Guidance to assist in producing in-house policy on adult protection

b) Guidance intended to assist a range of agencies (including care home owners) in drawing up an in house policy

Context:

A detailed multi agency policy and procedures to ensure the protection of vulnerable adults from abuse was produced in early 2002 and revised in 2003 and in 2005 following wide consultation across agencies in all sectors in Hampshire, Portsmouth and Southampton. This multi-agency document has been produced as a result of mandatory guidance from the Department of Health: “No secrets”: Guidance on developing and implementing multi-agency policies and procedures to protect vulnerable adults from abuse (DoH 2000.) All agencies must refer to the multi agency policy and procedures for detailed guidance when confronted with situations of abuse. It is available from Social Services Headquarters in each of the three Authorities to whom it applies and on their websites . However, in addition to this the Department of Health has stipulated that:

“Provider agencies will produce for their staff a set of internal guidelines which relate clearly to the multi-agency policy and which set out the responsibilities ofall staff to operate within it.

These will include guidance on:

  • Identifying vulnerable adults who are particularly at risk
  • Recognising risk from different sources and in different situations and recognising abusive behaviour from other service users, colleagues and family members
  • Routes for making a referral and channels of communication within and beyond the agency
  • Assurances of protection for whistle blowers
  • Working within best practice as specified in contracts
  • Working within and cooperating with regulatory mechanisms; and
  • Working within agreed operational guidelines to maintain best practice in relation to:
  • Challenging behaviour
  • Personal and intimate care
  • Control and restraint
  • Sexuality
  • Medication
  • Handling of user’s money
  • Risk assessment and risk management

Internal guidelines should also cover the rights of staff and how employees will respond where abuse is alleged against them within either a criminal or disciplinary context.”

“The starting point…must be that agencies have an organisational framework within which all concerned at the operational level understand the inter-agency policy and procedures, know their own role and have access to comprehensive guidance.” “No Secrets”, DoH, 2000

This mandatory guidance from the Department of Health further underlines and is referred to within the requirements of the Care Standards Act, 2000, the Care Homes Regulations 2001 and the National Minimum Standards. The regulations and standards contain many references to the protection of vulnerable adults including: a requirement that providers have robust procedures for responding to suspicion or evidence of abuse or neglect; that staff who may be unsuitable to work with vulnerable adults are referred for consideration for inclusion on the protection of vulnerable adults list (POVA List) kept by the Secretary of State (Part VII, Care Standards Act, 2000); to check the POVA List when employing workers in registered settings; that allegations and incidents of abuse are clearly recorded; that there are clear policies around involvement with service users’ finances; that physical and verbal aggression by service users is responded to appropriately. There are also requirements within the regulations: to prevent harm and abuse; to notify the National Care Standards Commission of “death, illness or other events.” The latter would include incidents of actual or suspected abuse. The standards also require staff to be trained in the prevention and management of abuse.

Where the perpetrator is a member of staff, proprietor or manager the disciplinary procedures must be implemented alongside the adult protection procedures. The disciplinary procedure must not be operated in isolation from adult protection considerations. (See section 4.2.1 multi-agency adult protection policy) Within this, where abuse is alleged against a member of staff a risk assessment must be undertaken immediately to assess the level of risk to all service users posed by the suspected perpetrator of abuse. This will include whether it is safe for them to continue in their role or any other role within the service whilst the investigation is being undertaken. The consideration of risk will be considered alongside employee rights. The safety of vulnerable individuals will be paramount.

The above context along with the following information and guidance will assist providers across a range of settings in producing the required internal guidelines relating to adult protection. It is not prescriptive but is intended to provide sufficient material to enable agencies in all sectors to adapt the material to suit their own setting/requirements.

Who abuses and where can abuse occur?

The following are extracts from the Department of Health document “No Secrets” referred to above and set the context of internal policy/guidelines:

“Vulnerable adults may be abused by a wide range of people including relatives and family members, professional staff, paid care workers, volunteers, other service users, neighbours, friends and associates, people who deliberately exploit vulnerable people and strangers.”

“There is often particular concern when abuse is perpetrated by someone in a position of power or authority who uses his or her position to the detriment of the health, safety, welfare and general well-being of a vulnerable person.”

“Abuse can take place in any context. It may occur when a vulnerable adult lives alone or with a relative, it may also occur within nursing, residential or day care settings, in hospitals, custodial situations, support services into people’s own homes, and other places previously assumed safe, or in public places.” “No Secrets”, DoH, 2000

Your response is crucial.

If you become aware of any situation which might be abusive to a vulnerable adult acknowledge it and take action.

The protection of a vulnerable adult or more than one vulnerable adult may well depend on your initial response.

Support for those who report abuse

All those making a complaint or allegation or expressing concern, whether they be staff, service users, carers or members of the general public, should be reassured that:

  • They will be taken seriously
  • Their comments will usually be treated confidentially but their concerns may be shared if they or others are at significant risk
  • If service users, they will be given immediate protection from the risk of reprisals or intimidation
  • If staff, they will be given support and afforded protection if necessary – under the Public Interest Disclosure Act 1998:

they will be dealt with in a fair and equitable manner; and

they will be kept informed of action that has been taken and its outcome

“No Secrets”, DoH, 2000

Rights as well as responsibilities of workers and managers are outlined in Section 1.4 of the multi-agency policy.

Public Concern at Work is a national organisation which provides legal advice to individuals concerned about malpractice at work. The service is free and strictly confidential. The telephone number is: 020 7404 6609 and is open from 9am until 6:30pm.

Staff training is a key element in protecting vulnerable adults from abuse as well as in supporting staff. The levels of training necessary for staff are outlined in section 3.2 of the multi-agency policy. Organisations should comply with the TOPPS requirements for Induction and Foundation training, which includes issues of abuse. Training is also identified as a priority within the National Minimum Standards and regulations.

Definitions to assist in the identification of abuse

A “vulnerable adult”…is a person “who is or may be in need of community care services by reason of mental or other disability, age or illness, and who is or may be unable to take care of him or herself, or unable to protect him or herself against significant harm or exploitation.”

“Abuse may consist of a single act or repeated acts. It may be physical, verbal or psychological, it may be an act of neglect or an omission to act, or it may occur when a vulnerable person is persuaded to enter into a financial or sexual transaction to which he or she has not consented, or cannot consent. Abuse can occur in any relationship and may result in significant harm to, or exploitation of, the person subjected to it.”

“No Secrets”, DoH, 2000

The local multi agency policy and procedure for adult protection endorses the following definition of abuse offered by The Centre for Policy on Ageing (1996). It gives further guidance on defining situations which must be dealt with within this policy and procedural framework and as such should be used alongside the definition given in “No Secrets”. It states:

“Abuse is the harming of another individual usually by someone who is in a position of power, trust or authority over that individual. The harm may be physical, psychological or emotional or it may be directed at exploiting the vulnerability of the victim in more subtle ways (for example, through denying access to people who can come to the aid of the victim, or through misuse or misappropriation of his or her financial resources). The threat or use of punishment is also a form of abuse. Abuse may happen as a “one-off” occurrence or it may become a regular feature of a relationship. Other people may be unaware that it is happening and for this reason it may be difficult to detect. In many cases, it is a criminal offence.”

Centre for Policy on Ageing (1996)

“No Secrets” states: Consensus has emerged identifying the following main different forms of abuse:

  • Physical abuse

Including hitting, slapping, pushing, kicking, misuse of medication, restraint, or inappropriate sanctions.

  • Sexual abuse

Including rape and sexual assault or sexual acts to which the vulnerable adult has not consented, or could not consent or was pressured into consenting.

Sexual abuse might also include exposure to pornographic materials, being made to witness sexual acts and encompasses sexual harassment and non-contact abuse.

NB. The Sexual Offences Act, 2003 has created a number of new offences which can be committed by care workers in respect of a person with a mental disorder. Sections 38 to 41 deal with the situation where a care worker involves someone in their care, who has a mental disorder, in sexual activity.

  • Psychological abuse

Including emotional abuse, threats of harm, controlling, intimidation, coercion, harassment, verbal abuse, isolation or withdrawal from services or supportive networks

  • Financial or material abuse

Including theft, fraud, exploitation, pressure in connection with wills, property or inheritance or financial transactions, or the misuse or misappropriation of property, possessions or benefits

  • Neglect and acts of omission

Including ignoring medical or physical care needs, failure to provide access to appropriate health, social care or educational services, the withholding of the necessities of life, such as medication, adequate nutrition and heating

  • Discriminatory abuse

Including racist, sexist, that based on a person’s disability, and other forms of harassment, slurs or similar treatment.

These definitions from “No Secrets” are expanded upon in the local multi-agency policy and procedures relating to adult protection.

Prevention of Abuse

In section 7 of “No Secrets”, the Department of Health outlines a number of suggestions which will be effective in contributing to the prevention of abuse. These include:

  • Rigorous recruitment practices (including volunteers). This now includes reference to the POVA (Protection of vulnerable Adults) List as set out in Part VII of the Care Standards Act, 2000. See section 10.2 of local Multi agency adult protection procedures (July 2005) for information.
  • Internal guidelines for staff
  • Training
  • Information for users, carers and the general public
  • Attention to issues relating to protection of vulnerable adults in Direct Payments arrangements
  • Commissioning of services and contract monitoring

Further information/guidance on these issues is given in section 3 of the multi-agency policy.

The issue of prevention by empowerment of vulnerable individuals is also outlined in section 3.5 of the multi-agency policy. Empowering individuals with knowledge and understanding so that they will be aware of what is appropriate or inappropriate behaviour towards them is an important aspect of prevention of abuse. Empowering individuals with knowledge and information as to their rights is also important and will include a well-publicised and user-friendly complaints procedure.
Intervention in situations of suspected abuse

The individual who suspects abuse/hears a disclosure or allegation will need to bear in mind the following:`

  • In situations of immediate danger take urgent action by calling the relevant emergency services (eg Police, ambulance, GP)
  • Log your concerns and any information given to you or witnessed by you. Do not ask leading questions (see guidance sect. 10.9, multi agency policy)
  • Remember that it is not necessary or advisable for you to seek evidence or proof at this stage. This is for a formal adult protection investigation to carry out. By supporting the vulnerable adult and carefully gathering any readily available information and logging it at this stage, you will lay the foundations for an effective formal investigation.
  • Understand the need not to contaminate (and indeed to preserve) evidence if a crime may have been committed.
  • Report concerns and information to the appropriate manager or supervisor. If this is not possible refer directly to Social Services Dept/Police/ Commission for Social Care Inspection
  • Understand that the Police must be contacted if a crime may have been committed.
  • Remember to have regard to your own safety. Leave the situation if it is not safe for you.
  • Listen to the vulnerable adult, offer necessary support and reassurance. Record what is said and what is observed, recording accurately and in detail the nature of allegations as well as your own actions/response, who was present at the time and the times and dates.
  • Issues of confidentiality must be clarified early on. For example where staff or volunteers working for an organisation are dealing with an initial concern/allegation it must be made clear that they will at least have to discuss the information/concerns with their supervisor/manager (see section 10.7, multi-agency policy)
  • Where a vulnerable adult expresses a wish for concerns not to be pursued then this should be respected wherever possible. However, decisions about whether to respect the service user’s wishes must have regard to the level of risk to the individual and/or others and their capacity to understand the decision in question and to make decisions relating to it. In some circumstances the vulnerable adult’s wishes may be overridden in favour of considerations of safety.
  • Decisions to override the vulnerable adult’s wish not to proceed with an investigation or not to allow referral to another agency such as the Police or Social Services Department will where possible be the product of discussion with appropriate line manager/supervisor within your organisation. These decisions will be clearly recorded.

“The first priority should always be to ensure the safety and protection of vulnerable adults. To this end it is the responsibility of all staff to act on any suspicion or evidence of abuse or neglect (see the Public Interest Disclosure Act 1998) and to pass on their concerns to a responsible person/agency.” “No Secrets”, DoH, 2000

Discussion and decision-making with line manager/supervisor

Concerns about suspected abuse of a vulnerable adult must where possible be reported to a line manager/supervisor as soon as possible.

A discussion will take place to decide whether the situation falls within the remit of the multi agency policy/procedure and to evaluate the seriousness of the situation. This will inform a decision as to whether to report the situation to the Police/Social Services/CSCI/others. This decision will be taken alongside a decisions as to whether internal disciplinary action is required.

Where the line manager/supervisor may be the perpetrator of the abuse (or where no such person is available), a direct referral to Social Services and/or the Police/ Commission for Social Care Inspectionmust be made.

Deciding whether to refer on to another agency (eg Police; Social Services, Commission for Social Care Inspection)

This decision, as to whether to refer elsewhere, is crucial and should make reference to:

  • The wishes of the vulnerable adult
  • The mental capacity of the vulnerable adult (see guidance, sect 10.11, multi-agency policy and procedures)
  • Known indicators of abuse
  • Definitions of abuse
  • Level of risk to this individual
  • Level of risk to others (public interest considerations)

Decisions as to whether to inform others will be concerned with:

  • The individual’s right to self-determination
  • The seriousness of the abuse
  • The pervasiveness of the abuse
  • The effect of the abuse on the individual in question, and on other vulnerable adults
  • The ability of others (eg Police, Social Services) to make a positive contribution to the situation
  • Whether a criminal offence has been committed or whether there are other statutory obligations to refer on (eg to Commission for Social Care Inspection )
  • The need for others to know (eg to protect others who may not be involved in the immediate situation)

Responsible sharing of information in the public interest is supported by: The Public Interest Disclosure Act, Data Protection Act, Crime and Disorder Act(see guidance, section 10.7, multi-agency policy and procedures)

Consideration of issues of mental capacity and consent:

The consent of the vulnerable adult to refer on must be obtained except where

  • The vulnerable adult lacks the mental capacity to make a decision regarding informing others and a risk assessment indicates that referral would be in their best interests
  • There are public interest considerations (others may be at risk)
  • A crime has been committed

Further guidance on the issue of consent and capacity can be found in section 10.11 of the multi-agency policy and procedures. The issue of sharing information with other agencies/confidentiality is covered in section 10.7 of the multi-agency policy.

Who to refer/report concerns to:

  • Relevant local Social Services team, depending on age/any mental health problems/any learning disability/any physical disability and also on area in which the vulnerable adult lives. Social Services Departments have the lead responsibility for coordinating all investigations into suspected abuse of vulnerable adults
  • Relevant hospital Social Services team if vulnerable adult is in hospital
  • Emergency Social Services duty team, if urgent and outside normal office hours
  • Community Mental Health Team (CMHT) where the vulnerable adult has an ongoing mental health need
  • Commission for Social Care Inspection (CSCI) where there are issues relating to standards and regulations in care homes and domiciliary care agencies (later on it is anticipated that day care settings will also be registered with CSCI). See specifically Regulation 37, Care Homes Regulations 2002, which includes a requirement for the Registered Person to give notice to the Commission without delay of the occurrence of any serious injury to a service user and /or of any event in the care home which adversely affects the well-being or safety of any service user. It also refers to any theft, burglary or accident in the care home or allegation of misconduct by the registered person or any person who works at the care home. (Refer directly to regulation 37 in the Care Homes Regulation 2002 as this is not a full quotation of that regulation).
  • Hospital Trusts/ Primary Care Trusts where there is a complaint of abuse by a member of staff.
  • The Police
  • if there is an emergency where delay in contacting emergency services may result in serious harm to the vulnerable adult
  • if the abuse may constitute a crime

(See section 4.2, multi-agency policy and procedures.)