From November 2019, the Care Inspectorate has received and reviewed initial and significant case reviews undertaken and submitted by adult protection committees across Scotland.

Initial case reviews set out how adult protection committees consider information relating to a case involving an adult at risk of harm, determine the actions required and recommend whether a significant case review or other response is required.

An adult support and protection significant case review is a means for adult protection committees to learn lessons from reviewing the circumstances where an adult at risk has died or been significantly harmed. Undertaking these reviews enables committees to keep their procedures and practices under review. They provide information and advice to various public bodies and help or encourage the improvement of skills and knowledge of employees across the adult support and protection sector.

The Care Inspectorate’s triennial report of these reviews highlights the following key messages:

• Neglect and self-neglect were the most prominent categories of harm identified. While there was evidence some partnerships were responding to these issues, more needed to be done nationally.
• The circumstances of those affected by mental health and substance misuse were most frequently considered in reviews. Health and social care partnerships should carefully consider this to inform future trauma informed improvement activity.
• Reviews did not routinely share information with, or include the views from, people with lived experience or their families/unpaid carers.
• Poorly planned hospital discharges were a significant feature in some reviews. This requires consideration and improvement across health and social care.
• Learning potential was maximised when frontline staff were involved in review processes.

Next steps for the adult support and protection sector should include the development of a national pool of well trained and skilled reviewers, the implementation of a national toolkit for good practice in conducting a review and establishing a co-ordinated approach to address the recurrent thematic issues identified in this report. The Care Inspectorate will continue to disseminate learning and learning review overview reports will be published annually.

Jackie Irvine, Chief Executive of the Care Inspectorate, said: “We thank adult protection committees for their engagement in this review process. Key areas for development have been identified and should provide a solid basis for ongoing development. We have outlined a number of next steps which should inform the national adult support and protection improvement plan. Progress should continue, to ensure adult protection review processes are as robust as child protection arrangements.”

The full report can be read here

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