1. Introduction
Large scale or whole service enquiries have an important role in understanding and
responding to concerns about organisational abuse or neglect. They provide an opportunity to
review multiple safeguarding concerns and/or enquiries together to evaluate if there are
systemic issues, patterns, or underlying causes of abuse and neglect. This is to support in
identifying the learning measures needed to safeguard the adults supported by that service.
In this way, large scale enquiries can have an important role in helping to prevent the
reoccurrence of abuse or neglect, and in supporting adults’ expectations, that they be safe
and feel safe, now and into the future.
Adult voices:
“I want to know this won’t happen to anyone else”
“I want to feel safe – and know this won’t happen again”
This overview guidance sets out when a large scale / whole service enquiry should be
considered, as well as general practice principles for Safeguarding Leads that will need to be
applied with professional judgement and proportionality in light of the specific circumstances.
This practice guidance will need to be read alongside the TDSAP Multi-agency Safeguarding
adult procedures and guidance.
2. Large scale / Whole service enquiries
A ‘large scale or whole service enquiry’ is an overarching safeguarding enquiry that should be
considered when there are concerns about organisational abuse.
Organisational abuse is defined in the Care Act 2014 statutory guidance as “including neglect
and poor care practice within an institution or specific care setting such as a hospital or care
home, for example, or in relation to care provided in one’s own home. This may range from
one off incidents to on-going ill-treatment. It can be through neglect or poor professional
practice as a result of the structure, policies, processes and practices within an organisation”.
A large scale / whole service safeguarding enquiry takes forward this approach, it enables a
number of individual safeguarding concerns/enquiries, significant incidents, or emerging
patterns to be considered in a way that helps to identify organisational causes of abuse or
neglect, and the measures needed to prevent its reoccurrence.
Where abuse or neglect arises due to underlying reasons, relating to the structure, policies,
processes and practices within an organisation it might be considered organisational abuse.
Identifying the underlying causes helps to ensure that safeguarding measures are targeted
appropriately, to safeguard all those concerned and others in the future. For further guidance
about organisational abuse see Section 6.1. The large scale / whole service safeguarding
enquiry thresholds are shown within the ‘Large Scale / Whole Service Safeguarding Enquiry
Overview’.
2.1 Relationship with other safeguarding enquiries
When there is a safeguarding concern about an adult, the focus of a safeguarding enquiry will
be on what has happened to that adult, their safety and wellbeing, on their desired outcomes
and what actions will be needed to support that adult to be safe. If there are concerns that
more than one adult is experiencing abuse or neglect within the same service or setting, then
this process should be followed for each adult. As such each individual safeguarding enquiry
will need to result in its own safeguarding plan and outcome discussion / meeting. This is
important to ensure that each individual adult’s needs, desired outcomes, circumstances and
personal safety are considered in their own right.
The large scale / whole service enquiry will need to draw upon the findings of each individual
safeguarding enquiry undertaken, and undertake additional enquiries and actions as required
in order to respond to the concerns of organisational abuse.
For further information, Section 6.5 provides illustrated case examples of when a large scale
/ whole service enquiry is required and when one is not.
3. Practice considerations
While the operational approach to large scale or whole service safeguarding enquiries will
differ across the two local authorities, each will convene dedicated enquiry meetings, and the
outcomes of these will be formally reported to determine what large scale / whole service
safeguarding actions may be required.
Large scale / whole service enquiries can be complex. This section sets out additional practice
considerations that are particularly relevant when a large scale / whole service enquiry is being planned and undertaken.
3.1 Who to involve within Large scale/ Whole service enquiries
Involvement in large scale / whole service safeguarding enquiries should be limited to those
who need to know and can contribute to the decision-making process. This may include an
appropriate representative of any organisation that has a specific role in:
- undertaking enquiries in relation to abuse or neglect
- assessing the risk
- developing or carrying out the safeguarding plan
- undertaking related enquiries e.g. criminal, regulatory
- taking other actions in relation to the organisation alleged to have caused harm
In all cases where the large scale / whole service enquiry is being considered involving a
regulated service provider, the following must be informed, invited and be offered copies of
minutes irrespective of attendance:
- Care Quality Commission
- Contracting/Commissioning authorities
Where a large scale / whole service safeguarding enquiry is undertaken in relation to an NHS
Trust, the Trust should ensure its Chief Executive Officer and the Executive Officer for
Safeguarding within the ICB, or relevant devolved commissioner, are notified and
involved/kept informed. Similarly, where a large scale / whole service safeguarding enquiry
involves a Torbay or Devon ‘in-house service’, the relevant Director of Adult Social Care must be notified, and involved/kept informed.
3.1.1 Involvement of adults at risk and their relatives
The adult at risk, and their relatives as appropriate, should be fully involved within individual
safeguarding enquiries relating to them as set out in the TDSAP Multi-agency Safeguarding
adult procedures and guidance.
The Large-scale/Whole service safeguarding enquiry must be informed by the views
of adults at risk and/or their representatives. The large scale/whole service safeguarding
lead should therefore consider the most appropriate ways to ensure these voices are
included. Many views will already have been captured during individual safeguarding
enquiries, though some adults or families may wish to provide additional feedback/views
specifically relating to the large scale / whole service safeguarding enquiry process.
Adults who have been safeguarded through individual enquiries should receive feedback
about the actions taken and decisions made as part of the large scale / whole service
safeguarding enquiry. Any implications for their own care must be discussed with them
directly and agreed in partnership.
Initial communication with the adults and families should be led by the Provider or Service,
as they are often best placed to respond to personal concerns. However, it is advisable that
this communication takes place in consultation with the large scale / whole service
safeguarding enquiry lead to ensure consistent and transparent communication. Where
appropriate, the large scale / whole service safeguarding enquiry lead may identify a
nominated professional link for the adults, families, and advocates to help maintain effective
communication, reduce anxiety, and support co-production and involvement.
Support for the adults affected must be considered throughout the large scale / whole
service enquiry and beyond, with minimum expectations for ongoing contact established.
3.1.2 Involvement of the service provider
It is essential that the service provider is made aware of the concerns in the first instance. In
exceptional circumstances where the concerns may relate to the manager, the owner or the
regional/company director, advice may need to be taken to ensure the most appropriate
approach to sharing of information is taken. The provider should be fully involved in the
process regarding the concerns about the service to enable them to ensure the safety and
wellbeing of the adults/patients receiving care, support and treatment within that service.
Depending on the size of the organisation and the nature of the concerns, the individuals
implicated, the appropriate representative for any large scale/whole service safeguarding
meetings might be for example, the manager, the owner or the regional/company director. It
is important that the representative is of appropriate seniority to respond on behalf of the
organisation to the service level nature of the concerns.
Where the given representative is directly implicated (or attendance may prejudice the
planning of an enquiry) it may not be appropriate for them to be present at the large
scale/whole service safeguarding meeting. If this is the case, an alternative manager should
be provided with an opportunity to attend to represent the service, for example, a regional
manager. Communication with and involvement of the organisation must be maintained as
fully as is possible.
The service provider’s organisation should have the opportunity to respond to any concerns
raised by the large scale / whole service enquiry, and to be able to review any large scale /
whole service safeguarding report and comment on its findings. This ensures that decision
making remains transparent and visible to the provider, enabling the provider to raise any
challenge as appropriate. The provider can also contact the enquiry lead directly outside of
any meetings. At the close of any enquiry process, the provider must be given the opportunity
to provide constructive feedback regarding their experience of the process. These questions
are shown in the ‘Large Scale / Whole Service Safeguarding Enquiry Overview’.
3.1.3 Involvement and responsibilities of non – TDSAP (Torbay or Devon) placing authorities
Where an adult at risk is placed in a service by non-TDSAP placing authorities, then those
placing authorities should also be invited to the large scale/whole service safeguarding
meeting. The ADASS (2025) Out-of-Area Safeguarding Adults Arrangements: Guidance for Inter Authority Safeguarding Adults Enquiry and Planning Arrangements establishes how authorities should work together in these circumstances. Key principles of this guidance are summarised in Section 6.2.
4. Enquiry planning
The decision to undertake a large scale / whole service enquiry is made by the relevant local
authority.
When undertaking a large scale / whole service enquiry, it will be necessary to:
- draw upon and summarise the relevant aspects and conclusions of any individual
enquiries - focus on the service wide concerns and/or common themes and the underlying
causes. - consider the need for additional enquiries as part of the Terms of Reference, as
required, to understand the presenting issues such as relevant policies, procedures,
training and staff practices. - provide opportunity for the service provider to respond to organisational abuse
concerns and large scale whole service enquiry findings (this is in addition to being
able to respond to the respective individual enquiries).
Large scale / whole service enquiries should be as timely as possible, to ensure underlying
issues and concerns are identified and addressed. For this reason, once a decision has been
made to undertake the large scale enquiry, it may not be possible to include subsequent
individual enquiries within its scope, as this may prevent the large scale enquiry from
concluding and delay required safeguarding arrangements being put in place. A judgement
will be required by the large scale /whole service enquiry lead.
4.1 Who should undertake a Large scale / Whole service enquiry?
The local authority will appoint a large scale / whole service enquiry lead, who will determine
how the enquiry is undertaken.
As large scale enquiries involve situations where there are serious multiple concerns or
repeated instances of abuse or neglect and/or where managers/senior managers may be
implicated within the organisation’s practices, it will usually be appropriate for this to be
undertaken by the local authority so as to achieve the safe outcomes required from the large
scale enquiry.
Where the local authority is leading a large-scale or whole-service safeguarding enquiry, the
enquiry lead must hold sufficient leadership and managerial authority to undertake this role
effectively. However, in situations where the provider is commissioned by a partner agency,
the local authority will request that the commissioning partner identifies the appropriate enquiry lead. For example, if the service is an NHS provider commissioned by NHS England, the large-scale or whole-service enquiry lead would be sought from NHS England.
5. Additional matters
5.1 Informing wider adults / patients
There may be circumstances where there is a need to inform wider adults/patients in the
service of the nature of the concerns and the actions being taken to respond to these. This
will be particularly relevant where there are widespread concerns, and where clear
communication will help to reassure wider adults/patients in the service and their
representatives of actions being taken. Such communications will usually be undertaken by
the service provider, who will be best placed to respond to individual concerns of the
adults/patients and is usually undertaken in partnership with the large scale/ whole service
safeguarding enquiry lead.
5.2 Wider adults / patient reviews
As part of undertaking a large scale / whole service enquiry it may become apparent that there
are adults/patients, who do not require the support of this safeguarding process but, who
nonetheless would benefit from a review of their needs.
The need for such reviews of individual adult/patient needs and provision may therefore also
be required, alongside or subsequent to the large scale / whole service enquiry. It is important
that the adults/patients, their relatives or representatives are appropriately involved in such
reviews.
Where placements are commissioned by non-TDSAP commissioning authorities, the
undertaking of reviews will be the responsibility of the relevant commissioning authority.
5.3 Media interest
Large scale / whole service enquiry leads, and their line management, including Chief
Executive Officer (NHS) or Director (Adult Social Care) and the relevant
communications/media team must be informed of any media interest as soon as possible.
Under no circumstances should Safeguarding Leads or those undertaking enquiries give a
comment or interview to the press.
5.4 Police involvement
There may be circumstances where the findings from individual enquiries and large scale /
whole service enquiries, indicate potential offences. Whilst concerns may relate to offences
committed by individuals; they may also be committed by services/organisations, by virtue of
how their arrangements are managed or organised. For example:
- Ill treatment and Wilful neglect: provider offence
- Corporate Manslaughter and Corporate Homicide Act 2007
Where there are such concerns, the police should be taking the leading investigative role.
6. Additional information and illustrative examples
6.1 Identifying organisational abuse
Where a large scale / whole service enquiry is being undertaken, many different forms of
abuse or neglect may be evidenced within the individual safeguarding enquiries being
undertaken. The overarching large scale enquiry will be able to consider these individual
enquiries together, to identify underlying factors that maintain the risk of abuse and neglect
(see Illustrative Examples, Section 6.5).
The following guidance can inform professional judgements and decision making as to
whether organisational abuse is a presenting concern.
As organisational abuse or neglect arises as a result of the structure, policies, processes and
practices within an organisation, it may be evidenced by certain characteristics:
- It is widespread within the setting (e.g. the abusive/neglectful practice is not confined
to the practice of a single staff member) - It is evidenced by repeated instances of abuse or neglect
- it is generally accepted that these things happen
- It is sanctioned – it is encouraged or condoned by line managers
- The absence of effective monitoring or management oversight by managers has
allowed the practice to occur. - There are environmental factors that adversely affect the quality of care (e.g.
unsuitable buildings, lack of equipment, challenges with retention of staff whereby
increased dependency on temporary staffing solutions is impacting safe delivery and
quality of care). - It is systemic e.g. factors such as a lack of training, poor operational procedures, poor
supervision and management all significantly contribute to the development of
organisationally abusive practice.
It is not necessary for each of these characteristics to be present. However, the presence of
one or more characteristic increases the likelihood that organisational abuse is taking place.
Please note: organisational abuse may also be indicated by a number of adversely affected
adults in the service. However, it could occur in relation to a single adult which will require
further information gathering to establish whether other adults are, or may be, affected.
The assessment of possible organisational abuse will need to be based upon professional
judgement, with consideration of all the individual circumstances. This should include
consideration of the actual or potential impact on the wellbeing of the adults concerned; as
well as the underlying causes of any abuse and neglect.
6.2 Out of area placements
Sometimes local authorities will need to work together to respond to safeguarding concerns.
This is most common when abuse or neglect occurs in one local authority area, but the adult
receives services funded/commissioned by another.
The ‘ADASS (2025): Out-of-Area Safeguarding Adults Arrangements: Guidance for Inter
Authority Safeguarding Adults Enquiry and Planning Arrangements highlights the need for
authorities to work together and outlines respective responsibilities.
Key general principles are summarised below:
The safeguarding adults procedures of the host authority (i.e. the local authority in the area
where the abuse occurred) will be followed. This means that, the host authority:
- will fulfil the role of coordinating and leading the safeguarding enquiry process
- will maintain effective communication with the placing authority(ies)
- may need to undertake immediate actions to ensure the safety of the adults, but
wherever possible this should be in consultation with the placing authority(ies)
Placing authorities (the local authority or NHS body responsible for commissioning care and
support services for that adult):
- will contribute to the safeguarding response as required
- have overall responsibility for assessing and ensuring the provision of care and support
to meet the needs of the adult at risk - will ensure, through contracting arrangements and in-service specifications, that the
provider has arrangements in place for protecting adults at risk of harm.
If the adult is a ‘self-funder’ (care and support provision funded by the adult themselves) and
there is no placing authority involved in commissioning care and support services, the host
authority has the duty to act under the multi-agency procedures and guidance regardless of
the area from which the adult originated.
The full ADASS guidance includes more information about the arrangements required in such
situations.
6.3 The role of the Care Quality Commission (CQC)
The Care Quality Commission (CQC) is the independent regulator of all regulated health and
adult social care services in England, including those provided by the NHS, local authorities,
private companies and voluntary organisations.
The role of the CQC includes:
- CQC registering and monitoring of care providers
- Inspecting and rating services
- Taking action to protect adults who use services
Fundamental standards
All service providers registered with the CQC are expected to meet fundamental standards,
below which care standards should never fall. These 17 standards include:
- Safeguarding from abuse: You must not suffer any form of abuse or improper treatment
while receiving care. - Duty of Candour: The provider of your care must be open and transparent with you
about your care and treatment. Should something go wrong, they must tell you what
has happened, provide support and apologise. Regulation 20: Duty of Candour: Care
Quality Commission
See more information about the CQC fundamental standards of care.
Statement on CQC’s role and responsibilities for safeguarding children and adults
The CQC sets out a range of roles and responsibilities in relation to safeguarding. These
include:
- Supporting the local authority’s lead role in conducting enquiries or investigations
regarding safeguarding children and adults. We do this by cooperating with them and
sharing information where appropriate from our regulatory and monitoring activity. We
assist the police in a similar way. - Holding providers to account by taking regulatory action to ensure that they rectify any
shortfalls in their arrangements to safeguard children and adults, and that they
maintain improvements. This includes requiring providers to produce action plans,
taking enforcement action to remedy breaches of fundamental standards, and taking
action against unregistered provider.
See the full CQC Our roles and responsibilities for safeguarding adults and children document.
6.4 The role of commissioning authorities
Commissioning authorities will have required standards for services and systems in place for
monitoring, inspection and for supporting service providers to achieve improved standards.
In the event that safeguarding concerns emerge, these roles and responsibilities will be
continuous with the safeguarding process, however liaison with the large scale / whole service
lead will be required to ensure that responses are coordinated and information shared
appropriately.
Depending on the circumstances, commissioning authorities may support the safeguarding
enquiry process by:
- Advising on past service performance issues and agreed actions to address concerns
- Advising on expected standards and identifying areas where the service provider has
not met their contractual requirements - Undertaking a review of systems or records
- Obtaining from the service provider all relevant policies and procedures
- Inspecting areas of organisational practice
- Requiring evidence of improved/agreed practice
- Identifying the need for service improvement plans
Service improvements may be required by the commissioning authority to achieve required
standards of service provision. The nature of such plans will be determined by the
commissioning authority, and may continue irrespective of the safeguarding adults
procedures.
The decision to suspend or end any suspension of placements with a service provider will be
made by each individual commissioning authority in accordance with the criteria and agreed
processes as set out in their own suspension policy. The decision may be informed by the
large scale / whole services safeguarding process.
6.5 Illustrative examples
6.5.1 Large scale / Whole service enquiry required
During April and May, there were 4 safeguarding concerns raised for residents in X, a small
Care Home.
In April, Mrs A’s daughter reported an incident when her mother fell whilst being supported to
dress herself, causing an injury to her hand. The service provider was asked to undertake an
enquiry, who found that the care plan was not being followed. The safeguarding plan
recognised the need for the new member of staff in question to be given more training.
Later in April, the care home reported that a member of staff reported a colleague under stress
shouting at a resident Mrs B. The service provider was asked to undertake an enquiry, who
found that the staff member was very apologetic. The resident was given support and the care
home recognised the need for the new member of staff in question to be given more training
and support to understand their role.
In May, Mr. C experienced an injury whilst being hoisted. There was an enquiry which
determined that Mr C’s care plans were regularly not being followed. Care Home X reviewed
the care plan and put in place regular checks to ensure this was being followed.
Later in May, a safeguarding concern was raised for Mrs. D by a Community Nurse in relation
to her pressure ulcers. The nurse was concerned that advice previously provided and care
plans were not being followed. An enquiry was undertaken for Mrs. D in relation to her safety
and wellbeing.
As a result of these concerns, and repeated concerns around neglect, care planning and
training within a short space of time, the local authority considered the thresholds were met
and raised these emerging themes with the provider. The local authority then coordinated a
large scale / whole service enquiry meeting.
The large scale / whole service enquiry considered the issue of potential organisational abuse. The findings of the enquiries for Mrs A, Mrs B, Mr C and Mrs D were collated. Further
information was sought from the service provider and others about care planning, induction,
supervision and training.
The safeguarding plan focused on measures to improve these issues for all residents and the
relevant commissioning teams agreed to monitor these improvements through their own
performance framework.
Mrs A, Mrs B, Mr C and Mrs D were provided with feedback on the conclusions of the large
scale enquiry and the actions being taken.
6.5.2 Large scale / Whole service enquiry not required
Example One: Single Enquiry, with service wide concerns
Mr E receives care support from domiciliary care service Y. A safeguarding concern was
raised for Mr E following an injury sustained whilst being hoisted at home by a formal carer.
An enquiry was undertaken, during which it was identified that his care plan was not adequate, and that training and record keeping was poor. There were no other safeguarding concerns raised in relation to this service provider, however similar practices were being followed for other clients. The individual safeguarding enquiry meeting raised concern of potential risk to other adults, with similar needs.
The service provider agreed to review all of Mr E’s care plans, and those of any other adult
using these kinds of hoists, provided specific training to staff and introduced new measures to
monitor effective recording. The service provider confirmed when these actions were
complete.
Comment:
Thresholds for a large scale / whole service enquiry were not considered to be met. There
were initially service wide concerns, however the provider implemented risk management
measures and gave assurances that there were no wider organisational abuse concerns.
Example 2: Multiple Enquiries, without service wide concerns
Between April and May, in day service Z, there were 3 safeguarding concerns raised for
adults.
During April, the day service reported that Mrs F had complained that a male service user
with dementia had made sexual comments and touched her chest, and was distressed by
her experience. An internal investigation was undertaken by the service provider which
supported her account of events. This behaviour was not a previously known risk. Support
was provided to Mrs F and the care plans for the male client were reviewed to prevent the
risk of reoccurrence.
During April, the day service reported concerns that a new member of staff had made racist
comments to an adult. This staff member had been suspended. A safeguarding enquiry was
undertaken and the day service followed their disciplinary process.
During May, the day service raised a safeguarding concern, that an adult was being
financially abused by a relative. A safeguarding enquiry was undertaken and the day service
and local authority worked together to put safeguards in place.
Comment:
Thresholds for a large scale / whole service enquiry were not considered to be met. Although
there were several safeguarding concerns involving the same service, there was no
indication that organisational abuse was an underlying cause. The risk to each adult was
addressed through their individual safeguarding plans.
With thanks to Leeds Safeguarding Adults Board whose guidance has been adapted to produce this document
Large Scale / Whole Service Safeguarding Enquiry Overview