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An advocacy perspective on safeguarding and the Care Act

Kathryn Holland, VoiceAbility safeguarding lead 15 September 2023

Abuse happens. It can be isolated or widespread. It can be, and often is, something rotten concealed beneath an apparently benign surface. 

The too many examples, including Winterbourne View in 2011 and Whorlton Hall in 2019, have made this crystal clear. 

Safeguarding under the Care Act

The Care Act was introduced between these two scandals and is an important piece of legislation in the safeguarding of people. 

It signalled a shift from a process to a person-led approach. It aimed to put the person’s voice at the centre. 

Rather than safeguarding enquiries simply being about a person, they now must be carried out in partnership with the person who is at risk of or experiencing abuse. 

And if someone has substantial difficulty’ in making their wishes known, then they have a right to an independent person to support them to be involved. Often that person is an advocate.

Ensuring that every person who is at risk of abuse is independently supported to make their experiences known is an important step in this direction. 

Good advocacy is skilled not only in listening to, taking seriously and articulating someone’s views, but also in gaining insights and understanding of the experience of people who cannot say what’s wrong.

And this is central to the identification and prevention of abuse.

Our study

VoiceAbility provides independent advocacy services in more than 30 local authority areas across the UK. We’ve been concerned for some time that, despite the well-intentioned principles within the Care Act, the reality for people using services is different. 

We’ve recently concluded a study to help us understand these concerns better, to shine a light on safeguarding culture and to open the conversation, from an advocacy perspective, about what this really looks like. 

This is part of our role to be a critical friend’ to health and social care professionals.


Our work looked at referral rates, comparing our own figures with official safeguarding data, and we spoke to many of our advocates with experience of raising safeguarding concerns.

The figures for referral rates for advocacy for safeguarding enquiries – known as Section 42 enquiries – are low, ranging from barely 1% to 21.1%, and the average was just 3.3%. What the figures can tell us has limits, and the true picture may be even bleaker. 

A key finding has been an apparent reluctance to open Section 42 enquiries in the first place.

The official statistics show a wide variation in what individual councils consider meets the statutory criteria for a Section 42 enquiry.

If these enquiries are not being opened when they should, then it follows that referral rates for advocacy may appear higher than they otherwise would.

Many advocates told us that even serious allegations of physical abuse by other professionals do not always lead to Section 42 enquiries because the local authority will carry out fact-finding’ or screening’. This often involves simply talking to a manager of the institution.

The advocacy duty applies in relation to the enquiry, so if this initial fact-finding enquiry’ happens outside of an official enquiry, there’s no referral for advocacy and the person is not provided with the independent support they’re entitled to.

Advocates told us they’re really concerned about this.

One reason a person may tell their advocate about abuse is because they’re independent. 

If the response to that abuse is for someone who works at the institution to talk to them, without their advocate present, the very independence that may have given them the confidence to speak up in the first place is lost.

This lack of independence was reflected in a further finding. 

We found that enquiries are routinely delegated to mental health hospitals to carry out their own investigations’, where advocates report being unclear as to whether an enquiry is taking place and importantly how the person is supported to be involved.

The independent Safeguarding Adults Review into the abuse of people with learning disabilities and autistic people at Whorlton Hall echoed these findings. 

The review – which VoiceAbility gave evidence to as one of the advocacy providers involved – found that many safeguarding enquiries lacked independence and an understanding of what a safeguarding enquiry under the Care Act should look like.

Our findings have helped us to articulate what safeguarding looks like from the perspective of independent advocacy. 

It has given us some vital insights into the reality, on the ground, for those who are the most at risk of abuse, and importantly why safeguarding processes may not be keeping people safe from harm.

What now?

As a result, we want to delve deeper into this work to understand why this is happening:

  • Why are local authorities routinely excluding advocates and their concerns?
  • What drives local authorities’ reluctance to open Section 42 enquires?
  • What needs to happen to improve the situation for the people we support?

Over the next few months, we are going to work with health and social care professionals to understand our data more. We will provide a further update on this work in due course.