Abstract
In 2016, the Health and Social Care Institute Adult Safeguarding Collection data indicated care homes are a setting of high risk of harm to adults. This research study considers the outcomes of a sample of 11 Serious Case Reviews into the abuse of adults in the care setting. Its purpose is to help identify professional practice messages that might lead to the prevention of harm in care homes for the future. Serious Case Reviews have recognised a weakness in safeguarding practice relating to the way in which practitioners have dealt with safeguarding events. In all the reviews, the practitioner response was observed to be one that focused on the individual harmed. There was an absence of regard to the wider picture of cumulative concerns, showing a worrying pattern of provider failure leading to the death or serious injury of further residents. In response it is proposed adult social care professionals consider a systems approach to safeguarding in the care home environment. Implementing a holistic view of the home that includes a data intelligence system to signify when there are cumulative concerns that could indicate the need for actions to prevent escalation to greater harm for adults.
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