1. Imogen Parry 18 th September 2014 Independent Safeguarding Adults Consultant, Researcher and Trainer for the Housing Sector Co-Chair Housing and Safeguarding Adults Alliance

2. 2 ‘The role of housing in preventing and addressing adult abuse is neglected in legislation, policy, practice and research’ Report of the joint committee on the draft Care and Support Bill, England March 2013, para. 163.

3.  A review of the circumstances of the death of a vulnerable adult if abuse or neglect was suspected  ‘The overriding reasons for holding a review must be to learn from past experience, improve future practice and multi-agency working’ (ADASS and LGA, 2013) 3

4.  Critiques of adult SCRs comment on their:  lack of: legal foundation, common format or threshold, obligation on agencies to cooperate  failure to disseminate learning  sometimes poor quality  Some previous attempts at thematic analysis of adult SCRs  No-one, as far as I know, has looked specifically at themes and lessons relevant to housing.... 4

5.  Only one quarter of 152 upper tier English councils had published SCRs on their websites  Out of 70 publicly available adult SCRs, 21 were relevant to housing (ie 30%)  Half the 21 subjects lived in specialist housing (or received specialist housing services), half lived in general needs housing  Thematic analysis identified 6 themes/lessons (A-F) 5

6.  BANES, 2013: ‘PQ’  Bucks, 2010: Mr B  Bury, 2010: ‘Adult A’  Cornwall, 2007, 2009: Steven Hoskin, JK  Coventry, 2012: Mrs C  Dorset,2013: JT  Leics, Leics and Rutland, 2008: Fiona Pilkington  Luton, 2011: Michael Gilbert  North Tyneside, 2011: Cynthia Barrass/Adult A  North Yorkshire, 2012: Robert  Sheffield, 2004: Margaret Panting  Southampton, 2012: Mr A  Stockport, 2011 : Martin Hyde  Sunderland, 2012: Mrs AM  Surrey, 2010, 2010: ‘CC’, 0001  Tameside, 2011: David Askew  Torbay, 2011: Ms Y  Warwickshire, 2011: Gemma Hayter  Worcestershire, 2010: A1 6

7. The ASB caseworker was commended for her ‘leadership and professionalism in dealing with a prolonged neighbour dispute involving several vulnerable tenants in close collaboration with colleagues in partner agencies’ 7

8. A. Poor data base of vulnerabilities (7 cases) B. Poor contract/support monitoring (6 cases) C. Narrow focus/poor understanding of safeguarding/not referring (12 cases) 8

9. ‘Commissioners cannot organise the improvement of services unless they know quite a lot about the people using them’ (The Information Governance Review, Dame Fiona Caldicott, 2013, p.14). 9

10.  Failure by landlords to record the vulnerabilities of all tenants was a contributory factor to the eventual death or serious harm of the 7 individuals  The reasons for these poor data bases included:  not understanding the nature of vulnerability  not asking the right questions  not recording the answers  not having an adequate IT system to record vulnerabilities.  In some cases, even where vulnerabilities were recorded, there were problems with the incompatibility of the data with other agencies’ systems. 10

11.  Missed opportunities by housing provider:  Rent arrears  Refusal to grant access for gas servicing  Garden maintenance issues  Housing provider was ‘reactive’, not proactive  Failure of systems to ensure follow up of the disconnection of gas, to insist on a home visit and to alert social services 11

12.  Landlord had no record of his vulnerabilities on their data bases – he couldn’t read but they kept writing to him about his noise nuisance  Important information about his vulnerability wasn’t transferred between housing agencies  ‘Warnings and missed opportunities’ 12

13.  Although most SCR discussion on contract monitoring focuses on failures by Adult Social Care (ASC), housing agencies can also be culpable.  The monitoring role of housing staff was often not made clear in the SCRs but this role is recognised in the Quality Assessment Framework of the Supporting People programme 13

14.  Mr B/Bucks – sheltered housing staff not given care plan, not officially able to support tenants (but rang him daily)  Mrs AM/Sunderland – contradiction re monitoring role of housing support agency  Mr A/Southampton – confusion between care, support and health support regarding respective roles Copyright Imogen Parry 14

15. Failure by housing staff to refer abuse or hate crime into safeguarding was a contributory factor in the deaths or serious harm of 12 individuals. 15

16. ‘All staff need to have a greater curiosity and enquiring approach about what they observe and to be aware when they need to pursue further information either directly with the individual or through other agencies’ (SCR concerning PQ, Bath and North East Somerset, para.24) 16

17. A narrow, uninformed focus by the housing provider Different definitions of vulnerability Erroneous belief that consent by the victim is always necessary Incorrect assumption that evidence is needed before making an alert or referral Inadequate policies regarding service refusal and insufficient understanding of the Mental Capacity Act 2005 Poor practice in offering accommodation to victims rather than addressing the abuse through safeguarding procedures. 17

18. D. Exclusion of housing from information sharing/ assessment/ monitoring (13 cases) E. Thresholds too high/ failure to capture low level concerns (7 cases) F. Problems with Adult Social Care: assessments (including risk, capacity); diagnosis; choice (18 cases) 18

19. ‘The duty to share information can be as important as the duty to protect patient confidentiality’ (The Information Governance Review, Dame Fiona Caldicott, 2013, principle 7, page 21). 19

20.  These cases illustrate, some very explicitly, that negative professional attitudes by ASC staff towards housing staff can be a factor in the exclusion of housing from partnership working and information sharing. 20

21.  The threshold issues in the 7 cases support the argument in favour of low thresholds that responding to low level concerns (that include harassment and disability hate crime) helps to prevent serious harm or death. 21

22.  Failures of assessment, diagnosis and multi- agency working were contributory factors to the death or serious harm of the individual.  Common themes included:  failures to assess capacity or risk; assumptions rather than assessments  the need for effective multi-agency working that led to holistic assessments (which were focused on the victims, not their families) 22

23.  Will the implementation of the Care Act in April 2015 make a difference to the quality of SCRs (to become Safeguarding Adults Reviews)?  Perhaps the new information sharing requirements will help, along with the requirement to commission and publish them?  How will you ensure that lessons from SCRs/SARs are learnt in your organisation? 23

24.  Please contact me:  to improve my three sets of tips  to pass on good practice  with any queries: email: imogen.parry@btopenworld.comemail: imogen.parry@btopenworld.com  References:  Parry, I. (2014) ‘Adult Serious Case Reviews: lessons for housing providers’ in Journal of Social Welfare and Family Law http://www.tandfonline.com/doi/full/10.1080/096490 69.2014.895506 http://www.tandfonline.com/doi/full/10.1080/096490 69.2014.895506  Housing and Safeguarding Adults Alliance www.housinglin.org.uk/AdultSafeguardingAndHousing 24