Safeguarding vulnerable adults Thinking the unthinkable ‘It could never happen here’

Vulnerable Adult ‘A person over 18 years of age….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.’ Lord Chancellor’s Department, 1997:69

Definition of Adult Abuse ‘Abuse is a violation of an individual’s human and civil rights by any other person or persons’. P9, Department of Health (2000) No Secrets London: HMSO

‘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.’ Ibid

‘Abuse can occur in any relationship and may result in significant harm to, or exploitation of, the person subjected to it.’ Ibid

Significant harm ‘….not only ill treatment (including sexual abuse and forms of ill treatment which are not physical), but also the impairment of, or an avoidable deterioration in, physical or mental health; and the impairment of physical, intellectual, emotional, social or behavioural development.’ P 68, Lord Chancellor’s Department (1997) Who Decides? Making Decisions on Behalf of Mentally Incapacitated Adults London: The Stationery Office

Types of abuse Physical abuse Sexual abuse Psychological/emotional abuse Financial/material abuse Neglect Discriminatory abuse Institutional abuse

Examples of physical abuse Slapping Hitting Pushing Pulling Rough handling Kicking Misuse of medication Unreasonable physical restraint Isolation or confinement Poor application of manual handling techniques

Indicators of physical abuse Any injury not fully explained by the history given Unexplained bruises and welts on face, lips, mouth, body, arms, back, buttocks, thighs Bruises in various stages of healing or in shape of article or finger marks Unexplained burns, especially on soles, palms and back; immersion scalds, rope burns, electric appliance, cigarette or carpet burns Unexplained fractures to any part of the body Unexplained lacerations or abrasions to mouth, lips, gums, eyes, external genitalia Malnutrition – rapid or continuous change in weight, dehydration, indications of force-feeding Stench or signs of urinary/faecal incontinence Use of furniture and other equipment to restrict movement

Examples of sexual abuse Inappropriate touching Masturbation Oral contact Genital contact Digital penetration (vagina or anus) Rape (vagina or anus) Penetration with objects Attempted penetration

Examples of sexual abuse Voyeurism Pornography Indecent exposure Teasing Innuendo Harassment Exploitation

Indicators of sexual abuse Full or partial disclosure or hints of sexual abuse Genital or urinary irritation or infection Sexually transmitted disease Love bites, bruises or finger marks on inner thighs or arms Pain or bleeding in the genital area Unusual difficulty in sitting or walking Unexplained onset of faecal or urinary incontinence Significant change in sexual behaviour, language or outlook Pregnancy in a person who is not able to consent Severe agitation when person is bathed, undresses or medically examined

Examples of psychological abuse Threats of punishment, harm or abandonment Humiliation, ridicule and insults Isolation or withdrawal from services or supportive networks Overriding/denial of basic human and civil rights such as choice, privacy, dignity and self-expression Bullying and harassment Blaming

Examples of psychological abuse Overprotection Deprivation of contact and/or freedom Intimidation and coercion Controlling Verbal abuse/swearing Treating someone inappropriately for their age and/or cultural/ religious background

Indicators of psychological abuse Fearfulness , avoids looking at caregiver, flinching on approach Sleep disturbance – insomnia or excessive sleep Low self-esteem Unexplained fear, defensiveness, paranoia Deference, resignation, passivity Emotional withdrawal Unusual bouts of sobbing or weepiness Punitive approach to bodily functions or incontinence Few visitors/ phone calls/outings Locking the person in the home or in a car Threats to abandon the person or “put them away” Ambivalent feelings between victim and caregiver

Examples of financial/material abuse Theft Fraud Exploitation Pressure in connection with wills, property, inheritance or money Misuse or misappropriation of property, possessions or benefits Preventing access to money

Indicators of financial/material abuse Unusual or inappropriate account activity Person lacks belongings or services which they can clearly afford Power of Attorney obtained when person lacks capacity and is unable to comprehend Recent change of deeds or title of house Person managing financial affairs is evasive or uncooperative Disproportionate interest or affection for person with money or property

Examples of neglect Ignoring medical or physical care needs Failure to provide access to appropriate health, social care, educational or housing services Withholding the necessities of life (nutrition, medication, heating) Failure to recognise and acknowledge religious and cultural needs Failure to acknowledge a person’s right to choice, dignity, privacy and independence

Indicators of neglect Person has inadequate heating and/or lighting Poor physical condition or appearance (ulcers, pressure sores, soiled or wet clothing) Malnourished, dehydrated, sudden or continuous weight loss Cannot access appropriate medication or medical care Person and/or carer has inconsistent or reluctant contact with health and social care agencies Callers/visitors are refused access to the person Person exposed to unacceptable risk

Discriminatory abuse Discriminatory abuse exists when values, beliefs or culture result in a misuse of power that denies mainstream opportunities to some individuals or groups in society.

Discrimination can take place on the grounds of: Race Gender Sexuality Age Disability Ethnicity, religion or culture

Discriminatory actions include: Unequal treatment Verbal abuse Inappropriate use of language Slurs Harassment Deliberate exclusion

Institutionalisation Block treatment Rigid routine Staff/patient division One place and authority Risks: De-personalisation De-humanisation

Role of alerter If you know or suspect that abuse is happening, you must report it formally and in writing, usually to your manager (unless they are potentially involved in the abuse). If no action is taken, go higher/to professional or inspection body/to relevant localauthority/to police If you do not do so, you become part of the abusive situation.

Safeguarding trumps confidentiality If the potential victim is a vulnerable adult, you must report even if they ask you not to do so. Good practice to tell them this, unless to do so will put them or you at risk

Emergency services Is urgent medical attention needed? Does the person have somewgere safe to go? Is there a need to protect physical/verbal evidence?

What to record The identity of the person reporting the incident and any other person present at the time Description of the scene of the incident State and behaviour of the victim, including anything said Details of any obvious injuries, on a body map if possible Date and time of incident and sign the record

Responding to disclosures Reassure Take seriously Avoid leading questions or helping to finish sentences Record the exact words used

Factors increasing risk of abuse Individual Sensory impairment Does not communicate verbally, Support needed with intimate personal care Lack of understanding Experience Learned compliance Abused before and thinks it is acceptable

Factors increasing risk of abuse Relationships Dependent, over-protected, devalued, lacking choice and control Mental or physical ill-health of carer History of alcohol or drug misuse Debt or poor housing, Changes in role Environment Social /geographical isolation Rigid routines Poorly trained/supported staff Low morale, low status of work

Safeguarding Vulnerable Groups Act 2006 identifies two sets of activities in relation to children and vulnerable adults sets out the requirements for vetting and barring people for these activities.

Regulated activities Contact with children or vulnerable adults (paid or unpaid) of a specified nature (teaching, training, care, advice, treatment, transport) or in a specified place (school, children’s home, hospital, juvenile detention, adult care homes) where the contact is frequent (once a month or more), intensive (3 or more occasions in a period of 30 days) or overnight (between 2am and 6am). Foster care Defined office holders (eg Directors of Children’s Services, trustees of children’s charities, school governors)

Controlled activities Frequent or intensive support work in general health settings, NHS and further education settings Frequent access to sensitive records about children and vulnerable adults Support work in adult social care settings It is mandatory to check the ISA status of an applicant for these roles but a barred person may be employed provided safeguards are in place.

Independent Safeguarding Agency Administers two lists: Vetted for work with children/vulnerable adults Barred from such work (criminal offence for them to apply or to knowingly employ them to carry out regulated activity) Information on lists can be accessed only by police and ISA case workers. Potential employers can check status through enhanced CRB check.

Service users can be helped to prevent abuse by: Access to user groups, advocacy schemes and independent feedback Being listened to Being given clear and accessible information about rights and services Shared decision making and person centred planning Well publicised and accessible Complaints Procedure

Staff can help to prevent abuse by: Following guidance re: personal care, behaviour issues and sexuality Acknowledging ‘it could happen here’ Being alert to signs of distress or intimidation Reporting concerns at earliest opportunity and keep reporting until action – line management, other professions, CSCI Requesting and attending training and development events Asking for help

Managers can help to prevent abuse by: Ensuring adequate staffing levels Recruitment procedures and checks Supervision and training Keeping communication channels open Clear polices which promote good practice Sound recording systems

Further Reading Working with Adult Abuse (e-book) by Jacki Pritchard Brown, K (2006) Vulnerable Adults and Community Care Exeter: Learning Matters www.isa-gov.org.uk ‘Lessons from the murder of Stephen Hoskins’ (audio-visual) www.scie-socialcareonline.org.uk under ‘Safeguarding Adults’