Page 26 - TSAB Adult B FINAL (1)

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c. TSAB should consider providing supplementary guidance for occasions when it is more
appropriate to cause others to make enquiries. (Learning Point 15)

d. TSAB should produce a learning briefing to remind all professionals of the effective use of the
safeguarding system to protect vulnerable individuals in need of care and support. The use of
the Professional Challenge Procedure should be included. Agencies should include
professional challenge in their single and multi-agency safeguarding training at all appropriate
levels. (Learning Point 13)

2. TSAB must seek assurance from local authorities and health trusts that there is clarity on any social
work roles outside of the Local Authority teams. This must include declaration of those with social
work roles, whether they are statutory or non-statutory roles, as well as supervision and management
responsibility for those roles. (Learning Point 14)

3. TSAB should produce a learning briefing regarding information about homelessness and the new
legislation as well as duty to refer for all agencies. The briefing should cover support and advocacy
that can be offered. (Learning Points 1, 2 &3)

4. Self-Neglect

a. TSAB must refresh and relaunch the Self Neglect Guidance, supported by an awareness raising
campaign with a focus on ‘non-typical’ self-neglect.

b. Agencies that have their own Self Neglect Policies should ensure it is congruent with the TSAB
Policy and guidance or adopt the TSAB Policy and Guidance.

c. TSAB, through its quality assurance role, should carry out multi-agency audits on self-neglect
cases to assess the success of the relaunch and learning from this SAR. Audit should include a
baseline audit followed by a further progress audit. Audits should cover evidence of
professional challenge and managerial oversight of complex cases.
(Learning Points 7-12)

5. TSAB should ask the relevant agencies to build on the current process and develop a shared protocol
for repeat attenders to the emergency department that is based on best practice and current
evidence of what works. The protocol should include

 Being inclusive of more agencies (including emergency services) in the initial phases to ensure
all information pertaining to the person is included
 Being outcome focussed
 Being person-centred
 Identification of different exit points or outcomes from sharing information such as a wider
multi-disciplinary team meeting or a safeguarding referral etc.
 Clear ownership
 Review dates and progress against plan.
(Learning Points 4, 5, 6, 9, 12 & 17)

6. In light of the learning from this and other local reviews, TSAB should seek assurance and an update
from commissioners of substance misuse services regarding progress to ensure that the contracting
and retendering process includes smooth transitions from one provider to another. Assurance is
needed that information is not lost, and that assessments and risks are transferred without the need
to immediately reassess. Length of contracts also needs consideration in order to reduce ongoing flux

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