Adult support and protection: learning review guidance

4. Undertaking the Learning Review

A systemic approach

This guidance is not prescribing a model for undertaking a Learning Review as it is recognised that APCs have a variety of review models that work well for them. However, it is important to emphasise that a Learning Review is a collective endeavour and that, whilst the detail of how a review is undertaken may vary, all reviews must adopt a systemic approach. Such an approach goes beyond individual or professional practice to explore underlying systemic factors, the links with organisational factors and the wider contexts.

The central idea is that any professional's performance is a result both of their own skills and knowledge, and of the organisational setting in which they are working. A Learning Review, therefore, must focus on understanding how people saw things at the time, why things happened as they did, what belief systems were operating and how capabilities and capacity were affected by the roles and positions adopted by family members and other professionals, together with the emotional impact of the work and the resources available.

An effective systemic model has the following components:

• it is truly participatory and collective, involving all relevant professionals, managers, agencies, and the adult and their family where appropriate. All participants in the Review contribute to the critical reflection and analysis of the situation under review and the development of strategies to support practice and improve processes and systems across agencies
• it adopts an analytical and evidence-based approach
• there is an appreciation that learning is not something 'done' to people but rather

something that people themselves do and own

• it takes learning to a deeper level by examining systems, structures, and cultural and contextual factors
• it explores the interrelated and interdependent parts of different services and agencies and the impact this has had on the lived experience of the adult who is the subject of the review
• it explores how user friendly systems are for adults at risk of harm, as well as for professionals
• it considers legislative, social policy and societal systems as well as local policy and practice
• it does not focus solely on what went wrong but also includes an examination and analysis of effective practice
• learning does not just come at the end of the Review once the report is published, there is a 'thread of learning' throughout the review process. The learning develops with each Review Team meeting and professionals' event, as hypotheses are formulated and tested, and issues identified and explored
• the learning from a Review is disseminated and implemented in practice and in systems at both a local and a national level

The Review Team

When a decision has been made to proceed to a Learning Review the first step is to set up a Review Team. The Review Team manages the process of the Review and is a multi-agency group whose members should have a working knowledge of the relevant services involved in supporting adults at risk of harm. Consideration must be given to ensuring a group size that is conductive to learning and joint working. The number and composition of the Review Team will be specific to each case and there may be situations where the initial membership will need to be adjusted after the first meeting of the Review Team, based on a better understanding of the situation under review. Nevertheless, efforts should be made to ensure consistent participation of all members throughout the Review and to keep membership changes to a minimum.

Good practice and sound governance dictate that only in unusual circumstances should a review team member have been directly involved in the case under consideration, have been overseeing the work within the case, or have been directly engaged in meetings with the lead reviewer(s).

It is the Review Team's responsibility to ensure the Learning Review remains proportionate and focused and is conducted in accordance with the underlying principles and values set out in this guidance.

The Review Team works together within a culture of collaborative problem solving to review and assess all information available; clarify issues for further exploration and to identify any gaps or deficiencies in the information available to the Review. The Review Team brings to the task the ability to reflect; to analyse and to look at the wider impact for practise and service delivery.

The Review Team consists of the separate roles of:

• the Chair
• team members
• the Reviewer(s)
• the Administrator

The role of the chair of the Review Team

The key components of the role of the Review Team Chair are to:

• Consider whether there are parallel processes ongoing i.e. criminal proceedings/FAI.
• Coordinate the identification and engagement of the relevant partners and suitable contributors to the Learning Review
• Coordinate the work of the Review Team
• Ensure that a clear and realistic timetable for the review process is set out and is adjusted where and when needed
• Ensure timely requests are made for key documentation relevant to the Review from organisations involved in the situation under review and to follow up instances when that information is not provided in a timely manner
• Chair and facilitate meetings of the Review Team
• Contribute to the development of the learning emerging through the review process
• As appropriate, meet with family members and attend practitioner and manager events alongside the Reviewer
• Provide regular updates as required to the APC and COG

The role of the Review Team members

Members of the Review Team have an important role to play in the process and outcome of the Learning Review and therefore, it is important that they manage and prioritise different work demands so that sufficient time is allocated to the Review.

The main aspects of the role of Review Team members are to:

• Attend the meetings of the Review team
• Contribute to the collection and collation of information throughout the Review
• Identify any gaps or deficiencies in the information available to the Learning review and seek to remedy this
• Act as an interface between their service or organisation the Learning Review Team, contributing to all practical aspects of the Review that are required from their service or organisation
• Identify those professionals within their service or organisation who will be part of the Review
• Help participants to feel informed and supported when they enter the Review, as well as throughout and at the end of the review process
• Contribute to the identification of emerging themes and issues
• Participate in the verification, interpretation and analysis of the information
• Assist in the drafting of the Review report by critical and constructive appraisal

The role of the Reviewer

The essential elements of the Reviewer's role are to:

• Work collaboratively and transparently with the Review Team Chair and members
• Attend the meetings of the Review Team
• Review and assess all information available to develop a full and multi-faceted understanding of the case
• Interpret and analyse the workings and shortcomings of complex, multi-agency systems
• Effectively facilitate group work and manage complex group dynamics
• Facilitate practitioner and manager events so that;
  • Participants understand the purpose of the Review as well as the underpinning principles and values of Learning Reviews
  • Trust is established between participants
  • All participants can voice their views in a safe manner
  • Discussion, debate, probing, and constructive challenge are encouraged
• Use a range of participatory and creative approaches to obtain the views and experiences of adults as risk of harm and their families/carers
• Pull together the learning and write the report, with the advice and guidance of the rest of the Review Team

In some circumstances it may be appropriate to have two Reviewers. For instance, if a case is particularly complex, or sometimes as a means of increasing the competence and confidence of someone new to the role of Reviewer. When there is more than one Reviewer it will be important that they work closely together and agree how tasks will be allocated. One person should be assigned the role of Lead Reviewer.

The role of the Administrator

To support and coordinate the Learning Review process it is essential that high quality administrative support is in place. The Administrator is an important member of the Review Team and the key aspects of this support role are to:

• Administer meetings and events that are part of the Review, including scheduling Review Team meetings, booking venues, and supporting with other associated practicalities.
• Take minutes and notes of Review Team meetings and practitioner and manager events
• Support the communications of the Review Team, including collating, distributing and storing documents and information as required

Skills, attributes, experience, and knowledge

The skills, attributes, experience and knowledge associated with the various roles within a Review Team will be dependent on the nature of the Review and the requirement of the Adult Protection Committee and Chief Officers Group. A person specification for the lead reviewer is attached at Annex 5.

Enabling Factors within the wider context

A supportive Chief Officers Group, including the active engagement of the Chief Social Work Officer, is an essential enabling factor in ensuring that Learning Reviews are effective and fulfil their purpose. This means the Chief Officers Group taking ownership of and a constructive interest in the review process, findings and learning, with a strategic level commitment to implement the actions and learning stemming from the Review.

The APC will need access to resources to support the Learning Review process. This will be negotiated as appropriate at a local level according to the needs of the particular review. Staff time must be made available to the Learning Review process. The APC may wish to consider additional supports that may assist the Review process; this could include (but is not limited to) a Communications Subgroup and/or a supervisor or mentor for the Lead Reviewer(s).

Terms of reference

Terms of reference are a guiding statement which define the scope of the Learning Review. Terms of reference should reflect the rationale for undertaking a Review and be relevant and specific to the situation under review. Based on the information knows at the time, proposed terms of reference will have been drawn up at the point a recommendation is made to the APC to proceed with a Learning Review. It should be noted that terms of reference are a living document and, once the Review is underway, may need to be amended as further information is collated by the Review Team. The APC should be informed of and be in agreement with any changes to the terms of reference.

The final terms of reference will be included in the Learning Review report at the completion of the Review.

Collecting and collating further information

The preparation of single agency chronologies is an important first step in the collection and collation of further information. The decision about how far back to go in terms of the time frame preceding the incident will be dependent on the situation under review.

However, in the interests of proportionality, timing, and timeliness the guiding principle must be that chronologies cover as short a timeline as possible. In most instances two to three years preceding the incident should be sufficient. If agencies and services have been involved with the adult for many years, then a brief summary of that earlier involvement should be prepared.

Chronologies might not necessarily conclude at the point of the precipitating incident. Sometimes the responses of agencies in the immediate aftermath will provide useful learning and should be part of the Learning Review.

Once single agency chronologies have been complied, they will be merged, thus providing an overview of the situation from which issues can be identified and questions developed in order to begin to explore what happened in the situation under review. Information on systems, structures, and cultural and contextual factors will also be explored in order to enhance the overview of the situation.

As the Review progresses gaps in information will emerge and it is the responsibility of Review Team members to facilitate the gathering of any additional information or access to other pertinent documents.

Managing emerging issues and challenges during the Review

There may be instances, when, during the course of a Learning Review, an issue arises that may challenge or confuse or add further complexity to the review. If this should happen it is important that the Terms of Reference are revisited, potentially leading to pausing the review process in order that the Review Team consider sources of advice and an appropriate strategy for moving forward. If it is likely that an issue or challenge will delay the review reaching the conclusion, then the APC and the COG must be informed.

Engaging the adult and family in the Review process

A Learning Review is a collective endeavor to bring together agencies, individuals, and families to learn from what has happened in order to better protect adults at risk of harm. As in many instances the family are likely to be integral to Learning Reviews, the Review Team must consider how to involve them in the process in a meaningful and sensitive way.

The purpose of engaging with the family is to explore their perspective and to elicit their opinions about the practitioners and services who were involved in the lives of the adult. This will include what they found helpful or unhelpful and their suggestions for how services could be improved. Their thoughts, opinions and feelings contribute to the overall learning. The adult and any family and relevant carers should be informed as soon as possible that a Learning Review is being undertaken and the purpose of that Review should be clearly stated.

Inviting them to take part in the Review must be done sensitively. If there are professionals still involved with the family then they may be involved as appropriate in explaining to the purpose of the Review and ascertaining their wishes as to if, how and when they want to be involved.

Where and how to meet will be dependent on the wishes of the adult and others who will be involved and consideration should be given for the need for any communication aids.

It is helpful if meetings can be arranged before any practitioner events or managers' events. This means that views can be taken into those forums for reflection and discussion.

There will be circumstances where the family/carers could be subject to investigation or have otherwise been involved in the events that led to the Review being commissioned. In these cases, information may need to be restricted. Close collaboration with Police Scotland, the Procurator Fiscal, and any other relevant agency will be required.

At the end of the review process arrangements should be made to feedback to the adult and family the conclusion of the Review, the learning identified and any strategies to improve practice and systems in the future. Again, this must be approached in a sensitive manner as the findings of the Review may not always be accepted by the adult or family members. Gathering views on how people found the process of the Review itself and their feedback should inform the conduct of future Learning Reviews.

Families may need support at the end of the review process, and in advance of and following publication of the review. The level and nature of support should be determined on a case by case basis.

Involving practitioners, first line managers and strategic managers

Whilst this Guidance does not prescribe a particular model for undertaking a Learning Review, all reviews must adopt a systemic and proportionate approach. Such an approach should be participatory and collective and will include those practitioners and first-line managers who were involved in the situation under review as well as strategic managers, who, though not directly involved in a review situation, are responsible for the development of process and structures to facilitate the delivery of services.

Bringing together practitioners and first line managers in a group ensures that their voice directly contributes to the Review and has two distinct purposes:

• Firstly, it enables them to describe what they did and why; the reflect on and analyze assessments and decision-making at the time and to identify what could have been done differently but also what prevented them from doing this. It also enables the group to recognise effective practice and what worked well and why.
• Secondly, it generates immediate learning, at both an individual and at a group level, that can be taken back into practice.

For strategic managers, meeting as a group is an opportunity to understand the learning from a particular situation in order to consider the implications from both a single agency and a multi-agency perspective.

Annex 6 provides guidance on how to facilitate and shape events for practitioners, first line managers and strategic managers.

The report

The purpose of a Learning Review report is to identify key learning points and how and why that learning has emerged throughout the review process.

Where a living individual can be identified from the report data protection principles, including a data subject's right of access, will apply. Personal Data includes opinions and indications of intentions. A Learning Review, by its very nature, will contain professional opinions, but it is important that these are recorded as such and distinguished from fact.

Whilst it is the responsibility of the Reviewer to pull together the learning and draft the report, this should be done alongside the Review Team whose role is to scrutinize, challenge appropriately and ensure that the report represents all the learning that has been generated by the Review process.

An exemplar report format is as provided at Annex 4. The report should include:

• A brief description of how the review was conducted
• A brief outline of the circumstances that led to the Learning Review
• The practice and organisational learning that has been identified and the evidence substantiating this learning
• Examples of effective practice in the situation under review and the reason why it was effective
• Suggested strategies for improving practice and systems. It is recommended that suggested strategies for improving practice and systems should be CLEAR. This means:
  • Case for change: the report should clearly identify the issues that give rise to the need for change, outlining the likely consequences should no change occur. Any proposed change should be set within the context of current policy or that which is known to be in preparation.
  • Learning orientated: any suggested strategies should highlight key lessons for practice identified by the review process and should promote the transfer of learning.
  • Evidence based: proposed strategies for improving systems and practice should draw on evidence of any shortcomings in policy or practice revealed by the Review and only be made if evidence exists that their implementation will effectively address the shortcomings identified in the Review report.
  • Assign responsibility: each strategy should identify the discipline or organisation with responsibility for implementation, recognising that some will require a collaborative response.
  • Review: any strategies recommended by the Review report should be amenable to review. This can be done by specifying desired outcomes and timelines and any additional resources required to achieve them.

The Learning Review report will be presented to the APC and the COG for consideration and sign off. It is recommended that the reviewer and the Chair of the Review Team take responsibility for presenting the report.

It may be that not all recommendations will be accepted by the APC. In such circumstances the APC will have to justify such actions, and again this will be ratified by the Chief Officer Group.

Publishing the Report

The COG, informed by a recommendation in this regard from the Adult Protection Committee, will decide if and when to publish the report. In making this decision issues of confidentiality and data protection principles must be considered. The adult and family should also be consulted, and their views taken into account and given due weight in arriving at a decision. Any publication must be suitably anonymised but also clearly reflect the learning emerging from the Review and the evidence for any proposed changes. Where a decision not to publish the report is reached, the exceptional circumstances underpinning that decision will be noted in the minutes of the COG meeting. If a report is not published, then the learning should be extracted from the report and be published separately.

Even if a decision is reached not to publish the report, there is always a possibility, particularly in high profile cases, that a Freedom of Information (FOI) request may be received. In such cases the relevant public authority will be obliged to disclose information on request, unless one of the fairly narrow exemptions apply, particularly where there is a public interest in doing so. Although there is an exemption for Personal Data when disclosure of which would breach the data protection principles, it may be difficult to justify withholding the report in its entirety and it may need to be issued under redaction of Personal Data.

Timescale for the Learning Review

If the learning identified throughout the review process is to be relevant and helpful to the development and improvement of adult protection practice and processes it is important that the Review is completed as soon as possible. Once a decision has been made to undertake a Learning Review, the process should aim to be completed within a timeframe of six to nine months.

However, in some situations there may be some unavoidable delay at any stage, for instance because of parallel processes. The Chair of the Review Team should communicate the reasons for any delay back to the APC, with a revised timescale.

Dissemination

The Adult Protection Committee will timeously agree a local dissemination approach which ensures the spread of any identified good practice as well as learning, particularly to front line staff.

Arrangements should be agreed for direct feedback of the conclusions and recommendations contained within the report to those front line staff and managers and with those service and agencies who were involved in the Learning Review.

The APC should submit the report to the Care Inspectorate.

The Care Inspectorate

The Care Inspectorate is the central repository for all Learning Reviews conducted in Scotland.

As identified above, the Care Inspectorate should be notified of the outcome of the decision making process as to whether or not to initiate a Learning Review in relation to a particular case. The APC is also required to submit the full, anonymised report to the Care Inspectorate. Both these submissions should be made through the Care Inspectorate's on line process.

The Care Inspectorate will support practice improvement as a result of national learning identified by Learning Reviews by holding learning events and by exploring the development of mechanisms to support better sharing of learning from Learning Reviews across the country.

The Care Inspectorate will conduct a regular review of the Learning Reviews completed in Scotland (as well as of Initial and Significant Case Reviews undertaken since November 2019) and report nationally on the key learning points for the benefit of relevant services across Scotland and the Scottish Government.