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Thematic Learning from Case Reviews – Adult Neglect

Date: Monday, 04th Mar 2024 | Category: Adults

Dudley Safeguarding People Partnership are undertaking a monthly thematic learning dissemination, which provides an opportunity for staff and partner organisations in Dudley to be made aware of the key learning from our quality assurance activity and case reviews along with offering information in relation to this learning.

During February, the focus has been on Adult Neglect as this has been a recurring theme in our children’s reviews.

How do we review multi agency practice and share learning?

DSPP seeks to promote a culture of continuous learning and improvement across the organisations that work together to safeguard and promote the welfare of children and adults, identifying opportunities to draw on what works and promote good practice

Our thematic learning plan is one of the ways we share learning to improve practice.

Adult Neglect Strategy

At the beginning of the month DSPP launched our Adult Neglect Strategy, which provides a comprehensive framework to guide our collective efforts in addressing adult neglect.


Please view our Adult Neglect Posters:

DSPP have developed a Flowchart to assist in making safeguarding adult referrals in Dudley, in addition to this please view the Adult Safeguarding Procedures for more information.

Within the local Inter-agency Adult Procedures prior to the Care Act 2014 there was provision for the conduct of Large Scale Investigations (LSIs) in situations where there were concerns about widespread institutional abuse or a range of safeguarding issues accompanied by regulatory or other failings.  This framework for responding to organisational failure or abuse gives an overview to ensure safe service provision and prevent organisational failure. Please also view the Large Scale Investigations Procedure for more information.

The Position of Trust Framework is available on the West Midlands Regional Adult Safeguarding Information Hub. Use the Dudley Position of Trust Process Flowchart and  PIPOT Referral Form to make a referral if there are allegations and concerns against people working with adults with care and support needs.

Making Safeguarding Personal toolkit The fourth edition of the MSP practice toolkit, produced in January 2020, outlines an approach to and effective application of safeguarding, alongside a range of resources and practice based case examples.

The Mental Capacity Act 2005 (MCA) is designed to protect and empower people who may lack the mental capacity to make their own decisions about their care and treatment. It applies to people aged 16 and over.

Training and Resources

The below DSPP courses are directly linked to the findings of our reviews:

Safeguarding Adults and when to refer to Adult Social Care

To raise awareness of the different types of abuse regarding adults with care and support needs can experience, who abuses, where abuse can take place and to offer support and guidance for making Safeguarding Adult Referrals, including providing a greater understanding of what is required in a Safeguarding Referral

Book your place here

Trauma Informed Practice

The training will equip practitioners:

  • To develop understanding of the theory and concepts behind the potential impact of ACEs and trauma across the life course
  • To understand what trauma-informed and trauma-responsive practice looks, sounds and feels like.
  • To gain a basic understanding into how an organisation can begin a journey towards a trauma-informed organisational culture. The session is structured to return to key ideas and reinforce core messages as take home learning.

Book your place here

Professional Curiosity

This Multi-Agency training course will increase practitioner’s knowledge and confidence in practising ‘respectful uncertainty’ by thinking outside the box’, beyond their usual professional role, and considering individual’s and families’ circumstances holistically. It will also be an opportunity to explore how as professionals differences of opinion, concerns and issues that arise for practitioners at work and are resolved as effectively and swiftly as possible

Book your place on this course here


To raise awareness of the different types of abuse adults with care and support needs can experience, who abuses, where abuse can take place and how to report concerns.

Access the eLearning here

This training has been designed to support your understanding of Mental Capacity Act and Deprivation of Liberty Safeguarding.

The knowledge that you will get from this course will help you understand the how to help people who may lack mental capacity and the implications of Deprivation of Liberty. It will help you to ensure that you are safeguarding their rights.

Access the course here

Safer7 Briefings

Seven minute briefings are based on a technique borrowed from the FBI. It is based on research, which suggests that seven minutes is an ideal time span to concentrate and learn. Learning for seven minutes is manageable in most services, and learning is more memorable as it is simple and not clouded by other issues and pressures. 

As part of the Thematic Learning from reviews we have promoted our Safer7 briefings which are directly linked to the findings of our reviews:

Self-neglect is defined as covering a wide range of behaviours – neglecting one’s personal hygiene, health or surroundings and includes behaviour such as hoarding.

Examples of self-neglect include:

  • Lack of self-care
  • Lack of care of one’s environment
  • Refusal of services that would lessen the risk of harm

View more here

The MCA 2005 applies to everyone over 16 years who may lack capacity to make specific decisions about their life. These decisions can range from simple, everyday things to more complex life changing matters such as where they live or receiving treatment.

The MCA protects the rights of individuals by creating a framework for decision making where someone may lack the mental capacity to make the decision for themselves.

View the MCA Safer7 here

Executive function is an umbrella term used to describe a set of mental skills that are controlled by the frontal lobes of the brain. When executive function is impaired, it can inhibit appropriate decision-making and reduce a person’s problem-solving abilities.

Professionals assessing capacity in this patient group are faced with a number of obstacles that make determination of capacity more challenging. This can have significant implications because failing to carry out a sufficiently thorough capacity assessment in these situations can expose a vulnerable person to substantial risk.

Access the briefing here

‘Think Family’ in safeguarding refers to the collaborative
approach outlined in the Working Together 2023 and
the Care Act 2014.

View more on this here

Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as harmful or life threatening. While unique to the individual, generally the experience of trauma can cause lasting adverse effects, limiting the ability to function and achieve mental, physical, social, emotional, or spiritual well-being.

View more here

Professional curiosity is having the capacity and communication skill to explore and understand what is happening with a child, adult with care and support needs or their family. It is about enquiring deeper and using proactive questioning and challenge. It is about understanding one’s own responsibility and knowing when to act, rather than making assumptions, or taking things at face value.

Access the briefing here

Sharing information is crucial to safeguarding children and adults – poor information sharing is repeatedly highlighted as an issue in CSPRs and SARs.

The most important consideration is whether sharing information is likely to safeguard and protect the child or adult with care and support needs.

View more here