North Wales Policy and Procedure for the Protection of Vulnerable Adults 2005 Agreed by: North Wales Local Authorities North Wales Police North Wales NHS Trusts North Wales Local Health Boards Care Standards Inspectorate for Wales North Wales Care Association
RESPONSIBILITIES: ALL AGENCIES AND INDIVIDUALS All agencies have a duty to work together to protect vulnerable adults. The identification, assessment, protection and care of vulnerable adults at risk is a multi-disciplinary, inter-agency responsibility, which should involve anyone with relevant knowledge to ensure the safety and wellbeing of the individuals concerned. Staff, professionals, managers and volunteers working in health and social care have a duty to raise concerns about vulnerable adults under the Public Interest Disclosure Act and to report any suspicion or allegation of abuse. Where a criminal offence is suspected, (e.g assault, rape, fraud, theft or other financial exploitation), the responsibility for initiating action is with the police and Crown Prosecution Service. In these cases, the police must be involved as a matter of urgency. The sharing of information between agencies is paramount for vulnerable adult protection work. Good communication, co-operation and liaison between agencies and disciplines are essential, and the responsibility of every worker and agency. Wherever possible, abuse must be prevented. Agencies should take all steps possible to reduce the likelihood of abuse and to promote measures which reduce the likelihood of abuse. Copyright:- North Wales Vulnerable Adults Forum
COMMITMENT Vulnerable adults should be enabled to live and receive services in an environment which is free from prejudice and safe from abuse. Where abuse is suspected, we will aim to provide a service which: IS PROMPT: in cases where there is any doubt about the person's immediate health and safety; IS SENSITIVE: to vulnerable adults and their representatives/carers and to care staff; IS EFFECTIVE: in providing or negotiating solutions which are as simple and practical as possible and aim to prevent the risk of abuse recurring; IS BALANCED: staff must exercise responsibilities and duties appropriately, avoiding unwarranted intervention into people's lives; IS AWARE: and does not discriminate against a person because of their religious and cultural beliefs, age, disability, gender, race, sexuality or language.
SUMMARY OF PROCESS FOR ADULT PROTECTION Within 24 hours Disclosure/Concern raised through Stage 1 Intital Contact/Referral Complete Incident Report No Yes Is urgent action needed? No Inform Appropriate Manager (App.Mgr) within Social Services Take necessary action App Manager. liaises with: Police/CSIW/Contracts/ Placing Authority as required Initial information gathering by Appropriate Manager./interagency Strategy Discussion Information recorded Stage 2 Day 1-2 Yes Is strategy No App Mgr. meeting arranges needed? meeting App Mgr. agrees to support care needs & signs off case as adult protection and App Mgr. gives feedback to referrer/vulnerable adult Stage 3 End By Day 3 If crime alleged, Police take lead in investigation Strategy Meeting held Actions agreed. Investigating Officer(s) appointed if required. Form PVA1 completed If non-criminal: Social Services/health/CSIW/ Services/Health/CSIW Contracts lead (as required) Investigation/Assessment report carried out by appointed person(s) Stage 4 Yes Is Adult Protection Case Conference needed? No By Day 15 Appropriate Managers arranges Adult Protection Case Conference which identifies future actions/ adult protection plans agreed and key worker appointed and review date set. Complete PVA 2. App.Mgr records decision and considers actions needed relating to risk management, support, monitoring. App.Mgr sets review date and if necessary appoints key worker and feedback to referrer/vulnerable adult Stage 5 Review Adult Protection Plan. Review takes place within 3 months or as within time scale determined by Case Conference and subsequent review dates set. End Stage 6
CONTENT 1. INTRODUCTION 2. POLICY STATEMENT Recognition Rules and Responsibility Prevention of Abuse 3. VALUES & PRINCIPLES Core Values Core Principles 4. DEFINITIONS Vulnerable Adults Definition of Abuse Stranger Abuse Significant Harm 5. CATEGORIES & INDICATORS OF ABUSE 5.1 Context of Abuse 5.2 Physical Abuse 5.3 Sexual Abuse 5.4 Psychological Abuse 5.5 Financial & Material Abuse 5.6 Neglect 5.7 Predisposing Factors which may Lead to Abuse 6. NORTH WALES ADULT PROTECTION PROTOCOL 7. THE ROLE OF NORTH WALES POLICE 8. LEGAL CONTEXT 8.1 Possible Legal Remedies when Dealing with Adult Abuse 8.2 Legal Remedies for Different Type of Abuse 8.3 Legislative Powers & Provisions 8.4 Summary of Legal Steps and Response
9. INFORMATION SHARING AND CONFIDENTIALITY 10. CAPACITY CONSENT AND DECISION MAKING 11. INTER-AGENCY PROTOCOLS 11.1 Disciplinary Procedures 11.2 Whistle-blowing Procedures 11.3 Staff Support 11.4 Allegations against Staff 11.5 Malicious and Vexatious Allegations 11.6 Responsibilities towards Perpetrators of Abuse 11.7 Commissioning and Contractual Issues 12. RECORDING AND DISCLOSURE 13. MONITORING, EVALUATING & IMPROVING 13.1 Introduction 13.2 Activity 13.3 Implementation 13.4 Improving 14. TRAINING AWARENESS AND SKILLS DEVELOPMENT 15. POVA LIST 16. GIVING EVIDENCE OR INFORMATION FOR PURPOSES OF CRIMINAL PROCEDURES. 17. CHECKLIST : PRESERVING EVIDENCE 18. REFERENCES 19. KEY CONTACTS IN NORTH WALES
APPENDICES 1. CONSTITUTIONS I. North Wales Adult Protection Forum Constitution II. Unitary Authority Adult Protection Committee 2. INDIVIDUAL AGENCIES PROTOCOLS Conwy and Denbighshire NHS Trusts North East Wales NHS Trust North West Wales NHS Trust Common Documents for all NHS Trusts North Wales Care Association 3. STANDARD FORMS Introduction 1. Incident Report Alleged Abuse of Vulnerable Adult 2. PVA1 Possible Adult Abuse Notification Form 3. PVA2 Adult Protection Referral Outcome Monitoring Sheet 4. NORTH WALES TOOLKIT 1) Handling Disclosures 2) Planning Investigations or Assessments: Points to Consider 3) Attendance List Meetings held under North Wales Policy and Procedures 4) Strategy Meeting Agenda 5) Strategy Meeting Minutes 6) Chairing an Adult Protection Case Conference 7) Adult Protection Case Conference Agenda 8) Adult Protection Plan 9) Investigation or Assessment Report 10) Learning from Cases 11) Adult Protection and Older People 12) Adult Protection and People with Learning Disabilities 13) Adult Protection and People with Mental Health Problems 14) Alleged Abuse by another Vulnerable Adult 15) Consent Issues 16) Co-ordinating a Large Scale or Complex Investigation 17) Evaluating Evidence 18) Evaluating Seriousness 19) Financial Arrangements 20) Working with the Police 5. RISK ASSESSMENT TOOLKIT AND FORMS
ACKNOWLEDGEMENTS The North Wales Vulnerable Adults Forum would like to acknowledge the assistance and guidance received from numerous individuals and to several Regional Vulnerable Adults Protection Forums who have assisted with the development of the revised North Wales Vulnerable Adults Policy and helped us learn from good practice. The Group wishes to formally acknowledge those who have given their permission and consent for us to adapt good practice used in other regions and/or who have advised and guided the drafting of these documents, especially: South East Wales Executive Group for the Protection of Vulnerable Adults; Dyfed Powys Vulnerable Adult Committee; South Wales Adult Protection Forum. We also owe a debt of gratitude to a number of individuals including Jacki Pritchard who developed the Risk Assessment Tool on our behalf. We would also like to refer to our Chair, T Gwyn Jones who steered the group and help bring this work to completion. Finally we would like to thank the members of the North Wales Adult Protection Forum for their contribution and perseverance in what appeared to be a never ending task of editing and re-editing infinite drafts. We appreciate that this document does not in any way bring this work to conclusion or provide a definitive answer to all circumstances. The Forum realises that the document will have to be revised and updated on a regular basis to ensure it remains relevant and reflects current best practice and is committed to this process.
SECTION 1-5 1. INTRODUCTION 2. POLICY STATEMENTS 3. VALUES & PRINCIPLES 4. DE INITIONS 5. CATEGORIES & INDICATORS O ABUSE
1.0 INTRODUCTION 1.1 This document builds on the North Wales Policies and Procedures for Responding to the Alleged or Confirmed Abuse of Vulnerable Adults (2000), takes account of the National Assembly for Wales guidance In Safe Hands and considers the experience of staff and agencies who have been responsible for responding to the alleged and confirmed abuse of vulnerable adults. As a direct consequence of the evaluation of existing practice, all 6 local authorities in North Wales will now adopt one common set of procedures and the 3 NHS Trusts will also follow common guidance. It is hoped this will reduce ambiguity and ensure a consistent response across North Wales. The development and implementation of effective policy and procedures for responding to the abuse of vulnerable adults requires a multi agency approach. Therefore, this document has been collectively developed by the North Wales Vulnerable Adult Forum. The Forum draws its representatives from: Ynys Môn Social Services Department; Gwynedd Social Services Department; Conwy Social Services Department; Denbighshire Social Services Department; Flintshire Social Services Department; Wrexham Social Services Department; North Wales Police; Conwy & Denbighshire NHS Trust; North East Wales NHS Trust; North West Wales NHS Trust; Care Standards Inspectorate for Wales; North Wales Care Association; Crown Prosecution Service; North Wales Probation Service; Age Concern. 1.2 The aim of the document is to provide a consistent framework for action and staff support across the partner agencies and to confirm lines of responsibility and accountability. 1.3 Other agencies that are not included as full partner agencies have contributed to the implementation and evaluation of the guidance. These include representatives from: the Voluntary Sector; Domiciliary Care Agencies.
2.0 POLICY STATEMENTS 2.1 Recognition 2.1.1 The Partner agencies recognise that some adults, by virtue of their illness or disability (physical, mental, learning or sensory) may be vulnerable to, or may experience, abuse. 2.1.2 Local Authority Social Services Departments have a lead role in co-ordinating the development of policy guidance for the protection of vulnerable adults who are at risk of abuse and for implementing that guidance. However, partner agencies have respective responsibilities to respond to suspicions, allegations or incidents of abuse as described in these procedures in collaboration with Social Services and where appropriate, to arrange support and/or care for the most vulnerable people in the Community. 2.1.3 Statement of Partner Agency Commitment The Partner Agencies are committed to: actively work together to ensure effective implementation and operation of these procedures; continuously improve the effectiveness of their response to suspected abuse; actively promote the empowerment and wellbeing of vulnerable adults through the services they provide; ensure the safety of vulnerable adults by integrating strategies, policies and services relevant to abuse within the framework of the NHS and Community Care Act 1990; act in a way which supports the rights of the individual to lead an independent life based on self determination and personal choice; ensure that when the right to an independent lifestyle and choice is at risk the individual concerned receives appropriate help, including advice, protection and support from relevant agencies; recognise that the right to self determination can involve risk and ensure that such risk is recognised and understood by all concerned, and minimised whenever possible; ensure that the law and statutory requirements are known and used appropriately so that vulnerable adults receive the protection of the law and access to the judicial process. 2.2 Roles and Responsibilities in Relation to Adult Protection 2.2.1 Local Authority Social Services Departments Social Services have the lead role in: co-ordinating the development of policy guidance on adult protection; safeguarding and promoting the welfare of vulnerable adults; co-ordinating the adult protection process where a vulnerable adult is at risk of significant harm. While Social Services have the lead role in co-ordinating the response to adult protection concerns, all agencies have a responsibility to work together to protect vulnerable adults. Social Services staff will work closely with other agencies to assist in taking action against perpetrators or abusive settings. This action may include: criminal prosecutions where abuse constituted an offence; action under the Care Standards Act; disciplinary action and employment tribunals; action taken by a professional body where its code of conduct had been broken.
Social Services covering the area where the vulnerable adult is living are responsible for co-ordinating the process of planning, investigation and case conferencing. This is regardless of where the vulnerable adult came from or who is responsible for funding. If another Authority funds the vulnerable adult, Social Services will inform the funding agency if there is an adult protection alert. Social Services will inform the Care Standards Inspectorate for Wales if a referral has been taken about an adult protection issue in a regulated setting. Social Services will inform the appropriate contracts or commissioning officer if a referral has been taken about an adult protection issue in commissioned or grant aided services. See: 'Responsibilities: Cross Boundary Issues' (see 2.2.7), for information about responsibilities where a vulnerable adult is funded by another Authority. 2.2.2 North Wales Police The Police are responsible for working jointly with other agencies to protect vulnerable adults, and for carrying out investigations, jointly as appropriate, into alleged criminal activity. The Police have a duty to obtain evidence of any offence, and to assist and support the victim in this. They also have a responsibility to investigate and interview any suspect. See practice guidance: Working with the Police. 2.2.3 Health (including Local Health Boards and NHS Trusts) Health commissioners and providers are responsible for working jointly with other agencies to protect vulnerable adults, and for ensuring action is taken within this framework if there are adult protection concerns. All health professionals including GPs and their practice staff, primary health care team workers, community nursing services, staff in hospital wards and accident and emergency units, are well placed to pick up signs of adult abuse and have a duty to report any concerns they have. 2.2.4 Independent Sector Provider Agencies Independent sector provider agencies (those providing commissioned or grant-aided services) are responsible for having in place their own adult protection policies and procedures. These should: be compatible and consistent with this manual, making clear how they will dovetail with these policies, procedures and guidance; reflect the fact that Social Services are the lead agencies for co-ordinating adult protection work. Managers and staff providing services to vulnerable adults will co-operate fully in adult protection investigation / assessment and with the recommendations of an adult protection plan. 2.2.5 Health and Social Care Professionals, Provider Agency Staff, Volunteers and Informal Carers Everyone has a duty to report allegations or suspicions of adult abuse to their line manager, or to Social Services or the Police. This includes abuse in a service setting, or by someone with whom the vulnerable adult has a personal or professional relationship.
All staff of provider agencies, health and social care professionals, volunteers and informal carers must know: the requirements of this framework and their own agency's adult protection policy; what services, advice and support are available locally and how to access them; how to make an adult protection referral if they have concerns. 2.2.6 Regulators, Commissioning and Contracts Officers Regulators and contracts officers will support the adult protection process. They will attend the Strategy Meeting, Adult Protection Case Conference and attend other meetings held as part of the adult protection process and will carry out agreed actions in agreed timescales. This includes support to actions agreed in an adult protection plan. Any concerns about abuse noticed by or reported to a regulator or contracts officer will be passed immediately to the appropriate Social Services Duty Officer or Social Services Designated Senior Officer for the user group, or the Police if there is reason to believe a crime has been committed. Regulators and contracts officers and the Designated Senior Officer will liaise closely in relation to any regulatory action or service changes agreed throughout the adult protection process. See: Care Standards Inspectorate for Wales guidance on the roles and responsibilities of the CSIW in local adult protection procedures: 'In Safe Hands' - Procedure for Responding to Alleged Abuse of a Vulnerable Adult. 2.2.7 Responsibilities: Cross Boundary Issues Some vulnerable adults may be at increased risk because of cross boundary issues and potential confusion about who is responsible for what. These issues can come about because: One Authority funds or commissions care, and concerns are raised in another Authority. The vulnerable adult lives in one Authority and receives services in another. There are different responsibilities in these circumstances: The host Authority, (i.e, where the abuse occurs), has overall responsibility for co-ordinating the investigation and facilitating the placing Authority's participation through timely intervention. The placing Authority, (i.e, the Authority with funding / commissioning responsibility), is accountable for reviewing, monitoring and decision making in relation to the vulnerable adult, thereby fulfilling its duty of care. 2.2.8 Alleged Criminal Offences Whenever complaints about abuse suggest a criminal offence may have been committed, the Police must be contacted urgently. This takes priority over other enquiries. The safety of the vulnerable adult must be given the highest priority. 2.3 Prevention of Abuse The focus of these procedures is on responding to abuse and the protection of vulnerable adults, through effective joint working. Partner agencies are also committed through their policies and practices to reduce the risk of abuse and to prevent the incidence of abuse through appropriate intervention. Wherever possible, abuse must be prevented. Agencies can take numerous steps to reduce the likelihood of abuse and the
Local Adult Protection Committees should review adherence to the preventative agenda in their area and promote measures which reduce the likelihood of abuse. 2.3.1 Prevention of Abuse - Examples of Good Practices Screening job applications so that unsuitable staff are less likely to be recruited; Training and supporting staff effectively; Ensuring good supervision of staff; Ensuring that services which are provided and purchased meet specified high standards and are monitored and supported to maintain these standards; Having clear policies on promoting good working practices (e.g. safeguards when providing personal care); Assisting vulnerable adults and their advocates to become more aware of their rights and to recognise when these are being infringed; Discouraging abuse by encouraging staff to be alert and to feel confident about reporting concerns; Promoting open care environments in which abuse is less likely to occur; Use of risk assessments; Wherever possible avoiding placing staff in 1:1 working situations which create opportunities for abuse to occur and which also leave staff open to allegations of abuse; Avoiding placing clients who are likely to abuse other clients, together in residential and day services; Recognising that some clients have a life-long history as abusers and require specialist services to assist them and protect others; Supporting carers and providing services which help them to avoid reaching breaking point; Ensuring that victims of abuse receive the support and services they need to help them to recover; Ensuring that occurrences of abuse are monitored and learnt from; Increasing professional and public awareness of abuse; Achieving prosecution of criminal acts as a deterrent to potential abusers; Deterring abuse by ensuring that allegations of abuse are investigated and dealt with in a professional, effective manner. This list is not exhaustive. Agencies can pass on examples of good practice through their local Adult Protection Committee or to the North Wales Vulnerable Adult Forum. 2.3.2 Empowering Individuals Vulnerable adults may not be aware that behaviour is abusive, and we have an obligation to ensure that each individual is aware of what constitutes abuse and why, and the risks they themselves face as a consequence. It is still the case that many individuals at risk of abuse are still not given appropriate levels of information in relation to either their rights or their associated responsibilities. Extensive support may be necessary to ensure adequate levels of understanding, and skills to ensure that rights and responsibilities are recognised and asserted. 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. For example, the knowledge that an abuser is committing a criminal offence may persuade an abused individual that the abuser's behaviour is unacceptable and that they should take action to stop it.
3.0 VALUES AND PRINCIPLES 3.1 The overarching principles of this framework are those of the European Convention on Human Rights and the Human Rights Act 1998. These are: Everyone has the right to live their lives free from coercion, intimidation, oppression and physical, sexual, emotional or mental harm; Everyone has the right to a family life and privacy; Everyone has a right to confidentiality in respect of personal information, where this does not infringe the rights of other people; Everyone has the right to receive full and comprehensive information to allow them to make informed choices about their own circumstances; Everyone has the right to the protection of the law and full access to the judicial process and criminal justice system. In protecting vulnerable adults, these overarching principles mean that: Everyone has the right to enjoy a lifestyle that: o supports their independence; o gives genuine choice; assists people to make informed choices; provides the opportunity to enjoy and contribute to society. 3.2 Core Values Listed below are the core values that will be adhered to by all organisations implementing these procedures: Privacy - the right of individuals to be left alone or undisturbed and free from intrusion or public attention into their own affairs. Dignity - recognition of the intrinsic value of people, regardless of circumstances, by respecting their uniqueness and their personal needs; treating people with respect. Independence and self determination - the opportunity to act and think without reference to another person, including a willingness to incur a degree of personal risk. Choice - the opportunity to select independently from a range of options. Rights - the maintenance of all entitlements associated with citizenship. Fulfilment - the realisation of personal aspirations and abilities in all aspects of daily life. 3.3 Core Principles The following core principles will apply in responding to suspicions, allegations or incidents of abuse involving a vulnerable adult: The person s right to self determination and involvement in decision making is promoted to the fullest capacity. The person is enabled to protect themselves from harm. The involvement of others significant to the person s life is identified and supported. The awareness and understanding of other agencies, organisations and the public is raised and promoted and with it a commitment to respond. The response is as appropriate and intensive as the situation demands. The person is enabled, where possible, to live in the environment of their choice and this includes supporting families to remain together. Where this is not possible, maximum choices are given as to where the person wants to live. The vulnerable adult and the alleged abuser have the right to the protection of the law.
4.0 DEFINITIONS 4.1 To assist implementation it is important to clarify how we define abuse, who is included under the heading of a 'vulnerable adult', and what kinds of abuse are covered. For the purpose of this guidance and to encourage consistency between local and national guidance the partner agencies in North Wales have decided to adopt the following definitions which are contained in the National Assembly for Wales Guidance 'In Safe Hands'. 4.2 For the purposes of this guidance a vulnerable adult is 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 himself or herself, or unable to protect himself or herself against significant harm or serious exploitation' Law Commission (Who decides?: Making decisions on behalf of mentally incapacitated adults 1997). 4.3 People with learning disabilities or mental health problems, older people and disabled people may fall within this definition, particularly when their situation is complicated by additional factors, such as physical frailty or chronic illness, sensory impairment, challenging behaviour, social or emotional problems, poverty or homelessness. In addition to information about client group, agencies may wish to make a separate note where clients are from ethnic or minority communities and / or where they are Welsh speakers or where neither English nor Welsh is their first language. 4.4 The following definition of abuse provides a basis from which to develop practice: 'Abuse is a violation of an individual s human and civil rights by any other person or persons'. 4.5 Abuse may take different forms. The Association of Directors of Social Services (ADSS) endorses the following categorisation and it is proposed that this be used as the basis of recording and monitoring in Wales. Physical abuse, including hitting, slapping, over or misuse of medication, undue restraint, or inappropriate sanctions. Sexual abuse, including rape and sexual assault or sexual acts to which the vulnerable adult has not or could not consent and/or was pressured into consenting. Psychological abuse, including threats of harm or abandonment, humiliation, verbal or racial abuse, isolation or withdrawal from services or supportive networks. Financial or material abuse, including theft, fraud, pressure around wills, property or inheritance, misuse or misappropriation of benefits. Neglect, including failure to access medical care or services, negligence in the face of risk-taking, failure to give prescribed medication, poor nutrition or lack of heating. 4.6 Racially motivated abuse could take any of these forms and this needs to be noted additionally in situations when the victim perceives abuse to have been racist in its intent.
4.7 Stranger abuse will warrant a different kind of response than the response to abuse within an ongoing relationship or care setting. Nevertheless in some instances it may be appropriate to use the inter-agency adult protection procedures to ensure that the vulnerable adult receives the services and support that they need. Such procedures may also be used when there is the potential for harm to other vulnerable people. 4.8 Some instances of abuse will constitute a criminal offence. In this respect vulnerable adults are entitled to the protection of the law in the same way as any other member of the public. In addition, statutory offences have been created which specifically protect those who may be incapacitated in various ways. Examples of actions which may constitute criminal offences are assault, whether physical or psychological, sexual assault and rape, theft, fraud or other forms of financial exploitation, and certain forms of discrimination, whether on racial or gender grounds. Alleged criminal offences differ from all other non criminal forms of abuse in that the responsibility for initiating action invariably rests with the state in the form of the Police and the Crown Prosecution Service (private prosecutions are theoretically possible but wholly exceptional in practice). Accordingly, when complaints about alleged abuse suggest that a criminal offence may have been committed it is imperative that reference should be made to the Police as a matter of urgency. Criminal investigation by the Police takes priority over all other lines of enquiry. 4.9 Multiple forms of abuse are often seen in an ongoing relationship or an abusive service setting, making it important to look beyond single incidents or breaches in standards to underlying dynamics and patterns of harm. Any or all of these types of abuse may be perpetrated as the result of deliberate intent and targeting of vulnerable people, negligence or ignorance. Where it is difficult to determine the point at which more insidious and pervasive forms of oppression should be named as abusive, action should be taken to challenge services which discriminate against, and/or ignore the needs of minority groups. 4.10 The seriousness or extent of abuse is often not clear when a concern is first raised so it is important to approach allegations or concerns with an open mind about the appropriateness of intervention. Factors informing any assessment of seriousness will include: The frailty or vulnerability of the person involved; The extent of harm; The length of time or frequency of the occurrence; The impact on the individual; The risk of repeated or escalating acts involving this or other vulnerable adult. 4.11 The Law Commission makes use of the concept of significant harm as an important threshold when considering the nature of intervention by which they mean: 'ill treatment (including sexual abuse and forms of ill treatment that are not physical); the impairment of, or an avoidable deterioration in physical or mental health; and the impairment of physical, emotional, social or behavioural development' (Law Commission report 1995- Page 207) 4.12 Significant harm may comprise a series of incidents which, when regarded in isolation, seem insignificant, but when frequent or continuous become serious.
4.13 Acts of random violence will warrant a different kind of response to abuse within an ongoing relationship, care setting or neighbourhood. While all abuse harms the individual and may signal a need for intervention there should be particular concern when abuse is perpetrated by someone in a position of power or authority. 4.14 Social care agencies always have a responsibility towards vulnerable victims and this will usually involve making an assessment of their needs and taking steps to protect them from further harm. The agency s role, powers and duties to the alleged abuser will vary and the action they will need to take will depend on whether the alleged abuser is: A member of staff, proprietor or service manager; A member of a recognised professional group, such as a doctor, accountant, clergy or counsellor; A volunteer or member of a community group such as a church or social club; Another service user; A spouse, relative or member of the person s social network; Someone who is also a carer in their own right; A neighbour, member of the public or stranger. 4.15 Intervention will also be determined by the setting in which abuse has occurred. Residential and nursing homes are subject to specific actions set out in legislation and relevant guidance; caring relationships in domiciliary settings and within family relationships are inevitably more complex and difficult to interpret. Unregulated settings such as day centres, supported housing, informal or unsupervised adult placement schemes, may require particular vigilance. 4.16 Abuse which occurs within an institutional setting often includes more than one form of harm as a result of rigid and insensitive routines, unskilled, intrusive or invasive interventions or an environment which allows inadequate privacy or physical comfort. This type of abuse falls within the remit of regulators as well as purchasers of care. Legislation is being introduced to widen the type of settings which are regulated. However, contract specification monitoring also has a role to play in protecting vulnerable adults. Institutional abuse is therefore not a separate category of abuse but a particular manifestation of, and context for, it. (Refer to toolkit for more information). 4.17 The effects of institutional routines and care practices are often not obvious and can be difficult to recognise. There may be no obvious signs of harm. However, the consequences of such abuse can be as harmful as those caused by other types of abuse. Therefore, all staff and managers involved in the delivery of health or social care have to operate within a culture, framework and procedures that minimise the negative effects of living within institutions and maintain a high standard of quality service provision. Settings Where Institutional Abuse May Occur These procedures apply to vulnerable adults receiving care on a long or short term basis in the following settings: hospital in-patient; day hospitals; day care centres; residential care homes; nursing care homes.
4.18 Where a vulnerable adult appears to be able to make informed choices and is not being unduly intimidated the available options should be explored with them and their wishes respected, unless these conflict with a statutory duty to intervene, or unless another person(s) is considered to be at risk. In all circumstances they should be consulted and involved in decision making as far as possible. Service users have a right to make choices and maintain their independence even when this involves a degree of risk. Where the individual chooses to accept this risk, their wishes should be respected within their capacity to anticipate and understand the risk. Making sound professional judgements in these situations may require formal assessment of capacity in relation to consent. Sexual acts or financial transactions are abusive in the absence of valid, informed consent. Lack of understanding, misuse of authority, intimidation or coercion cut across autonomous decision making on the part of vulnerable adults so that an initial refusal of help should not always be taken at face value.
5. 0 CATEGORIES AND INDICATORS OF ABUSE 5.1 Context of Abuse Adult Abuse can be viewed in terms of a number of key categories which are described below and which mirror the categories in 'In Safe Hands'. It is not unusual for an individual to be abused in more than one way and to fit into more than one category. Abuse can occur in a wide range of community and care settings including care homes, day centres, the person's own home or the home of a relative, worker or volunteer. 5.2 Physical Abuse Physical abuse can be caused either through acts of commission (action) or omission (inaction) including hitting, slapping, pushing, kicking, over or misuse of medication, undue restraint or inappropriate sanctions. a) Bodily Assaults infliction of pain; injury such as burns, bruises, fractures, dislocation of joints, welts, wounds, marks of unnecessary physical restraints. b) Bodily Impairment malnutrition including inappropriate diet and dehydration; poor hygiene; misuse of alcohol; sleep deprivation; improper ventilation (temperature); creating unsafe physical environment. Possible Indicators history of unexplained falls or minor injuries; bruising; bruising on normally well protected areas e.g. inside thigh or inside upper arms; finger marks - grip or poking; burns in unusual places or of an unusual type; evidence of physical restraint, e.g. arms or legs tied to bed frame; injuries / bruising found at different stages of healing that would suggest a non accidental cause; injury shape similar to an object; injuries to head, face or scalp; pressure sores and being left in wet clothing; hypothermia; dehydration and / or malnourished without an illness related cause or when not living alone; vulnerable person is often unkempt, unwashed, smelly. c) Misuse or Restriction of Medication The consequence of receiving medication improperly i.e. being refused medication, receiving too much or too little medication. Medical care may be made unavailable or be inappropriately provided when needed.
Using medication that has been prescribed for another person or for another purpose. Using medication for the purpose of confinement and restraint or primarily for the convenience of staff or carers. Possible Indicator excessive request for repeat prescriptions by carer or under use of medication. 5.3 Sexual Abuse (a) Intentional Sexual Abuse Involving the vulnerable adult in such acts as rape, actual or threatened or sexual assault, or sexual acts to which the vulnerable adult has not or could not consent and/or was pressurised into consenting. (b) Denial of Rights This includes denial of sexual expression or fulfilling sexual needs within the accepted norms of society. Possible Indicators sexual behaviour which is out of keeping with the vulnerable adult s usual relationship or level of sexual knowledge; the vulnerable adult behaves in a substantially different manner and inappropriately in the presence of certain persons, e.g. exhibiting sexually implicit / explicit behaviour, etc, unexplained change in behaviour, e.g. showing overly compliant behaviour, self mutilation, acting out aggressive behaviour, or becoming withdrawn, choosing to spend the majority of time alone; physical signs and symptoms such as recurrent genital infections or soreness, bruises or bleeding in the genital or anal area, unexplained difficulty in walking or sitting, love bites; frequent complaints of abdominal pain without any obvious cause; torn, stained, or bloody underclothes. 5.4 Psychological Abuse (a) Persecution / Harassment Incidents including threats of harm or abandonment, verbal or racial abuse, isolation or withdrawal from services or support networks. (b) Humiliation Making the vulnerable person feel ashamed of his/her involuntary behaviours, blaming the vulnerable person for attitudes, actions or events beyond their control, ridiculing the vulnerable person for his/her conduct, disregarding their presence and/or the request of the vulnerable person. Coercion into activities that are inappropriate e.g. age, gender. (c) Confinement Involuntary withdrawal of a person from a valued activity; Imposing isolation or confinement to the immediate environment e.g. constantly sending people to their bedroom, locking doors; Confinement of the movement of a person s body, e.g. Buxton chair, tying to chairs.
(d) Denial of Human Rights Denial of choice and privacy; Not allowed to take risks, being overprotected; Denial of dignity and respect; Denied involvement in making decisions about self; Deliberate withholding of information on choices and options. Possible Indicators The vulnerable adult: appears withdrawn, agitated or anxious in general, or intimidated or subdued in the presence of the carer; may complain of feeling humiliated, depressed or consumed by hopelessness; may be frightened of making choices or exercising their rights because of threats or bribes; may have a change in their eating pattern resulting in unusual weight gain / loss; may have sleep problems, either insomnia or the need for excessive sleep; may be tearful, confused or have an air of resignation. The carer talks about the vulnerable adult in a dismissive or derogatory manner. 5.5 Financial or Material Abuse Resulting from acts of commission and omission on the part of others including theft. fraud, pressure around wills, property or inheritance, misuse or misappropriation of benefits. Possible Indicators unexplained or sudden inability to pay bills; unexplained or sudden withdrawal of money from accounts; disparity between assets and satisfactory living conditions; reluctance by vulnerable adult / relatives to accept any necessary assistance requiring expenditure when finances are not a problem (NB some people are naturally thrifty); extraordinary interest by family members and other people in the vulnerable adult s assets; missing personal belongings such as art or jewellery. 5.6 Neglect Including failure to access medical care or services, negligence in the face of risk-taking, failure to give prescribed medication, adequate nutrition or failure to provide heating. Possible Indicators Dirt, faecal/urine smell, or other health and safely hazards in a person s living environment; Prolonged loneliness; Sense of isolation and depression; Rashes, sores, lice on person; Person is poorly or inadequately clothed; Person is malnourished or dehydrated; Pressure sores; Person has an untreated medical condition; Person has withdrawn behaviour; Over or under medication;
Dishevelled appearance; Basic needs appear not to be met e.g. person is always hungry, looks emaciated, person is left unattended at home and so put at risk; Home environment does not meet basic needs e.g. no heating. 5.7 Predisposing Factors Which May Lead to Abuse The following factors may make abuse more likely to occur. 5.7.1 Victim Characteristics a. Research has indicated that individuals with the following conditions and characteristics are more likely to be abused. Where the vulnerable adult: has communication difficulties; rejects help; has unusual behavioural traits; does not consider the needs of the carer and other family members; is socially isolated; is dependent on the carer for financial purposes; is highly dependent on the carer for physical and/or psychological care. b. If the family: has poor family relationships or where family violence is the norm; is under stress due to poor income or housing conditions; roles have been reversed, where for example, a domineering parent becomes dependent. c. The stress of caring for a physically and/or mentally frail adult without adequate support can lead to abusive behaviour towards an individual if the carer: has unwillingly changed their lifestyle; is not receiving practical and/or emotional support from other family members; is showing signs of physical or mental illness or becoming dependent on drugs or alcohol; is feeling emotionally and socially isolated, undervalued or stigmatised; has other responsibilities. e.g. family, work; has no personal or private space or life outside the caring environment; has frequently requested help but the problems have not been solved; is being abused by the vulnerable person; is reliant on the vulnerable person for financial assistance or has financial difficulties. 5.7.2 Abuser Characteristics Some abusers have some form of mental health problem, personality problem, addiction to alcohol or drugs or dependency on the vulnerable person for income, shelter or emotional support. Mistreatment of the vulnerable adult may be more likely where individuals: lack support and social contact; lack understanding of the ageing process/illness/disability/need of the vulnerable adult and how to offer adequate care; have experienced major lifestyle changes which will have affected personal ambitions; feel emotionally isolated; have financial problems because of low income or debt problems; are dependent upon the person they abuse for accommodation, financial or emotional support;
have made frequent requests for help from Health and Social Services without any resolution; have experienced previous relationship difficulties within the family setting; have no personal space; are in a role reversed relationship where for example, domineering parent becomes dependent; have poor housing conditions; lack self esteem and feel uncared for; feel resentment that they are being treated unfairly or feel that they are being victimised; suffer severe stress or are exhausted through lack of sleep and or heavy physical demands; feel exploited by relatives or service providers; are themselves abused by the vulnerable adult; demand or need a level of care beyond the capacity of the carer; feel isolated and lack other relationships which give social, physical and emotional satisfaction and support; have conflicting responsibilities or financial difficulties. 5.7.3 Employees / Workplace Characteristics Abuse may be more likely to occur in work place situations where the following factors are prevalent: low staffing levels over a long period of time; low staff morale; inappropriate staff attitude; inadequate staff training and support; high staff turnover; isolated, few visitors.
SECTION 6 NORTH WALES ADULT PROTECTION PROTOCOL
6.0 NORTH WALES VULNERABLE ADULT PROTOCOL Principles of Response to Suspected Abuse: (a) (b) (c) (d) (e) (f) (g) Every incident of abuse or suspected abuse must be discussed immediately with an appropriate manager. The manager will refer the allegation to an appropriate person to investigate and/or record and monitor the situation whilst providing suitable support to the service user prior to an investigation. If the manager is not available, a senior member of staff must be contacted and a referral made to the appropriate agency and given all available information. All staff involved at every level in any suspected incident of abuse must treat it as urgent and take action the same working day. If a suspected incident of abuse occurs outside office hours, then it should be referred as soon as possible to the Out of Hours Service. In cases of suspected abuse occurring in an independent sector or a Local Authority care home, it must be reported to the home s manager who should notify the Care Standards Inspectorate for Wales. The Care Homes Wales Regulations 2003, Clause 38 requires that the registered person gives notice to the Care Standards Inspectorate for Wales without delay of any event in the care home which affects the wellbeing or safety of any service user and any allegation of misconduct by the registered person or any person who works at the care home. If there is urgent need to protect an abused adult, such a person will, or may be, given priority to obtain safe alternative accommodation if he/she is willing to go, and/or provided with other safety measures. Upon allocation to investigate abuse, the responsible Investigating Officer shall ensure a comprehensive assessment is completed which must be holistic, needs led, and involve other individuals and agencies as appropriate. Where a crime is suspected it is imperative that the Police are informed as soon as possible in order not to compromise staff in the event of a subsequent criminal trial. In consultation with the Police a joint investigation may be necessary. Consideration should be given to the protection of evidence in cases where a crime is suspected to ensure that forensic experts employed by the Police can secure evidence which will be admissible in any subsequent Court action. If an adult protection investigation identifies that a child or young person is, or may be, associated / affected then the Child Protection Co-ordinator must be contacted immediately in order to seek advice on the most appropriate action to take.
6.1 Introduction This protocol aims to provide a consistent framework for action and staff support and is aimed at improving practice amongst employees with regard to the recognition and investigation of abuse of vulnerable adults over 18 years of age who are, or may be, in need of community care services and who meet the eligibility criteria for social care. 6.1.1 These procedures cover concerns of abuse identified by: Front-line staff who have contact with vulnerable adults, either in the community, or in residential establishments. Staff within the Social Services Department and other agencies who receive a referral which involves the abuse or alleged abuse of a vulnerable adult. This applies whether or not the vulnerable adult is already known to the Social Services Department. Staff who become aware that a vulnerable adult may be at risk of abuse. 6.1.2 These Procedures are to be used to guide the response of staff members when they are faced with an allegation, disclosure or concern about an adult who is being abused, or is at risk of being abused. 6.1.3 The procedures below are to be followed where the Social Services Department has the lead responsibility for managing the response. If the Police or the Care Standards Inspectorate take lead responsibility Social Services staff will co-operate in their management of the response. Social Services retain the responsibility for gathering information and monitoring information about adult protection investigations carried out within the Authority area whether or not the Department takes a leading role in the investigation. It must be recognised, however, that it may not be possible for Social Services to intervene in every case; unlike the field of child protection, legislative powers in which to operate to protect adults are more limited. If the criteria for the Vulnerable Adult Procedures are not met the case may be closed or referred to a more appropriate agency or service provider. 6.1.4 It is important to recognise that carers may be under extreme stress as a result of their caring role. The person being abused in these circumstances may well have mixed feelings about what is happening to them and why. Nonetheless, the primary consideration has to be whether abuse is / was taking place, and if so, what can be done to protect the individual. 6.1.5 In cases where a colleague or a manager in Social Services is suspected or alleged to be responsible for abuse of a vulnerable adult, then each individual member of staff in the Department has a duty to report this within internal procedures. 6.1.6 Guiding Principle It is important to remind ourselves that as staff we are working with, and supporting adults who have the same basic rights as everyone else. It is important that adults involved in possibly abusive situations are enabled and encouraged to take for themselves those decisions which they are able to take. Where it is necessary in their own interests or for the protection of others, that someone else should take decisions on their behalf, the intervention should be as limited as possible and concerned to achieve what the abused person would have wanted.