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Safeguarding Adults Board Reports

Partners and professionals are welcome to use these reports for briefing their organisations/teams on the work of the Board.





OSAB Annual Report 2022-23

“As the Independent Chair of the Board, one of the most rewarding parts of the role is producing the Board’s Annual Report to highlight all the work that has been done by organisations in Oxfordshire. This opportunity to reflect on the year and all that has been achieved and learnt is valuable as it can so often feel that progress is minimal when looking at day-to-day changes. Taking that step back and looking at the year overall really allows us to appreciate the volume of work that has been done and appreciate the cumulative impact of all the hard work across the partnership.


While we feel we know how the year has been for people working in safeguarding, we know there is lots more to learn and do in respect of hearing the voice of the person receiving services. This will remain a priority for the Safeguarding Board and the Engagement Subgroup, which has recently had a review of its membership and purpose to refocus it on that key priority.


This year has been the first where the Multi-Agency Risk Management (MARM) process in Oxfordshire has been in place and it was reassuring to see how well this process has been embraced by organisations. The highlights of the MARM annual report are included further down this page and there is a link to the full report which sits in another part of the website.


Similarly, the Homeless Mortality Review (HMR) process has provided its first report since having a dedicated Officer resource to support the process. The learning from these deaths is a sobering reminder that for some of the issues that are most challenging for organisations, these are the result of trauma experienced in childhood that has not been resolved. The lessons again reinforce the necessity to meet the people we are working with where they are. As services we need to do more to adapt our approaches to work to the person rather than expecting people to fix our services, truly embracing a person-centred approach.


We are still learning as a partnership but I am certain that when compared year-on-year, there is a continuous story of growth and development across the organisations and the system as a whole.”



Dr Jayne Chidgey-Clark,

Oxfordshire Safeguarding Adults Board, Independent Chair

The aim of safeguarding adults is to:

  • prevent harm and reduce the risk of abuse or neglect to adults with care and support needs
  • stop abuse or neglect wherever possible
  • safeguard adults in a way that supports them in making choices and having control about how they want to live
  • promote an approach that concentrates on improving life for the adults concerned
  • raise public awareness so that communities as a whole, alongside professionals, play their part in preventing, identifying and responding to abuse and neglect
  • provide information and support in accessible ways to help people understand the different types of abuse, how to stay safe and what to do to raise a concern about the safety or well-being of an adult
  • address what has caused the abuse or neglect

Safeguarding Adults Boards are established under the Care Act 2014. Their main objective is seek assurance that local safeguarding arrangements and the organisations in those arrangements are working to help and protect (safeguard) adults who cannot protect themselves from abuse, neglect and self-neglect, because of their care and support needs.

The Board is a strategic body, it does not deliver any frontline safeguarding services. The safeguarding responsibility sits with Oxfordshire County Council.

The Board works strategically to coordinate the work of its members and other agencies and ensures the effectiveness of what each of its members does.

Safeguarding Adults Boards have specific duties as set out in Schedule 2 of the Act. These relate to producing Annual Reports, Strategic Plans and the undertaking of Safeguarding Adults Reviews.

In Oxfordshire the Board does facilitate the Multi-Agency Risk Management (MARM) process, a preventative pre-safeguarding process that brings together organisations when there are escalating risks to a person but no statutory safeguarding duty on the Local Authority.

A wide range of organisations are represented on the Safeguarding Adults Board in Oxfordshire. This includes senior representatives from:

  • Oxfordshire County Council
    • Adult Social Care
    • Fire & Rescue
    • Public Health
  • Thames Valley Police (TVP)
  • Buckinghamshire, Oxfordshire and west Berkshire (BOB) Integrated Care Board (ICB)
  • Oxford University Hospitals NHS Foundation Trust (OUH)
  • Oxford Health NHS Foundation Trust
  • South Central Ambulance Service (SCAS)
  • National Probation Service
  • Oxford City Council
  • Cherwell District Council
  • West Oxfordshire District Council
  • South Oxfordshire District Council
  • Vale of White Horse District Council
  • AgeUK Oxfordshire
  • Healthwatch Oxfordshire

The Board also has a Lay Member sit on the Board to offer another perspective.

Independent Chair

The Board appointed Dr Jayne Chidgey-Clark to be its Independent Chair, whose role involves providing leadership, challenge and support to the Board in achieving its ambitions.


The Board has a number of standing subgroups which report directly back to it.

  • Safeguarding Adults Review (SAR) Subgroup – Oversees the management of Safeguarding Adults Reviews and advises the Board on required actions.
  • Homeless Mortality Review (HMR) Subgroup – Oversees the management of the Homeless Mortality Reviews and advises the Board on required actions.
  • Vulnerable Adults Mortality (VAM) Subgroup – Oversees the management of the reviews into the deaths of those with a Learning Disability (LeDeR Process) and advises the Board on required actions.
  • Performance, Information & Quality Assurance (PIQA) Subgroup – oversees Board assurance processes and data analysis.
  • Training Subgroup – Joint with the Children’s Board – Oversees the multi-agency safeguarding training offered by the Safeguarding Board.
  • Procedures Subgroup – Oversees the production of multi-agency safeguarding policy & procedures.

Board Business Support Unit

The Board employs a small team to act as a dedicated resource to support its workstreams and assist the Board in achieving its strategic ambitions.

Key strategic partnerships

The Board has close working relationships with a range of organisations and networks that enable the Board to work in partnership towards making Oxfordshire a safe place for everyone. This includes:

  • Oxfordshire Safeguarding Children’s Board
  • Safer Oxfordshire Partnership
  • Health & Wellbeing Board

The Chairs from the Safeguarding Adults Board and Safeguarding Children’s Board meet regularly to share information and identify common priorities and opportunities for collaborative working. This is looking to expand to include the Safer Oxfordshire Partnership from 2023-24.

Funding arrangements

The Board is funded by Oxfordshire County Council, BOB ICB, Thames Valley Police, Oxford City Council, Cherwell District Council, West Oxfordshire District Council, South Oxfordshire District Council and the Vale of White Horse District Council. This enables the Board to fund specific workstreams, commission an Independent Chair and a Strategy Unit to support its work.

In November 2020 the Oxfordshire Safeguarding Adults Board (OSAB) received a report on the Thematic Review into Deaths of Homeless People. The review focussed on the deaths of 9 people between November 2018 and June 2019 in Oxford and made a number of recommendations in regard to how risk is managed in Oxfordshire.

From these recommendations, the Board created the Multi-Agency Risk Management (MARM) Framework and in this year invested in an Officer role to coordinate the process and lead the meetings.

The MARM Framework is designed to support anyone working with an adult where there is a high level of risk and the circumstances sit outside the statutory adult safeguarding framework, but where a multi-agency approach would be beneficial.

It enables a proactive approach which helps to identify and respond to risks before crisis point is reached, focusing on prevention and early intervention.

Themes from MARMs

Involvement of the Person – The referring organisation is encouraged to inform the referred person of the referral to MARM as well as being offered the opportunity to speak with the MARM Officer prior to any meetings. There is more to do to embed involving the person at the meetings themselves as currently the person being discussed is often informed of the outcome rather than present at the meeting. Usually this is due to the person choosing not to be directly involved, which is their right, but this can mean that their voice and experience of services is missing from the richness of the conversation held at the meeting.

Risk and needs assessments – Organisations have their own risk assessments, some of which are focussed on the specialist work they carry out with the person i.e. drug and alcohol treatment, mental health, day to day support etc.  This approach can divide a person’s risks into siloed assessments that fail to consider them (and their risks) as a whole. There is also the issue of differences of opinion as to what the risks and needs of a person are, and how they should be met.

Geographical boundariesAs a two tier Authority area, with a number of the countywide services also divided down into area teams, if a person moves to another part of the county, this can affect waiting times for assessments and their ability to access services as they may have to reapply for a service or be reassessed in their new area.

Challenge of power imbalances An important part of the role of Chair is challenging power imbalances, this can be between the person being discussed and the other professionals, or between various professionals involved, to ensure a perceived perception of power or authority over another does not inhibit good outcomes.

Attendance at meetingsThe individuals who have attended their meetings have engaged well, considering they are virtual Teams meeting where the majority of faces on the screen will be unfamiliar and where personal information about their circumstances is discussed and they are questioned as to their views, wishes, thoughts and understanding.  This could be quite daunting and oppressive, but with the meetings being person-centred and strengths based, it has appeared people feel at ease to contribute and be heard, with one person saying they “felt famous” because “all these people are here for me”.

Proactive workSome agencies have demonstrated taking quick action to meet with a person and offer practical help that they may need straight away, I.E., food parcels, bus pass, etc.  This can help start to build a working relationship of trust and has led to positive outcomes for a number of people discussed at MARM meetings.

The MARM process has offered a reminder to organisations that sometimes it is not grand changes that are needed to help people who are struggling but simply that outward demonstration that a number of people care enough to meet together with the person to see how they can help.

There are several Reflective Questions documents produced out of the learning from MARMS which can be accessed here.

To align with national collection on the number of deaths of people experiencing homelessness, the HMR Subgroup reports on a calendar year rather than financial year. From January to December 2022 there have been 13 deaths reported that fit the criteria for a HMR.  All the HMR Reports are reviewed by the HMR Subgroup. It is the responsibility of the member agencies to feedback the learning from the reports to their staff and to consider where changes can be made within their own organisations.

There were a number of causes of death noted on death certificates, most of which related to an existing health condition, such as heart or circulatory issues, background of epilepsy or brain injury, cancer and diabetes. Less than 5 deaths noted a cause related to alcohol or drugs.

Only one person was sleeping rough at the time of their death.

Themes from Reviews

Multi-Agency Working – there is evidence that a number of cases would likely have benefitted from a Multi-Agency Risk Management approach as well as a shared database. MARM process is new in Oxfordshire and more work is needed to ensure that all organisations are accessing the MARM process as often as they could. The new database for those experiencing homelessness has been commissioned and is being developed. This work is being overseen by the Countywide Homelessness Steering Group.

Flexibility of approach – There is some evidence that the approach to clients lacks flexibility and an expectation of an adherence to organisational policies and procedures. This way of working is poorly suited to people who have the level of need seen in those experiencing homelessness. The methods of engagement and the offers of support could be better adapted to the people attempting to access the services, with a better appreciation of the complexities for organisations of working with this client group.

Health & Wellbeing – it can be difficult meeting the physical care needs of a person experiencing homelessness who is mistrusting of statutory services. It can also be difficult to get the person assessed for physical or mental health to understand their needs. This may be the result of past experience with services or a result of mental ill health but the effect is the same. This challenge for organisations is adapting their approach and working collaboratively with workers who have established a good relationship with the person.

Support & Supervision – While supervision is a relatively established process in some organisations, it is not a universal experience for all workers. Having supervision and/or support available is also not an indicator of the quality of that support. There is also the matter of organisations supporting a trauma-informed approach to working with clients and how does this look within organisations.

The Reflective Questions for senior managers, team leaders and frontline workers can be found on the website here.


There were 44 deaths notified to the LeDeR process during the year 2022-23. The Oxfordshire Safeguarding team, within the ICB, has been coordinating the review process supported by the OSAB business unit. In 2023-2024 this is changing to new arrangements following the ICB restructure. The coordination will move to the Quality Improvement Manager.

Provider teams and support organisations contribute records and information which is centrally collated and written up ready for the reviewer. The reviewer is responsible for contacting the family and carers, ensuring their contribution is integrated into the review documentation. Analysis and identification of learning points in undertaken.

In 2022-23, 100% of reviews were completed by BOB ICB reviewers from within the Oxfordshire Safeguarding team. The reviewer profile includes frontline staff who contribute effectively and offering real-time learning. This year they have been focused on supporting care provision.

 Learning from the reviews

  • Conversations about death and dying are never easy, but where they have been proactive there is evidence of much greater levels of understanding. There are also more opportunities to represent views and wishes of an individual more effectively in times of crisis and sadness.
  • There is evidence of some excellent multiagency working crossing acute and community services.
  • Healthcare provision remains fragmented at times and there needs to be more work to ensure that annual health checks and health action plans are linked in order improve healthy living and better understanding of health needs.
  • To ensure a safe and effective discharge, a solid discharge planning procedure should be put in place that involves next of kin and allied health providers. The process should include; checks on caregivers’ physical health and abilities, competency in planned discharge care updates for family, and that mutual agreement on discharge arrangements have been completed.
  • Developing anticipatory end of life plans has been recognised as good practice and is valued by friends and family and carers. More work is needed to make this consistent.

The full LeDeR Annual Report can be found elsewhere on the website by following this link here [TO BE ADDED ONCE PUBLISHED].

There are two stages to reporting a concern about abuse or neglect. These are referred to as a safeguarding concern and a safeguarding enquiry. Safeguarding concerns about abuse and neglect can be raised by anyone –  the person themselves, their family, friends, a member of the public such as a neighbour, or a paid worker.  These concerns are then assessed by the Safeguarding Team in the County Council who decide if it meets the legal criteria for a safeguarding enquiry. Where the adult is currently receiving mental health services from Oxford Health NHS Foundation Trust, the safeguarding concern will be followed up by them as they have a Social Work Team embedded within their organisation. However, the legal responsibility remains with the local authority.

In Oxfordshire, there were 6,770 safeguarding concerns raised in 2022-23. This is a 14% increase from the previous year (5,934). Of these concerns, 1,921 went on to be safeguarding enquiries, up from 1,738 in the previous year (11% increase). The conversion rate from concern to enquiry has remained in line with the previous year, 28% in 2022-23 and 29% in 2021-22. The conversion rate for concerns raised by the person themselves, family or friends has remained high year on year (72% in 2022-23). As there was a significant increase in the level of safeguarding concerns, the Adult Safeguarding team were required to work flexibly to ensure that concerns were managed and completed earlier which resulted in less cases requiring formal enquires.

The majority of safeguarding issues still occur in the person’s own home or in the community (58% of all enquiries). This is a small decrease from the previous year (61%). The reasons for this need further exploration but the data suggests that this is balanced by a small increase in abuse in the community and in residential settings.

Making Safeguarding Personal Information

Where it is possible, an adult at the centre of the enquiry, or their representative, should always be empowered to make decisions about their own lives and define what they want to happen. This includes when there are safeguarding concerns and how the person would like these addressed. This is referred to as Making Safeguarding Personal.

  • 74% of adults who were involved in a safeguarding enquiry defined the outcome they wanted
  • 68% of those adults reported that they were completely satisfied with the outcome of the safeguarding enquiry, 99% were either completely or partially satisfied with the outcome.

In 1% of cases the adult was not satisfied with the enquiry and the risk remained (8 cases). In all these cases an audit was conducted by senior staff independent of the safeguarding enquiry to ensure that everything possible had been done to remove or reduce the risk and to satisfy the adult. In all cases, these adults had outcomes that could not be achieved by services (such as wanting to move to a different area, finding their exploitative adult child their own home, etc) and/or did not accept what help could be offered.

For those who struggle to be involved in the safeguarding process themselves, services are expected to ensure that an appropriate advocate is able to represent them through the process.

21% of Safeguarding Enquiries were for people who were judged to lack capacity, as laid out in the Mental Capacity Act 2005. Of these 80% were supported by an advocate (a slight improvement from 79% in the previous year). It is a requirement of The Care Act 2014 that anyone lacking capacity is supported through the safeguarding process and where there is no-one appropriate within their family or friends it should be an independent advocate.

The annual Safeguarding Self-assessment is a joint piece of work between the Adults Board and Children’s Board. The purpose of the Safeguarding Self-Assessment is to formally request and gather information from member agencies on the safeguarding arrangements made in line with section 11 of the Children Act 2004, as well as the standards developed by the Local Government Association for Adult Safeguarding Services.

The assessment tool provides agencies with the opportunity to highlight areas of strengths in practice, identify areas for development, and provide evidence of the impact of policies and practice on children and adults with care and support needs in Oxfordshire. It is intended to be useful as a self-assessment tool to measure and provide assurance on the quality of the safeguarding arrangements that agencies have in place.

Overall, the self-assessment returns submitted provide assurance that board member agencies across Oxfordshire have procedures in place to safeguard children and adults with care and support needs, are compliant with the standards examined, and committed to ensuring safeguarding practice is embedded in their day-to-day practice. For those areas where more work is required, there was a clear action plan provided by organisations.

Peer Review

The Peer Review event is held each year for organisations to explain their return responses to a small group of their peers and to receive constructive challenge from them on how they could improve and to provide some moderation to the self-assessment ratings. For 2022-23, the peer review meeting repeated the process of the previous year. Board Members were divided into small groups of three or four organisations. Each organisation was given the complete Peer Review response for the others in their small working group in advance of the peer review day. This meant that members were able to ask questions spanning the entirety of the returns of their fellow participants rather than the scrutiny being on standards decided by the Board Business Units.

The event was held virtually and there was good discussion in groups, both to provide scrutiny of evidence submitted in relation to ratings given, and in highlighting examples of good practice. There was also some discussion around the challenges and opportunities resulting from the pandemic, examples of how organisations and practitioners have worked creatively to provide support to vulnerable children and adults, and the high level of commitment shown to safeguarding in challenging circumstances.

Overall Conclusions of the Self-assessment 

Overall, the peer review groups felt that returns showed a strong level of critical self-analysis. There were some excellent examples of good practice and a very high level of evidence submitted for review. The following were most commonly highlighted areas for actions to improve practice within agency returns;

  • Training – Nearly all agencies highlighted a training need for their staff, although there was no common theme to these needs.
  • Multi-agency Procedures and Tools – As in previous years, a number of agencies recorded an action to improve knowledge of or use of the multi-agency tools.
  • Monitoring Arrangements – A number of organisations noted actions to monitor current arrangements to ensure they are fit for purpose and high levels of safeguarding and other service delivery can be maintained.

The Board’s Strategic Plan sets out its objectives for the next five years. This is reviewed annually to ensure that the priorities remain relevant and that new or emerging themes are incorporated, where necessary. Examples of key priorities are included below, but the full plan is available to read elsewhere on the Board’s website OSAB Strategic Plan + Action Plan – 2023-27 V2.

Ambition One: Working in Partnership 

The Board is only effective if the partners around the table are working together to safeguard adults with care and support needs at risk of abuse and neglect. The Board will build upon the close working arrangements already in place to achieve the following:

  1. The Board Members will work together as a partnership at all levels, looking to strengthen that relationship, empowering those working within our systems.
  2. The Board and its partners will look for greater integration across the Adult and Children’s Board, either at Full Board or at subgroup level. This does not have to mean combining the groups but reviewing Board processes and aligning the group agenda it may streamline some of the discussions.
  3. All work will be done with the “so what?” question in mind. If work does not actively improve practice outcomes and is not linked to clear outcomes in the purpose of the work then it will not be taken forward.
  4. The Board will work to improve the understanding of the roles and responsibilities of the organisations working with adults across Oxfordshire, what they offer, what are the thresholds for those services and what to do when there are professional differences of opinion about accessing services.

Ambition Two: Preventing Harm Occurring 

It is always better to prevent harm occurring rather than responding once harm occurs. The Board will build upon the work that is already in place to achieve the following:

  1. Improve the use of the Multi-Agency Risk Meeting (MARM) to assist providers who have cases that are not progressing, such as cases where there are lots of agency involvement but not necessarily a key lead, so that ideas and actions can be shared to improve outcomes. This requires a senior leadership ownership and active engagement to promote the process and hold their own and other organisations to account for its effectiveness.
  2. Develop an overarching practice framework for the whole partnership, which includes restorative practice and trauma-informed working and clearly defines what these mean.
  3. Develop an overarching commitment and strategy to tacking inequality and anti-discriminatory practice within safeguarding, and actively assess and respond to any identified issues.
  4. Improve awareness of the safeguarding support available, the pathways and mechanisms e.g. how to trigger a statutory response before serious harm has occurred, amongst people most at risk and those supporting and working with them.

Ambition Three: Responding Swiftly when Harm Occurs

When organisations are alerted to abuse occurring, we are responsible as a system for responding swiftly and intervening as early as possible. The Board will build upon what is already in place to achieve the following:

  1. Initiate a system-wide discussion on how we share information and intelligence in a way that reduces requests from information between partners (i.e. proactive information sharing), improving our intelligence and therefore the support we offer in an effort to reduce or remove the risks people are facing, where possible.
  2. Adopting a collaborative problem-solving approach in the face of learning from MARMs, SARs, SI’s and difficult or complex safeguarding events. This must come with an acknowledgement that decisions can be extremely complex with no clear right/wrong answer and we will not be able to protect everyone as well as we would want to.
  3. Reviewing the Board’s dataset to ensure that the Board is assured when an issue occurs that the system responds in a timely fashion and in line with Making Safeguarding Personal principles.

Ambition Four: Engaging Effectively with People at Risk

The Safeguarding Board and its partners should be engaging with those who are using services or have experience of the safeguarding process to better inform our work and improve how we react to incidents of safeguarding. The Board will work to achieve the following:

  1. Hearing the voice of the adult at every meeting, whether it is a success story, a concern or just the experience of someone on the receiving end of our services
  2. Consider an expert by experience at the Board or its subgroups or link into existing expert by experience panels run by partner agencies
  3. Work closely with Advocacy organisations/providers to include the voice of those they work with are also heard at Board level
  4. Review the strategic plan for 2024 onwards to co-create with people using our services the safeguarding priorities for the partnership

Previous Annual Reports

These reports outline the role, function and purpose of the Board as prescribed by the Care Act 2014 and lists the organisations represented. It highlights the risks faced by the most vulnerable and most importantly what local agencies both statutory and voluntary are doing to safeguard them.

This will be added when ready for publication.

These reports give an overview of the discussions held at the OSAB Full Board meetings.

May 2023 (awaiting upload)

September 2023

November 2023

January 2024

March 2024