Where next for adult safeguarding in the HSE?

By Catherine Reilly - 03rd Jun 2022 | 451 views

There have been serious staffing deficits in the specialist adult safeguarding team covering Co Donegal, where the HSE’s governance and oversight of disability centres has been under scrutiny. Catherine Reilly reports on continuing gaps in adult safeguarding resourcing, policy, and law.

Critical staffing deficits in the HSE adult safeguarding and protection team (SPT) covering Co Donegal, during 2020 and 2021, are revealed in documents obtained by the Medical Independent (MI).

On 3 June, Community Healthcare Organisation (CHO) 1 informed MI that the referenced deficits had been addressed. This newspaper had sought comment on a number of occasions since 26 April*.

The resource shortfalls that have affected the SPT are particularly concerning in light of the HSE’s inadequate governance and oversight of disability centres in Co Donegal, as outlined by HIQA in a review published in April. 

HIQA’s review followed “recent serious concerns regarding safeguarding” in a HSE residential centre in Co Donegal and “ongoing concerns regarding the sustainability of effective governance arrangements” in the area. Inspectors found “the supervision and governance of centres from middle management and senior management was poor”. 

Since the commencement of regulation of residences for people with disabilities in 2013, HIQA’s Chief Inspector had raised concerns about the HSE’s governance and oversight in CHO 1 (Cavan, Donegal, Leitrim, Monaghan, and Sligo). While improvements had occurred in Co Sligo, there has been “an ongoing requirement for escalated action” in relation to centres in Co Donegal. 

HIQA has now commenced a programme of inspections in Co Donegal to assess implementation of a HSE action plan. Minister of State for Disability Anne Rabbitte has proposed an independent review of adult safeguarding in disability centres in Donegal, but no further details have been released. 

SPTs 

CHO 1 has one SPT established under a 2014 HSE adult safeguarding policy in social care. There are nine SPTs nationally, which provide expertise in adult safeguarding within their CHO. Under the 2014 policy, HSE and HSE-funded disability and older persons services are required to submit safeguarding concerns (‘preliminary screenings’) to the SPT for specialist review and support. It remains the responsibility “of all staff and services to take action to ensure the protection and welfare of vulnerable people”. 

SPTs review safeguarding plans and directly manage complex cases and community referrals, as well as providing training on safeguarding issues. However, they operate in the absence of primary adult safeguarding legislation and under a policy that has been inconsistently interpreted and implemented nationally. 

Furthermore, as noted in a HSE business case in 2021, “there has been no ring-fenced investment in adult safeguarding since the initial establishment of safeguarding [and] protection teams in 2016,” despite rising caseloads. 

The SPT in CHO 1 sought three temporary replacement posts for social workers in February and April 2021. If these posts were not approved “concerns of abuse will not be assessed leading to high-risk situations”, outlined the business cases. The three posts “were never filled”, according to an internal email from an SPT staff member in March 2022. The records were obtained under Freedom of Information (FoI) legislation.

Documents also stated a social work team leader was acting up as a principal social worker (PSW).

On 3 June, CHO 1’s spokesperson stated: “The posts mentioned above have now been filled.” They added:  “The PSW post has been permanently replaced.  There is a PQSW [professionally qualified social worker] acting up into the social work team leader role in Sligo/Leitrim.  The social work team leader post in Donegal has been filled.”

A social care risk register for the SPT (dating from 2021) showed that risks related to staffing were ongoing. The SPT had been operating at 75 per cent capacity since March 2020 due to staff “redeployment”, according to a risk entered in September 2020 and due for review in early 2021. There was a risk of the SPT “not being able to continue to provide a cohesive service across CHO 1 if staffing falls any further due to leave or illness of remaining staff”. A “contingency plan” was in place. 

On 28 June 2021, another staffing risk was recorded, which was due for review on 3 July 2021. It read: “Due to 50 per cent reduction in staff there is a significant risk that the safeguarding team may not be in a position to provide a cohesive service across CHO 1. We currently have no staff in Donegal and have lost .5 of our staff in Cavan/Monaghan. 

“This will result in a delay in responding to safeguarding notifications… and may result in the establishment of a waiting list of notifications….” The control measures included staff covering Sligo/Leitrim extending cover to Donegal. The PSW was “pursuing additional staff urgently”, including two whole-time equivalent (WTE) replacement posts and two WTE new posts. 

According to CHO 1’s spokesperson: “These posts are now filled.” Asked how many staff had been redeployed during the pandemic, the spokesperson responded that two staff members from the SPT had been redeployed for approximately one year – one PSW and one clerical officer grade III staff member. 

The spokesperson said there have been two risks added to the risk register in 2022.  “One relates to the introduction of the assisted decision making legislation and the other is in relation to reduction in working hours for the team due to the Haddington Road Agreement.” 

The SPT was able to respond promptly to abuse concerns and had no waiting list, according to the spokesperson.

Backlogs 

As well as lack of investment, the SPTs are not resourced relative to referral rates. This has led to extraordinary pressures on some teams and increased risk of abuse and harm for adults at risk of abuse. 

The SPT in Dublin South, Kildare and West Wicklow (DSKWW) – CHO 7 – receives around 20 per cent of national safeguarding referrals. This workload has not been reflected in funding allocations despite appeals from successive PSWs and numerous risk assessments and business cases. 

By late 2020, due to these deficits, 1,812 alleged abuse cases submitted by services had not been examined. Some of the cases dated to June 2019. The team also had 1,626 safeguarding plans dating to 2016, which it had been unable to examine, as reported by MI last year. 

By autumn 2021, the SPT had made significant inroads on addressing the unreviewed cases, despite ongoing resourcing challenges and the cyberattack. While some agency resourcing had been provided, this arrangement was fragile. In September 2021, the backlog of preliminary screenings was approximately 600 dating to January 2020, and 1,636 safeguarding plans dating to 2016. 

A risk register dated November 2021 referred to “risk of harm” to adults at risk of abuse “due to inadequate number” of safeguarding social workers to provide timely access to appropriately trained professionals to case manage, investigate allegations, and deliver training, etc. 

In the same month, a status report on safeguarding operations in DSKWW outlined: “Our PSW is of the view that this CHO requires 16 funded social work posts in order to ensure the current service can operate without a backlog. The CHO is currently funded for 10 and there are recruitment and retention difficulties which are further impacting on this. In January without urgent support to improve staffing there will be one staff member available for duty and the PSW has informed us that the backlog will grow again….” 

The partially redacted report, prepared at the request of the National Director of Community Operations, added: “There is little doubt that the current resources of the safeguarding team will not allow them to address the backlog. Additionally, it would seem that recent attempts to provide time limited funding hasn’t resolved the longstanding issues. The team need to fill all of their funded posts urgently and it would seem that additional funded posts are now needed to ensure the team can match demand and capacity going forward.” 

In late January 2022, a DSKWW spokesperson said the SPT had reviewed the “historic backlog” of preliminary screenings. However, there remained an “historic backlog” of 1,784 unreviewed safeguarding plans, which dated as far as April 2016. The spokesperson acknowledged staffing levels “do impact the length of time that cases are open in the community” and that priority was given to cases where an individual was at immediate risk of harm. 

As of May 2022, the SPT still had only 10 funded posts. DSKWW did not specify how many posts were filled. 

“In the safeguarding team, agency posts are also approved in order to support the service when staff leave,” said the DSKWW spokesperson. “In addition to the 10 funded social work posts, the service has recently been allocated a business manager and two additional social work posts. In addition the National Director of Community Operations has committed to the provision of a senior resource to address the backlog and provide a future needs analysis.” 

The SPT was “in general” processing all preliminary screenings within a week of receipt. The backlog of safeguarding plans was approximately 1,572 as of 9 May. 

“There is no waiting list at present in the community or delays in providing intervention,” added the DSKWW spokesperson.

Long-term solution 

Commenting after the HSE’s partial publication of the Brandon review in December, CEO Mr Paul Reid said it had introduced “dedicated safeguarding resources and procedures”. 

However, the HSE had emphasised in communications with the Department of Health that current adult safeguarding resources and procedures were far from adequate. 

The referral rates to SPTs had increased annually with “no corresponding increase in capacity”, stated an amended HSE adult safeguarding business case dated 16 August 2021. 

The business case was submitted by HSE Community Operations to the Department of Health following recommendations from the Covid-19 nursing homes expert panel in August 2020. 

“Current capacity simply cannot meet pre pandemic demand and this has resulted in the development of backlogs in some areas, particularly the East of the country. While these have been responded to and addressed with interim measures such as agency staffing – the backlogs indicate a system beyond capacity and requiring a long-term solution.” 

Due to 50 per cent reduction in staff there is a significant risk that the safeguarding team may not be in a position to provide a cohesive service across CHO 1 

The HSE business case also noted that SPTs “have experienced issues in the past in accessing residents in long-term care and, therefore, there is a large population of the most vulnerable in this society who must be afforded the protections provided by the safeguarding service”. There is no legal or contractual obligation on private nursing homes to cooperate with the safeguarding teams. 

The business case proposed that a social work team leader and social worker be included in each of nine new community support teams (CSTs) for nursing homes. 

It also outlined: “The safeguarding protection teams require additional social worker capacity to meet the demands from the HSE and voluntary sectors, support the CSTs and wider community safeguarding.” 

“Ensuring responsive safeguarding operations is critical to risk reduction – particularly in the absence of any primary safeguarding legislation in the State, a matter of ongoing concern to the HSE.” 

The 18 social worker posts for the CSTs were approved as part of Budget 2022. A Department spokesperson told MI: “These new resources will enhance the HSE’s safeguarding and protection teams in each CHO and will be assigned to work with the new CSTs, having a particular focus on the non-HSE residential care services.” 

New HSE policy 

A revised HSE adult safeguarding policy, which is intended to extend to all of health and social care, has remained in draft since 2019. 

Some of the flaws in the operation of the current policy were described in the Report of the Working Group on the Role of Social Workers (September 2019). The working group was comprised of Forsa and HSE representatives with an independent Chair. It aimed to “clarify” the role of social workers in the safeguarding process, “cognisant of the need for an integrated approach to reporting, assessment, and management.” 

The key issues raised included no specific national policy for HSE divisions outside of social care and that interpretation and implementation of the 2014 policy “created challenges in respect of the reporting, assessment and management of allegations of abuse”. There was a need for clarity around “the issue of thresholds throughout the safeguarding process”. 

Furthermore, social workers in primary care asserted that they were being directed, in some cases, by members of SPTs to assess and manage safeguarding abuse concerns where the adult at risk of abuse met the criteria for referral to the SPT (which primary care social workers deemed contrary to their code of ethics and employment terms and conditions); social workers in all care divisions highlighted “challenges similar to those identified” by the primary care social workers; and there was an assertion that SPTs were specialist social work teams. 

The group found an inconsistent approach to implementation of the safeguarding policy, inconsistent development and resourcing of social work services across HSE divisions nationally, and social work job descriptions not being reflective of current service requirements. “All social workers are committed to implementing best practice in respect of adult safeguarding,” it stated. 

The working group recommended legislation to support the adult safeguarding process and implementing a national adult safeguarding policy covering all HSE divisions. It said social workers were best placed to be the lead profession in implementing the policy and a “dedicated social work resource needs to be provided to ensure implementation across all HSE divisions”. This could take the form of SPTs being resourced to provide a service to all divisions or providing additional social work resources within each division to specifically implement adult safeguarding. 

The group stated that “staffing levels need to reflect the workload and complexity of providing a robust and comprehensive safeguarding and protection service nationally”. 

However, the revised HSE draft policy has presented further concerns. It introduces new roles of ‘safeguarding manager’ and ‘safeguarding coordinator’, but lacks clarity as to who would assume such positions in clinical settings. It suggested a more distanced role for the SPTs. A 2020 position paper on adult safeguarding by the Irish Association of Social Workers (IASW) stated: “While the IASW agrees that it is essential that all health and social care professionals can identify risk and abuse, it is also vital that adults experiencing abuse and harm have direct access to the expertise of frontline safeguarding social work professionals.” 

Speaking to MI in January 2022, Ms Chris Cully, Assistant General Secretary at Forsa, said: “Safeguarding is everybody’s responsibility, but there are certain responsibilities that should remain the domain of social workers from a statutory, advocacy point of view.” 

She said subject to negotiations, there could be more safeguarding case co-working between social workers in different settings, but also between social workers and other healthcare professionals, in the future. 

This month, a Forsa spokesperson said there had been “no further update to the unions from the HSE and no meetings have taken place with us”. 

MI asked the HSE about the timeline for implementation of the new policy and whether there would be any revisions to the draft policy prior to publication. A HSE spokesperson said: “A revised HSE policy will be finalised and implemented aligned with Sláintecare reforms and the Department of Health future policy on adult safeguarding. In addition, there will be engagement with staff representatives on the detail of the implementation plans.” 

The HSE National Service Plan 2022 stated that current safeguarding operations “remain under resourced to fully meet the increasing demand for adult safeguarding in social care, and a requirement to extend safeguarding operations to all HSE provided and funded services. 

“In 2022, the risk will be mitigated by the provision of a case management system and increasing the capability of all staff to recognise and respond to risk of abuse of adults in order to maximise the effectiveness of current capacity. 

“The future of safeguarding operations will need to be considered in the context of the operating model of community healthcare networks and the design of integrated healthcare areas during 2022.” 

New Department policy 

Meanwhile, the Department of Health is “at an advanced stage” of developing a national policy on adult safeguarding for health and social care. It will apply to all public, voluntary, and private health and social care settings and agencies under the Department’s remit. 

A spokesperson commented: “The Department is now preparing for a formal public consultation exercise and a costing study anticipated to occur in Q3 2022, with a view to submitting a costed draft policy to Government for approval and, thereafter, preparing any legislation required to underpin the approved policy. 

“The extent of underpinning legislation will be determined once the final policy has been drafted; the anticipated vehicle for this underpinning legislation is the Health (Adult Safeguarding) Bill.” 

The costing study will consider the resource requirements of implementation. It was “reasonable to presume that this will influence the 2023 estimates process”, stated the spokesperson. 

“Any request for additional funding through that process will be informed by engagement between the Department, the HSE and the Department of Public Expenditure and Reform, and is required to take into consideration the overall funding envelope.” 

The commencement of adult safeguarding legislation in health and social care would be a step forward. However, a number of key organisations, including the IASW and Safeguarding Ireland, have emphasised the need for a whole-of-society legislative framework, including an independent safeguarding authority in adult safeguarding. 

The Law Reform Commission is due to publish a regulatory framework for adult safeguarding before the end of the year. 

*This article was updated on 3 June to include comment from CHO 1.

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