Safeguarding Adults - Preventing Abuse and Responding to Poor Practice Practitioner Level 9.30 welcome and introduction to course Welcome Practitioner safeguarding – follow on from alerter – also MCA course available – different expectations of you to alerters Me, care worker, social worker – adults – MH, LD, OP, OPMH, Sensory, PD - safeguarding Ensure that between 915-930 people sign in and state whether or not they have completed the pre-work For those arriving late they will be given the laminated ground rules card. The agreed cut off for arriving late and leaving early is 10% of the course which means that generally if people miss 35 mins or more they will not be able to stay / get a certificate.

Mobile Phones / Devices Housekeeping Fire Procedure Smoking Toilets Trainer to locate toilets and tell attendees where they are Familiarise yourself with the fire procedure and assembly point Smoking – ensure that you are familiar with the requirements of the venue and that the attendees are encouraged to adhere to them. E-cigarettes are to be smoked during breaks only Mobile Phones / Devices – Not to on unless an emergency / on-call. May need to labour the issue and remind people after lunch Breaks - 15 minutes am and pm. 45 minutes lunch. Please return promptly so that the day can stay on track Finishing time – 16.30 including completion of evaluation forms etc Breaks Finishing Time Mobile Phones / Devices

Training Transfer Getting learning into practice “50% of learning fails to transfer to the workplace” (Sak, 2002) “The ultimate test of effective training is whether it benefits service users” (Horwath and Morrison, 1999) 9.34-9.36 discuss research by ripfa/plymouth Uni/cornwall cc Lots of research shows that learning fails to transfer to the workplace Lectures – only 10% stays So much going on in our lives We need this to transfer in safeguarding

Training Transfer 9.36-9.40 – the factors for successful transfer Individual Characteristics Training Design and Delivery Workplace Factors 9.36-9.40 – the factors for successful transfer Individual characteristics: motivation, understanding of reason for training/benefits for service user/agency Training Design & Delivery: designed to appeal to everyone’s needs; although everyone has different experiences, ability, skills, styles, needs, expectations and knowledge; designed to be as close as possible to real life/cases/job/task. Workplace factors: manager/organisation should identify opportunities/time for you to practice and provide feedback/supervision Pre and post learning has been designed to address individual motivation and workplace feedback. Useful for CPD Course design designed to meet individual needs Participation - essential to learn through exploring / reflection. Please ask questions as we go through. Active listening – one person talking at a time. Try not to interrupt / talk over. Really listen don’t switch off Awareness of others’ emotions – this is very difficult subject and some attending may have had recent or historical work / home situations that they may be reminded of Value each other’s views and opinions – goes with listening but you can disagree in a professional manner that’s okay

Introductions Name Place and nature of work What do you want to know by the end of today’s session? 9.35 introductions Name, Place and nature of work / role – try and establish specifically what their role in A is Pre-read - are there any areas that you are unsure of? Any questions? Anything you want to get out of today generally, questions, challenges and so on. Find one thing from each person to discuss / reflect back to them etc to start to develop a confidence in contributing to group discussions

Outcomes By the end of the session you will: Understand your responsibilities Be able to recognise and respond to poor practice and know who else to involve Recognise missed opportunities through learning from Serious Case Reviews Have a greater awareness of the legislative framework, regulation and guidance that contribute to the prevention agenda Identify opportunities for intervention through the assessment, care or treatment planning and review processes Recognise the role of person-centred support in preventing abuse Be able to consider the ongoing balance between prevention, protection and a person's right to choice 9.45

Ground Rules Confidentiality within the group will be respected but may need to be broken if a disclosure of unsafe practice, abuse or neglect is made during the course – this will normally be discussed with you first. Safeguarding is about partnership, it is not about blame. All agencies and individuals need to take responsibility, to reflect and learn to safeguard people who may be vulnerable. ground rules Confidentiality – individual comments are not passed on. SA issues will be highlighted – trainers responsibility to alert – will discuss with person. Recurring themes are passed on. Respectful discussions about other disciplines / agencies – SA is not about a culture of blame. Easy to state that it’s the fault of X professional X organisation but all agencies and people take responsibility Anything else anyone would like to add? Just ask the question. Also check for physical as well as emotional comfort at this time

Underpinning message for session Positive approach – promotion of good practice and early intervention to avoid harm The rule of optimism - maintaining healthy scepticism and respectful uncertainty Munro – baby P – identified too much optimism among workers about motivations of perpetrators e.g. Believing the parents too much “It could happen here.”

Setting The Scene Where does our learning about Safeguarding come from? Serious Case Reviews/Complaints/Near misses Research/Surveys/Data Analysis Practice Experience/Theory/Reflection www.devonsafeguarding.org www.scie.org.uk 9.50 Whole group - where does our learning come from? We will be giving you snippets of information from these sources – a reference list will be provided at the end of the session for you to develop your understanding further.

Six Safeguarding Adults Principles Empowerment Protection Prevention Proportionality Partnership Accountability ‘Adult Safeguarding: Statement of Government Policy’ 2011 9.55 These were developed in response to no secrets review 2008/9 People said they did not want to be treated like children and wanted to be given relevant timely information so that they could make informed choices. Empowerment - Presumption of person led decisions and informed consent. Protection - Support and representation for those in greatest need. Prevention - It is better to take action before harm occurs. Proportionality – Proportionate and least intrusive response appropriate to the risk presented. Partnership - Local solutions through services working with their communities. Communities have a part to play in preventing, detecting and reporting neglect and abuse. Accountability - Accountability and transparency in delivering safeguarding

‘Prevention in Adult Safeguarding’ “It does not mean being over-protective or risk-averse. Prevention needs to take place in the context of person-centred support and personalisation, with individuals empowered to make choices and supported to manage risks.” Report 41, SCIE, 2011

What does the term ‘vulnerable’ mean? Vulnerability What does the term ‘vulnerable’ mean? 10.00 – small group activity 2-3 mins

The Traditional Model Risk factors for being abused – poor communication skills, low self esteem, challenging behaviour, cognitive difficulties, lack of education/experience, loneliness Risk factors for carers abusing - isolation, stress, lack of knowledge of condition, substance misuse, lack of support Risk factors for services – poor management, high turnover of staff, low pay, lack of staff In the traditional model we focus on risk to an individual that comes from the person’s perceived deficits. This means we focus our attention on them for change.

The Social Model of Vulnerability A way of thinking about vulnerability that is not patronising or impairment specific because the vulnerability is outside the person Vulnerable groups tend to be placed in, or left in, situations of higher risk than would be tolerated for others Not heard, believed or taken notice of when they make complaints Not helped to recover or recompensed Because of these situations vulnerable groups risk being seen as “easy targets” (Prof. Hilary Brown) copyright hilary.brown@canterbury.ac.uk Canterbury Christ Church University UK 2012

‘Constellations of Abuse’ Targeted abuse Domestic abuse Professional abuse Institutional abuse Family violence, neglect or negligence partner violence between parent and adult child between adult child and older parent more distant relatives breaches of professional boundaries by arrogant grandiose and unaccountable staff resentful, down-trodden and hard-done-by staff rigid de-personalised regimes neglectful care staff out of their depth or not available cruel, humiliating individuals hate crimes predatory crimes sexual and financial Parasitic, exploitative “mate” crime Unethical practice Unethical, unjustified and/ or unauthorised practice in response to challenging needs Systemic abuse and social exclusion copyright hilary.brown@canterbury.ac.uk Canterbury Christ Church University UK 2012 10.20 – whole group – how might we intervene on a personal, cultural, structural level? Personal: making people aware of dangers, ways of keeping safe, support to explore options Cultural: families not accepting poor care standards/bullying or harrassment – how to report/complain - reassurance Structural: MP Exclusion from mainstream service provision Discrimination in health, education, housing, employment , justice and welfare Unable to access public places and spaces Denied legal advocacy and routes for challenge Invisible or stigmatised in media Prof. Hilary Brown, 2012

PCS Analysis Neil Thompson Psychological Personal/ Cultural Structural This analysis reinforces the message that vulnerability comes not just from an individual’s impairments but an internalisation of the way society is unfairly structured and the way culture reinforces/normalises those structures. S: Lack of/under investment and lack of training/support leads to C: poor care standards; bullying and harrassment in our communities, e.g. Name calling/joke telling/derogatory language, Dehumanising language – they/the doubles/the feeds; Not taking reports seriously/not being a ‘credible witness’/not being believed leads to P: internalisation of low self worth, Acceptance of culture as norm, Also demonstrates how workers may view S/C and internalise leading to lack of motivation/valuing role Neil Thompson

Opportunities for intervention Assessment & Planning Care, Support or Treatment Review Service monitoring/Complaints What are your responsibilities? 10.10

Prevention: Your Responsibilities people being informed of the right to be free from abuse; and supported to exercise these rights, including having access to advocacy thorough needs assessments supported by risk assessments where required to inform people’s choices access to good universal services targeted at older and disabled people that can reduce the risk of people experiencing abuse, for example community safety services or services that increase people’s access to advice or maintain informal support networks a well informed, competent and properly vetted workforce operating in a culture of zero tolerance of abuse a sound framework for confidentiality and information sharing across agencies (CSCI, 2008) Commission for Social Care Inspection report (2008) Safeguarding adults: A study of the effectiveness of arrangements to safeguard adults from abuse, London: CSCI

ISA Report “Safeguarding in the Workplace: What are the lessons to be learned from cases referred to the Independent Safeguarding Authority?” March 2012 General indicators carelessness, breaches of policy, attitudinal problems, emotional detachment and persistent non-attendance, portrayal of a close personal relationship with the victim Financial indicators talking about money worries, seeking advances or requesting overtime, failure to complete documentation and protocols regarding the handling of money 200 cases examined (1/2 adult, ½ children). Warning signs in behaviour and working practices identified. “Safeguarding in the Workplace: What are the lessons to be learned from cases referred to the Independent Safeguarding Authority? “ March 2012 Financial Abuse referrals made more often on one off incident than other types of abuse

Creating Safer Organisations Recruitment - VBI CRB/ISA Checks and References Induction and Probation Policies and Procedures Setting Standards and Professional Boundaries Training Supervision Performance Management 10.40

Serious Case Reviews Take place where a vulnerable adult has: died, suffered serious sexual abuse, a potentially life-threatening injury or serious and permanent impairment of health or development or when serious abuse takes place in an institution or multiple abusers are involved AND the case gives rise to concerns about the way in which local professionals and services work together to safeguard vulnerable adults OR where it is believed to be in the public interest to conduct such a review. What are SCRs, why they are undertaken? Group discussion regarding Serious Case Reviews - requirement of pre-read Explain that this course was partly developed in response to SCRs in Devon. EXPLAIN there are 4 on Devon site which will be referred to throughout the day (as well as others which are on each local authority’s website). 9.55-9.57 Just run through this for information only Death Serious sexual abuse Life threatening injury or serious and permanent impairment of health or development Serious abuse in an institution Multiple abusers AND Concern about professionals working together OR Public interest

Serious Case Reviews aim to: Establish whether there are lessons to be learnt about the way in which local professionals and agencies work together to safeguard vulnerable adults Improve practice by acting on learning NB: The purpose of having a serious case review is not to reinvestigate or to apportion blame. They consider individual actions as well as the systems and processes within which individuals operate. Aim: to learn lessons/improve practice not to blame people Discuss the difference with Adults / Childrens

Serious Case Reviews – recurring national themes Inter-agency communication No lead agency Training needed Threshold issue Assumptions Jill Manthorpe and Stephen Martineau, 2009 research Serious Case Reviews in Adult Safeguarding in England: An Analysis of a Sample of Reports Jill Manthorpe and Stephen Martineau These themes frequently recur

Devon SCRs A: High number of deaths raised by CSCI Poor care standards not previously picked up by many and various professionals B: 2 falls resulting in deaths raised by PALS Environmental risks not previously picked up by many and various professionals H: Resident murdered by another on respite Poor transfer of risk information from hospital to care home Lessons learnt regarding DCC whole homes SCRs Whilst they are very sad reading it is important to make time to read them as they are powerful learning These are awful cases but if the issues had been picked up earlier ....... Take the following SCR’s Care home A Care home B Care home H Bring it back to harm – if you don’t challenge then this could be the outcome Learning: not knowing standards & not challenging poor practice – training developed not recording/cross-referencing – Mr. Manager Also discuss any current / new SCR (use the ones most relevant to the groups roles) e.g. JK (Cornwall), Gemma Hayter (Warwickshire), person A1 (Warwickshire)

Devon SCRs – combined learning Duty on all health and social care professionals to record and act upon, any concerns about health, safety or wellbeing. This should include possible risks that are not necessarily the main focus of their contact. Ensure that a Service Provider is fully aware and able to safely meet someone’s needs. Other important considerations such as accessibility, peoples preferences, resource pressures and cost, should not compromise the primacy of ensuring safe care/support arrangements. The care needs and vulnerability of people are increasingly acute and complex.

Common Safeguarding Challenges (care homes) Lack of social inclusion Institutionalised care Physical abuse between residents Financial abuse www.scie.org.uk Maladministration of medication Pressure sores Falls Rough treatment, being rushed, shouted at or ignored Poor nutritional care commissioning care homes: common safeguarding challenges (guide 46) Includes a prevention checklist and resources for each category Also looks at underlying causes each of which has a prevention checklist and resources: Recruitment Staffing levels Adherence to policy and procedures Training Choice of service Record keeping dehumanisation

Health and Social Care Act, 2008 Single registration system acts as a “licence to provide services” Established Care Quality Commission to: Regulate the quality of health care and adult social care Look after the interests of people detained under the Mental Health Act 11.15 background to the Act and the standards Apply to a wide variety of services that provide regulated activities (care, support and treatment) across Health and Social care. This includes residential, domiciliary and day care, GPs, dentists, hospitals and so on. Depends on what services you provide not what type of service you are. Excludes independent personal assistants EXAMPLES of regulated activity are: • Personal care • Accommodation for person who require nursing or personal care • Accommodation for persons who require treatment for substance misuse • Accommodation and nursing or personal care in the further education sector • Treatment of disease, disorder or injury • Assessment or medical treatment for persons detained under the Mental Health Act 1983 • Termination (do NOT use the term abortion please) of pregnancies • Services in slimming clinics • Nursing care Dental treatment • Family planning services If you carry on any of these activities in England, you must register.

Health and Social Care Act 2008 Focused on outcomes rather than policies, systems and processes (inputs) CQC to monitor compliance – risk register New enforcement powers for CQC overview of the Act/Essential Standards Clear guidance about the outcomes we expect people to experience if the provider is compliant with the new regulations. (Outcomes are what people get rather than what we give). Not as prescriptive as before - shift from service focus to person focus. E.g. keeping clean – bath, shower, strip wash There are prompts for each outcome for providers to consider. There are references to other legislation e.g. Medicines Acts, Health and Safety at Work Act, COSHH, MCA and so on Each provider to demonstrate that they have achieved the outcome and is compliant with the regulation – CQC compile a risk register with information received. 28 outcomes, we will focus on the 16 that apply to all types of provider - they relate directly to the quality and safety of care. Other 12 regulations may apply differently to different types of provider. (Providers who are not required to register may use them as their benchmark.) Really helpful to have common standards and language in health and social care ASK GROUP how many of them feel confident that they understand the outcomes. If lots of commissioners ask them if they can name any!?

Snap! 11.20 Look at just 16 standards – once completed discuss See Tutor Notes and then give out handout

Behind Closed Doors Watch the DVD Area of Concern / Poor Practice 11.30 watch DVD and complete column one – give specific examples, not general issues Example: the manager made a joke about dementia – not the manager is disrespectful Everything in the DVD actually happened but not all in the same care home at the same time. If all this was happening then it would definitely be Safeguarding but we are thinking about what we would do if we saw/heard about one or two of these poor practice issues in isolation. Complete the FIRST column ONLY

Behind Closed Doors Area of Concern/ Poor Practice Which CQC outcomes does this relate to? 11.40 Complete the SECOND column ONLY

Behind Closed Doors Area of Concern / poor practice Which CQC outcomes does this relate to? What might you see, hear or smell? Consider the indictors and signs that there might be if you hadn’t actually observed the behaviours Complete the THIRD column ONLY 11.45 Small group Assume that the person can’t tell you OR is unwilling What will you actually see/hear/smell OR be informed of by provider OR ‘sense’ (if its sense, try to unpick what you saw/heard/smelt) In the small groups ask them to pick ONE example from each person in the group

What might you see? Empty hours, bored residents Empty and scrappy staff rotas (turnover, absences and not enough staff) Erratic medication charts Dirty rooms Dirty linen No training or “going through the motions” Policy documents and care plans kept in the drawer Rushed staff Dirty, untidy and unlooked after clothes

What might you smell? Urine Faeces Stale food Body Odour

What might you hear? Dehumanising: “they” - people are lumped together – “they eat like animals”, “the doubles” Sexualising: “they’re at it like rabbits”, “she’s gagging for it” Blaming:“he knows what he’s doing,” “she’s manipulative”, “he’s winding me up” Punitive: “they’ve got it coming”, “she needs to be taught a lesson”, “if he thinks he can treat me like that” Discrediting: “he doesn’t notice”, “they don’t care” “they are zombies”

Barriers to addressing poor practice Lack of a tangible sense of what is wrong Lack of certainty that your concerns are reasonable or proportionate Lack of “evidence” to back up concerns Fear of immediate reprisals or long term detrimental consequences Fear that concern or complaint will not be handled well so that their intervention will be in vain barriers Large or small group discussion lack of time – challenge this strongly from a values, contractual and legal perspective Lack of knowledge re: standards Afraid, upset, angry, frustrated Don’t know service type/client group Lack of confidence The particular staff member may be difficult/having a bad time General staff resistance to change Very close relationships between managers/staff – even all related My age My qualifications If staff have shared things – can be difficult as the other member of staff will know who has ‘grassed’ If staff have complained about team leader/manager The person may be the only other person on duty Finding the right things to challenge/is it significant enough? Want to avoid conflict Especially difficult when they’ve been challenged before and no improvement has occurred Fear of opening up a can of worms Professor Hilary Brown

How do you verbalise ‘gut instincts’? Hull University: ‘Abuse in Care?’ (http://www2.hull.ac.uk/fass/care/safeguardingadults.aspx) A practical guide to protecting people with learning disabilities from abuse in residential services A practical guide to protecting people with dementia from abuse in residential services 11.55 : Early indicators of concern in 6 key areas (one for dementia and one for LD) The guide should be read before using the checklist / tool

Service Monitoring Checklist Leadership and Management Staff behaviours and attitudes Behaviours and interactions of residents Isolation and lack of openness Service design, delivery and make up Environment and basics of care Adapted from ‘Abuse in Care?’ Has been developed into the Devon service monitoring checklist To provide a prompt / guide to reviewing within services

If you suspect a criminal offence, do not ask any further questions. Practitioners’ Role Information received about or poor practice observed Gather Information Poor practice? Safeguarding? practitioners – not alerters you need to be making decisions about what to do with issues. You may have witnessed or someone has told you one thing and you will need to gather info in order to decide what to do. We will look more in depth at the threshold for safeguarding later. EXAMPLE: You go into someone’s garden and want to know what’s growing. Gathering info means recording how many apples, pears etc are on the trees, picking up empty seed packets and asking the gardener. Investigating means digging up plants to see what’s underneath, asking neighbours to see if they know what’s growing, looking in the shed, going to the garden centre and asking what they’ve bought and so on. If you suspect a criminal offence, do not ask any further questions.

Behind Closed Doors Complete column FOUR Area of Concern / poor practice If you hadn’t observed it what other indicators might there be? What might you see, hear or smell? What information do you need to gather? Where/ who from? What questions might you need to ask to establish the facts of the situation? Be specific! 12.05 DETAIL: What questions would you ask?, how might you challenge? Immediately, in supervision? , who would you discuss with and what exactly?

What to do with concerns about poor practice Discuss with the professional concerned Discuss with the service manager Discuss with your manager immediately, in supervision or at a team meeting Discuss directly with the person, family, organisation. Once discussed then back up in writing - SMART. Record in Mr Manager if appropriate Discuss with co-workers or Safeguarding Adults team Encourage people to use the complaints process Discuss with procurement / contracts team Discuss with CQC What you do will depend on your role Discuss with professional concerned – NOT if SA. May need to speak with their manager – your professional judgement Provider or commissioner Discuss directly with the person, family, organisation. Once discussed then back up in writing. Have SMART discussions with SMART recording (as an observation ) Provider or commissioner Record in Mr Manager – DCC or stat partners Discuss immediately with manager OR In supervision, or at a team meeting Provider or commissioner Discuss with co-workers or Safeguarding Adults team Provider or commissioner Encourage people to use the complaints process Provider or commissioner – how do you get residents to do this? Discuss with procurement / contracts team DCC or stat partners Discuss with CQC DCC or stat partners OR providers

Feelings / Emotional Responses Ask group what there emotional response is when they have to address a concern with someone? Usually it will be some of all of these Worried about time Almost wish they hadn’t seen it Fear Upset Apologetic etc etc Physical feelings as well We all have to find ways of dealing with / managing these so we can challenge effectively

Communication Verbal Tone Body Language We experience a wide variety of emotions and these can come through in our body language. Research suggests that Communication is composed of Body Language= 55% Tone / intonation etc (delivery of words)=38% Words =7% Our thoughts, emotions, behaviours, physical reactions and environment all work together to effect a person’s state of mind: Feelings / Thoughts help define the moods (positive or negative) we experience. Feelings / Thoughts influence how we behave, what we choose to do, or not to do. Feelings / Thoughts (and beliefs) affect our biological, physical reactions. All of the above are surrounded by life situations and environmental changes. To give you confidence, it may be helpful to remind yourself why you are doing this – to protect people, it’s the law and so on

Neil Thompson What is a problem? ‘....a problem is anything that either brings about negative ...or blocks positives or a mixture of the two.’ Neil Thompson Highly recommended Can get from Amazon etc Before you discuss an issue you need to be clear that you have a shared understanding of the problem. Example – teenager who leaves clothes on floor, dirty, cleaned, ironed etc does not why parents get so cross or upset. Need to explain impact on parent who my buy clothes, wash them and iron. Also the fact that clean and dirty get muddled so clean clothes may need washing again. May also be useful for teenager to do the washing / ironing to understand impact Need to have shared understanding of problem / issues / poor practice

An Elegant Challenge Being constructive in challenging unacceptable behaviour or language Collusion / Elegant Aggressive no challenging challenge challenge From his book along with may other good points / tips Restaurant Example Creating a small positive change in one area, will gently shift small changes in other areas.

Practice Choose one of the scenarios from the film (or your own) and make ‘an elegant challenge’ to your partner. Partners – What did it feel like? What could be done differently? Swap over. 12.15

Any Questions? 12.25-12.30 Questions, Evaluation forms Feedback, Finish

Prevention is Better Than Cure Keep the course in context. Whilst there are some very worrying situations occurring everyday there is also good practice in all care environments Remember to vigilant and deal with things at the earliest opportunity. Whether it’s poor practice or abuse doing nothing isn’t an option. If time ‘’What pro-active methods do we have available to us to ensure that the risk of abuse is reduced and that people aren’t placed at avoidable risk?’’. Also remind them that abuse can happen in all types of care environment but also so can good practice Large groups to flip chart fast and punchy positive end exercise Should come up with Good planning of care (covered later) Robust monitoring of care – Audit CQC / internal / care mgt etc Response to complaints / concerns / alerts Induction / training / ongoing Supervisions / appraisal / communication / team meetings Good shift patters / staff who are rested etc Strong value based leadership Sufficient focused resources etc etc etc LEAST restrictive options

Resources Dementia care mapping www.bradford.ac.uk CQC observation tools www.cqc.org.uk/information-our staff/observation-tools SCRs www.devonsafeguarding.org Remind them that there is a lot of information ‘out there’ which is simple to implement and can make a huge difference Dementia care mapping based on work of Tom Kitwood – personhood essential to wellbeing – measures quality of staff/resident interactions/activity – training required to undertake this type of mapping Could use CQC observation tools instead – available on website

Resources Social care governance – audit tool Common Safeguarding Challenges Minimising the Use of Restraint www.scie.org.uk Good Ideas! www.kissingitbetter.co.uk/ www.myhomelifemovement.org/ Useful tools for providers and commissioners