Thematic Review

Message from the Independent Chair 

Following a media report in December 2023 into the care offered by Addison Court Care Home, Crawcrook the Gateshead Safeguarding Adult Board (GSAB) commissioned an independent thematic review into how Gateshead partners work to safeguard our communities.  This review is now complete, and the final report (PDF, 698 KB) and recommendations are available for public scrutiny. 

First and foremost, I would like to acknowledge what a difficult, distressing and upsetting time this has been for the residents and families of Addison Court, and I want to formally extend my thanks to them for their patience and support throughout the completion of the review.  

The review was completed under Section 44 of the Care Act whereby Safeguarding Adult Boards can arrange a Safeguarding Adult Review (SARs) for adults in its area with needs for care and support. The purpose of a SAR is to: 

• establish whether there are any lessons to be learnt the way in which local professionals and agencies work together to safeguard adults 
• review the effectiveness of safeguarding procedures 
• inform and improve local inter-agency practice 
• improve practice by acting on learning 
• highlight good practice 

This holistic review of safeguarding practice was commissioned to explore experiences thematically and it has drawn on information provided in respect of many residents but does not offer any commentary on individual cases. The aim was to provide an independent view on the robustness of safeguarding processes in Gateshead.  The report acknowledges that there were wider concerns raised within the original media report that are beyond the statutory remit of the GSAB, but these wider concerns are being investigated separately to the review by the appropriate agencies and authorities.  

The review was undertaken by Safeguarding Circle, which is a completely independent organisation to GSAB and any of its statutory and non-statutory partners. It was important to appoint fully independent authors to ensure openness and transparency. 

What did the report look at?

The six key lines of enquiry for the review were agreed by a panel of representatives from agencies across Gateshead, including GSAB statutory partners, advocacy providers and Healthwatch. They were to consider: 

1. The safeguarding adults' thresholds and triage processes in Gateshead  
2. The safeguarding adults' enquiry process
3. System wide assurance of care quality within residential care 
4. Strategic oversight of safeguarding and quality of care incident reporting  
5. Professional obligations to escalate concerns, 'speak up' and whistle blow 
6. The interface between requirement to undertake a safeguarding enquiry and learning lessons to improve safeguarding practice' 

What did the report find? 

There are a total of 8 recommendations within the report, which cover areas including; triangulation of information between partners to identify, action and monitor risk, provision of clinical and criminal expertise to support the safeguarding process and the development of guidance on the gathering and preserving of evidence, as well as how learnings from this review can be escalated to a national level to support the improvement of safeguarding to protect our communities across the country.  

What are the next steps? 

A multi-agency working group will be set up to take forward the recommendations from the review. The group will be chaired by myself Nicola Bailey, as the GSAB Independent Chair. Actions will be monitored via GSAB and its executive group, which is made up of senior management from the three statutory partners: the Local Authority, Health and Police.   I have also asked the Council Chief Executive to consider how this group can feed into the most senior officers locally in the police, ICB and the council itself.   

While we move forward with the actions, I want to take this opportunity to share that we took the issues raised by the media investigation very seriously. The subsequent review means the GSAB, and partners can learn from the findings and recommendations to improve safeguarding practice and processes in our area. This review serves to assure ourselves, residents, their families, and the wider population of Gateshead that we have independently reviewed the safeguarding actions undertaken at that time and that action will be taken and processes and practice will be improved as a result of this review. 

Nicola Bailey  

Independent Chair  

Gateshead Safeguarding Adults Board 

Gateshead SAB Thematic Review (PDF, 698 KB)