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Leicester Safeguarding Adults Board Annual Report 2022-2023


I was delighted in December 2022 to be offered the role of chairing the Leicester Safeguarding Adults Board (LSAB) and the Leicestershire and Rutland Safeguarding Adults Board (LRSAB). Partners have already impressed me with the commitment to people who use our services, and working together to make sure that we understand the profile of those adults at risk, and ensuring they receive the care, support and services they require when necessary.

Since taking up the role I have stated to make sure that I get out and about in the area to gain an understanding of the local issues. I am passionate about supporting the Board to constantly ensure that residents are at the centre of all that we do, and that our processes and procedures support this focus.

The subgroups that support the work of the Safeguarding Adults Boards have delivered a great amount this year which is all detailed in the Report; however, partners are aware we still have a lot of work to do. Currently we are looking at the information and data collected by partners across the Boards to see what this is telling us about the nature of safeguarding activity, so that we can consider how we prevent adults being in vulnerable situations which lead to them being at risk of abuse. It is also important where there are risks that we all work together to swiftly address any concerns highlighted. All partners want to ensure that we work, and make decisions that are evidence based, and take account of the people who use our services views and aspirations.

It is hard for people at the current time, with emergence from COVID 19 where isolation and loneliness is still a significant issue for many, and the pressures on households may continue in the foreseeable future with the fluctuations of economic pressures, which partners are all aware can add to stress within families, this at times can be very challenging.

I would like to thank all partners for their hard work and dedication and professionalism in working to support adults at risk and being open to continually looking to improve the services/support provided, and I look forward to continuing the work with them in the future.

I hope you will find that this Annual Report reflects well on the work of the Safeguarding Adults Board for 2022/23 as already highlighted and the challenges some of which remain for our communities.

The Safeguarding Adults Boards are currently reviewing their 5-year strategy and refreshing some elements of this, so that we focus on the issues that really matter in Leicester, Leicestershire, and Rutland, and we work to increase our ability to gain feedback from as many people as possible to inform future objectives.

We are also working with other partnership Boards, and the Health and Well Being Board to continue to coordinate across the area with regard to protecting and supporting any adult at risk, is safe from harm.

There is a lot that we need to do and want to do to reduce the risks of abuse and neglect in our communities and support people who are most vulnerable to these risks. This is a journey that we are all making together, and I look forward to chairing the Safeguarding Adults Boards in the next year to continue this journey.

Seona Douglas, LSAB Independent Chair

The Board

The main objective of a Safeguarding Adults Board is to assure itself that local safeguarding arrangements and partners act to help and protect adults in its area who meet the following criteria:

  • Adult has needs for care and support (whether or not the Local Authority is meeting those needs)
  • Adult is experiencing, or at risk of experiencing, abuse or neglect
  • As a result of their care and support needs, adult is unable to protect themselves

Leicester’s Safeguarding Adults Board (SAB) must seek to achieve this objective by coordinating and ensuring the effectiveness of each of its members in relation to adult safeguarding. We have a strategic role that is greater than the sum of the operational duties of our partners; we oversee and lead adult safeguarding across Leicester and are interested in a range of matters that contribute to the prevention of abuse and neglect.


Criminal justice

  • Leicestershire Police
  • HMP Leicester
  • National Probation Service, Leicestershire (NPS)

Emergency services

  • East Midlands
  • Leicestershire Fire and Rescue Service


  • Leicester, Leicestershire and Rutland Integrated Care Board (ICB)
  • Leicestershire Partnership NHS Trust (LPT)
  • University Hospitals Leicester NHS Trust (UHL)
  • NHS England

Local authority

  • Adult Social Care
  • Children's Social Care and Education
  • Housing
  • Community Safety
  • Trading Standard
  • Lead Member


  • Care Quality Commission (CQC)

Consumer champions

  • Healthwatch

Care home associations

  • East Midlands Care Association

As a partnership, Leicester Safeguarding Adults Board appoints an Independent Chair to oversee the work of the Board, provide leadership, offer constructive challenge, and ensure independence. To support consistency, alignment where appropriate, and a shared understanding of effectiveness across the two partnerships, our Independent Chair is shared with Leicestershire and Rutland Safeguarding Adults Board, as are a number of our sub-groups. The day to day work of Leicester Safeguarding Adults Board is undertaken by the sub-groups. The board office supports the operational running of these arrangements and manages the Board on behalf of the multi-agency partnership.

Safeguarding adults in Leicester

During 2021 Leicester’s population reached nearly 370,000 and Leicester was noted as the most densely populated local authority area across the East Midlands (Office of National Statistics, 2022). It is home to around 36 people per football pitch-sized piece of land.

According to the Office of National Statistics ‘In the latest census, around 213,600 Leicester residents said they were born in England. This represented 57.9% of the local population’. The 5 most common countries of birth for the population of Leicester in 2021 were England, India, South and Eastern Africa (other than Kenya, Somalia, South Africa and Zimbabwe), Poland, and Kenya.

In 2021, 43.4% of usual residents in Leicester identified their ethnic group as “Asian, Asian British or Asian Welsh” followed by 40.9% who identified themselves as “White”, 7.8% as “Black, Black British, Black Welsh, Caribbean or African”, 4.1% as “Other ethnic groups” and 3.8% as “Mixed or Multiple Ethnic Groups” (Office of National Statistics, 2022).

Along with every local authority area across the East Midlands, the 2021 Census for Leicester saw a decrease in the proportion of residents who identified as being “disabled and limited a lot”. This fall was from 11.5% of residents in 2011 to 8.8% of residents in 2021.

Just over half of the population of Leicester during 2021 were recorded as female (186,466) with just under half recorded male (182,115). 1649 people recorded their gender identity as different from sex registered at birth with no specific identity given, 437 people identified as trans women, 496 people identified as trans men, and 328 people were recorded as “all other gender identities”.

Safeguarding adults data for Leicester 2022/2023

An alert is made to raise concerns that an adult is experiencing, or at risk of abuse or neglect. An alert may arise as a result of a disclosure, an incident, or other signs or indicators. An alert can be raised by anyone including the person at risk, family, friends, professionals, and other members of the public. During 2022/23 in Leicester a total of 1,831 alerts were made relating to a total of 1,094 people. Where concerns are identified that require further investigation under s42 of the Care Act 2014, a safeguarding adults enquiry is initiated. This enables concerns to be addressed promptly, minimising risk. During 2022/23 in Leicester a total of 498 enquiries were made relating to a total of 464 people. In 27% of incidents risk was removed, risk was reduced in 61% of incidents, and in 12% of incidents risk remained. Where risk remained action plans were put in place. Making Safeguarding Personal outcomes were achieved 91% of the time.

Safeguarding enquiry data

  • When reviewing safeguarding enquiries by ethnicity over 70% of enquiries were made for people who identified their ethnicity as “White” with the next highest group being “Asian/ British Asian” which make up over 15% of the enquiries made with lower percentages labelled as “undeclared/ not known” (5%).
  • When looking at safeguarding enquiries by sex 45.3% identified as Male and 54.7% identified as Female.
  • In 66.9% of enquiries the abuse or neglect is reported to have taken place in the adult’s own home.
  • 1% of enquiries involved someone who was aged 65 an over, with 42.9% of enquiries involving someone between 18-64 years old.
  • When we analysed the safeguarding enquiries by the type of abuse Physical abuse was the highest at 27% with Psychological abuse being the second highest at 21%, then Neglect (14%), Domestic abuse (12%), Financial abuse (10%), Self neglect (8%) then “Other” making up the last 8% of enquiries.

Ongoing work continues to explore, understand and address disproportionality relating to ethnicity for S42 Safeguarding Enquiries in Leicester.

Meeting our strategic priorities

As a partnership, Leicester Safeguarding Adults Board outlined its strategic priorities in its five-year strategic plan which was published in 2020. Core priorities are ensuring statutory compliance and enhancing everyday business. Developmental priorities are strengthening citizen and carer engagement, raising awareness within our diverse communities, understanding how well we work together, and prevention (helping people to stay safe, connected, and resilient to reduce the likelihood of harm, abuse or neglect).

Our annual business plan priorities for 2022/23 were Hidden Harm and Care Homes.

Core Priority 1: Ensuring statutory compliance

Safeguarding Adults Boards have a statutory duty under S.44 of the Care Act 2014 to undertake safeguarding adults reviews (SARs) in circumstances which meet the criteria. The purpose of a review is to identify lessons to be learnt and to apply those lessons for the future.

During 2022/23 Leicester’s SAB received two new referrals but commissioned no new reviews. The LSAB’s Review Subgroup was satisfied that all the referrals received were appropriate referrals. This provides a level of assurance that partners are aware of our statutory duty in relation to SARs and are making referrals in line with that duty. For the purposes of transparency, a table of 2022/23 SAR referrals, decisions, and outcomes is provided:

SAR referrals and decisions 2022/2023

Case 1

Referral Date: September 2022

Date Referral Considered by the LSAB Review Subgroup: October 2022

Decision Made: The criteria for a mandatory SAR were not met. Whilst the individual had died, and there were some concerns about how members of the SAB worked together, it was not known or suspected that the death resulted from abuse or neglect. Causation was not evidenced. A LeDeR (Learning Disability Mortality Review) had taken place which identified learning.

Outcome: No SAR

Case 2

Referral Date: March 2023

Date Referral Considered by the LSAB Review Subgroup: April 2023

Decision Made: There was not reasonable cause for concern about how organisations worked together and therefore the criteria for a mandatory SAR are not met. There are ongoing investigations taking place and there is the option for the referral to be resubmitted should further issues arise.

Outcome: No SAR

During 2022/23 Leicester’s SAB concluded one SAR whist 5 remain outstanding. A decision has not yet been made about publication in relation to the one review concluded during 2022/23.

The Vulnerable Adult Risk Management (VARM) guidance is currently being revised in line with recommendations from the one review that has concluded. Throughout 2023/24 and until conclusion, Leicester SAB’s Review Subgroup will monitor progress of this work alongside other actions being taken in relation to all recommendations made in the review.

In addition to learning from our own local SARs, Leicester SAB’s Review Subgroup also considers learning from other SABs across the country and considers local impact and action required. During 2022/23 reviews considered by the group included:

Action taken locally having considered these reviews from other SABs included:

  • Sharing across the wider partnership, details of the Oliver McGowan Mandatory Training on Learning Disability and Autism
  • Exploration of local partnership forums where homelessness risks and complex issues would be considered
  • Assurance that questions had been explored previously locally through similar reviews
  • Learning shared across the wider partnership, with care homes quality meetings, within the Integrated Care Board (ICB), and with the mental health collaborative

This business year, Leicester also added its published reviews to the National Safeguarding Adult Review (SAR) library developed by the National Network for Chairs of Adult Safeguarding Boards.

The impact of this work is difficult to measure, and Leicester Safeguarding Adults Board is focusing on measuring impact during 2023/24.

Core Priority 2: Enhancing Everyday Business

Policies and Procedures:

Leicester Safeguarding Adults Board works with Leicestershire and Rutland Safeguarding Adults Board to maintain up to date inter-agency adult safeguarding policies and procedures across Leicester, Leicestershire and Rutland. These policies and procedures are hosted on our dedicated policy and procedures website called the MA PP (Multi Agency Policies and Procedures). Throughout 2022/23 these policies and procedures continued to be reviewed and updated in line with learning from reviews, audits, and best practice.

Updated chapters include:

  • A new chapter added on No Recourse to Public Funds
  • Resolving Professional Disagreements updated
  • Modern Slavery chapter updated
  • Mental Capacity chapter updated
  • Making Safeguarding Personal chapter updated
  • Disclosure and Barring chapter updated
  • The Care Act 2014 chapter updated
  • A new chapter added on Whole Family Approach
  • Safeguarding Adults Data Returns chapter updated
  • Best Interests chapter updated
  • Criminal Offences and Adult Safeguarding chapter updated

A full list of new chapters and amendments made can be found on the ’amendments’ page of the MAPP.

Training: Safeguarding adults multi-agency training has been provided throughout 2021/22 in line with business plan objectives. Training for Mental Capacity Act was rolled out across LLR, well established Mental Capacity Act forums have continued to run across the city for care home providers, a trainers’ network has been facilitated across LLR, and weekly briefings and quarterly newsletters have been published and circulated.

The SAB training subgroup is now LLR and has launched its YouTube channel, the first video developed and published is the ‘Tricky Friends’ animation for adults with learning disability and autism. This was followed by our ‘See Something Say Something’ awareness-raising video. A financial abuse task and finish group was set up in response to a previous multi-agency audit, and videos for practitioners were developed including interviews with the Office of the Public Guardian (OPG). A PowerPoint resource pack on ‘Professional Curiosity’ has also been produced and published in response to learning from our reviews.

A ‘building confidence in practice’ resource on professional curiosity was developed by the Training Subgroup in partnership with Leicester, Leicestershire and Rutland Safeguarding Children Partnerships and was published in March 2022. The resource pack aims to address Professional Curiosity so that practitioners can fully understand what it is and how to develop their skills when they are working with people whether they are children or adults. The expectation is that practitioners and managers will use it in team meetings, as part of a group/individual supervision, and for their own development. It has not been possible to determine how many times this resource has been accessed, and therefore the impact, but this is something that the SAB is working on with the use of a learning management system. Now this local resource is in place, training for managers around supporting professional curiosity in staff is in the process of being developed. This training will be in the form of videos that will then be promoted to managers across the partnership.

A regular trainers’ network has been facilitated, weekly briefings and regular Safeguarding Matters newsletters have been published, and the SAB’s YouTube channel has continued to develop.

This year, Safeguarding Matters Live was launched: a live online briefing for all staff across the children and adults multi-agency partnerships. The live briefings run online share learning from reviews and audits, procedure and guidance updates, and resources to support practice. The June 2022 briefing was attended by 289 delegates with the December 2022 briefing attendance increasing to over 500 delegates. The December 2022 session is available to watch on the Safeguarding Children Partnerships’ YouTube Channel.

Performance: The Performance Subgroup set up a new dataset for the Safeguarding Adults Boards (SABs). Returns are now being considered on a quarterly basis and exceptions reported into the SABs. A Safeguarding Adults Assurance Framework (SAAF) has been undertaken across the partnerships, with returns to be analysed at the start of the 2023/24 business year. The group also refreshed the Quality Assurance Framework (QAF).

Developmental Priorities 1 and 2: Strengthening user and carer engagement and raising awareness within our diverse communities

During this business year, the Leicester Engagement Subgroup updated its terms of reference to become the Leicester, Leicestershire and Rutland Engagement and Communication Subgroup. ‘What is Adult Safeguarding?’ briefings continued to be facilitated to Leicester’s local community members and groups.

“Adult safeguarding is complicated – this session has helped me to understand it better and know what help is out there, thank you” –  Delegate at an in-person information session on ‘what is adult safeguarding?’ (Paraphrased, not an exact quote)

Our “See Something Say Something” awareness campaign and video continued to be promoted with the video having reached 1,041 views by quarter one and over 1,500 views by the end of the business year. In November 2023 the Engagement and Communication Subgroup split this longer video into three shorter videos to make them more accessible on social media:

The Engagement Subgroup oversaw the SAB’s promotion of adult safeguarding during National Safeguarding Adults Week 2022 (15-21 November). This included an awareness campaign and promotion of the above safeguarding animations.

In response to the potential for exploitation, the local ‘Tricky Friends’ animation (adapted from Norfolk SAB’s animation) was translated into Ukrainian and promoted across the partnership.

Developmental Priority 3: Understanding how well we work together

The local information sharing agreement, shared between Leicester, Leicestershire and Rutland Safeguarding Children Partnerships and Safeguarding Adults Boards was updated throughout 2022/23 and re-published in April 2023.

Also see annual business plan priorities.

Developmental Priority 4: Helping people to stay safe, connected and resilient to reduce the likelihood of harm, abuse or neglect

See annual business plan priorities.

Annual Business Plan Priority: Care Homes

In relation to the SAB’s business plan objective involving Care Homes, a resource pack has been developed by the Training Subgroup for care providers. It highlights procedures, guidance, information and resources available to care homes, including:

  • A brief overview of the role of Safeguarding Adults Boards
  • Local Multi-Agency Policies and Procedures
  • Escalation guidance
  • Thresholds guidance
  • Causing enquiries to be made
  • Information about Leicestershire Social Care Delivery Group (LSCDG)
  • Safeguarding adults trainer’s network
  • Safeguarding matters newsletter
  • Our YouTube channel and resources
  • Social Care Institute for Excellence (SCIE)
  • Research in Practice for Adults (RiPfA)
  • Where to find our local, published safeguarding adults reviews
  • Free Mental Capacity Act Training
  • Our local basic safeguarding awareness resource for safeguarding children and adults

The resource has been added to the safeguarding section of the website. Oversight of the document remains with the LLR SABs Training Subgroup where it will be reviewed on an annual basis.

In addition, contracts and commissioning teams across Leicester, Leicestershire and Rutland Local Authorities and the Integrated Care Board (ICB) have reviewed the NICE safeguarding in care home guidance published in 2021.

Local escalation procedures have also been reviewed in line with NICE safeguarding in care home guidance.

A multi-agency audit on care homes was completed by the SAB’s Audit Subgroup. The audit focused on situations where there were 3 repeat safeguarding referrals/alerts for adults living in a care home within in a 6-month period (from 1st June 2021 to 1st December 2021).

Action required as a result of the audit included:

  • Training Subgroup taking forward Trauma Informed Practice as a training need relating to Safeguarding Adults.
  • Policy and Procedures Subgroup to develop a template letter to notify LPT to aid trauma informed practice and care planning around those who have made allegations.
  • Policy and Procedures Subgroup to review the ‘incident reporting’ procedure.
  • Policy and Procedures Subgroup to re-launch the ‘Causing Enquiries to be Made’ guidance, with additional information regarding the importance of timely information sharing.
  • Policy and Procedures Subgroup to consider guidance regarding information sharing with GPs.
  • Policy and Procedures Subgroup to consider the best way to reiterate with all professionals involved in Adult Safeguarding that contact with the Police regarding open cases should be via the Police Adult Safeguarding Hub, not 101.

All the above actions have either been successfully completed or remain in progress.

During 2022/23 the SABs received assurance on dementia care home oversight across Leicester, Leicestershire and Rutland with all three local authorities and the Integrated Care Board providing reports.

The Performance Subgroup collated data and assurance on safeguarding in care homes and provided its report to the March 2023 SAB meeting.

Annual Business Plan Priority: Hidden harm

Domestic Abuse Act

An update was provided to the June 2022 SAB about the Domestic Abuse Act local impact.

Domestic Abuse and Safeguarding Research Project

Initial findings from research project between LLR Safeguarding Adults Boards and Durham University were received at the start of the year, with a fuller update provided during March 2023. The research focuses on (i) perpetrators of domestic abuse and (ii) safeguarding older adults from domestic abuse. Leicester Safeguarding Adults Board is privileged to have been involved in this research, with learning identified that is likely to be important nationally. Full analysis and outcomes will be shared once the research has been published and, in the meantime, our 2023/24 business plan will focus on actioning areas of improvement and promoting best practice identified so far.

Multi-Agency Audit – Cuckooing

A multi-agency audit focusing on “cuckooing” was facilitated by the Audit Subgroup. A local Safeguarding Adults Review (Leicestershire and Rutland SAB, Person D, Published June 2022) identified that there was a gap in understanding the level of recording of cuckooing incidents locally.

Cuckooing is a practice where people take over a person’s home and use the property to facilitate exploitation. It takes the name from cuckoos who take over the nests of other birds. Locally we have produced Guidance for Working with Adults at Risk of Exploitation: Cuckooing.

The audit results identified that whilst cuckooing guidance had been produced and promoted locally, and there was good awareness locally of what cuckooing is, there was not much awareness of the existence of the local guidance. Despite this, there was good evidence of multi-agency working even though the cuckooing guidance was not being used. Eight learning points and actions were identified from the audit and these will be progressed during 2023/24.


The Engagement Subgroup has fed information on hidden harm from Leicester residents into the Performance Subgroup. The Performance Subgroup collated data and assurance on safeguarding and hidden harm and provided its report to the March 2023 SAB meeting.

Looking to 2023/2024

Looking to 2023/24 we are developing our annual business plan jointly with Leicestershire and Rutland Safeguarding Adults Board. It will be published alongside our strategic plan, on the ‘plans, reports, and strategies’ page of our web pages.

If you have problems accessing or viewing the annual report, please email

Appendix 2023-2024 LSAB structure chart

The Leicester Safeguarding Adults Board has 6 subgroups, 4 jointly governed with the Leicestershire and Rutland Safeguarding Adults Board, these are noted below:

Performance Subgroup (LLR)

Chair: Ruth Lake, Director Adult Social Care and Safeguarding, Leicester City Council.

Remit: Develops and oversees the Quality Assurance Framework (QAF) and undertakes the Safeguarding Adults Assurance Framework (SAAF) on behalf of the SABs.

Review Subgroup

Chair: Chris Baker, Detective Superintendent, Leicestershire Police.

Remit: Receives Safeguarding Adults Review (SAR) referrals and makes recommendations to the Independent Chair on behalf of the SAB. Oversees the commissioning and effective running of SARs. Considers local impact of national reviews.

Training Subgroup (LLR)

Chair: Alison Taylor-Prow, Designated Professional for Safeguarding Adults, LLR Integrated Care Board.

Remit: Facilitates multi-agency safeguarding adults training, seeks training assurance from partners, and oversees the Safeguarding Matters newsletter, the Trainers’ Network, and city Mental Capacity Act (MCA) Forums.

Engagement Subgroup (LLR)

Chair: Jo Dyke, Principal Social Worker, Leicester City Council.

Remit: Engages with the citizens and communities of Leicester city around adult safeguarding.

Audit Subgroup (LLR)

Chair: Griff Jones, Head of Service, Mental Health, Safeguarding and DOLS, Adults and Communities Department, Leicestershire County Council.

Remit: Undertakes multi-agency safeguarding adults audits in line with business plan objectives.

Policy and Procedure Subgroup (LLR)

Chair: Karen Stanton, Leicestershire Police.

Remit: Oversees and updates Multi-Agency Policies and Procedures (MAPP) in line with local and national learning and legislative changes throughout the year.

VSC Safeguarding Forum (LLR)

A new forum for the Voluntary and Community Sector across Leicester, Leicestershire, and Rutland, run jointly between the Safeguarding Adults Boards and Safeguarding Children Partnerships. facilitated by LLR business managers.