1. Safeguarding adults is everybody’s business.
If not you, then who?

2. Safeguarding Adults – BMA Toolkit
Health professionals
Should be able to identify adults whose physical, psychological or social condition are likely to render them vulnerable
Should be able to recognise signs of abuse and neglect, including institutional neglect
Need to familiarise themselves with local procedures and protocols for supporting and protecting vulnerable adults

3. Do you know about these cases?

4. Scale of the problem
In there were 1,522 safeguarding adults referrals in Buckinghamshire, 587 went to full assessment
The majority of people have a GP
Serious case reviews nationally and locally almost always demonstrate GP involvement
A tiny number of alerts are made by GP practices

5. Legislation and guidance
Civil Law
Criminal Law
Regulations/Guidance
Mental Health Act 1983
Offences against the person Act 1861
No Secrets 2000
Public Health Act 1984
Housing Act 1985
Theft Act 1968
PACE 1984
NHS & Community Care Act 1990
Protection from Harassment Act 1997
Family Law Act 1996
Human Rights Act 1998
Data Protection Act 1998
Public Interest Disclosure Act 1998
Public Order Act 1986 Sexual Offences Act 2003
SI 2009/2023 Family Law Act 1996 forced marriages / relevant 3rd party
Domestic Violence Act 2004 (amendment 2012)
Mental Health Act 1983s 127
Mental Capacity Act 2005
Mental Capacity Act 2005 s.44
SI 2009/3112 CQC registration
Safeguarding Vulnerable Groups Act 2006
Health & Social Care Act 2008
Equality Act 2010
Fraud Act 2006
Manslaughter (common law or corporate homicide Act 2007)
SI 2010/781 HSC Act 08 regulated activities
Legislation and guidance

6. Draft Care and Support Bill
Most important piece of adult social care legislation in 60 years
40 statutes in one piece of legislation
New safeguarding duties
Adult Safeguarding Boards

7. Definitions Vulnerable Adult
“Anyone aged 18 or over who is or may be in need of care services by reason of mental or other disability, age or illness; and who is unable to take care of him or herself or unable to protect him or herself against significant harm or exploitation”
Significant Harm
Ill-treatment (includes sexual abuse and forms of ill-treatment that are not physical)
impairment of, or an avoidable deterioration in, physical or mental health
Impairment of physical, emotional, social or behavioral development
Abuse
“A violation of an individual’s human and civil rights by any other person or persons”
“A single or repeated act or lack of appropriate action occurring in a relationship where there is an expectation of trust which causes harm or distress”

8. This includes people who have:
a mental health problem
(including dementia or memory problems)
a physical disability or illness
drug and alcohol related problems
a sensory impairment
a learning disability
an acquired brain injury
frailty or a temporary illness

9. What Can Practices Do? Training and awareness Information for patients
Asking questions
Consider in reviews e.g. chronic disease
Follow up non attenders e.g. Repeat prescriptions
Carers policy
Flag records of vulnerable adults
Discuss concerns and significant events
Contribute to meetings

10. Practice Checklist Safeguarding adults policy Safeguarding adults lead
See the child behind the vulnerable adult
Highlight records of vulnerable adults
Information available for patients
Regular training
Significant events reviewed discussed
Concerns shared with CCG
Application of Mental Capacity Act to practice
Minimum safety criteria for staff employment
Complaints and whistle-blowing policy

11. How can you recognise abuse?
There may be a perfectly reasonable rational explanation so ask some open questions
Remember that the carer or accompanying person may be the abuser so may not always give a true reflection of events
Check for corroboration from GP, community nurses or care home referral letter, ambulance notes etc
Look at the social history, medical history, list of medication, risk assessments and observations
When you have a fuller picture are you still worried?

12. Types of abuse Physical Sexual Psychological (or emotional)
Neglect (or acts of omission)
Financial
Institutional
Discriminatory or rights abuse
(Domestic violence)

13. Physical Abuse
Is the non-accidental physical mistreatment of one person by another which may or may not result in physical injury. It can be the use of force that results in an unwanted change in a person’s physical state.
Physical violence: Hitting, slapping, pushing, kicking, shaking, scalding, dragging, pinching hair-pulling.
Rough or inappropriate handling: Careless/rough handling; force-feeding; inappropriate application of physical techniques such as manual handling, restraint or physical intervention; involuntary isolation or confinement.
Medical Mistreatment: Misuse of medication; withholding of medication; inappropriate use of medical procedures, such as catheterisation.

14. Physical abuse causes
injury, fear, intimidation
and sometimes death

15. Physical Abuse - possible Indicators
Delays in seeking medical attention.
Shaped injuries
Multiple old or new injuries
Records of different visits for treatment
Skin infections/Inconsistent or unexplained injuries (bruises, cuts, burns, blisters, scratches, fractures, sprains)
ions
Weight loss
Medications withheld or omitted
Fear/reluctance to be with someone
Incontinence
Changes in behaviour, mood or usual routine, (sleep patterns or eating habits).

16. Sexual Abuse
Is the direct or indirect involvement in any sexual activity to which a person does not give valid consent or cannot give valid consent.
A person cannot give valid consent when they lack capacity to make a decision or if they are coerced into activity because the other person is in a position of authority, trust or power.
Non-contact abuse:
Indecent exposure, inappropriate looking, photography, harassment, serious teasing or innuendo, pornography.
Contact Abuse:
Rape or sexual assault, masturbation (of either or both persons), inappropriate touching of breast, genitals, anus, mouth.

17. Sexual abuse - possible Indicators
Bruising to inner thighs, genital or anal areas
Persistent and inappropriate sexual behaviour or pronounced overly affectionate behaviour
STI or unexpected pregnancy
Torn or blood stained clothing/bedding
Love bites
Obsessive behaviour/ Changed behaviour
Difficulty sitting/standing
Bulimia/Anorexia/Self Harm /Self neglect

18. Psychological abuse
Is the use of threats, humiliation, bullying, other verbal conduct or any other form of mental cruelty that results in mental or physical distress.
Emotional abuse is any act which negatively affects the emotional well being of a person or impairs their psychological development.

19. Psychological abuse – possible indicators
Anxiety
Low self esteem
Difficulty communicating with vulnerable person or gaining access to visit
Deference /submission to the perpetrator
Sleep disturbance
Confusion

20. Financial abuse
Is the unauthorised and improper use of funds, property or any resources belonging to an individual.
Unauthorised would include the coercion or misleading of an individual, or any lack of informed consent from the individual.

21. Financial abuse
can lead to
deprivation,
humiliation and
starvation

22. Financial abuse – possible indicators
Lack of basic necessities or inability to provide for basic needs (food, rent etc.)
Inability to retain control over home lifestyle and/or apparently chaotic lifestyle
Denying access to or controlling accounts
Removal of items without consent
Overcharging
Theft or “borrowing”
Unexplained financial activity
Unexplained interest in someone

23. Neglect Poor personal hygiene or mouth care
Malnutrition and / or dehydration and weight loss
Constipation
Hypothermia
Inappropriate and / or dirty clothing
Category 3 or 4 pressure ulcers
Untreated or delay in seeking treatment for medical problems or falls resulting in injury
Incomplete or inconsistent records of care

24. Neglect is degrading and undignified and can endanger life

25. Institutional abuse Rituals and routines Confinements
Stark environments
Lack of stimulation
Lack of consultation
Use of restraint
Use of power/control

26. Discriminatory abuse
Is the harassment, unfair treatment, exploitation or denial of mainstream opportunities and services to individuals because of their race, religion, culture, gender, age, sexuality or disability.
Discrimination can be a motivating factor in other forms of abuse

27. Discriminatory abuse – possible indicators
Not providing food consistent with a person’s culture or beliefs
Use of derogatory names or teasing about differences
Lack of appropriate social contacts
Not allowing attendance or observance of at religious festivals
Low self esteem, confidence or expressions of low self-worth

28. Prevent Prevent is concerned with safeguarding individuals at
risk of exposure to extreme ideologies, either through
personal contact or via the internet
These ideologies could be international terrorism, the
extreme right or left wing, animal rights, environmental
protest, the IRA etc
The Prevent team provide awareness sessions for
professionals working with vulnerable young people
and adults and can be delivered across the Thames
Valley at your convenience

29. Domestic Violence

30. Disclosure What should you do if someone discloses abuse to you?
Be calm and do not show shock or disbelief
Listen carefully to what is being said
Do not ask detailed or probing questions (investigator will do this)
Ensure that any emergency action needed has been taken to ensure the person’s safety
Do not attempt to confront the alleged perpetrator
Demonstrate a sympathetic approach by acknowledging regret and concern that what has been reported has happened
Confirm that the information will be treated seriously
Give them information about the steps that will be taken
Inform them that they will receive feedback as to the result of the concerns they have raised and from whom
Give the person contact details so that they can report any further issues or ask any questions that may arise
Ensure that an appropriate person within your organisation has been notified e.g. Line Manager, Safeguarding Adults Lead

31. The safeguarding process - reporting
Report the abuse
If in doubt then discuss concerns, better to over report than to say nothing
Liaise with Bucks CC &/or Safeguarding Lead
CQC?
Fill out the SVAB or local alert form
fax or as instructed
Confirm receipt of fax
If member of staff or line manager suspected of being perpetrator refer direct to Senior Manager
Check whistleblowing policy?
Public Disclosure Act 1998

32. The safeguarding process – communicating and helping
Ensure persons safety and protection
Inform police if criminal act suspected
Protect evidence
Work with adult social care
Reassure
Explain processes
Consent and information sharing

33. Case One Harry is 78 yrs old and lives alone in a flat
His daughter, Elaine, is very worried about him, he has always drank heavily but recently she feels he has worsened. She has seen bottles and rubbish strewn over the flat. Her dad looks very thin and observed injuries to his face she thinks are from falls. He refuses to let her take him to hospital, which was her plan
His daughter, upset and anxious, calls Social Services who advise her to phone Harry’s GP Practice and discuss her concerns.
What can the Practice do?

34. Case Two
Patricia has Dementia, she is in a nursing home and she experiences periods of agitation and confusion that make her management difficult. Patricia refuses to take the Trazodone that has been prescribed so staff ask you to write it up as a covert medication which they will put in to her drink.
What are the issues?

35. Summary of MCA Principles
Presumption of capacity.
Unwise decision making.
Practicable steps.
Best interest.
Least restrictive option

36. What is Capacity?
Mental Capacity is the ability to make a decision e.g.
Daily life decisions.
Serious or significant decisions
Decisions that may have legal consequences.
These decisions must be viewed as
Time specific
Decision specific

37. Decisions that cannot be made
Divorce
Marriage
Voting
Sexual relations
Adoption

38. New Power - Ill treatment or neglect.
For those who have care of someone who lacks or is believed to lack capacity
Also if they have LPA, EPA or are COP deputy
If found guilty of willful neglect or ill treatment liable to be imprisoned or fined or both
S.44 Mental capacity Act 2005

39. Two Stage Test of Capacity
Does the person have an impairment of or a disturbance in the function of their mind or brain?
Proceed to stage 2 only if YES to this question.
Stage 2
Does the impairment or disturbance mean that the person is unable to make the decision in question at the time it needs to be made?
A person is deemed unable to make a decision if once given the relevant information they cannot
Understand it
Retain it
Use or weigh it
Communicate their decision
(p44 MCA Code of Practice)

40. Arriving at a decision re capacity
Identify the Decision Maker:
“The person who is most appropriate to make a particular decision or has the specific authority to make the decision
Reasonable belief ( on the balance of probability)
Acts or decisions must be made in the person’s best interests
Use a Best Interest checklist
Evidence how the decision was arrived at.
Record your decision, including date and time

41. Best Interests

42. Example Checklist Is the person likely to regain capacity? Yes/No
If yes, is this likely to be in time to make the decision in question? Yes/No
Have all practicable steps been taken to encourage the person to participate in the decision? Yes/No
If Yes then briefly describe how….……………………………………………………………………………………………………………………………………………………………………………………………
Have any statements or wishes of the person been taken in to account? Yes/No
If practicable and appropriate, have the following views been taken in to account:
Anyone named by the person to be consulted? Yes/No/Not Applicable
Anyone engaged in caring for the person? Yes/No/Not Applicable
Any Court Appointed Deputy? Yes/No/Not Applicable
The Attorney under any Lasting Power of Attorney? Yes/No/Not Applicable
Anyone interested in the welfare of the person? Yes/No/Not applicable
If Yes, name the person consulted………………………………
IMCA if no close persons
How is this the least restrictive/harmful option?

43. Best Interests
Following Best Interests assessment where no consensus can be reached, the Court of Protection must be approached to resolve the issue

44. Case Study
Selima is a 75 year old lady in a residential care home. She has dementia and she suffers periods of acute confusion and agitation, she also suffers from Asthma. It is October time and Selima is due a Flu vaccination which she refused.
What are the issues?
What information do you need and from where?
What needs to be documented?
Who is the decision maker?

45. Case Study Two
Sarah has complex learning and physical disabilities. She has never been sexually active, at her Annual Health Check should she have a Cervical Smear Test?
Issues?
Documentation?

46. Contact details Adult Social Care Teams Out of hours 0800 9997677
central access team adult social care
SVAB Team at County Hall, Aylesbury
Duty Desk
Careline
Police 101/999

47. Discussion and support
Tania Atcheson
Safeguarding Lead CCG’s
Vikki Gray
Safeguarding Manager CCG’s
Sarah Pady
Joint Mental Capacity Act Coordinator

48. Thank you Key message from today? Email presentation
Change to practice?
Further study/training?
presentation
Visit
Collect a Mental Capacity Act card as you leave

49. Call Careline