Learning Themes Library

Learning Themes Library

Welcome to the learning themes library

The learning themes library is your go-to hub for guidance and information to support your safeguarding practice. Here, you’ll find resources that help practitioners and managers improve their knowledge in areas where common learning themes have been identified across Safeguarding Adult Reviews, Child Safeguarding Practice Reviews, Domestic Abuse-Related Death Reviews, and LeDeR Reviews in Derbyshire and Derby City.

Hosted on the Derby Safeguarding Adults Board website, this library is regularly updated to reflect new and emerging learning from reviews. Use this library to learn and improve your knowledge and confidence to drive better outcomes for the people we support.

If you would like to read published local reviews or learn more about the different types of review undertaken, you can visit the following pages:

• Derby City Safeguarding Adult Reviews
• Derbyshire Safeguarding Adult Reviews
• Derby and Derbyshire Safeguarding Children Partnership Child Safeguarding Practice Reviews

Domestic Abuse

Domestic abuse is rarely a one-off incident, but a pattern of power and control over you. It is any threatening behaviour, violence or abuse between adults who are or have been in a relationship, or between family members.

Domestic abuse can include, but is not limited to, the following:

• coercive control (a pattern of intimidation, degradation, isolation and control with the use or threat of physical or sexual violence)
• psychological and/or emotional abuse
• physical or sexual abuse
• financial abuse
• harassment and stalking
• online or digital abuse

You may just want someone to listen, or help to stop your abuser hurting you further.

All services in Derby follow the same guidelines when dealing with domestic abuse, whether you talk to someone at your health centre, school, housing office or social services office. They will offer someone to talk to, legal information, help available to you, support in your home or long term help.

Live chat is available at The Elm Foundation on Monday to Friday from 8am to 7pm. Outside these hours the service will send an email that will be responded to as soon as possible.

Deaf and hard of hearing people can text 07534 617252.

In an emergency, or if you are in any danger, always tel: 999.

If you phone 999 from a mobile phone but it is not safe for you to speak, Silent Solution is a system the police use to assess and respond to your call. Phone 999 and if it is not safe to respond to the BT operator when they ask what service you want, stay connected. If the operator hears any suspicious noise you will be transferred to the police. If nothing is heard you may be asked to press 55. This will connect you to a police call handler. Listen carefully to their questions and instructions so that they can assess your situation and arrange for assistance. This system means that the police can respond to genuine emergencies when people are in danger, and accidental or hoax 999 calls do not distract them. Accidental 999 calls from a landline are less likely, so if you phone 999 from a landline but are unable to speak you will be connected without being asked to enter 55.

Coercive and controlling behaviour

Coercive control is a criminal offence and is a form of domestic abuse.

The Derbyshire Safeguarding Adults Board, together with Safer Derbyshire, have produced a multi-agency practitioner briefing about coercive control, which is attached to this page.

Older adults and domestic abuse

Abuse can occur at any age and is often under reported when it related to adults over the age of 65. Safeguarding often considers “carer’s stress” when incidents occur, and while one-off events do happen, it needs to be explored to see if there are any patterns or history. Based on the power and control wheel as adapted by Dewis Choice, the aim of this short animation is to help support practitioners and families start a conversation with an older adult.

We know from research that this is a very sensitive topic to talk about. Older adults may be more reluctant to talk about problems at home due to experiential, cultural, and social factors, and this combined with ageing and subsequent care needs leaves them vulnerable to having domestic abuse overlooked.

The hidden harms animation has been co-created by survivors aged between 60 and 93 years old from Dewis Choice, who are now in recovery and living free from harm, fear and abuse. Talking to someone about the behaviour will not mean having to make decisions you are not ready for, but it will create options to help you get the support you need to feel safer and happier.

We would like to thank Norfolk Safeguarding Adults Board for granting permission to adapt this animation for Derbyshire and Derby Safeguarding Adults Boards and Derbyshire and Derby City Safer Communities Boards.

Derbyshire Constabulary domestic abuse guidance

Derbyshire Constabulary provides guidance on domestic abuse, including clear explanations of what it is, how to identify warning signs, and the steps you can take to report it. Their resources also include details of local and national support organisations that can offer help and advice.

Children and families

The Derby and Derbyshire Safeguarding Children Partnership provides information and practical resources to help individuals and professionals understand, prevent, and respond to domestic abuse and violence. Their guidance covers recognising signs of abuse, accessing support services, and promoting safety for children and families affected by these issues.

Fire Safety

Since 2022, Derbyshire Fire and Rescue Service has recorded 19 fire-related deaths and 12 serious injuries.

Analysis found no clear link between demographic factors and these incidents; however, it has highlighted the possibility that care and support needs such as physical disabilities, frailty, and cognitive or mental health issues may have contributed in some cases.

The analysis also showed that a higher number of formal care visits per day indicated a greater level of support needs. Additionally, there were instances where individuals may have had care and support needs but declined available support.

Advice for professionals

Supporting Derbyshire Fire and Rescue Service with preventing further deaths and serious injuries

Derbyshire Fire and Rescue Service (DFRS) has established a process to help professionals identify individuals at risk and facilitate referrals for a Safe and Well check. These checks are designed to address potential fire-related hazards, recommendations specific to the home environment, fire escape plans and we may also fit smoke alarms if needed.

Identifying people who are at risk

Professionals working within the community are encouraged to be vigilant in recognising signs that someone may be at heightened risk of fire due to physical disabilities, frailty, cognitive or mental health challenges, or a high number of formal care visits. It is also important to consider the home environment and practices within this that could start a fire.

Referral process

When professionals identify individuals who may benefit from additional safety measures, they can refer them to DFRS for a safe and well check. This referral process supports proactive engagement, helping to reduce the likelihood of fire related deaths or serious injuries among those with care and support needs. This referral process is called CHARLIE.

CHARLIE-M

The CHARLIE-M referral process gives professionals a guide to what Derbyshire Fire and Rescue Service believes are risks in the home that could cause or may result in a fire in the home, which are:

• care and support needs
• hoarding
• alcohol
• reduced mobility
• lives alone
• inappropriate smoking
• elderly 65 or over
• mental health

The Multi-Agency Hoarding Framework (MAHF) provides a collaborative multi-agency ‘person centred approach’ for addressing matters arising as a result of hoarding in Derby City and Derbyshire County.

If professionals visiting people in their homes identify any of the CHARLIE-M risks, prompt action should be taken by referring the person to Derbyshire Fire and Rescue Service for a safe and well check. This ensures that those at heightened risk receive tailored advice and support to reduce potential fire hazards. By making a referral, professionals play a vital role in safeguarding vulnerable individuals and helping to prevent fire-related incidents in the community.

Professionals can refer by visiting the Derbyshire Fire and Rescue Service website or access the advice for professionals page. This will provide you with a link to complete a referral form. The form will take you through several questions about the person you wish to refer, and the activities or risks observed in the home environment that you believe puts them at risk of having a fire. It is, therefore, important that the referral is submitted by someone who has visited the home. We are unable to accept referrals without this information.

Who else can have a safe and well visit?

Derbyshire Fire and Rescue Service (DFRS) target areas and households where we know there is a higher risk of fire, primarily the more vulnerable groups in the community. As such we do have an eligibility criterion for our safe and well checks.

If you do not qualify for a free safe and well visit you can use the DIY online home fire safety check tool and carry out your own check.

A visit can take anywhere between 30 minutes to 1 hour dependant on the size of the property and the risks identified. You must reside at the property, so that DFRS can assess what risks are associated with how you live within the property. You are, however, able to ask a friend or relative to be present if you feel you would need this extra support. Should you require any further information regarding a safe and well Visit or to see if you or someone you know is eligible, please contact your local area office:

• East Area Admin – email eastareaadmin@derbys-fire.gov.uk telephone: 01246 223500 – North East Derbyshire, Chesterfield, Bolsover and Amber Valley
• South Area Admin – email southareaadmin@derbys-fire.gov.uk telephone: 01332 777850 – Derby City, South Derbyshire, Erewash
• West Area Admin – email westareaadmin@derbys-fire.gov.uk telephone: 01298 608720 – High Peak and Derbyshire Dales

British Sign Language information about fire safety in the home

Derbyshire Fire and Rescue Service offers a British Sign Language (BSL) video designed to help keep people safe at home, along with several BSL videos that explain how and when to use the 999 BSL service. The main video shares practical tips to reduce fire risks and includes important advice like general fire safety and specialist guidance on smoke alarms for people who are hard of hearing – there’s also a BSL pictorial home fire safety guide.

15 minutes to save a life fire safety campaign

Derbyshire Fire and Rescue Service’s fire safety campaign is called ‘15 Minutes to Save a Life’. Fifteen minutes is all it could take to protect someone you care about from the risk of a fatal accidental house fire. To support the campaign, you can download posters and leaflets.

Fire safety when using emollients

Emollient creams are moisturisers that can be used to prevent or treat dry skin conditions like eczema, pressure ulcers (bed sores), ulcers and psoriasis.

Emollients come in a variety of forms, like creams, lotions or gels. All cover the skin with a protective film to reduce water loss. They are highly flammable and pose a fire risk, especially for people who spend long periods in bed or an armchair due to illness or limited mobility. It's important to be aware of the fire safety risks if you or a person you care for needs moisturising creams.

Legal Literacy

The Care Act

The Care Act 2014 sets out a clear legal framework for how local authorities and other parts of the system should protect adults at risk of abuse or neglect.

Local authorities have new safeguarding duties. They must:

• lead a multi-agency local adult safeguarding system that seeks to prevent abuse and neglect and stop it quickly when it happens
• make enquiries, or request others to make them, when they think an adult with care and support needs may be at risk of abuse or neglect and they need to find out what action may be needed
• establish safeguarding adults boards, including the local authority, NHS and police, which will develop, share and implement a joint safeguarding strategy
• carry out safeguarding adults reviews when someone with care and support needs dies as a result of neglect or abuse and there is a concern that the local authority or its partners could have done more to protect them
• arrange for an independent advocate to represent and support a person who is the subject of a safeguarding enquiry or review, if required

Any relevant person or organisation must provide information to safeguarding adults boards as requested.

Safeguarding adults boards need assurance that local safeguarding arrangements are in place as defined by the Care Act 2014 and statutory guidance.

View the Care Act statutory guidance.

Legal literacy

An article by Suzy Braye and Michael Preston-Shoot discusses the importance of legal literacy in adult social care as the ability to connect relevant legal rules with professional priorities and objectives of ethical practice.

Research in Practice's Legal literacy practice tool aims to support adult social care practitioners in developing legal literacy and using it in their practice. It is designed as an overview of the topic of legal literacy, not as a detailed account of adult social care law.

Case law

The Research in Practice podcast, using case law in social care practice, by Laura Pritchard-Jones and Tony Anyaegbu, uses examples of where case law has had an impact, and has advice on balancing case law with other sources of evidence, as well as top tips for integrating case law into practice.

Community Care Inform Adults case law knowledge and practice hub includes expert-written case law summaries that set out the implications for your practice.

39 Essex Chambers has a case law database that includes summaries and comments upon cases decided by the Court of Protection and other courts considering the Mental Capacity Act (MCA).

For full case details, the British and Irish Legal Information Institute (BAILII) has a searchable case law database.

Mental capacity resources

A basic guide to the Court of Protection explains the roles, processes and jargon, useful for professionals and family members

My Adult Still My Child is MCA guidance written for parents/carers of people aged over 16

Promoting Less Restrictive Practice is a practical tool from ADASS (Association of Directors of Adult Social Services and the LGA (Local Government Association) to help analyse if a person’s care is the least restrictive possible. 

Introducing the MCA is Mental Capacity Act (MCA) and Deprivation of Liberty Safeguards (DoLS) guidance from the Social Care Institute for Excellence (SCIE).

The aim of the Assessing Mental Capacity and Making Best Interests Decisions document is to provide guidance in accordance with the Mental Capacity Act 2005 (MCA).

The British Institute of Human Rights resources hub has helpful guides and information promoting human rights and includes an easy-read hub.

The Mental capacity guidance vote: relevant information for different categories of decisions lists a range of different decisions you may complete a mental capacity assessment for and includes the relevant information to consider supported by case law. 

Special Guardianship Orders

A Special Guardianship Order (SGO) is a private law order made by the Family Court under the Children Act 1989 as a way to provide greater security and stability for children who cannot live with their parents. The Derby and Derbyshire Safeguarding Children Partnership has created a best practice guide on Special Guardianship Orders. It gives practitioners clear principles to help them work well with children and families, alongside following the law and local procedures.

Making Safeguarding Personal (MSP)

The Care Act 2014 emphasises a personalised approach to adult safeguarding that is led by the individual, not by the process.

It's important that the adult feels that they are the focus and they have control over the process. The approaches of agencies and services to adult safeguarding should be person-led and outcome-focused.

Making safeguarding personal (MSP) is not simply about gaining an individual’s consent, although that is important, but also about hearing people’s views about what they want as an outcome.

MSP is also about ascertaining the extent to which the outcomes the individual wanted were achieved in the end.

Read more about making safeguarding personal:

• Local Government Association (LGA)
• Social Care Institute for Excellence (SCIE)

The Local Government Association (LGA) and the Association of Directors of Adult Social Services (ADASS) have produced a resource to support safeguarding adults boards and partners in developing and promoting MSP. The document, which is attached to this page, supports boards both in their assurance role and in actively supporting and leading a culture change towards MSP.

The safeguarding adults what to expect leaflet is an accessible guide for adults aged 18 years old or over and/or their advocate to explain what to expect if they are involved in the safeguarding adults process.

Making safeguarding personal resources

Research in Practice has developed making safeguarding personal resources for the safeguarding adults workstream of the Care and Health Improvement Partnership.

The resources are tools for practitioners, trainers and anyone else to be used to promote a person-centred, outcome-focused and strength-based approach to safeguarding adults

Myths and realities about making safeguarding personal

The Local Government Association (LGA) ‘Myths and realities about Making Safeguarding Personal’ briefing is aimed at front line practitioners and operational managers in all organisations that have a role in safeguarding adults. It is aimed at leaders at all levels and local councillors. It can also be used by anyone interested or involved in safeguarding adults because safeguarding is everyone’s business.

A series of podcasts exploring and busting myths about making safeguarding personal is available on Soundcloud.

Management of constipation and recognition of sepsis

Management of constipation

Constipation can be dangerous for people with a learning disability. Some people with a learning disability are more at risk of constipation than the general population. Reviews into the deaths of people with a learning disability have shown that too many people are still dying from constipation.

LeDeR stands for learning from lives and deaths – people with a learning disability and autistic people. LeDeR has guidance and standards in constipation care, along with constipation resources that may be of use to health and care professionals supporting people with a learning disability or people who are autistic with their health or care.

Recognition of sepsis

Sepsis is a life-threatening condition that can be hard to spot.

The UK Sepsis Trust (UKST) aims to end preventable deaths and improve outcomes for sepsis survivors, striving to raise public awareness and working to support anyone affected by this devastating condition.

NHS England is working to improve the identification, diagnosis and management of sepsis. Also available is a general guide that anyone can use about what sepsis is, the signs to look for, who is at risk, and how it can be treated.

The Royal College of Nursing library provides a subject guide with resources about recognising and caring for adults with presumed sepsis, including books, reports and journal articles.

Clinical knowledge summaries (CKS) provide primary care practitioners with a readily accessible summary of the current evidence base and practical advice on best practice. The clinical knowledge summary about sepsis is available from the National Institute for Health and Care Excellence (NICE).

Multi-agency working and information sharing

The Derbyshire Safeguarding Adults Board (DSAB) has in place an information sharing agreement (ISA) in relation to safeguarding adults. This agreement was signed off by Board members in December 2018. The agreement is attached to this page.

A guide called 'Safeguarding adults: sharing information' is available from the Social Care Institute for Excellence (SCIE). It is part of a range of products to support implementation of the adult safeguarding aspects of the Care Act 2014. Registration with SCIE may be required to download some documents.

Sharing information without consent

You can share information relating to abuse, without consent from the person:

• if the person lacks capacity to make the decision (Mental Capacity Act 2005)
• for the prevention and investigation of crime (Crime and Disorder Act 1998)
• to prevent serious harm/distress or threat to life (Data Protection Act 2018)
• if there is a risk to others / children
• if the person is under duress, coercion or undue influence
• if staff are implicated
• domestic abuse which meets the MARAC threshold
• if there is a court order/other legal authority in place instructing you to do so
• where the alleged abuser has care and support needs and may be at risk

Recording information in the case file

If you share information without consent, you must record the following information on the person’s case file:

• Why? What is your concern and reason for overriding consent?
• When? Date and time you shared the information.
• Legal basis for overriding consent
• How? In what format you have shared the information such as verbally or in writing?
• What? Exactly what information have you shared?

In cases where a crime is occurring or someone is in need of immediate medical or police assistance, please contact emergency services tel: 999.

Further resources

The following link has further resources around Multi-agency working and safeguarding.

Derby and Derbyshire Safeguarding Children Partnership has produced two best practice guides about multi-agency working:

• Hints and tips for effectively meeting the needs of children through multi-agency Child in Need arrangements
• Reunification – reunifying children with their parents

The Social Care Institute for Excellence (SCIE) has two articles: one on multi-agency working and another about Information Sharing.

Professional curiosity

Professional curiosity is looking, listening, asking questions, checking out information, and reflecting on information received. It means being curious and seeking clarity around a situation, bringing together information from different sources to gain a better understanding of a person’s circumstances and level of risk.

Applying professional curiosity can help practitioners to identify the less obvious signs of abuse and neglect.

A recurring theme within Derby Safeguarding Adult Reviews (SARs) is a need for professional curiosity to be applied when safeguarding adults who have care and support needs.

Key principles of professional curiosity:

• do not make assumptions
• have an awareness of your own personal bias and how may affect the way you view a set of circumstances.
• remain open minded
• obtain information from different sources rather than taking information from one source at face value
• ensure you have an understanding of the person's past history
• ask clear questions in a respectful manner
• challenge the information you are being given if contradicts with what you have seen

A strategic briefing from Research in Practice examines professional curiosity in safeguarding adults. Curiosity is required to support practitioners to question and challenge the information they receive, identify concerns and make connections to enable a greater understanding of a person’s situation.

• Have you thought about Professional Curiosity - Resources

Substance use

The Derby and Derbyshire Safeguarding Children Partnership (DDSCP) offers guidance and resources on safeguarding children in situations where parents, carers, or children are affected by drug or alcohol misuse.

On their website, Derbyshire County Council has gathered information and resources for people who are experiencing drug or alcohol related issues.

People who have a drug addiction can get treatment in the same way as anyone else who has a health issue. Find out from the NHS about getting help for drug addiction.

Unpaid carers

Carers come from all walks of life, cultures, and age groups – anyone can become a carer.

If you are someone who regularly provides unpaid support to a family member or friend with daily living or personal care – whether they are ill, frail, disabled, or experiencing poor mental health – you are a carer.

Carers podcast

It’s important for unpaid carers to see themselves as carers so their efforts are recognised and they receive their rights under the Care Act. It's a priority area of work for the Derbyshire Safeguarding Adults Board (DSB) to prevent safeguarding concerns by making sure carers and the people they support know how to get help and advice to stay safe and well.

In the DSAB carers podcast Tom Brown speaks with Bev and Lisa about their experiences as unpaid carers. He also chats with Jude Boyle, Carers Lead at Derbyshire County Council and Helen Weston, Interim CEO from Derbyshire Carers Association, to explore the support available for carers.

Derbyshire Carers Association

Derbyshire Carers Association (DCA) support carers who look after a family member, partner, or friend who needs help because of their illness, frailty, disability, mental ill health or an addiction. The care these people give is unpaid.

Carers in Derbyshire – regardless of how long they've been caring and or who they care for – are encouraged to register with Derbyshire Carers Association (DCA). Registering helps put support in place early to reduce breakdown and ensures carers feel informed, connected and empowered.

You can contact DCA, telephone: 01773 833833 or by email info@derbyshirecarers.co.uk.

Skills for carers

Ensuring carers have the skills and knowledge to provide good care can reduce the risk of abuse and the stress and pressure carers experience. Feeling well-informed can make carers feel more confident and more effectively manage potentially challenging behaviour.

The NHS website has a health A to Z guide about conditions, symptoms and treatments, including what to do and when to get help, as well as a medicines A to Z guide about how medicines work, how and when to take them and possible side effects.

Information and advice

Many older people aged 50 and over, and their carers, live with issues that can be resolved or improved. Age UK has information and advice about welfare benefits, housing options, aids and adaptations, keeping homes maintained and warm, managing money and paying for care and support, and planning for the future, which can all help older people live well and be less vulnerable to abuse.

Age UK works closely with other charities and services so that their information and advice service can act as a gateway to other services such as Derbyshire Carers Association. For free, independent and expert advice, telephone: 01773 766922, or access the Age UK free factsheets and guides online.

Loneliness and isolation

Loneliness is as big a killer as smoking fifteen cigarettes per day. Reduced social interaction and contact with others can make older people more dependent on their abuser or increase the demands and therefore put stress on carers.

Age UK Derby and Derbyshire can also help with information about different ways of reducing loneliness and isolation, telephone: 01773 766922. The national Age UK website has a section dedicated to information and advice that can help if you or someone you know is feeling lonely.

The Better Health – Every Mind Matters campaign can help people find out about possible signs of loneliness, reasons why people feel lonely, and ways to manage it. There are also links to more support if you or someone else needs it.

The Campaign to End Loneliness believes that people of all ages need connections that matter. Their vision is that everyone can live a life free from chronic loneliness.

Mind offers helpful information about loneliness – what causes it, how it connects to mental health, and practical tips to cope. You’ll also find guidance on where to get extra support if you or someone else needs it.

The Mental Health Foundation breaks down what loneliness is, who can experience it, how to cope, and how to support someone else who is feeling lonely.

Derbyshire County Council has gathered information and resources about tackling loneliness.

As part of their England Loneliness Project, the British Deaf Association (BDA) commissioned 3 British Sign Language (BSL) translated videos about loneliness covering definitions of loneliness, how to cope with loneliness, and top ten tips to reduce loneliness. These videos may help you understand loneliness and how to cope if you are feeling lonely.

Falls prevention

Falls are the most common cause of sudden increases in care needs and admittance to long-term care. Reduced mobility and the fear of falling can lead to increased care demands, and vulnerability to physical violence.

Find out from Derby and Derbyshire Age UK about falls prevention classes around Derby and Derbyshire.

Footcare

Providing personal care, and especially ‘marmite’ care tasks such as footcare, which many people find repulsive, can increase carer stress.

Foot pain can increase symptoms such as irritability, reluctance to mobilise and anxiety. Age UK Derby and Derbyshire and the NHS in Derbyshire are working together to offer an affordable, long-term footcare solution for people aged fifty and over. For more details, please telephone: 01773 766922.

If you have a problem that is affecting your foot health, you may be able to refer yourself for an assessment with the Community Podiatry Service.

Taking a break

Respite for carers is essential to relieve the pressure of the responsibility of caring. Even long-distance carers report experiencing an impact on their mental health and wellbeing.

Respite can be achieved using some creative thinking. For example, carers can resume or maintain a hobby or activity supported by some telecare devices. Older people can attend a day centre or activity group giving their carer some time off. Carer and cared for can attend an activity together such as a lunch club or falls prevention class. Grant funds or savings can pay for a short-break or equipment that reduces the impact of a routine task such as washing.

Incontinence

Incontinence can be one of the biggest triggers for admission to care settings and carers often describe it as the last straw. Incontinence can increase the caring role and intimate care with its associated risks of abusive behaviour, as well as increasing laundry and household tasks, decrease attendance at social activities, leading to increased costs for incontinence equipment.

The NHS has information and sources of support about urinary incontinence.

Carers Speak video

To mark Carers Rights Day in November 2019, Carers in Derby and Derbyshire spoke to local carers asking them about their caring roles, the support they received – good and bad – from health and social care staff, and how they manage their own wellbeing. They were also asked what matters to them most. A video has been produced with the responses. Watch the Carers Speak video.