Local ASP procedures
Adult support and protection enquiries and investigations are undertaken by NHS Highland Adult Social Care Professionals who work in partnership with Police Scotland and Highland Council and other agencies. This work is overseen by the Highland Adult Protection Committee.
Information in this section is relevant to the Highland Health and Social Care Partnership area. For the Argyll and Bute Health and Social Care Partnership area, read about Adult Protection at the Argyll and Bute Council website.
On this page
1. Introduction
Welcome to the Highland Adult Protection Local Procedures webpage – “Local Practice in Highland”.
Comprehensive Practice Guidance for the Adult Support and Protection (Scotland) Act 2007 is contained within its Code of Practice, July 2022. It is important that professionals – officers from the Council, Health Board and Police - refer directly to the Code of Practice when they are performing functions under the Act.
Information on this webpage relates to our local, multi-agency and multi-disciplinary Highland procedures and practices which partners use to co-ordinate the protection of adults at risk in our Area. In particular, the information provided details the procedures and practices which involve co-operation between the local authority (as effected by the Highland Council and NHS Highland Adult Social Care) and its other local partners. These local procedures therefore address:
- referral and initial response;
- inquiry, including an investigatory stage if required;
- assessment and risk assessment;
- adult protection conferences and protection planning;
- risk and protection planning monitoring; and
- risk and protection plan review.
Note: the following links are to documents which are essential to our local procedures:
3. Inquiry, including an investigative stage, if required
The Adult Support and Protection (Scotland) 2007 Act, Section 4, places a duty on us to make inquiries about an adult at risk's well-being, property or financial affairs where we know or believe that we may need to intervene to protect the adult's wellbeing, property or financial affairs. Please note - The Adult Support and Protection (Scotland) Act 2007 (the Act) revised Codes of Practice (COP) indicate that an inquiry can be undertaken by a non-Council Officer, unless there is a need to use investigative powers.
The COP stipulates that ‘Good practice would ensure that a Council Officer is involved in overseeing or supervising all activity relating to the Act’ (Pg. 48, ASP Code of Practice). For more information on the Non Council Officers role in the inquiry please see the following document:-
Document: Oversight Of Non Council Officers Guidance
Non-Council Officers undertaking inquiries must be supported by a Council Officer (who could be a frontline practitioner or manager*) regarding their ASP role and the related tasks involved in the inquiry work, supporting the non-Council Officer to adhere to local ASP procedures.
Once non-Council Officers have completed the tasks required as part of the desk-top inquiry, their findings should be reviewed by a Council Officer and/or a manager
An Inquiry is seen as the overarching process within which the investigatory powers set out in the Act may be used to enable us to fulfil our obligations to conduct inquiries.
Initial information gathering might determine whether or not further action is required under our ASP processes. Where information gathering finds no evidence to suggest there may be an adult at risk, then inquiries would cease. However, other support or intervention activity may still be required, including onward referrals and provision of services to the adult.
All decision making and reasoning should be recorded on the appropriate CareFirst Assessment form (CareFirst 1&2 Assessment form).
5. Adult Protection Case Conferences and Protection Planning (including Review Case Conferences)
Following an ASP Inquiry and use of investigatory powers, where the adult is considered to be an adult at risk of harm and in need of protection, the Council Officer's assessment, recommendations and an up-to-date inter-agency chronology will be considered by an Adult Protection Case Conference. The purpose of the Case Conference is to consider risk, identify strengths and protective factors, support participation of the adult, and agree a Protection Plan where required. A Case Conference should be held within 21 days of an Adult Concern being recorded (ASP1&2).
Responsibility for arranging, coordinating and recording Adult Protection Case Conferences and Review Case Conferences sits with the locality social work team, who will retain responsibility for the case until adult protection processes conclude.
The Chair must be a suitably experienced and authorised practitioner with a sound knowledge of the Adult Support and Protection (Scotland) Act 2007, the Code of Practice and Highland ASP procedures. The Chair is responsible for ensuring effective participation, robust decision-making, clear recording of rationale and outcomes, and constructive challenge where required.
The Case Conference will consider whether the adult continues to meet the three-point criteria and whether a Protection Plan is required. Where a Protection Plan is agreed, this is a formal and statutory output of the adult protection process. The Protection Plan must clearly identify risks, agreed protective actions, responsible persons, timescales and review arrangements.
The adult should be invited and supported to participate in all Case Conferences unless there is a recorded reason why this would not be appropriate. The Chair and locality team should consider advocacy, communication needs, accessible information and any support required to maximise participation. Where the adult does not attend, their views and wishes must be sought and represented.
Recording is an essential safeguarding activity and forms part of the protection process. An initial summary of the Case Conference, including decisions and agreed actions, must be recorded as a case note within 3 working days and shared as appropriate by the Chair. A full minute, including the agreed Protection Plan and rationale for decisions, must be completed and shared within 10 working days by the Chair. The Case Conference record must clearly evidence the decisions reached, the rationale for those decisions, differing professional views where relevant, and how the adult's views and wishes were considered. The views, decisions and rationale of the Nominated Officers should be clearly recorded within the Case Conference record.
Microsoft Copilot may be used to support minute-taking, production of post-meeting summaries and drafting of minutes and Protection Plans. Responsibility for reviewing, validating and approving all records remains with the Chair. Professional judgement and decision-making cannot be delegated to Copilot.
Core Groups
The Case Conference may identify the need for a Core Group to oversee the implementation of the Protection Plan. The Case Conference will also determine the timescale for review, based on the adult's individual circumstances and level of risk. Review Case Conferences should normally take place within a maximum period of 3 months.
Review Case Conferences
The initial Case Conference will determine the timescale for the Review Case Conference based on the adult's circumstances and level of risk. This should not exceed 3 months. Responsibility for arranging, coordinating and recording Review Case Conferences remains with the locality social work team until adult protection processes conclude.
The Review Case Conference will consider:
• progress against the Protection Plan;
• the effectiveness of protective actions;
• current risks and protective factors;
• the adult's views and wishes;
• review and update the risk assessment where required;
• whether the adult continues to meet the three-point criteria; and
• whether adult protection measures should continue, be amended or conclude.
The Review Case Conference record must clearly evidence decisions reached, the rationale for those decisions, any differing professional views where relevant, and how the adult's views and wishes have been considered. The Nominated Officer decision-making, views, and rationale should also be recorded. The Protection Plan remains the central document for managing and monitoring risk and should be actively reviewed throughout the adult protection process.
An initial summary of the Review Case Conference, including decisions and agreed actions, must be recorded as a case note within 3 working days. A full minute, including any revised Protection Plan and rationale for decisions, must be completed within 10 working days. Recording is an essential safeguarding activity and forms part of the protection process.
Microsoft Copilot may be used to support minute-taking, production of immediate post-meeting summaries and drafting of minutes and Protection Plans. Responsibility for reviewing, validating and approving all records remains with the Chair. Professional judgement and decision-making cannot be delegated to Copilot.
Closure
Where the Protection Plan is considered effective and the Review Case Conference determines that risks are being appropriately managed and the adult no longer requires protection through formal Adult Support and Protection procedures, the Adult Support and Protection process may be closed. Closure decisions should ordinarily be made through a Review Case Conference to support multi-agency decision-making, oversight and consideration of any ongoing support needs.
Closure decisions must be based on an evidenced review of risk, protective measures and the adult's current circumstances. Closure must not occur solely because actions have been completed or a Review Case Conference has taken place.
The decision to close Adult Support and Protection processes must be clearly recorded, including:
• the rationale for closure;
• whether the adult continues to meet the three-point criteria;
• any remaining risks and how these will be managed;
• any ongoing support arrangements or services involved;
• any onward referrals or actions; and
• confirmation that the adult and relevant agencies have been informed of the outcome.
The closure decision, views, decision and rationale of the Nominated Officer must also be clearly recorded. Closure records should support accountability, auditability and future review where required.
6. Risk and Protection Planning Monitoring
The Council Officer will, ordinarily, take a lead role in monitoring the effectiveness of any support and protection plan. This will need to be done in alongside all those involved in effecting the plan, the adult at risk and, where appropriate, their network. In situations where actions are not considered effective in managing risks the Council Officer will need to escalate the circumstances of the case to their Nominated Officer and/or the Chair of the initial Case Conference. New protective actions will need to be taken as required; and consideration should also be given to holding a Review Case Conference earlier than scheduled.
Dependent on the circumstances and complexity of the case (and/or effecting a Protection Plan) the decision may be taken at the Case Conference to convene a core group between the initial and review case conferences. A lead professional, ordinarily the Council Officer, should be identified to be kept informed of and collate relevant updates relating to the adult and implementation of the support and protection plan. Other professionals will be identified to comprise the core group – they will work alongside the lead professional to ensure the implementation of the protection plan is both progressed and its effectiveness monitored.
The core group would be those who have direct and ongoing involvement with the adult, and may also include the adult. They are responsible for implementing, monitoring and reviewing the support and protection plan, in partnership with the adult. The core group should:
- be co-ordinated by the lead professional
- meet on a regular basis to carry out their functions
- keep effective communication between all services and agencies involved with the adult
- activate contingency plans promptly when progress is not made or circumstances deteriorate
- recommend the need for any significant changes in the plan to the case conference chair and provide updates to the review case conference, including any update to risk assessment and chronology
- be alert, individually and collectively, to escalating concerns that may require immediate response and/or additional support.
7. Large Scale Investigations (LSIs)
LSIs may be viewed as an example of public bodies and other agencies / office-holders performing their functions under s.5 and co-operating with each other to protect adults at risk of harm. Practitioners should also consult our local procedures. LSIs frequently involve other agencies including the Care Inspectorate, the NHS and the Police.
An LSI may be required where there is reason to believe that adults who are service users of a care home, supported accommodation, an NHS hospital or other facility, or who receive services in their own home, may be at risk of harm due to another service user, a member of staff, some failing or deficit in the management regime, or in the environment of the establishment or service.
An LSI may also be indicated by the need to address structures or systems that lead to possible harm for all those under such structures. In such circumstances, this means that there is a belief that a particular service may be placing some or all of its residents or service users at risk of harm.
An LSI should be considered if one or more of the following applies:
- an adult protection referral is received that involves 2 or more adults living within or cared for by the same service;
- a referral is received regarding one adult, but the nature of the referral raises queries regarding the standard of care provided by a service;
- where more than one perpetrator is suspected;
- institutional harm is suspected;
- a whistle-blower has made serious allegations regarding a service;
- there are significant concerns regarding the quality of care provided and a service's ability to improve. These concerns could come from a regulatory body such as the Care Inspectorate;
- an adult or adults are living independently within the community but are subject to harm from a perpetrator or group of perpetrators, or it is strongly suspected that more than one adult is subject to such harm;
- concerns regarding an adult are raised following their admission to hospital or discharge. This may include concerns about a care service that are evidenced by an admission to hospital, or concerns regarding an NHS service area;
- concerns are raised via a complaint to the Care Inspectorate, NHS Board, or the local Council or Health and Social Care Partnership;
- concerns are raised by General Practices, District Nurses, Dentists, Allied Health Professionals etc. who attend a service.
Within the setting of a care provision, harm may include:
- financial, physical or sexual abuse;
- neglect or omission of care;
- exploitation, coercion or undue influence to the detriment of the adult;
- psychological abuse, however subtle;
- undignified or degrading treatment.
Document: Highland Large Scale Investigation Procedures - January 2024
Document: LSI Risk Analysis & Protection Plan V2 2
LSIs often take place in parallel with other investigations, for example NHS-led Adverse Event Reviews or Care Inspectorate activity. Every effort should be made to coordinate such overlapping investigations to minimise duplication and maximise the opportunity for interagency learning.
Senior managers are responsible for initiating and overseeing LSIs. They should keep the Adult Protection Committee regularly appraised of the progress of any LSIs that may be underway, and provide the Committee with a final report once the LSI is concluded. Such a report might include the identification of patterns or themes arising in regulated care settings. This will ensure that any necessary actions arising out of the LSI relating to the duties of the APC can be noted and necessary responses actioned, noting that regulatory bodies may have ongoing responsibilities in keeping with their remit.
Initial Learning Opportunities
Initial Learning Opportunities (ILOs)
The ILO framework provides a structured yet flexible way to capture and embed learning from incidents at an early stage. ILOs take place once a situation is no longer active, creating space for reflective discussion and formal debriefing. Insights are documented and shared to improve practice, inform team development, and strengthen partnership learning. Where criteria for a Learning Review is met, a notification to the Learning Review Governance Group will follow the ILO. This framework ensures learning is not lost and feeds into APC sub-groups, development sessions, and wider communication channels.
8. Learning Reviews
An Adult Support and Protection Learning Review is a means for public bodies and office holders with responsibilities relating to the protection of adults at risk of harm to learn lessons from considering the circumstances where an adult at risk has died or been significantly harmed.
It is carried out by the Adult Protection Committee under its functions of keeping procedures and practices under review, giving information and advice to public bodies and helping or encouraging the improvement of skills and knowledge of employees of public bodies as set out in section 42(1) of the Adult Support and Protection (Scotland) Act 2007.
Learning Reviews should be seen in the context of a culture of continuous improvement and will focus on learning and reflection around day-to-day practices, and the systems within which practice operates.
Adult Protection
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Adult Protection
Information for Adult Protection (AP, or Adult Support and Protection ASP) professionals. These include nominated or ...
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Highland Adult Protection Committee
Information and news about the Highland Adult Protection Committee and the work it does.
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Local ASP procedures
Adult support and protection enquiries and investigations are undertaken by NHS Highland Adult Social Care Profession...
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News, reports and audits
News, audit reports, national and other Area review and Investigation reports - for Adult Protection Professionals.
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Protection topics
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Tools, links, legislation and national guidance
Helpful links, tools, templates, legislation and national guidance pertaining to adult protection.
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ASP training
Highland Adult Support and Protection (ASP) trainer-led events and e-modules are accessed via the Turas Learn system.