2.6. Quality and safeguarding

2.6.1. Introduction

This section considers issues regarding the interface between quality of care and safeguarding in health and social care settings. It sets out how commissioners, contracts, quality monitoring, and/or market support departments work with providers to enable adults to receive high quality safe services. It details how good communication and collaboration can support providers to take early action to reduce risk and safeguard adults. 

The aim of commissioners and service provider should be the delivery of effective, high-quality care and support for every individual. When issues arise in relation to quality, adults may be placed at risk of abuse or neglect and it is key this is identified at an early point, and appropriate action taken. Many of the issues raised as safeguarding concerns, such as falls, pressure damage, wrongly administered medication or poor nutritional care, are rooted not in intentional or malicious harm but in poor practice and poor-quality care. Nonetheless, the impact to the adults can be just as great, regardless of whether harm is intended.

Effective partnerships between safeguarding, commissioning, contracts, quality monitoring and/or market support functions, across health services, integrated care boards and social care teams together with an understanding of their interdependent roles and responsibilities, are essential to support a positive culture of cooperation and information sharing. Focusing on preventative support and working in partnership can assist with early identification when health and social care providers are at risk of not meeting required quality standards that might lead to wider concerns and the need for safeguarding interventions.  

2.6.2. Responsibilities for quality

Managers of care and support services and agencies responsible for the regulation and commissioning of those services have overall responsibility for ensuring the quality of the care and support services and ensuring that these meet required standards of care.

Care providers are accountable both to commissioners and to adults using their services and are expected to have a robust quality assurance framework in place that evidences a commitment to prevention and early intervention. There is a clear responsibility on providers and managers in these services to ensure safe, quality services that reduce the need for safeguarding interventions.

As part of the procurement processes for new services commissioners of services need to ensure that safeguarding responsibilities of providers are detailed in the contract terms conditions and service specifications. Safeguarding and the management of incidents is part of the tender evaluation process for contracts which take place pre procurement, and many also have safeguarding management as a key performance indicator.

2.6.3. The role of the regulatory authority – Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care services in England. The CQC register, monitor, inspect and rate health and care services to ensure they meet fundamental standards of quality and safety. They publish their findings, including performance ratings, to help people choose care services. 

The CQC is responsible for setting fundamental standards of safety and quality by registration of services and by the ongoing monitoring of a provider’s compliance, and information relating to the quality of care and support services should always be shared with them.

The CQC can deploy a range of enforcement powers where registration requirements are not being met in services with poor or inadequate standards of care. Where the CQC identifies safeguarding concerns about an adult they advise the local authority by raising a safeguarding concern.

The CQC must always be made aware of any safeguarding concerns in regulated services by care providers. Care providers must tell the CQC without delay about abuse or allegations of abuse concerning a person using their service if any of the following applies:

• The person is affected by abuse
• They are affected by alleged abuse
• The person is an abuser
• They are an alleged abuser

Further guidance for provider can be found at Guidance for providers - Care Quality Commission (cqc.org.uk).

If the concern is reported to the local authority, the local authority should notify the CQC where on receipt of concerns or in the course of enquiries they are concerned that the Regulator (CQC) should have additional oversight of their involvement and/or are increasingly concerned about risk to a person or service provision. The outcome of any assessment or enquiry must also be shared with the CQC if it is related to a regulated service.

The CQC may be directly involved with a safeguarding adults process where:

• One or more registered people are directly implicated;
• Urgent or complex regulatory action is indicated;
• A form of enforcement action has been commenced or is under consideration in relation to the service involved.

Where the safeguarding concern suggests breaches of regulation and standards, the CQC may conduct enquires or initiate a random inspection. This activity may take place as well as other enquiries being undertaken by another organisation.

Please visit the CQC website for more information on Safeguarding People.

2.6.4. Quality monitoring in social care and health

Across Sussex our local authorities and Integrated Care Boards have a range of support, monitoring, and oversight measures in place. These focus on assurance, quality and contracts monitoring, service improvement, and market support. It is important to note that each local authority area has different mechanisms in place with regards to contractual arrangements and expectations with providers, but through the various support and quality processes local authorities and the Integrated Care Board are able to gather relevant information and trends from complaints, safeguarding enquiries, assessment teams, safeguarding leads, and whistle blowers. They can work closely with other professionals and the CQC to share information in order to build a picture of care services. This information may be used to help support providers to maintain and improve the quality of the care they provide. This information may also be shared with Lead Enquiry Officers undertaking safeguarding enquiries under section 42 of the Care Act (safeguarding duties) to support risk management and decision-making.

Responses relating to the quality of care and support services, which sit outside of the safeguarding enquiry process, will be led and coordinated by the responsible commissioning organisation, in close partnership with the managers of those services, the CQC and any other agencies or organisations that need to be involved or informed.

When it is unclear which agency’s commissioners would have responsibility for leading and coordinating a response relating to quality, this should not cause a delay in responding to issues about quality of care. In these situations, the local authority commissioners will take responsibility for convening a multi-agency planning meeting. This will determine which agency is most appropriate to coordinate any ongoing quality assurance response. 

2.6.5. When do concerns about quality require a safeguarding concern to be raised with the local authority?

Incident procedures cover a wide range of issues including minor incidents that may happen as a result of issues to do with practice or the quality of care provided. It is the provider’s manager’s responsibility to ensure that these are addressed proactively and effectively through internal processes and to ensure the service they provide meets the required standards of care.

Care providers are responsible for taking appropriate action in line with their own policy and procedures for incident reporting. This should reflect the Care Quality Commission’s Fundamental standards (2024).

Consideration should also be given, depending on the nature of the incident, as to whether it may be necessary to notify relevant parties such as relatives, or any external agencies or organisations, due to contractual or regulatory requirements.

Care providers need to consider whether any incident or issue should be raised as a safeguarding concern and reported to the relevant local authority, and to other organisations such as their professional regulator, the Care Quality Commission, and other commissioners of services. The care provider will also need to consider if it does not raise an incident or issue as a safeguarding concern how that will be recorded, and who this needs to be reported to.

The views and wishes of the adult should always be sought prior to passing information regarding a safeguarding concern to other organisations. However, this does not override professional responsibilities for passing information to relevant agencies, in order to protect an individual and others using the service (see Section 2.2 Recognising and Reporting Abuse and Neglect).

Care providers are advised to refer to the Pan-Sussex Safeguarding Adults Thresholds Guidance if they are unclear regarding a safeguarding concern. This is designed to support professionals, partner agencies and providers working with adults who have care and support needs to identify and report safeguarding concerns when appropriate to do so.

The role of the local authority on receipt of a concern

On receipt of a safeguarding concern the local authority will make a decision as to whether the duty to undertake a safeguarding enquiry is triggered (see Section 2.3 Receiving Concerns and Undertaking Enquiries).  

On receipt of a safeguarding concern regarding a care and/or health provider the local authority will consider whether there is a need to inform the relevant quality monitoring team and/or market support team within the local authority and the Integrated Care Board if it relates to a concern about the delivery of health care (in line with the approach highlighting the importance of sharing information and of notifying the ICB outlined in section 2.11 of these procedures). The local authority should also feedback the outcome of any safeguarding concerns or safeguarding enquiry to the relevant quality monitoring and/or market support services and commissioners (Refer to local pathways in each local authority).

Causing others to undertake an enquiry

The local authority may cause all, or part, of an enquiry to be carried out by another professional or organisation who may be best placed to do this. This is referred to as “causing others” to make enquiries (see Section 2.3.7 The local authority causing others to make enquiries).  A Making Safeguarding Personal approach requires that the most appropriate professional is identified to carry out an enquiry e.g. health professionals may undertake enquiries relating to management of medication or pressure damage. Care home managers may be best placed to enquire about something that may have happened to one of their residents as a result of abuse or neglect by one of their staff.

Where it may not be appropriate for an employer to undertake an enquiry

In some cases, the local authority will cause the care provider to undertake the safeguarding enquiry (and provide the support that the adult may need) where it is regarding a person receiving care and support from that provider, unless there is a compelling reason why it is inappropriate or unsafe for the organisation to do this. For example, there could be a conflict of interest, concerns about ineffective previous enquiries, multiple concerns, or a matter that requires investigation by the police.

Where there is a conflict, the provider may still be required to provide information and be involved in the enquiry, but not be formally requested to undertake it.

2.6.6. Responding to organisational risk

Organisational risk is a broad concept which develops when key factors such as poor management and support, staffing challenges, inadequate training, supervision, and quality of care issues combine to develop a picture of increasing risk. In some situations, organisational abuse and/or neglect of residents may occur. Organisational risk develops where care and support is being provided and it could relate to an institution or a specific care setting, such as a hospital or care home for example, or relate to care in a person’s own home.

Taking a multi-agency approach to responding to organisational risk and identifying emerging pictures is key. Supporting providers and involving them in discussions at an early point wherever possible can prevent organisational risk issues from developing further into organisational abuse or neglect. Effective quality, health and social care commissioning, contractual and assurance monitoring and support arrangements can assist providers of care with effective communication, support, and early intervention.

Across Sussex there are a variety of approaches and pathways that organisational risk is responded to, at its heart is a multi-agency approach which includes all and supports the provider to improve.

Organisational abuse

Operational abuse is an umbrella term defined as “the mistreatment of an adult at risk by a regime or individuals within settings and services that adults at risk live in or use, that violate the person’s dignity, resulting in lack of respect for their human rights" (Care and Support Statutory Guidance, 2014). 

Indicators of organisational abuse

Organisational abuse includes neglect and poor professional practice that has been allowed to occur unchecked within an organisation, such as in a hospital or care home. It can look like:

• inappropriate use of restraint or restrictive practices;
• not providing adults with appropriate choice over aspects of their life, such as food, clothing, or their own schedule;
• not providing adults with a safe environment;
• not respecting adults as individuals, with their own beliefs and cultural backgrounds;
• restricting contact with friends and family; and
• a number of types of abuse including physical, psychological/emotional, financial, neglect and acts of omission and discrimination.

Risk factors for organisational abuse

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

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

Circumstances leading to enquiries into organisational abuse

The circumstances in which an enquiry into organisational abuse may be required can include, but are not limited to: 

• Safeguarding concerns and enquiries with evidence and concerns of criminal neglect or ill treatment.
• Where it is suspected that a number of adults have been abused by the same person, or group of people in the same setting.
• Where there are indicators from safeguarding activities relating to an individual adult that other adults are at risk of significant harm.
• Where patterns or trends are emerging which suggests serious concerns about poor quality of care from a provider.
• Where a provider has failed to engage with other safeguarding activities resulting in continued harm or continued risk of harm to one or more adults.
• Where there is evidence that despite contract monitoring, quality improvement and/or Care Quality Commission action planning, there remains insufficient improvements within the service, resulting in continued harm or continued risk of harm to one or more adults.

Responses to organisational abuse

Responses to organisational abuse should involve key partner agencies and sufficiently senior managers from the earliest stage. This is essential in ensuring the appropriate personnel and resources are identified to carry out the enquiry. The level and nature of the concern will influence which organisations need to be involved and the required level of authority to make decisions on behalf of those organisations. 

Many enquiries into organisational abuse will involve consideration about a number of adults who are at risk. It is vital that the enquiry includes the consideration of the views and outcomes of any individual adult involved and incorporates these into any wider strategic learning within the enquiry, whilst at the same time ensuring the confidentiality of specific individuals is maintained.

It is good practice in any enquiry for providers to be fully involved from an early stage to promote effective partnership working and bring about the best outcomes for adults with care and support needs.

Other funding authorities, including the Integrated Care Board as a funding authority, will need to be involved from an early stage regarding safeguarding concerns and enquiries involving a person placed by that organisation, and of any decisions for suspending placements due to safeguarding concerns. Where there are concerns about a provider who operates across geographical areas, concerns should be flagged to the relevant local authorities in which the provider operates.

Communication with adults who use the service, and their representatives, needs to be considered, and in the majority of cases this would be taken forward by the provider. In a residential setting, residents and their families may become anxious about increased activity, such as seeing more visiting professionals, and have the right to be informed of concerns, though care should be taken not to raise anxiety. Information sharing should always include adults who use services and their representatives so that they are able to make informed choices and retain their independence.

Local reporting and responding to organisational abuse

Where organisational abuse is suspected, the process for reporting concerns remains the same, regardless of your locality within Sussex:

• Discuss the concerns with your supervisor/manager and local safeguarding lead/team and submit a safeguarding referral to your local authority;
• If there are suspicions of a criminal nature, contact the police;
• If it would not interfere with any investigations, or lead to additional risk, discuss concerns with the organisation involved;
• If it is not possible or appropriate to speak directly with the organisation, or the response received is unsatisfactory, refer to your organisation’s Whistleblowing Policy.

Once concerns of organisational abuse have been received, the response to the concerns may be managed through slightly different processes, depending on your locality. You can find out more about these processes below.

Duty of candour

The intention of the duty of candour under the Health and Social Care Act 2008 is to ensure that providers are open and transparent with people who use services and other 'relevant persons' (people acting lawfully on their behalf) in relation to care and treatment. It also sets out some specific requirements that providers must follow when things go wrong with care and treatment, including informing people about the incident, providing reasonable support, providing truthful information and an apology, as appropriate.

Duty of candour regulations (CQC, 2022) apply as soon as reasonably practicable after the screening service has become aware that a notifiable safety incident has occurred.

The duty of candour legislation (GOV.uk, 2020) applies to all NHS trusts, foundation trusts, special health authorities and all other health and care service providers and registered managers.

The Department of Health and Social Care will lead a review into the duty of candour for health and social care providers in England (GOV.uk, 2023).