Positive Practice Hub – Good Practice in Safeguarding

North Northamptonshire Council Adult Social Care supported a 19-year-old male, who had a diagnosis of autism, verbal and communication challenges where concerns were raised by his parents about possible neglect and physical/psychological abuse by his care provider. The parents also contacted the Care Quality Commission (CQC).

A Section 42 safeguarding enquiry was initiated immediately, resulting in a same-day visit. The individual agreed to meet with a duty worker, supported by his carers. No immediate risks were identified, but the investigation continued due to the number of concerns raised. An advocate was involved to support communication, and a person-centred approach was used including visual tools and gestures to help the individual express his feelings. The care manager viewed care records, spoke with the registered manager, and gathered additional views, including from a personal assistant. Regular updates were provided to the parents throughout the process.

The enquiry found no evidence to support the allegations of abuse and concluded that the concerns were more likely linked to parental anxieties. It was also identified that the individual lacked peer support, which was addressed by the social worker.

In January 2024, Executive approval was granted for North Northamptonshire Council to utilise Public Health Reserves to fund specialist wraparound support roles for individuals experiencing rough sleeping. These roles were designed to complement the Council’s existing Rough Sleeping Team by providing targeted drug and alcohol support, as well as mental health intervention. The aim was to improve engagement with this often complex and transient cohort, while advocating on their behalf to ensure access to appropriate treatment pathways where rough sleeping had previously presented a barrier.

A Band 6 Mental Health Social Worker commenced in post in July 2024 and initially worked alongside Street Outreach Workers to identify individuals requiring mental health support and build rapport with them. It was quickly recognised that the role could have a broader impact, particularly in supporting individuals experiencing homelessness by providing important information to help assess ‘priority need’.

Where individuals present to the Council and are assessed as homeless, eligible and in priority need they are entitled to be provided with temporary accommodation while their homeless application is assessed. Priority need can be established through factors such as vulnerability due to mental health conditions, physical disability, serious illness, or a history of care or imprisonment. However, evidencing these vulnerabilities can often be challenging and time-consuming.

Since taking up the role, the Band 6 Mental Health Social Worker has helped prevent several individuals from becoming street homeless by verifying and evidencing their priority need in accordance with the statutory assessment.

One example is Peter, who presented to the Council as homeless on the day of his release from a CAS3 property following a period in prison. Without intervention, he would likely have slept rough that night. Peter disclosed a diagnosis of schizophrenia, and, with Peter’s consent, the Mental Health Social Worker accessed his medical records, confirmed the diagnosis, and enabled immediate accommodation, preventing a first night on the streets.

A second example is Alan, who was already rough sleeping when he engaged with the Rough Sleeping Team. It was quickly identified that he had significant and longstanding mental health needs. Drawing on specialist knowledge and access to relevant records, the Mental Health Social Worker was able to produce a clear summary of Alan’s condition, evidencing his vulnerability and priority need status. As a result, Alan was placed in temporary accommodation, removing him from the street and enabling ongoing support while he awaited settled housing. Without this intervention, his needs may not have been sufficiently recognised, and he could have faced delays in accessing both accommodation and mental health services.

A third example involves Sarah, who was rough sleeping and engaging with services provided by a local homelessness partner. Sarah had a history of three strokes but this important had not been included in her application, and her summary care record was unavailable. With her consent, the Mental Health Social Worker accessed her medical records, verified her condition, and secured accommodation for her on the same day.

These examples illustrate the significant impact of embedding a Band 6 Mental Health Social Worker within the Rough Sleeping Team. The role has strengthened the Council’s ability to identify and evidence vulnerability, preventing and alleviating rough sleeping for individuals in priority need who may otherwise have remained on the streets or without accommodation for extended periods.

This case involves  a woman accepted into NDAS’s substance misuse refuge. She was experiencing domestic abuse and had mobility and mental health issues, alongside a diagnosis of stage 4 cancer. She had relocated from outside Northamptonshire, creating complexity around service responsibilities.

During her time in refuge, she was supported as well as she could be whilst navigating the complexities of her situation.

She received a significant amount of money each month which put her at risk of exploitation. She was very aware of her cancer diagnosis and was in a lot of pain which made it difficult for her to abstain from using substances.

She displayed sporadic engagement with services but was supported with getting to appointments, was able to safely access care for her cancer, and was successfully linked with palliative care and adult safeguarding.

She wished to return to where her family was from and agencies were working together to try and achieve this. Unfortunately, this did not happen before she passed away, through no fault of the team in putting measures in place. During her final months, she was as safe and supported as she could be, which meant a great deal to her family.

This case is a reminder that whilst we may not always be able to affect the outcome, we must reflect on the importance of our role in someone’s journey.

Northamptonshire Fire and Rescue Service supported ‘Maria’ who had been recently widowed and targeted by individuals who exploited her vulnerability, gradually isolating her and taking control of her finances and property under the guise of support. As the abuse escalated, ‘Maria’ was moved between unsuitable accommodations, left without proper food, heating, communication, or medical care, and lived in hazardous conditions while suffering significant health issues. NFRS received a referral from the Police Complex Fraud Team who supported her with getting her health reviewed and with support during the prosecution of the perpetrators. Through positive multi‑agency working focusing on ‘Maria’s wishes and wellbeing, ‘Maria’ received medical treatment, safeguarding support, and was rehoused in supported living, where she is now safe, stable, and thriving.

​Barry is under 65 and lives alone, he rented a first floor flat from a housing association, formally owned by the county council.

From December 2024 until July 2025 Barry had eight recorded incidents where he would leave cooking unattended. Other residents within the block became increasingly concerned around the frequency of these incidents and due to Barry leaving the property completely when his hob was on. Crews would regularly arrive, isolate the cooking and look to see if they could locate Barry to provide advice. Each time he returned home, Barry would not respond to the crew when they spoke with him or he would tell them he was moving out the next day. There was also evidence of smoking within the flat and a mattress on the floor in the lounge was found to have over 100 cigarette burn marks in.

Along with the Housing Officer, The Complex Case Officer and Adult Social Care, multiple door knocks and home visits were completed to try and engage with Barry, to offer advice, provide fire retardant bedding and to assess his capacity and offer support, however, Barry did not engage. There were concerns around Barry’s mental health, he would talk about voices he could hear, he pulled wiring out of ceilings and walls, believing bees were following him around and stinging him. When the GP made contact with Barry, they shared no concerns around his mental health or capacity so he was closed to social care following the outcome and due to lack of engagement.It was unclear how he was managing his basic care needs as his benefits had also stopped. Housing attempted to deliver food parcels, but they were never taken in. He had no access to cooking facilities as his gas was capped, he also had no heating or hot water.

Due to the level of incidents, and Barry’s large amount of rent arrears exceeding over £2000, housing were awarded a court order to contact Police each time a cooking incident occurred, this included powers to arrest due to the risk to himself and others. Housing also went to court to seek possession of the property and this resulted in Barry’s eviction.

Barry ended up living in an old car, just outside of the block of flats he was evicted from. The car was not road worthy, there was evidence of damp and mould on the windows and Barry had covered the windows in sheets and cardboard, which were covered in condensation, so you couldn’t see in the vehicle. As the car was parked on the land which belonged to the housing association, there were concerns this would be removed and Barry would have nowhere to stay.

When speaking with the Rough Sleeper team, who had been trying to engage Barry into temporary accommodation, they shared that Barry was definitely smoking within the car but not cooking, they were unsure what he was eating as he was heavily fixated on needing to lose weight and being stung by bees. Barry was referred to Housing Options to carry out an assessment regarding his accommodation. Barry was assessed to lack capacity around maintaining a tenancy. Due to this, he was unable to be housed but was not living safely within the car. It was around this time that Barry was also removed from his GP and no longer had one allocated to him.

An MDT meeting was held, and it was agreed that social care would attempt to complete a Care Act Assessment, and the Complex Case Officer would try and visit to provide a fire-retardant blanket and winter warmth pack to support. Several visits to the car were made, however, Barry could not be located. He would frequently be at the local day centre, where social care were attempting to complete the Care Act Assessment.

THE LEARNING:

• Despite submitting a number of referrals for Barry, due to his lack of engagement, services closed without being able to offer support.
• The Complex Case Officer and colleagues had 6 failed attempts at delivering fire safety advice, Barry did engage in one visit prior to his eviction but there were 3 subsequent failed visits to the vehicle Barry was staying in.
• Barry’s neighbours were identified as vulnerable when carrying out hot strike engagements, neighbours reported being concerned the incidents would impact on their safety. Home Fire Safety visits were carried out to those who consented.
• Barry was deemed to lack capacity around being able to sustain a tenancy. Due to this, it was highlighted that Barry would not be eligible for temporary accommodation, although concerns were raised that he was rough sleeping in his car. It was unclear during the MDT meeting whether social care could meet any needs as he would not engage with a formal care needs assessment.
• Within the MDT meeting, professionals’ were required to think outside the box when engaging with Barry to ensure the Care Act Assessment could be completed. Effective communication was required between services to ensure interactions with Barry were meaningful and support offered to him.
• Due to the complex nature of Barry’s case, the rough sleeper team managed to secure a property for him under the Never Give Up Scheme

THE OUTCOME:

Barry was supported by the Rough Sleeper team via their ‘Never Give Up scheme.’ They have a series of properties in which they house vulnerable people who may not be able to sustain a tenancy. Barry was offered a one-bedroom flat, within another town in the county. They assigned Barry a support worker who has contact with him daily and they have been able to support him to move into a new flat, provide some furniture and appliances. The support offered to Barry was to teach him the skills to maintain a successful tenancy. This current accommodation is not a permanent move but a stepping stone in the right direction. The Complex Case Officer was able to visit Barry at the property alongside the tenancy support worker and complete a Home Fire Safety visit. Barry engaged really well and was very proud to show his new accommodation.

​Sarah is an 84-year-old female, who lives alone in a ground floor flat within a supported living scheme. Sarah is a retired Intensive Care nurse. She worked in the local hospital right up until her retirement and would talk very fondly of the work that she did.

Sarah has suffered a lot of bereavement over the years, the most recent loss being her husband. Growing up, Sarah shared that she was always a bit of a collector and so was her sister, and she always struggled to let go of things. She shared she was raised in a family who didn’t have a lot of money so when she qualified as a nurse, she enjoyed being able to buy things she likes and formed an attachment to them. When she raised her own family, she stated that she never used to live in a home full of posessions and everything was ‘spick and span.’

Sarah has a formal diagnosis of Hoarding Disorder on her GP records.

Over the last few years, Sarah’s health has taken a decline and she has multiple diagnosis which she is receiving medical attention for, including heart failure, diabetes, no vision in her right eye, she suffers from a lot of pain in her joints causing reduced mobility and required an operation to amputate her toe. Sarah’s mobility is very limited; she uses aids to mobilise and has access to a mobility scooter.

Despite her ailments, she remains an active member of the community, she visits the town centre daily via the bus, she attends local church groups and socialises with other residents within the scheme.

Sarah was previously decanted into her current flat, due to a forced clearance of a previous flat within the same scheme, due to a high level of posessions and a rodent infestation.

Within her current flat, she had a high level of posessions with just enough space for Sarah to access her chair in the lounge. The bedroom is not accessible, and so Sarah was sleeping and sitting on a recliner chair. The kitchen was full, with a small walkway to the microwave where Sarah managed to cook herself a microwave meal every day. She has lost confidence using the kettle due to burning herself. There were a large number of flies present, and rotten food within the kitchen and the lounge.

Sarah has support from her two daughters, one lives local and the other lives in America but visits when she can. She also has several grandchildren who have supported her with various things, but none have entered her flat for a number of years. Sarah spoke about her end goal being able to invite her family and friends into her home for a cup of tea. Sarah is a very proud lady and did not want any support from her family, she felt she would be a burden asking for help and she also shared she felt embarrassed by her living conditions. The neighbours had made multiple complaints to the scheme manager around the smell and level of flies within the area of Sarah’s flat. She was spoken to on several occasions around breeches in her tenancy and potential eviction should things not improve.

THE LEARNING:

The initial referral came in from the scheme manager due to the level of complaints received by other residents. Sarah had agreed to a visit, but no one had been in her home for a very long time, so she was very anxious for it to go ahead. The CCO started off by introducing themselves and their role. This was the opportunity to capture Sarah’s wishes and feelings, to offer reassurance and start building a rapport. It was established that Sarah did want support but felt embarrassed. Due to her decline in health, she wanted the flat sorted so the burden would not be placed on her children in the event she is no longer here.

Sarah showed insight into her hoarding and the risks and potential consequences of having the level of posessions in her home.

Sarah agreed to multiple follow up visits so we were able to build a rapport and advocate for Sarah whilst advising on any fire risks. Sarah did take advice on board and allowed posessions to be moved from heat sources and to allow for a clear walkway near to her front door. She would wear her lifeline but would sometimes misplace it.

Sarah initially agreed to a referral to Adult Social Care but despite multiple attempts to speak with her, they closed due to non-engagement.

Sarah initially felt she could sort the posessions herself, she had a friend who agreed to complete a few tabletop sales at the local church.

Sarah agreed to a decluttering company visiting and providing a quote and talking about the support they offer. Sarah went ahead and booked the clean to go ahead, but cancelled the appointment the day before it was due as she felt the price was unaffordable.

Sarah declined multiple offers of mental health support, she felt she didn’t need it and was committed to making the change but was struggling to make the changes herself. Sarah was able to open up to her family and allowed her daughter to understand her situation and offer support.

Housing began to receive further complaints, one being to the ombudsman and involving the company’s health and safety team. The housing officer shared concerns that they may have to enforce if no changes are made due to complaints reaching a high level.

Due to multiple different stays in hospital and some health scares involving her heart, Sarah felt she required support from housing to clear the property on her behalf as she did not feel well enough. She wanted to come home to it already done as she felt being able to part with her items would be easier than being there.

THE OUTCOME:

Sarah returned from hospital to a clean and clear home, her posessions were organised and she had clear spaces to eat, sleep and relax. Sarah was pleased to share that she had managed to have her friend and grandson over on separate occasions for a cup of tea and a biscuit. She shared that without the support of the CCO, emotionally, she felt that she would not have been able to cope with the changes, she was grateful for the advocacy around her mental health and ensuring she had a role in improving the conditions within her flat. The CCO was able to complete a full Home Fire Safety visit. Ultimately the changes led to Sarah being able to keep her tenancy and maintain relationships with her neighbours. She was very proud to have reached the goal she set for herself, despite not being able to sort through the items herself. She still continues to access the community but is more conscious about what she is purchasing and bringing home. The family are able to offer more support in the home and Sarah was also looking to employ a cleaner to visit every couple of weeks to keep on top of the housekeeping.

​William is a 24-year-old male, who lives alone in first floor flat which he owns. William worked in the trades industry but became addicted to substances early on in his career. He is no longer able to work and, as a result of his addiction, has multiple health needs including incontinence from increased ketamine use. William is very close to his family, in particular his twin sister and mother. The family visit him as often as they can to support with managing his condition and home environment.

William suffers from paranoia following a previous burglary where he was stabbed in his leg, he alleges this was due to a drug debt but refused to speak with Police around who the perpetrators were.  This has caused him heightened anxiety when he is alone in his flat, where even the smallest of noises cause him to feel as though someone is breaking in. William would often call his mother or the Police at all hours due to the fear of someone breaking in, but again, would persist on not revealing the perpetrators. As a result of an alleged break in, he spent some time in hospital after jumping out of the window and breaking his leg.

William, unable to mobilise well, appeared to be self-neglecting and not prioritising his heath and the environment. His leg became infected and the ambulance service called upon the fire service to support with extricating William safely so he could be conveyed to hospital to have urgent treatment.

Fire crews reported the environment to be heavily cluttered, with visible drug paraphernalia within his flat and evidence of bodily fluids and poor sanitation throughout. There is evidence of burn marks on his clothing, in the lounge, William’s bed and kitchen floor. We were also informed that William will cook up his substances and forget he has left the gas hob on. This has previously been left on for three days when William was conveyed to hospital. It wasn’t until the family went to fetch him some clothing that they could smell gas and saw the hob on.

With William’s reduced mobility he would not be able to evacuate in the event of an emergency and there were concerns he would not react appropriately should he be under the influence of substances. Safeguarding referrals were completed, and William was placed under the Adult Risk Management process to gather professionals and William’s family, to support with a risk assessment and safe discharge planning for William’s return home.

THE LEARNING:

As part of the ARM process, the Chair was able to include partners from Social Care, the Hospital, District Nursing, GP, Police and Fire, as well as the family advocating for William, to establish the concerns around his situation and compile a list of actions to support with mitigating any risks.

Between Health and Social Care, they were able to co-ordinate a ‘safe’ discharge home, with support from the district nursing team to continue with wound dressing and care support whilst William had reduced mobility, including support with personal care needs, medication and making him something to eat. This also supported the family who were dealing with a bereavement at the time, as well as caring for an elderly relative with dementia, who resides out of county.

The Fire Service actions were to complete a Target Hardening/Home Fire Safety visit alongside the Police Crime Prevention team due to the ongoing concerns around William’s associates and his anxieties around feeling unsafe and people entering the home. The ARM was made aware that William was misusing substances whilst in hospital and continued to have deliveries and associates in the house. His mother expressed her concerns around a potential drug debt and the uncertainty around how and where he is getting the substances from. William refused to share any information around this. William was deemed to have capacity by health and social care professionals when assessed. These visits were completed once William was home so we could establish how to support him best with the concerns he shared. We maintained contact with William’s mother to coordinate and be present during the visits.

William was encouraged to report any concerns to the Police; he showed reluctance around this as he feared the repercussions would be detrimental to him and shared his current group of associates are not the same as the people who harmed him.

William spoke about wanting to move and have a fresh start, he felt he needed to sell his flat and move into a rented shared accommodation. His mother shared her reluctance to him around this as she felt this would put him at increased risk of harm.

The ARM continued to stay in place whilst the situation was monitored, and William continued to recover, and professionals felt the risk to William had reduced.

THE OUTCOME:

Whilst William was in hospital, the family were able to complete a deep clean of the property, removing any drug paraphernalia and sharps that could compromise any care support being implemented upon discharge.

Once medically fit for discharge, the ARM worked together to discuss the formation of a risk assessment within health and social care to support with the ongoing community care William would require, this included the District Nursing team, to support with dressing changes and ongoing care to his leg whilst it healed. They agreed on a two person visit to support with safety. The GP would also complete home visits, knowing that William would not be able to attend the surgery due to his mobility.

Adult Social Care were able to source a care provider to support with Williams personal care, medication, safety and food. Although William preferred his mother to support with personal care, he did maintain positive engagement with the care agency.

As Williams mobility improved, he decided he no longer needed the support of the care agency as he regained some of his independence.

NFRS Actions completed:

• Target Hardening/Home Fire Safety visit carried out. We were able to provide and fit William with a flap lock on his letter box, fire retardant bedding, blanket and rug, fit a heat alarm in the kitchen to provide some extra detection. We gave advice to William and his mother around any fire risks observed and spoke to him about an escape plan.
• Due to the risks observed and discussed within the ARM, information was sent to our mobilising system should any further incidents occur at the address.
• A Carers Fire Safety advice sheet was given to the care agency who had been implemented to support William, and it was incorporated into his care plan of support.
• Crime Prevention were able to provide William with window sash jammers, which were fitted by his father, and door handle alarms to co-exist with the CCTV and ring doorbell William had fitted by his family. Following the visits William expressed that he did feel safer in the home, he was again encouraged to report any concerns around his safety.
• William refused a lifeline as he had access to a phone, he felt this was not required at the time.
• Following our visits, William did share that he felt safer in the home following our input.

West Northamptonshire Council Adult Social Care supported a 53-year-old woman, previously unknown to them, who was referred by a district nurse due to her mental health struggles and not taking her medication. A home visit revealed additional issues including financial hardship, lack of food, tenancy concerns, and unmanaged diabetes. The individual was ‘open’ to support, and with a multi-agency, person led response focusing on the individual’s preferred outcomes, she was supported with her medication, wound care, memory concerns, food access, and finances. Despite complex family dynamics, adult social care remains involved as her health needs are addressed.

West Northamptonshire Council Adult Social Care supported a 90-year-old Romanian woman who had come to Northampton to support her granddaughter but wished to return home after a period of time when her support was no longer needed. When a social worker became involved, the lady was a patient at Northampton General Hospital after the police had found her wandering in the street. There were initial concerns about her mental capacity.

The social worker assessed her mental capacity to make decisions and determined that she had capacity to do so. The social worker advocated her wishes and raised safeguarding concerns. She had a valid passport; however, her family had hidden this from her and were preventing her from accessing her documentation to return home. She agreed to a temporary care home placement while her passport was retrieved. After six weeks and a further hospital admission at Northampton General Hospital visit, she expressed her distress about not returning to Romania.

Through collaborative work with health services, the police, and social services in Romania, the social worker successfully retrieved her passport, arranged her a flight, and safe return home. She expressed deep gratitude upon receiving her travel documents and kissed the social worker’s hand (a gesture of gratitude in Romanian culture). It was later confirmed that she was happily settled back in her community. The case highlighted the importance of cultural awareness and multi-agency working in achieving person-centred outcomes.

A range of winter support services delivered by West Northamptonshire Council (WNC), in partnership with local organisations, have made a positive difference to people experiencing rough sleeping across West Northamptonshire. Throughout the winter period, partners worked intensively to ensure people sleeping rough or at risk of homelessness were offered accommodation, safety, and support into longer-term housing where possible. Initiatives included the Winter Night Shelter – delivered in partnership with Northampton Hope Centre – St John’s supported accommodation, and the activation of the Severe Weather Emergency Protocol (SWEP).

The Winter Night Shelter received 39 referrals over the season, with 30 people accepted for support. Outcomes from the shelter were positive, with 13 individuals successfully moving into accommodation, supported through a combination of WNC, through the private rented sector, via Northampton Partnership Homes (NPH), and supported accommodation. The shelter played a vital role in providing immediate safety, stability and engagement opportunities during the coldest months of the year. Five people were supported on a solidarity or health-related basis despite having no immediate housing pathway, receiving essential respite, recovery time and support.

During the winter period, SWEP was activated on two occasions in response to severe weather conditions supporting over 60 people. On the busiest night, 29 people were accommodated through a combination of SWEP provision and Winter Night Shelter support, ensuring that no one was left exposed to dangerous conditions. This proactive, preventative approach continues to help West Northamptonshire maintain lower-than-average levels of homelessness and rough sleeping compared with many areas nationally.

In addition, St John’s accommodation service continues to deliver life-changing support. Since it opened in November 2025, 28 people have been accommodated at St John’s, with seven individuals moving directly from the Winter Night Shelter. Four residents have already successfully moved into other accommodation, demonstrating the importance of strong, joined-up services and wraparound support.

Former service user Emma first came to St John’s when she was facing significant life challenges and had limited confidence in her ability to move forward. With consistent support and encouragement, she began engaging in activities and building positive relationships within the centre. Today, Emma works to help and encourage others facing similar circumstances. Her journey reflects remarkable personal growth and demonstrates how the right support can empower someone not only to rebuild their own life but to positively impact the lives of others.

These outcomes build on the Council’s wider homelessness prevention work, including specialist accommodation services designed to reduce rough sleeping before it starts. WNC will continue working with local charities, housing providers and community partners to improve access to stable housing, strengthen support services and ensure people are treated with dignity, respect and care at every stage of their journey.