and Criminal Evidence Act 1984 (PACE)

E.g. through MAPPA, MARAC, etc.

E.g. through PreVent, National Referral Mechanism for Modern Day Slavery

Care Act duty to make enquiries

THINGS TO CONSIDER

Closing an enquiry

People raising a concern should be mindful of the need to record key information throughout the process. This checklist is intended only to assist good recording and doesn’t override national, local policy, or professional judgment.

Where it is reasonably concluded that the risk did not require a safeguarding enquiry under s42 Care Act, this should not prevent multi-agency risk and/or needs assessments being undertaken.

Similarly, where it is determined that the risks and/or needs might be better addressed through an alternative local risk management process, this should be clearly recorded and the person raising the concern notified. Practitioners must also remain open to reviewing decisions on risk management processes if circumstances change.

This checklist is derived from a local safeguarding policy document

Guidance may differ from one area to another

Where the raising of the concern has led to an enquiry under s42 Care Act, then local safeguarding process will likely lead to protection planning. This section suggests useful checks to perform prior to closing an enquiry.

This checklist is provided as a generic aide memoir

You are advised to also check and follow your local safeguarding policy and process

Practitioners must act on concerns and actively gather information until satisfied there is no reasonable cause to suspect the 3 part test set out in s42(1) Care Act is met. Practitioners are permitted to share information, but must record their rationale for believing this was necessary and proportionate to cooperate (according to, and in line with powers under s7 Care Act) so as to support the duty to conduct an enquiry [s42(1) Care Act]. This will be a matter of professional judgment, but important to remember:

Circumstances may change as an enquiry unfolds, for example, the adult s preferred outcome may fluctuate.

• The adult may give permission for disclosure and, unless there is reasonable cause to suspect this might not be safe, should be asked for permission to share info and agree to the enquiry plan in line with ‘Making safeguarding Personal’ principles

It s important that these changes are recorded (preferably as they happen)

• The law provides an exceptions to the usual rule, that information cannot be shared without express consent, if it is necessary to meet a legal obligation, public task or for vital interests, including safeguarding!

• Most safeguarding local policies and procedures will have an information sharing agreement; these confirm powers to share and set out how to agencies working within the partnership can resolve a dispute

Enquiry closure checklist

As the person raising the concern, you should be satisfied that the following has been recorded, assessed, and / or understood:

• What was the concern leading to the enquiry? 

• What was the outcome that the adult wanted? 

• What was the assessed risk of harm to the adult? 

• What action was taken to protect the adult? 

• What are the protective factors mitigating harm? 

• Who was contacted during the enquiry and how? 

• What are the established facts of the case? 

• What consideration was given to mental capacity? 1 

• What were the views regarding the source of risk from: 

• The adult and / or their advocate 

• Any carer, family member, or significant other? 

• Were the following consequential matters recorded: 

• Conclusions or professional judgements? 2 

• Any substantiated allegations? 3 

• Was the Protection Plan recorded and communicated? 

• Who is coordinating and leading outstanding actions? 4 

THINGS TO CONSIDER

It s important that mental capacity is considered at each stage of the safeguarding process

Conclusions or professional judgements are made by suitably qualified or experienced people based on their knowledge and understanding of the situation through the application of their specialist knowledge and professional curiosity taking into account the legal, practice, ethical frameworks and relevant principles

Safeguarding enquiries may well be triggered or otherwise lead to allegations of abuse or neglect, it s important that the outcome of such allegations is recorded including the evidence and reasoning behind the decision

When an enquiry in closed, there may still be actions outstanding, it s important to be clear about who is coordinating the protection plan and who is leading on each outstanding action

How should partner agencies work together?

Conclusions

The duty to undertake an safeguarding enquiry enables multi-agency responses by any relevant partners, it is not however a substitute for duties to:1

• provide support those at risk of homelessness2 and promote wellbeing through the provision of social care3 (local authority)

• protect life and property, preserve order or prevent crime (police)

• provide necessary care/ treatment for illness (NHS organisations)

In fact any relevant partner is expected to carry out their functions in a manner that safeguards and promotes the wellbeing of adults (s6(d) Care Act 2014) and welfare of children (s11 Children act 2004).

Practitioners should be receptive to constructive challenge across specialisms and sectors.

Those practitioners regulated by professional bodies will be aware of their duties to raise safeguarding concerns, including duties to whistle blow’.

A person does not have to have a ‘Local connection’ to receive support from a local authority under the Housing Act or be ‘ordinary resident’ to access all social care functions under the Care Act. A person’s ordinary residence or local connection is only relevant when determining which local authority will be responsible for arranging (and possibly funding) after the person has been assessed as eligible for support. It does not prevent a local authority from carrying out an assessment of need, providing advice and information, providing services to preventing homelessness or the escalation of social care needs or putting in place urgent provision whilst they complete their assessment [s19 (3) Care Act 2014 and s188 Housing Act 1996]

But it is also import to highlight local escalation policies exist to ensure that disputes are resolved quickly and are explicit that a dispute about funding responsibility must never prevent or delay the provision of support.

Medically fit for hospital discharge is a clinical decision, whether a hospital discharge is safe is a public law decision for which practitioners (and ultimately hospital managers) should ensure they have complied with their statutory duties to consider if the adult has an appearance of need on discharge and, if so, consider if they require a full assessment under the National framework4 for Continuing Health Care. If not, they must refer for social care assessment.

1 http://www.legislation.gov.uk/ukpga/2014/23/contents/enacted

2 https://assets.publishing.service.gov.uk/ media/5a969da940f0b67aa5087b93/Homelessness_code_of_guidance.pdf

3 https://www.gov.uk/government/publications/care-act-statutoryguidance/care-and-support-statutory-guidance#first-contact-andidentifying-needs

Resources

Provision of accommodation to protect the adult at risk:

• This will require consideration as to whether accommodation is needed to protect the adult at risk and, if so, what type of accommodation is ‘suitable’.

• The principal duty to provide accommodation is set out in Housing Act 1996, s.23 Care Act prohibit provision of where individuals are eligible for support under 1996 Act or would be if they had not been deemed ineligible under 1996 criteria: GWA v Lambeth

• Duties are only owed to those eligible and in ‘priority need’, but any assessment of vulnerability, must reference the duties under Equalities Act 2010. The test is whether a person is “significantly more vulnerable than ordinarily vulnerable as a result of being rendered homeless” relatively to “an ordinary person if rendered homeless”: Hotak v LB Southwark5 [2015]

• People who have ‘no recourse to public funds’ due to their immigration status are unlikely to be able to access more than information and advice or the temporary relief duty under this legislation

• Anyone leading on the development of a protection plan should ask housing practitioners to consider whether they can assist with information, advice or practical support to help secure suitable accommodation

Where a duty to accommodate does arise, this must consider suitability with reference to the adults medical and physical needs arising from illness or impairment. Consideration also needs to be given to:

• The reasonable steps taken to enable carers to provide support

• Whether to provide discretionary payments for extra bedrooms if this is necessary

• Location of accommodation so practicalities as to how the adult will access other necessary support (with medical treatment it is crucial to consider any established therapeutic relationships and impact of any disruption). Nzolameso V City of Westminster6 [2015]

4 https://www.gov.uk/government/publications/national-framework-fornhs-continuing-healthcare-and-nhs-funded-nursing-care

5 https://www.supremecourt.uk/cases/docs/uksc-2013-0234judgment.pdf

6 https://www.supremecourt.uk/cases/docs/uksc-2014-0275judgment.pdf

Housing First

International studies indicate that the Housing First model produces exceptional housing retention outcomes (around 80%).

This is relevant, to safeguarding protect plans because a human rights approach requires practitioners to adopt a stepped approach to safeguarding.

This may mean tackling the most pressing problem first in order to enable the person to address longer term conditions impacting on their safety.

Useful contacts

Bruno Ornelas, bruno@csafeguardinghub.co.uk

Andy Meakin, andy.meakin71@outlook.com

Training & consultancy

Expert Citizens CIC

Provides a range of training opportunities informed by people with lived experience:

www.expertcitizens.org.uk

Safeguarding Circle

Provide safeguarding and training consultancy offering innovative and sustainable solutions to strengthen safeguarding practice:

www.safeguardingcircle.co.uk

Collaborative Safeguarding Hub

Provides practical courses that focus on legal literacy, fact-finding, defensible decision making, collaboration and a rights-based approach to complexity.

www.collaborativesafeguardinghub.co.uk

Acknowledgements

The original version of this toolkit was made possible by the National Lottery Community Fund through Fulfilling Lives: Supporting people with multiple needs (2014 2022)

Disclaimer

Expert Citizens CIC, Keele University, and Kings College London offer no warranty and accept no liability whatsoever for losses of any kind incurred as a result of using this toolkit.

This toolkit is intended only to provide a general understanding and general information for practitioners. This toolkit does not provide legal advice nor does it create any relationship between you and the authors or their respective organisations past, present, or future.

Use of the toolkit is permitted on the understanding that this is entirely at your own risk.

www.expertcitizens.org.uk