Report evidence summary
Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised. 28
East London NHS Foundation Trust Use established joint-working forums for practitioners to discuss service-user mental-capacity concerns.
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East London NHS Foundation Trust Provide quarterly safeguarding supervision to every Trust team through Named Safeguarding Professionals.
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East London NHS Foundation Trust Remind staff to discuss carer self-referral or make carer-assessment referrals on carers’ behalf when concerns arise.
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East London NHS Foundation Trust Remind Newham Community Health Services staff to follow the internal safeguarding escalation pathway and escalate barriers without waiting for monthly forums.
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East London NHS Foundation Trust Implement monthly joint safeguarding meetings, safeguarding forums and escalation processes between Trust and local authority services.
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East London NHS Foundation Trust Deliver quarterly safeguarding adults training for Newham Community Health Services staff, including guidance on completing high-quality referrals.
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East London NHS Foundation Trust Remind community health staff during safeguarding supervision about support from the Mental Capacity Act Lead for necessary cross-body escalations.
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London Borough of Newham Create and circulate an anonymised seven-minute briefing on lessons learned from the case across Adults and Health staff groups.
View source
London Borough of Newham Review all current direct-payment users with double-handed care packages for indicators of under-utilised care.
View source
London Borough of Newham Convene a multi-disciplinary shared learning event with ELFT staff to explore the case themes from clinician and practitioner perspectives.
View source
London Borough of Newham Jointly review information provided to families and informal carers about pressure care, risks and exacerbating factors with ELFT.
View source
London Borough of Newham Maintain enhanced direct-payment monitoring through increased monitoring capacity and six weeks of setup support for recipients and representatives.
View source
London Borough of Newham Review the Direct Payment Policy and develop practice guidance and a practitioner checklist covering capacity, best interests, double-handed care, hospital discharge, quality concerns and safeguarding thresholds.
View source
London Borough of Newham Complete and submit the section 44 Safeguarding Adult Review referral for consideration by the Safeguarding Adults Board subcommittee.
View source
London Borough of Newham Share case themes with the borough’s Mental Capacity Act Oversight Group.
View source
London Borough of Newham Assign action-plan accountability to named senior officers and monitor progress against timescales through the Practice and Workforce Development Team, reporting to the Quality and Governance Board.
View source
London Borough of Newham Implement a defined process for third-party fund managers to escalate personal-assistant sourcing issues to the Council within specified time bands.
View source
London Borough of Newham Publish newly created public-facing carer videos and improved information resources.
View source
London Borough of Newham Review meeting attendance to consider involving the Council’s Safeguarding Adults Team in safeguarding discussions.
View source
London Borough of Newham Update carer definitions, recording processes and frontline documentation under the borough’s established all-age Carers Strategy and delivery board.
View source
London Borough of Newham Develop specific Mental Capacity Act training for occupational therapy staff through peer learning and a separately planned formal training session.
View source
London Borough of Newham Convene reflective-practice sessions for frontline operational staff on professional curiosity, cultural needs and risk management in light of the case.
View source
London Borough of Newham Add mandatory pressure-care refresher training, including reporting, notification and safeguarding interfaces, to the 2024/25 training plan for operational adult social care staff.
View source
London Borough of Newham Review and improve Mental Capacity Act training and refresher provision for all adult social care professional groups.
View source
London Borough of Newham Roll out refresher carer-awareness training for all frontline adult social care staff.
View source
London Borough of Newham Enhance the AzeusCare system so double-handed care packages are prominent and reportable, first considering local flags or form questions pending supplier development.
View source
London Borough of Newham Develop guidance for frontline adult social care staff on informal and family carers and safeguarding adults.
View source
London Borough of Newham Maintain regular safeguarding meetings between ELFT Community Health Newham and Council neighbourhood teams to address referral quality, thresholds and recurring safeguarding themes.
View source
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to formally assess mental capacity
Wider context from the report “1. From October 2023 until her death in March 2024, Regina Ademiluyi was deprived of the state-funded domiciliary care to which she was entitled. The NHS Trust and local authority responsible for her care during this period failed to ensure effective care was provided in the following ways;
a. A safeguarding report submitted by NHS district nurses was insufficiently detailed to reflect the concerns that had developed regarding the deceased. The content of the safeguarding report did not trigger the threshold to investigate the matter further.
b. When faced with the limited information within the safeguarding report the local authority did not seek further information or clarification from the Trust on the basis of the report.
c. The Trust failed to formally assess Mrs Ademiluyi’s mental capacity , had they done so it is possible that an IMCA would have been appointed to act as her voice, over-ruling her daughter’s views which may have resulted in effective care being put in place.
d. Despite the concerns raised regarding the behaviour of Mrs Ademiluyi’s daughter no effort was made to offer a carers assessment to address whether she was overwhelmed by the task in hand.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Insufficiently detailed safeguarding reports failing to trigger further investigation
Wider context from the report “1. From October 2023 until her death in March 2024, Regina Ademiluyi was deprived of the state-funded domiciliary care to which she was entitled. The NHS Trust and local authority responsible for her care during this period failed to ensure effective care was provided in the following ways;
a. A safeguarding report submitted by NHS district nurses was insufficiently detailed to reflect the concerns that had developed regarding the deceased. The content of the safeguarding report did not trigger the threshold to investigate the matter further.
b. When faced with the limited information within the safeguarding report the local authority did not seek further information or clarification from the Trust on the basis of the report.
c. The Trust failed to formally assess Mrs Ademiluyi’s mental capacity, had they done so it is possible that an IMCA would have been appointed to act as her voice, over-ruling her daughter’s views which may have resulted in effective care being put in place.
d. Despite the concerns raised regarding the behaviour of Mrs Ademiluyi’s daughter no effort was made to offer a carers assessment to address whether she was overwhelmed by the task in hand.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure to offer a carers assessment in response to concerns about carer capacity
Wider context from the report “1. From October 2023 until her death in March 2024, Regina Ademiluyi was deprived of the state-funded domiciliary care to which she was entitled. The NHS Trust and local authority responsible for her care during this period failed to ensure effective care was provided in the following ways;
a. A safeguarding report submitted by NHS district nurses was insufficiently detailed to reflect the concerns that had developed regarding the deceased. The content of the safeguarding report did not trigger the threshold to investigate the matter further.
b. When faced with the limited information within the safeguarding report the local authority did not seek further information or clarification from the Trust on the basis of the report.
c. The Trust failed to formally assess Mrs Ademiluyi’s mental capacity, had they done so it is possible that an IMCA would have been appointed to act as her voice, over-ruling her daughter’s views which may have resulted in effective care being put in place.
d. Despite the concerns raised regarding the behaviour of Mrs Ademiluyi’s daughter no effort was made to offer a carers assessment to address whether she was overwhelmed by the task in hand.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure of the local authority to seek further information or clarification from the Trust
Wider context from the report “1. From October 2023 until her death in March 2024, Regina Ademiluyi was deprived of the state-funded domiciliary care to which she was entitled. The NHS Trust and local authority responsible for her care during this period failed to ensure effective care was provided in the following ways;
a. A safeguarding report submitted by NHS district nurses was insufficiently detailed to reflect the concerns that had developed regarding the deceased. The content of the safeguarding report did not trigger the threshold to investigate the matter further.
b. When faced with the limited information within the safeguarding report the local authority did not seek further information or clarification from the Trust on the basis of the report.
c. The Trust failed to formally assess Mrs Ademiluyi’s mental capacity, had they done so it is possible that an IMCA would have been appointed to act as her voice, over-ruling her daughter’s views which may have resulted in effective care being put in place.
d. Despite the concerns raised regarding the behaviour of Mrs Ademiluyi’s daughter no effort was made to offer a carers assessment to address whether she was overwhelmed by the task in hand.
” Is this part of a recurring concern? No recurring-concern membership is currently published.
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.
PFD Monitor interpretation Failure of the local authority to undertake meaningful significant event analysis of care failings
Wider context from the report “2. Despite the death of Mrs Ademiluyi’s occurring in the spring of 2023 no meaningful reflection or remediation had been undertaken by the Local Authority into the failings in care by the time of the inquest almost a year later. It was suggested by the legal representative of local authority that the inquest hearing itself was the extent of the significant event analysis undertaken by their professional client.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use established joint-working forums for practitioners to discuss service-user mental-capacity concerns.
Verbatim wording from the response “12. I asked the Trust’s Mental Capacity Act Lead to explore issues surrounding Ms Ademiluyi’s capacity. They confirmed that in-line with the provisions of the Mental Capacity Act 2005 (the ‘MCA’) the Trust is only the decision-maker in relation to decisions pertaining to her health care. The social care provider (LBN) is responsible for assessing capacity in relation to care and support needs.” Source location Response from East London NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide quarterly safeguarding supervision to every Trust team through Named Safeguarding Professionals.
Verbatim wording from the response “9.2. Each of the Trust’s Named Safeguarding Professionals meets with every single team within the Trust for quarterly supervision. This case has been considered in the most recent supervision.” Source location Response from East London NHS Foundation Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind staff to discuss carer self-referral or make carer-assessment referrals on carers’ behalf when concerns arise.
Verbatim wording from the response “Carer’s Assessment” Source location Response from East London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind Newham Community Health Services staff to follow the internal safeguarding escalation pathway and escalate barriers without waiting for monthly forums.
Verbatim wording from the response “11. Additionally, Newham Community Health Services staff have been reminded of the Trust’s internal escalation pathway which they are expected to follow when there are concerns about the safeguarding process between public bodies during supervision. The escalation pathway is a tool to support staff with recognising their” Source location Response from East London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement monthly joint safeguarding meetings, safeguarding forums and escalation processes between Trust and local authority services.
Verbatim wording from the response “8. The Named Professional, the Lead Nurse and LBN have implemented arrangements to improve collaborative working and developed processes to escalate any drifting delays and/or cases with significant level of risk. These are as follows:” Source location Response from East London NHS Foundation Trust
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver quarterly safeguarding adults training for Newham Community Health Services staff, including guidance on completing high-quality referrals.
Verbatim wording from the response “9. Whilst the detail in the safeguarding referral was not the reason the safeguarding concern was not investigated further; the Named Professional agrees that it provided insufficient information. To ensure this does not occur again, the following training and supervision has been arranged for Community Health Services staff in Newham area:” Source location Response from East London NHS Foundation Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind community health staff during safeguarding supervision about support from the Mental Capacity Act Lead for necessary cross-body escalations.
Verbatim wording from the response “14. Furthermore, Newham Community Health Services staff have been reminded, during their quarterly safeguarding supervisions, about the support offered by the Trust’s Mental Capacity Act Lead (the “MCA Lead”). The MCA Lead also supports practitioners with necessary escalations across public bodies.” Source location Response from East London NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Create and circulate an anonymised seven-minute briefing on lessons learned from the case across Adults and Health staff groups.
Verbatim wording from the response “1.3 Convene focussed reflective practice sessions for frontline operational staff based around circumstances highlighted in Mrs Ademiluyi’s care, thematically orientated around “professional curiosity” and “cultural needs vs. risks” (reinforcing the message that risk management comes first). | Strategic Safeguarding, Practice and Workforce Development Team | December 2024
1.4 Creation of an anonymised ‘7 minute briefing’ note concerning the lessons learned from this case for circulation across all Adults and Health staff groups at LBN. | Strategic Safeguarding, Practice and Workforce Development Team | June 2024” Source location Response from London Borough of Newham
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review all current direct-payment users with double-handed care packages for indicators of under-utilised care.
Verbatim wording from the response “Action: | By who: | By when:
2.1 Desktop reviews of all current DP users with double-handed packages for indicators of under-utilisation of care.” Source location Response from London Borough of Newham
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Convene a multi-disciplinary shared learning event with ELFT staff to explore the case themes from clinician and practitioner perspectives.
Verbatim wording from the response “double incontinence). Alongside this we are eager to convene a shared learning event with multi-disciplinary staff from across both organisations to explore the themes identified in Mrs Ademiluyi’s case from a clinician/practitioner perspective. These discussions are being progressed separately with our counterparts at the Trust.” Source location Response from London Borough of Newham
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Jointly review information provided to families and informal carers about pressure care, risks and exacerbating factors with ELFT.
Verbatim wording from the response “We also intend to work with ELFT to jointly review the information provided to families and informal carers about pressure care, the associated risks and exacerbating factors (for example, friction and” Source location Response from London Borough of Newham
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain enhanced direct-payment monitoring through increased monitoring capacity and six weeks of setup support for recipients and representatives.
Verbatim wording from the response “Through 2022/23 work took place to review and improve DP monitoring processes with a series of changes coming into effect from August 2023. This included an increase to the number of established posts for DP Monitoring Officers. This has allowed for faster feedback to operational teams on any future monitoring issues/irregularities.” Source location Response from London Borough of Newham
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the Direct Payment Policy and develop practice guidance and a practitioner checklist covering capacity, best interests, double-handed care, hospital discharge, quality concerns and safeguarding thresholds.
Verbatim wording from the response “In addition to this, the new DP set up process provides additional ‘hand holding’ support for the first 6 weeks to ensure that DP recipients and their representative(s) fully understand how to utilise their DP. | Direct Payments Team | End of May 2024
2.2 Undertake a review of the Council’s Direct Payment Policy, and develop associated practice guidance (including a practitioner checklist). This will encompass:” Source location Response from London Borough of Newham
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete and submit the section 44 Safeguarding Adult Review referral for consideration by the Safeguarding Adults Board subcommittee.
Verbatim wording from the response “Action: | By who: | By when:
1.1 Immediate s.44 Safeguarding Adult Review (SAR) Referral completed and submitted for presentation at the next SAR subcommittee of Newham’s Safeguarding Adults Board on 7th May 2024 | Team Manager Neighbourhood Team | 27.03.24
1.2 Review and improve training and awareness of pressure care and risks for ASC staff. This will include:” Source location Response from London Borough of Newham
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share case themes with the borough’s Mental Capacity Act Oversight Group.
Verbatim wording from the response “Action: | By who: | By when:
3.1 Improve consistency of MCA practice and decision making in the context of best interest decisions which override family where appropriate (including the use of Independent Mental Capacity Advocacy). This will encompass:” Source location Response from London Borough of Newham
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assign action-plan accountability to named senior officers and monitor progress against timescales through the Practice and Workforce Development Team, reporting to the Quality and Governance Board.
Verbatim wording from the response “The Directorate Management Team (DMT) for Adults and Health and the departmental Quality and Governance Board have been sighted on the action points identified here. All elements of the full plan are now linked to named senior officers with accountability for their delivery. Oversight of the action plan is being held by the Practice and Workforce Development Team who will monitor progress against the stated timescales and then report back to the Quality and Governance Board. We also recognise that the overall plan will need to remain agile and be adapted if further information comes to light, particularly if Mrs Ademiluyi’s case is the subject of an independent Safeguarding Adults Review (SAR).” Source location Response from London Borough of Newham
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a defined process for third-party fund managers to escalate personal-assistant sourcing issues to the Council within specified time bands.
Verbatim wording from the response “2.3 Implement a defined process for 3rd Party Fund Managers to escalate issues relating to PA sourcing to LBN, within specified time bands. | Direct Payments Team | July 2024
2.4 Enhancements to be made to the AzeusCare case management system to make double-handed care packages more prominent for system users and reportable. The longer-term solution will require development from the software supplier; in the short term other local options are being considered including flags and additional question(s) in core forms. | Head of Brokerage and Transaction Management | December 2024” Source location Response from London Borough of Newham
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Publish newly created public-facing carer videos and improved information resources.
Verbatim wording from the response “In addition, a suite of new public-facing videos and improved carer information resources have been created. These will go live in May 2024.” Source location Response from London Borough of Newham
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review meeting attendance to consider involving the Council’s Safeguarding Adults Team in safeguarding discussions.
Verbatim wording from the response “In addition to this summary of internal action, we also recognise that further activities need to be considered with our system partners at East London NHS Foundation Trust (ELFT). Regular Safeguarding meetings have now been established between ELFT Community Health Newham and the Council’s Neighbourhood Teams for Older People and Disabilities (mirroring the same processes which are in place in Mental Health services and have been shown to be successful in improving communication between professional groups). This space will be used to address issues such as the quality of referrals, thresholds and reoccurring safeguarding themes. Attendance at these meetings will also be reviewed to consider involvement from the Council’s Safeguarding Adults Team who are responsible for screening referrals.” Source location Response from London Borough of Newham
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update carer definitions, recording processes and frontline documentation under the borough’s established all-age Carers Strategy and delivery board.
Verbatim wording from the response “Action: | By who: | By when:
4.1 An all-age Carers Strategy is in place for the borough and overseen by a multi-agency delivery board. Further work has taken place through 2023/24 to update carer definitions, improve recording processes and enhance documentation used by frontline staff with carers.” Source location Response from London Borough of Newham
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop specific Mental Capacity Act training for occupational therapy staff through peer learning and a separately planned formal training session.
Verbatim wording from the response “• Developing specific training interventions for Occupational Therapy staff regarding the application of the Mental Capacity Act in practice – this has been planned as a topic for the borough’s cross-organisational OT Peer Learning session in May 2024. A separate formal training date is being planned. | Principal Occupational Therapist” Source location Response from London Borough of Newham
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Convene reflective-practice sessions for frontline operational staff on professional curiosity, cultural needs and risk management in light of the case.
Verbatim wording from the response “1.3 Convene focussed reflective practice sessions for frontline operational staff based around circumstances highlighted in Mrs Ademiluyi’s care, thematically orientated around “professional curiosity” and “cultural needs vs. risks” (reinforcing the message that risk management comes first). | Strategic Safeguarding, Practice and Workforce Development Team | December 2024
1.4 Creation of an anonymised ‘7 minute briefing’ note concerning the lessons learned from this case for circulation across all Adults and Health staff groups at LBN. | Strategic Safeguarding, Practice and Workforce Development Team | June 2024” Source location Response from London Borough of Newham
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Add mandatory pressure-care refresher training, including reporting, notification and safeguarding interfaces, to the 2024/25 training plan for operational adult social care staff.
Verbatim wording from the response “Action: | By who: | By when:
1.1 Immediate s.44 Safeguarding Adult Review (SAR) Referral completed and submitted for presentation at the next SAR subcommittee of Newham’s Safeguarding Adults Board on 7th May 2024 | Team Manager Neighbourhood Team | 27.03.24
1.2 Review and improve training and awareness of pressure care and risks for ASC staff. This will include:” Source location Response from London Borough of Newham
Open published response
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and improve Mental Capacity Act training and refresher provision for all adult social care professional groups.
Verbatim wording from the response “Action: | By who: | By when:
3.1 Improve consistency of MCA practice and decision making in the context of best interest decisions which override family where appropriate (including the use of Independent Mental Capacity Advocacy). This will encompass:” Source location Response from London Borough of Newham
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out refresher carer-awareness training for all frontline adult social care staff.
Verbatim wording from the response “An updated round of refresher training on carer awareness for all frontline ASC staff is being rolled out in May 2024. | Carers Strategy Delivery Board | End of May 2024
4.2 Develop specific guidance for frontline ASC staff on informal/family carers and Safeguarding Adults. | Strategic Safeguarding, Practice and Workforce Development Team | End of June 2024” Source location Response from London Borough of Newham
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enhance the AzeusCare system so double-handed care packages are prominent and reportable, first considering local flags or form questions pending supplier development.
Verbatim wording from the response “2.3 Implement a defined process for 3rd Party Fund Managers to escalate issues relating to PA sourcing to LBN, within specified time bands. | Direct Payments Team | July 2024
2.4 Enhancements to be made to the AzeusCare case management system to make double-handed care packages more prominent for system users and reportable. The longer-term solution will require development from the software supplier; in the short term other local options are being considered including flags and additional question(s) in core forms. | Head of Brokerage and Transaction Management | December 2024” Source location Response from London Borough of Newham
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop guidance for frontline adult social care staff on informal and family carers and safeguarding adults.
Verbatim wording from the response “An updated round of refresher training on carer awareness for all frontline ASC staff is being rolled out in May 2024. | Carers Strategy Delivery Board | End of May 2024
4.2 Develop specific guidance for frontline ASC staff on informal/family carers and Safeguarding Adults. | Strategic Safeguarding, Practice and Workforce Development Team | End of June 2024” Source location Response from London Borough of Newham
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain regular safeguarding meetings between ELFT Community Health Newham and Council neighbourhood teams to address referral quality, thresholds and recurring safeguarding themes.
Verbatim wording from the response “In addition to this summary of internal action, we also recognise that further activities need to be considered with our system partners at East London NHS Foundation Trust (ELFT). Regular Safeguarding meetings have now been established between ELFT Community Health Newham and the Council’s Neighbourhood Teams for Older People and Disabilities (mirroring the same processes which are in place in Mental Health services and have been shown to be successful in improving communication between professional groups). This space will be used to address issues such as the quality of referrals, thresholds and reoccurring safeguarding themes. Attendance at these meetings will also be reviewed to consider involvement from the Council’s Safeguarding Adults Team who are responsible for screening referrals.” Source location Response from London Borough of Newham
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The safeguarding referral’s insufficient detail did not cause the investigation failure; LBN’s backlog delayed the safeguarding enquiry.
Verbatim wording from the response “6. According to LBN, the referral was screened according to their own internal safeguarding policy and the Trust was advised that it met threshold for the Section 42 safeguarding enquiry. However, LBN is managing a backlog of such referrals. Therefore, it was not addressed before Ms Ademiluyi’s sad death. Please refer to LBN’s response to this Regulation 28 report.” Source location Response from East London NHS Foundation Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation An IMCA would be unlikely because statutory involvement generally concerns serious medical treatment or a new permanent residence.
Verbatim wording from the response “15. It is unlikely that an IMCA would be appointed in this situation. According to sections 37-39 of the MCA, the statutory requirement for the IMCA to be involved relates to situations when the matter pertains to the serious medical treatment or the care plan involves a new, permanent place of residence.” Source location Response from East London NHS Foundation Trust
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PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation LBN, not the Trust, is responsible for assessing capacity concerning social care and support needs.
Verbatim wording from the response “12. I asked the Trust’s Mental Capacity Act Lead to explore issues surrounding Ms Ademiluyi’s capacity. They confirmed that in-line with the provisions of the Mental Capacity Act 2005 (the ‘MCA’) the Trust is only the decision-maker in relation to decisions pertaining to her health care. The social care provider (LBN) is responsible for assessing capacity in relation to care and support needs.” Source location Response from East London NHS Foundation Trust
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