Bristol City Council: local authority assessment

National data from the Adult Social Care Survey for 2023/24 showed 91.04% of people who use services said those services have made them feel safe and secure. This was somewhat better than the England average (87.82%). However, national data from the Adult Social Care Survey for 2023/24 showed 63.43% of people who use services felt safe. This was worse than the England average (71.06%).

Staff involved in safeguarding work were suitably skilled and supported to undertake safeguarding duties effectively. A virtual Multi-Agency Safeguarding Hub (MASH) was introduced in November 2024 and was currently being piloted, running a minimum of 2 days a week, reviewing more complex cases with the final intention of every case going through the MASH. There was a Safeguarding Advice line in place which had widened its remit to support enquiries of potential safeguarding referrals. This supported the changes made to the safeguarding professionals referral form implemented to improve process following outcomes and findings from a safeguarding adults review.

Partners told us they queried whether there was a shared risk management model in place around safeguarding with partner agencies. Phase 2 of the MASH development was going to address this. Feedback from the local authority in relation to this was the MASH was a growing process that supported the regular sharing of safeguarding risk 'in real time' with multiple agencies. Risk was considered jointly as per the MASH Draft Standard Operating Procedure and actions agreed by multiple agencies.

Systems, processes, practices were in place to ensure people were protected from abuse and neglect. However, feedback was these still required some improvement. The Swift response team at the front door worked closely with the Safeguarding Team to ensure the most appropriate action was taken with referrals. Some staff told us they did not feel they always had the resources or time to do the work they would like to do. Decisions taken by partners agencies had an impact on their work, for agencies not always responding to mental health calls which created a knock-on effect.

Staff expressed some anxiety about how safeguarding risk was 'held' between the time the Safeguarding Team role ended (after triage of referrals) and the time the enquiry was allocated to a worker in a locality team. They felt more clarity was needed around this to ensure the risk continued to be well managed whilst people were waiting. Staff felt safeguarding was prioritised in locality teams, but this could be at the expense of other work and there was a currently a disconnect from the vision of the local authority and the reality of what happened at the front door. Feedback from the local authority was this was being addressed in the short term through the introduction of the safeguarding hub, and in the medium and longer term through the new target operating model.

The Organisational Safeguarding Team sat within the Safeguarding Team, undertaking section 42 enquiries relating to providers and organisational concerns, including related to persons in positions of trust. Established working relationships with key partners including the Police and the Care Quality Commission (CQC) were an integral part of the response provided by the team. In situations where there were concerns about widespread institutional abuse or a range of safeguarding issues accompanied any regulatory or other whole service performance failure, the local authority conducted a whole service performance failure investigation. This process was well established and contributed to the co-ordination of multi-agency efforts where there have been systematic failures.

The Keeping Bristol Safe Partnership strategy plan for 2023-26 outlined the vision and values for safeguarding which was the development of a culture that promoted good practice and continuous improvement, where agencies worked together in a timely and effective way and services delivered high quality support and care. A safeguarding adults procedures document supported staff practically in managing safeguarding referrals and cases correctly.

The local authority previously undertook a review of the Standard Operating Procedure for Safeguarding. The local authority recognised that since the COVID-19 pandemic safeguarding had become more complex and staff resources had reduced. Areas of concern included people were waiting too long, and decision making was compromised which challenged best practice. The local authority had set out an action plan to reduce these concerns at an operational level with a data review, case audits, reviews of capacity and training. They worked with staff and carried out internal audits in 2022-2023. Quality monitoring arrangements for safeguarding enquiries were in place. In April and May 2024 workshops were held for leaders and practitioners and subsequently a new quality assurance framework was developed.

Consistent feedback from a number of care providers was that communication could be better in relation to safeguarding as they often had to chase up outcomes. It could be difficult to get hold of certain staff at times and other staff did not seem to be able to update in their absence, which partners felt was a risk.

Information provided by the local authority in relation to safeguarding trends and themes documented that hidden and unheard voices were frequently overrepresented where risk was the highest. In the Joint Strategic Needs Assessment data there were high levels of substance misuse in Bristol, with the second largest estimated rate of opiate and/or crack users of the English core cities. There were 2,727 hospital stays in Bristol due to alcohol-related harm in 2022/23, a rate of 675.1 persons per 100,000 population. This remains significantly worse than the national average of 474.6 per 100,000.

There was a clear understanding of the safeguarding risks and issues in Bristol. Senior leaders told us the main area of risk was around Deprivation of Liberty Safeguards (DoLs) and people waiting, within that area, the risk over time had been greater. However, the overall trajectory around safeguarding waiting times was now reducing. Staff told us they saw a lot more self-neglect cases now however did not always feel they had resources to deal with those well and this was an area that needed more work. Safeguarding and equality, diversity and inclusion was also noted as an area for development. There had been some serious safeguarding cases involving people such as asylum seekers and other ethnically diverse groups, where staff felt they did not fully understand the nuances of these situations and therefore the impact on people.

Actions had been taken by the local authority to enhance safeguarding arrangements. For example, the local authority had developed three decision support tools to improve practice around intersectionality in safeguarding decision making. This came from a Safeguarding Adults Review learning which showed the local authority and partner agencies did not consider the layers of risk inherent in intersectionality, to inform protection planning. Intersectionality is a framework for understanding how people's social and political identities can result in unique combinations of discrimination and privilege.

The pilot of a financial protection lead officer in the Safeguarding Team had been successful and was now being extended. This role focused on prevention in relation to financial protection and staff worked in partnership with locality teams, reducing the risk of exploitation of people, for example, by using statutory functions such as appointeeship to prevent situations from escalating.

The local authority worked with partners to deliver a coordinated approach to safeguarding adults in the area. The Keeping Bristol Safe Partnership priorities relating to safeguarding adults included the implementation of a MASH arrangement which was underway, improve systems for safeguarding and managing risk to adults experiencing multi-disadvantage and complex needs, plus improving safeguarding for young adults. Feedback was partners were well engaged in the partnership, however more effective relationships could be developed, for example, with the Police and health partners. Also work tended to be mainly local authority led and other agencies could take a greater lead in some areas in relation to safeguarding.

Lessons were learned when people had experienced serious abuse or neglect with action taken to reduce future risks and drive best practice. Following a Safeguarding Adults Review, practice was updated to ensure other local authorities were notified when placements were made outside of Bristol. Safeguarding Adults Reviews were now taken to the Adult Social Care Policy Committee Chair’s Briefing which provided additional learning and scrutiny from members. A Safeguarding Risk and Assurance Meeting, chaired by the Chief Executive, and attended by directors from across children's, adults, housing and legal services met monthly where issues of safety were discussed across the city.

Staff told us they tried to keep informed of Safeguarding Adult Reviews and for example, now involved the fire service in discussions following recent incidents the local authority had learnt from. However, staff felt robust dissemination and clear evidence of learning from Safeguarding Adult Reviews could still be improved further across the directorate and they would welcome being able to undertake more learning.

Strategic safeguarding was now part of the Adult Social Care quality assurance framework (launched in April 2024). This included a listening audit where feedback was requested from people after a safeguarding intervention and used to create a feedback loop to make service improvements. Audits so far had taken place on intersectionality, repeat referrals and risk, and protection planning.

Partners feedback was generally positive about safeguarding in terms of the local authority response to risks and issues. Examples included concerns being easy to raise, staff were quick to respond, and they had confidence in the local authority's safeguarding systems and processes, that concerns would be dealt with thoroughly. Other partners were involved in regular safeguarding meetings and training. The local authority advised partners on identifying safeguarding issues, for example, in one case looking at issues around isolated people becoming radicalised. However, it was felt the local authority could not easily do any preventative work due to resources and changes around staff responsibilities. Some partners were involved in some joint working on how learnings from safeguarding could be fed up better to be considered at a system level and were committed to ensuring quality assurance was done in partnership across the system.

National data from the Adult Social Care Workforce Estimates for 2023/24 showed 29.20% of independent/local authority staff completed Mental Capacity Act and Deprivation of Liberty Safeguards (DoLS) training. This was worse than the England average (37.58%). National data from the Adult Social Care Workforce Estimates for 2023/24 showed 37.83% of independent/local authority staff completed safeguarding adults training. This was worse than the England average (48.70%). However, we did not find that staff understanding of the Mental Capacity Act 2005 or safeguarding was noted as an area of concern during our assessment.

Feedback from the local authority was that staff also completed optional training modules not included in this data, so the true training rates were higher. Data provided by the local authority stated 88% of adult social care staff completed compulsory safeguarding training in 2024 which was above the national average.

Whilst there were some evident improvements in safeguarding waiting times for people, there was further work to be done to continue this trajectory and maintain these improvements. In the last 12 months to 19 January 2025 there were 9,264 safeguarding concerns received which was a 12% increase from the previous year. The average waiting time to enquiry decision had reduced from 9 to 6 days. The number of people waiting for a safeguarding response had reduced by 44% from 970 in April 2024 to 506 in January 2025. The average number of days to allocate cases was 18. These improvements were in part due to the new safeguarding hub being implemented in February 2024.

The number of people awaiting a DoLS authorisation had also reduced by 17% in the last 12 months from 1007 to 831 people. The median period had reduced from 15 days in July 2024 to 12 days in January 2025. The local authority was using a nationally recognised prioritisation tool as part of their people waiting well strategy to monitor who was waiting and continually reprioritise where needed. The strategy and prioritisation system (including the prioritisation tool) supported authorisations for people at the highest risk at the right time. In the 12 months to 31 March 2024 there were 2233 DoLS decisions made. In January 2025 831 people were waiting for assignment and 138 were being assessed. Staff told us some DoLS were not person centred and the quality of referral forms and DoLS applications was sometimes an issue.

There was effective triaging of referrals combining a positive strength-based approach taken by staff. The introduction of a safeguarding hub had reduced safeguarding Section 42 enquiries within the locality teams substantially. Section 42 enquiries are the action taken by a local authority in response to a concern that a person with care and support needs may be at risk of or experiencing abuse or neglect. Staff worked with partners where relevant to produce good quality safety plans.

Staff told us there was a positive attitude from partners to engage with them and reduce risks for people. Although there were more limited staff resources available in some areas, for example, when working with care homes, which could cause delays at times. The Quality Assurance Team had a proactive role in safeguarding relating to providers. This included sharing intelligence to support safeguarding triage decisions and there was a Quality Assurance Officer dedicated to safeguarding activity. As well as providing intelligence or gathering additional information to support decision-making, they would carry out enquiry actions and work jointly with practitioners. Where enquiries were not required, the Quality Assurance Officer would support colleagues in their team to carry out monitoring activity and support providers to address safety issues.

Although feedback from some partners was that they did not receive updates on outcomes, other partners cited good communication with the local authority, describing the safeguarding team as understanding and knowledgeable.

The local authority had recognised there was work to do to ensure that the Making Safeguarding Personal (MSP) approach was embedded through systems and processes and monitored at the first stage of people’s journey, from referral, through to team level. The forms used to record safeguarding activity were being amended to support this approach with plans to use the local authority quality, improvement and performance board to focus on assurance. Staff practice, supervision and team management, as well as independent audits and listening exercises, were also utilised to embed this further.

Staff told us the safeguarding team worked in a person-centred way and championed human rights. Their focus was to ensure people’s best interests were kept at the heart of everything they did. They used creative means of communication where necessary, for example, the use of drawing to support people to be involved in the safeguarding process if they could not communicate by other means. MSP was considered with each case and meaningful. When cases were allocated, leaders considered who would be best placed to support the person considering factors such as continuity and whether they had worked with a social worker before.

Social Workers worked from a strengths-based approach. We found evidence case recording was thorough and proportionate to the risks identified, whilst remaining in line with the person's wishes and preferences. The person's voice and aspirations were clearly documented in the assessment and review process with evidence of a positive relationship between the social worker and person in records.

Staff told us about instances of how people’s preferences or voice was not always considered in decision making, for example, in relation to deprivation of liberty safeguards (DoLS) however they had challenged this. For example, in a situation where a young person was objecting to their support and a DoLS had not been applied for. This resulted in the young person’s voice not being heard through the DoLS process. However, staff worked within the principles of the Mental Capacity Act 2005, assuming capacity until they met the person to carry out a further assessment.