Norfolk review

To overcome the disparity in definition of domestic abuse under which the Police, CPS and other criminal justice agencies operate, and the definition used for convening a Domestic Homicide Review (which includes ‘a member of the same household’), consideration should be given by the Home Office and Ministry of Justice to aligning definitions to achieve a common working definition.

That the Liquid Logic case management system provider should review the LAS case management system and ensure that an immediately accessible chronology of referrals, major events, and safeguarding incidents are easily visible for practitioners.

All agencies involved in this review should ensure that information provided by family members is given importance and status in assessments, is accurately recorded, shared appropriately, and thoroughly investigated where concerns are raised for a person’s safety. This should be monitored in supervision and reinforced in agency practice guidance.

Safeguarding Adult Board & Community Safety Partnership - All relevant agencies in the county should:
a) Audit their safeguarding training and confirm that awareness and identification of ‘cuckooing’ and the steps to take when it is identified is included in the course materials.
b) Evidence that this review is included, and remains integral, in training as an anonymised case study to highlight the vulnerability of older adults to raise awareness that ‘cuckooing’ can take place outside of ‘county lines’ and ‘trafficking’ cases.
c) Evidence procedures are in place for staff to follow which includes instructions for working with cases involving ‘cuckooing’ of a vulnerable person who is a homeowner, and in such situations, they must convene a multi-agency strategy/professionals’ meeting to construct a safety plan for the victim which includes the consideration of legal injunctions to remove the person who has moved in and stayed against the owner’s wishes.
.These actions to be put in place within 6 months of completion of the review.

To produce effective fully informed risk assessments agencies should take steps to promote a culture of multi-agency working and the value of a coordinated multi-agency approach (including improving the use of professionals’ meetings) to risk assessments. This should be imparted by managers in team meetings and supervisors in supervision and advice sessions. It should include utilising opportunities for shared learning events and/or multi-agency training programmes for staff at least once per year.

All agencies raising a safeguarding concern to the local authority should ensure the documentation submitted contains all relevant background information held on the subject/s particularly information necessary to inform risk assessments such as physical or mental health vulnerabilities, substance misuse, and/or offending history.

All agencies involved in undertaking assessments of concerns and of a safeguarding nature, or which require the assessment of risk, should be reminded to ensure their practitioners:
a) Demonstrate professional curiosity and ask open probing questions when gathering information to inform assessments.
b) Make detailed and accurate records which include examples of incidents or behaviours raising concerns or which indicate risk.
c) Are supported and guided by management to fully probe risk levels and avoid premature closing of cases.
d) Audits of safeguarding concerns and referrals should take place annually to ensure that holistic information has been gathered from a range of sources to fully inform risk assessments and the progress of the case.

To address deficits in understanding and application of the Mental Capacity Act it is recommended that agencies:
a) Review and develop Mental Capacity Assessment (MCA) training for the Norfolk partnership workforce to support full and effective assessments of capacity.
b) The training must include assessment of mental capacity, recognition of the various impacts of coercive control a person's mental and physical wellbeing, and their ability to freely make decisions in their best interests.
c) The evaluation of the training must provide measurable outcomes which demonstrates the workforce understand, apply, and have confidence in using the MCA and the ways in which coercive control affects capacity.

The Norfolk Safeguarding Adults Board should produce and publish a clear and updated organogram which clearly articulates current safeguarding terminology, roles, responsibilities, and processes.

The Norfolk County Community Safety Partnership should work with key stakeholders (e.g. Norfolk County Council) to ensure that all publicly available information (including websites) relating to the MASH is accurate and current.

Adult Social Care should ensure all safeguarding referrals are assessed as per the Care Act 2014 definition of an ‘adult at risk’ to include: (a) is experiencing, or is at risk of, abuse or neglect, and (b) as a result of those needs is unable to protect himself or herself against the abuse or neglect or the risk of it, in addition to (c) has needs for care and support (whether or not the authority is meeting any of those needs), taking account of all available information from agencies and family members.

When staff have concerns about domestic abuse, but the risk assessment does not meet the MARAC referral level, staff should be reminded and empowered by managers to make a MARAC referral based on ‘professional judgement’.

Training input to be included to all frontline officers to help them recognise adults at risk and understand the impact of cumulative risk – case example arising from this review to be used. To be drafted into a training slide by the safeguarding development team with immediate effect. Success will be measured with a dip sample of incident logs and APIs to be conducted by the MASH Detective Inspector.

An automated triage tool to be developed to address the backlog of APIs, to prioritise risk in the backlog and to recognise repeat victims. Current multi-agency processes to be reviewed to understand thresholds and ensure information is shared with support services, either within the MASH or on districts with adults at risk, depending on potential harm or abuse and frequency. Success will be measured with a dip sample when the triage tool is in place and cases are being prioritised based on risk. Quality assurance checks to ensure that OPTs or MASH services are being made aware of appropriate APIs.

Norfolk Police to create a referral mechanism between MASH and EHH/OPT when cases do not fit the criteria for safeguarding within the MASH. Current processes will need to be reviewed. It would likely be an internal process within Police systems. Success would be measured by having a formal process to pass regular information between MASH & OPT/EHH structures within each district.

When previous convictions of potential perpetrators are relevant to the risk presented to the adult at risk, details to be shared with other agencies to help them form safeguarding plans and further support in appropriate cases.

Training slides to be added to the vulnerability training day to show the importance of recording details of safeguarding advice and action. This will be done by the safeguarding development team. Exact details of advice and action taken to be recorded appropriately to assist those trying to secondary safeguard, including partner agencies. It would also provide a log of actions and advice that has been tried and tested when trying to problem solve repeated issues.

That Adult Social Care reminds its practitioners that they must be clear about the decision that needs to be made when mental capacity is being considered.

That managers at Adult Social Care ensure mandatory training (particularly DASH) is carried out and that the learning and development team sets up a system to monitor whether mandatory training has been completed.

That the ASC quality assurance team audits whether practitioners are reviewing, consolidating and summarising information on cases at least once a year so that information is easier to find for practitioners reviewing records when a safeguarding concern is raised.

That the ASC quality assurance team to audit whether SCCE are clearly stating why a face-to-visit is necessary and whether this advice is followed by locality teams.

ASC practitioners are reminded to review the record of the person alleged to be the cause of risk/harm when taking a safeguarding concern and considering raising a referral.

To remind ASC practitioners to contact the Police for information if there is a concern about a potential criminal history of an alleged perpetrator so that an accurate picture of risk can be established.

ASC to work with the Police to ensure information-sharing about the criminal history of alleged perpetrators is completed when raising safeguarding concerns with ASC.

To remind ASC managers about the need to carry out regular caseload supervision and reflective case discussions with teams and individuals. This will provide support and guidance and promote a culture of curiosity.

Norfolk and Waveney ICB to commission training for primary care professionals specific to mental capacity act and appropriate functional assessment of mental capacity and feedback to be collected from attendees.

Staff completing initial sentence plans in cases where the person on probation is not engaging should be based on previous information, Crown Prosecution Service document and liaison with other agencies for information. This will support a fully informed risk assessment and risk management plan.

Initial sentence plans should not be countersigned by line managers unless the above actions have been undertaken and there is a comprehensive risk assessment and risk management plan. This will ensure that risk assessments and sentence plans adhere to organisational standards.

At pre-sentence report stage, there should be Police intelligence checks completed to inform both the pre-sentence report and the initial sentence plan. If for any reason these checks have not been completed, the allocating manager will set an action for this to be undertaken. This will ensure that risk assessments and sentence plans are fully informed and relevant safeguarding actions are undertaken.

In the event that there is poor compliance during community sentence, a Police intelligence check should be undertaken to establish if there are any additional safeguarding actions that need to be undertaken.

In the event that there is poor compliance during the period of probation supervision, Probation staff should firstly establish whether there are any other agencies involved in the case by undertaking MASH checks. Once these details are obtained, probation staff should liaise with relevant agencies and work collaboratively to re-engage the person on probation and to manage risk.

Cases that are not complying i.e. in breach of Community Orders/Suspended Sentence Orders and are registered as homeless should have a management oversight discussion and entry put onto case records to ensure all required steps are undertaken to manage risk.

All staff to be reminded of the importance of applying the principles of routine enquiry during interactions with patients.

GYBC to work with partners to ensure that clearer guidance / training is provided by MASH and MARAC to all of its partner agencies to include:
a) An explanation of the roles and processes of the MASH and MARAC.
b) The correct referral route for staff to take when they have concerns about an individual to enable staff that work for these agencies to understand when to use each type of referral mechanism.
And that GYBC to work with partners to ensure that a clear differentiation between MASH, MARAC, etc. be provided to all partner agencies to enable staff that work for these agencies to understand when to use each type of referral mechanism.

Workshops to be held in each locality as part of local Integrated Governance Team Meetings to explore professional curiosity to ensure staff are confident to use proactive questioning to understand what is happening with an individual and or family.