Liverpool Safeguarding Adults Board Inter-agency Safeguarding Adults Procedures 2013 The Procedural Framework for Safeguarding Adults Recognise Abuse Report Abuse Stop Abuse 1
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Letter from the Co-Chairs of Liverpool s Safeguarding Adults Board Dear Colleagues Welcome to Liverpool s Safeguarding Adults Procedural Framework. We have recently been reviewing and updating the Safeguarding Adults process in Liverpool. It was felt that this was an appropriate time to update the existing procedures document to reflect the most current research and best practice. In Liverpool we have a strong and long standing multi-agency approach to safeguarding adults, the Safeguarding Adults Board having been established in 2001. Board membership is made up of organisations who work directly with those who may be vulnerable to abuse. The focus of the Board is to ensure that the safeguarding process is robust, allowing people to live without fear, be treated with dignity and have their choices respected. We know that the most effective way of protecting people is through a joint approach. We are committed to developing a procedure which acts as both a useful tool for frontline staff across all organisations and for social work practitioners who are central to the investigation process. We would welcome your comments on this document. Contact details can be found at the end of the document. Samih Kalakeche Director of Adult Services and Health Liverpool City Council 3
Contents Page 1 INTRODUCTION...10 2 WHAT IS ABUSE?...13 3 HOW TO RAISE AN ADULT SAFEGUARDING CONCERN (ALERT) FLOW CHART...24 4 CORE RESPONSIBILITIES OF ALERTER...25 5 THRESHOLD FOR INITIATING SAFEGUARDING PROCEDURES...30 6 MANAGERS FROM PROVIDER SERVICES SECTION...47 7 TEAM MANAGERS FROM COMMISSIONING, SOCIAL WORK AND INTEGRATED TEAM...51 8 ROLE OF INVESTIGATING SOCIAL WORKER...57 9 STRATEGY MEETINGS...67 10 CAPACITY AND CONSENT...70 11 RECORD KEEPING...75 12 INFORMATION SHARING...77 13 DOMESTIC VIOLENCE (ABUSE)...82 14 SERIOUS CASE REVIEWS...88 15 THE LEGAL FRAMEWORK...89 APPENDIX A LIVERPOOL S DIGNITY IN CARE CHARTER...106 APPENDIX B COMMUNITY PROVIDER NOTIFICATION OF CONCERN...107 APPENDIX C HOSPITAL NOTIFICATION OF CONCERN...110 APPENDIX D ONGOING RESOLUTION PROCESS REPORT...112 APPENDIX E MANAGING ALLEGATIONS AGAINST PROFESSIONALS.114 APPENDIX F POLICE REFERRAL FORM...125 APPENDIX G MERSEYSIDE RISK IDENTIFICATION TOOL (MERIT)...127 APPENDIX H NHS FLOWCHART FOR INVESTIGATIONS...131 APPENDIX I AGENDA FOR SAFEGUARDING ADULTS STRATEGY MEETING...132 APPENDIX J WITNESS SUPPORT PREPARATION AND PROFILING...134 APPENDIX K STATEMENT SHEET...135 APPENDIX L INVESTIGATION OUTCOME REPORT...137 APPENDIX M ADULT SAFEGUARDING INVESTIGATION OFFICER CHECKLIST...145 APPENDIX N ACKNOWLEDGMENT LETTER, RECEIPT OF REFERRAL 147 APPENDIX O CLOSURE LETTER TO REFERRER...148 APPENDIX P CONTACTS...149 4
APPENDIX Q OTHER INFORMATION...151 1 INTRODUCTION...10 1.1 HISTORICAL CONTEXT...10 1.2 USING THE TERM ADULT AT RISK...10 1.3 LIVERPOOL S SAFEGUARDING ADULTS BOARD POLICY...11 1.4 PRINCIPLES OF THE SAFEGUARDING ADULTS PROCEDURE...11 1.5 THE PROCEDURES ARE INTENDED TO SUPPORT GOOD PRACTICE AND SOUND PROFESSIONAL JUDGEMENT, AND TO:...11 1.6 WHEN THIS DOCUMENT MUST BE USED...12 2 WHAT IS ABUSE?...13 2.1 DEFINITIONS...13 2.2 SETTINGS...14 2.3 PERPETRATORS...14 2.4 RANGE OF ABUSE...14 2.5 MULTIPLE INCIDENTS...14 2.6 PERPETRATORS OF ABUSE...14 2.7 INFORMAL CARE...15 2.8 RISK FACTORS...15 2.9 CATEGORIES OF ABUSE...16 2.10 INDICATORS OF ABUSE...16 2.11 DEFINITION OF PHYSICAL ABUSE AND WHAT TO LOOK FOR...17 2.12 DEFINITION OF SEXUAL ABUSE AND WHAT TO LOOK FOR...18 2.13 DEFINITIONS OF PSYCHOLOGICAL ABUSE AND WHAT TO LOOK FOR...19 2.14 DEFINITION OF FINANCIAL ABUSE AND WHAT TO LOOK FOR...20 2.15 DEFINITION OF NEGLECT AND WHAT TO LOOK FOR...21 2.16 DEFINITION OF DISCRIMINATORY ABUSE AND WHAT TO LOOK FOR...22 2.17 DEFINITION OF INSTITUTIONAL ABUSE AND WHAT TO LOOK FOR...23 3 HOW TO RAISE AN ADULT SAFEGUARDING CONCERN (ALERT) FLOW CHART...24 4 CORE RESPONSIBILITIES OF ALERTER...25 4.1 ALERTING PROCEDURE...26 4.2 MAKING A REFERRAL...27 4.3 RESPONDING TO DISCLOSURE...28 5 THRESHOLD FOR INITIATING SAFEGUARDING PROCEDURES...30 5.1 CONSIDERATIONS...30 5.2 DETERMINING FACTORS...30 5.3 GUIDANCE FOR THRESHOLDS...31 5.4 QUALITY CONCERNS REGARDING COMMUNITY PROVIDER SERVICES....36 5.5 INCIDENTS IN HOSPITAL SETTINGS- QUALITY CONCERNS...36 5.6 GUIDANCE FOR HOSPITAL SETTINGS...37 5.7 ALL OTHER COMMISSIONED PROVIDER SERVICES...39 5.8 ONGOING RESOLUTION PANEL (ORP) ROUTE...39 5.9 INVESTIGATION BY A SOCIAL WORKER...40 5.10 QUALITY ASSURANCE...40 5.11 AUDIT OF RECOMMENDATIONS...41 5
5.12 MULTI AGENCY ONGOING RESOLUTION PANEL (ORP)...41 5.13 GOVERNANCE ARRANGEMENTS - HOSPITALS...42 5.14 COMMUNITY SETTING PROVIDERS SERVICES...42 5.15 FLOW CHART FOR CARELINE IMPLEMENTATION OF THRESHOLDS COMMUNITY SETTING PROVIDERS FLOW CHART...43 5.16 FLOW CHART FOR CARELINE IMPLEMENTATION OF THRESHOLDS HOSPITAL SETTING...44 5.17 FLOW CHART - ADULT SAFEGUARDING INVESTIGATION PATHWAY...45 5.18 FLOW CHART - OVERVIEW OF ADULT SAFEGUARDING STAGES AND TIMESCALES...46 6 MANAGERS FROM PROVIDER SERVICES SECTION...47 6.1 PROVIDER SERVICES...47 6.2 GENERIC PROCEDURE FOR ALL INCIDENTS OF ABUSE...47 6.3 INFORMATION FOR MAKING A REFERRAL...48 6.4 CARE QUALITY COMMISSION (CQC)...48 6.5 LOCAL AUTHORITY CONTRACTS AND COMMISSIONING...48 6.6 HEALTH COMMISSIONED SERVICE...48 6.7 SUSPENSION OF STAFF...48 6.8 RECORD KEEPING...48 6.9 STRATEGY MEETINGS...48 6.10 DELEGATING RESPONSIBILITY IN MANAGERS ABSENCE...49 6.11 INTERNAL INVESTIGATIONS CONDUCTED BY PROVIDER ORGANISATION...49 6.12 ONGOING RESOLUTION PANEL...50 6.13 INVESTIGATION CONDUCTED BY SOCIAL WORKER...50 7 TEAM MANAGERS FROM COMMISSIONING, SOCIAL WORK AND INTEGRATED TEAM...51 7.1 THE WIDER IMPLICATIONS OF A SAFEGUARDING INVESTIGATION...51 7.2 DISCLOSURE / SHARING OF INFORMATION...52 7.3 ON RECEIPT OF A SAFEGUARDING ADULTS REFERRAL...52 7.4 OPEN CASES...52 7.5 SELF FUNDING RESIDENTS...53 7.6 RISK ANALYSIS...53 7.7 CONTACTING PROVIDERS...53 7.8 NETWORKING...53 7.9 LIVERPOOL COMMUNITY HEALTH (LCH) ADULT SAFEGUARDING TEAM...54 7.10 STRATEGY MEETINGS...55 7.11 MANAGING THE INVESTIGATION...55 7.12 TIMESCALES...55 7.13 CLOSURE OF CASES...55 7.14 COMMISSIONING AND INTEGRATED HEALTH TEAM MANAGER REFERRAL PROCESS...56 8 ROLE OF INVESTIGATING SOCIAL WORKER...57 8.1 SERVICE USER S WISHES...57 8.2 THE WIDER IMPLICATIONS OF A SAFEGUARDING INVESTIGATION...57 8.3 DISCLOSURE / SHARING OF INFORMATION...57 8.4 WHAT THE INVESTIGATING PROCESS WILL INVOLVE:...58 8.5 THE ROLE OF THE INVESTIGATING OFFICER...59 6
8.6 NETWORKING...59 8.7 IMPORTANCE OF CONTACTING THE POLICE...59 8.8 ACHIEVING BEST EVIDENCE...60 8.9 THE ROLE OF THE CARE QUALITY COMMISSION (CQC)...61 8.10 ADASS CROSS BOUNDARY PROTOCOL...61 8.11 THE INVESTIGATION...61 8.12 EVIDENCE...63 8.13 THE INTELLIGENCE / INVESTIGATION CYCLE...63 8.14 WORKING WITH PARTNER AGENCIES...64 8.15 LCH ADULT SAFEGUARDING TEAM...64 8.16 CLOSURE OF CASE...65 8.17 TIMESCALES...65 8.18 FLOWCHART FOR INVESTIGATING SOCIAL WORKERS...66 9 STRATEGY MEETINGS...67 9.1 PURPOSE OF THE STRATEGY MEETING(S)...67 9.2 THE MEETING WILL NOT PROVIDE ANY OF THE FOLLOWING:...67 9.3 TIME SCALE FOR STRATEGY MEETING...67 9.4 CALLING A STRATEGY MEETING...67 9.5 ATTENDANCE AT STRATEGY MEETINGS...68 9.6 INVITING PROVIDER AGENCIES...68 9.7 ROLE OF THE CHAIR...68 9.8 CONFLICTS AND DISAGREEMENTS...68 9.9 AGENDA FOR STRATEGY MEETINGS...69 9.10 RECORD OF STRATEGY MEETING...69 10 CAPACITY AND CONSENT...70 10.1 INTIMIDATION AND COERCION...71 10.2 WHEN A PERSON HAS CAPACITY...72 10.3 MEANINGFUL CONSENT...72 10.4 MEDICAL EXAMINATIONS...72 10.5 INDEPENDENT MENTAL CAPACITY ADVOCATE (IMCA)...72 10.6 MENTAL CAPACITY ACT - DEPRIVATION OF LIBERTY SAFEGUARDS (DOLS) 73 11 RECORD KEEPING...75 11.1 KEY QUESTION...75 11.2 WHAT TO RECORD...75 11.3 DOCUMENTATION WHICH MUST BE KEPT ON FILE:...76 11.4 SERVICE USER AS PERPETRATOR...76 12 INFORMATION SHARING...77 12.1 LEGAL FRAMEWORK...79 12.2 SEVEN GOLDEN RULES FOR INFORMATION SHARING...80 13 DOMESTIC VIOLENCE (ABUSE)...82 13.1 DEFINITION OF DOMESTIC VIOLENCE (ABUSE)...82 13.2 RANGE OF ABUSE...82 13.3 LEGISLATION...82 13.4 WHAT TO DO IF YOU SUSPECT DOMESTIC VIOLENCE...83 13.5 IMMEDIATE DANGER...84 7
13.6 MERSEYSIDE POLICE RESPONSE...84 13.7 INITIAL REFERRALS...84 13.8 DOMESTIC VIOLENCE (ABUSE) LOCAL SUPPORT SERVICES...84 13.9 MERSEYSIDE RISK INDICATOR TOOLKIT (MERIT)...85 13.10 LIVERPOOL MULTI-AGENCY RISK ASSESSMENT CONFERENCES...85 14 SERIOUS CASE REVIEWS...88 15 THE LEGAL FRAMEWORK...89 15.1 HEALTH AND SOCIAL CARE ACT 2012...89 15.2 NATIONAL ASSISTANCE ACT 1948...90 15.3 MENTAL HEALTH ACT 1983...92 15.4 MENTAL CAPACITY ACT 2005...95 15.5 GENERAL NEGLECT...95 15.6 FINANCIAL PROTECTION...96 15.7 ADMINISTRATIVE LAW...96 15.8 CRIMINAL LAW...97 15.9 CORPORATE MANSLAUGHTER ACT 2008...99 15.10 THE SAFEGUARDING VULNERABLE GROUPS ACT 2006...100 15.11 PROTECTION OF FREEDOMS ACT...100 15.12 CIVIL LAW...102 15.13 COMMON LAW...103 15.14 LAW OF TORT...104 15.15 THE HUMAN RIGHTS ACT 1998...104 APPENDIX A LIVERPOOL S DIGNITY IN CARE CHARTER...106 APPENDIX B COMMUNITY PROVIDER NOTIFICATION OF CONCERN...107 APPENDIX C HOSPITAL NOTIFICATION OF CONCERN...110 APPENDIX D ONGOING RESOLUTION PROCESS REPORT...112 APPENDIX E MANAGING ALLEGATIONS AGAINST PROFESSIONALS.114 APPENDIX F POLICE REFERRAL FORM...125 APPENDIX G MERSEYSIDE RISK IDENTIFICATION TOOL (MERIT)...127 APPENDIX H NHS FLOWCHART FOR INVESTIGATIONS...131 APPENDIX I AGENDA FOR SAFEGUARDING ADULTS STRATEGY MEETING...132 APPENDIX J WITNESS SUPPORT PREPARATION AND PROFILING...134 APPENDIX K STATEMENT SHEET...135 APPENDIX L INVESTIGATION OUTCOME REPORT...137 APPENDIX M ADULT SAFEGUARDING INVESTIGATION OFFICER CHECKLIST...145 APPENDIX N ACKNOWLEDGMENT LETTER, RECEIPT OF REFERRAL 147 APPENDIX O CLOSURE LETTER TO REFERRER...148 APPENDIX P CONTACTS...149 APPENDIX Q OTHER INFORMATION...151 8
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Section 1 1 Introduction This section includes the historical context, definitions, principles and purpose of the document. This document updates and supersedes all other Safeguarding Adults Procedures. Please note that the intranet version of this document is the only version that is maintained. Any printed versions should therefore be viewed as uncontrollable and may not be the most up-to-date. 1.1 Historical Context No Secrets 1 was issued in March 2000 by the Department of Health. This document gave local authorities the legal mandate to develop inter-agency procedures for the protection of adults. No Secrets was issued under S.7 of the Local Authority Social Services Act 1970 and is therefore statutory guidance. No Secrets inform the underpinning framework of this document 1.2 Using the term Adult at Risk The term adult at risk has been used to replace vulnerable adult. This is because the term adult at risk focuses on the situation causing the risk rather than the characteristics of the adult concerned. The term adult at risk is used as an exact replacement for vulnerable adult, as used throughout. No Secrets Guidance 2000 defines an adult at risk as a person aged 18 or over whom: '...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 (Who Decides: Lord Chancellor s Department 1997) What Constitutes Abuse? 2 Abuse is a violation of an individual s human and civil rights by any other person or persons. 1 No Secrets can be found at http://www.dh.gov.uk/en/publicationsandstatistics/publications/publicationspolicyandguidanc e/dh_4008486 2 No Secrets: Page 9, 2.5 10
1.3 Liverpool s Safeguarding Adults Board Policy The Safeguarding Adults Board Policy Document outlines the remit and rationale for the management of safeguarding adults in Liverpool 3 1.4 Principles of the Safeguarding Adults Procedure The overriding consideration at all times will be the appropriate protection of adults who may be vulnerable to abuse Appropriate protection takes place alongside the need to ensure that individuals have self-determination and autonomy of choice Actions comply with Liverpool s Dignity in Care Charter All staff have a duty to ensure that adults who have been abused receive the protection of the law when a crime has been committed All staff have a duty of care and must take professional / personal responsibility for responding to any concerns about possible abuse All staff have a duty to share information appropriately, to act and to co-operate with colleagues across all agencies, consistent with this procedure Action taken must reflect a commitment to anti-discriminatory practice, to ensure that responses are culturally appropriate, and to promote human rights As far as possible all action taken must be with the knowledge and consent of the individual concerned. 1.5 The procedures are intended to support good practice and sound professional judgement, and to: Provide a coherent and consistent framework for recognising and taking action to prevent the abuse of adults Recognise and promote the benefits of effective inter-agency working through dialogue and co-operation, to form a collaborative partnership between the agencies that have contact with adults Describe the common values, principles and law that underpin the safeguarding of adults Define the different types of abuse, signs, symptoms and indicators Ensure that information on allegations and incidents of abuse are collected, monitored and reviewed in order to inform future practice Complement other related policies, procedures and guidance. 3 http://www.liverpool.gov.uk 11
Using this document 1.6 When this document must be used These procedures MUST be used where there is a concern, allegation or disclosure of abuse in relation to any adult at risk who is a resident of the City of Liverpool or is in receipt of services in Liverpool. Safeguarding procedures from the area where the abuse took place must be used, irrespective of who the placing authority is or which GP the person is registered with. ADASS Protocol for inter-authority investigation of vulnerable adult abuse: Available at: http://www.adass.org.uk/images/stories/safeguarding%20adults/ad SS%20Cross%20Boundary%20Protocol%20-%20Jan%2005.pdf 12
Section 2 2 What is abuse? For the purposes of these procedures the following definition of abuse applies: 2.1 Definitions Abuse is any behaviour towards a person that deliberately or unknowingly causes him or her harm, endangers their life or violates their rights. Abuse may be perpetrated as the result of deliberate intent, negligence or ignorance. Abuse may consist of a single act or repeated acts. It may be physical, sexual, verbal, financial 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 any transaction to which he or she has not consented, or cannot consent. Abuse may be motivated by prejudice or hate; this would be defined as discriminatory abuse. An individual, a group or an organisation may perpetrate abuse. Abuse concerns the misuse of power; control and/or authority and can manifest itself as: Domestic abuse, sexual assault or sexual harassment Institutional abuse Forced Marriage (See link below Liverpool Forced Marriage Protocol) http://www.liverpoolscb.org/files/forced_marriage_protocol.pdf Hate Crimes/ Incident which includes: Any incident which may or may not constitute a criminal offence, which is perceived by the victim or other person as being motivated by prejudice or hate The Hate Crime or incident can be any incident which is usually targeted at someone or a family due to their: Race Disability Gender Age Religion Sexual Orientation Transgender. Information relating to Hate Crimes is available from the Home Office website: 13 Available at: http://www.homeoffice.gov.uk/crime/hate-crime/
2.2 Settings People can be abused in any setting. People may experience abuse where they live, which could consist of their own home, residential or nursing homes and places where they spend their days, for example attending day services including transport to and from places of work, hospitals or colleges. 2.3 Perpetrators It must be acknowledged that perpetrators of abuse can be any of the following: Informal carers, including neighbours, friends and relatives Partners, ex-partners and other family members People in a position of trust People paid to provide care or services Other users of services Strangers Organisations by the way they conduct their day to day practice can cause harm Those who deliberately target others, whom they perceive as vulnerable, in order to exploit them. 2.4 Range of abuse Abuse can range from isolated incidents of poor practice at one end of the spectrum, through to pervasive ill treatment and/or gross misconduct at the other. Abuse may be intentional or unintentional. 2.5 Multiple incidents Incidents of abuse may be multiple: To one person in a continuing relationship or service context To more than one person at a time By more than one perpetrator at a time. Repeated incidents of poor care may be an indication of more serious problems, for example institutional abuse. Institutional abuse features poor care standards, lack of positive responses to complex needs, rigid routines, inadequate staffing and an insufficient knowledge base within the system. 2.6 Perpetrators of abuse There is particular concern when someone perpetrates abuse when they are in a position of trust, power or authority, and where they may have access to a number of potential victims. 14
Perpetrators may be in need of safeguarding themselves. Organisations will have a responsibility to these individuals as well as to the victim. As an increasing number of people receive support through Direct Payment and Self Directed Support there is potential risk from unregulated care providers / personal assistants A key factor in assessing the environment will be the degree of coercion or intimidation that may be present, often covertly, rendering an adult incapable of making their own decisions. 2.7 Informal care In the context of informal care abuse can be an isolated incident, repeated acts or pervasive ill treatment resulting in harm. Abuse may be intentional or unintentional. 2.8 Risk factors There are certain factors and situations that may place people at particular risk of being abused. The presence of one or more of these factors does not automatically imply abuse will result, but may increase the likelihood: Need for intimate personal care Certain personal care needs may present more opportunity for abuse Role reversal, for example, the adult child taking over the parental role A person needing care which is beyond the ability of the carer to provide Living in the same household as a known abuser Long-term abuse in the context of an ongoing family relationship such as domestic violence between spouses or between generations Where an adult is dependent on others or others are dependant on them Inappropriate or dangerous physical or emotional environment, for example, lack of personal space Where there is a change in the life style of a member of the household, for example, unemployment, employment, illness A member of the household experiencing emotional or social isolation The existence of financial problems Difference in communication or a breakdown in communication A carer has been forced to substantially change their lifestyle Isolated families may become victims and targets of bullying, harassment, hate crime and anti-social behaviour. 15
2.9 Categories of abuse Abuse can be viewed in terms of five main categories: Physical Sexual Financial Neglect Psychological. Institutional Abuse Institutional abuse relates to regimes and practices which can and sometimes do cause harm. Discriminatory Abuse and Hate Crimes This abuse is motivated by discriminatory and oppressive attitudes Domestic Violence is a form of abuse This is any form of threatening behaviour, violence or abuse (psychological, physical, sexual, financial, or emotional) between adults aged 18 or over who are or have been intimate partners or family members regardless of gender or sexuality A Forced Marriage Is one in which one or both spouses do not consent to the marriage and some element of duress is involved, including the use of physical and emotional pressure Forced Marriage is not sanctioned within any culture or religion See link below Liverpool Forced Marriage Protocol http://www.liverpoolscb.org/files/forced_marriage_protocol.pdf The Government regards Forced Marriage as an abuse of human rights and a form of domestic abuse and, where it affects children and young people, child abuse. Mate Crimes - Mate crime happens when people befriend someone with learning disabilities in order to abuse or exploit them. Many situations will involve a combination of different kinds of abuse. However, it is useful to start by considering the definition of each category in turn, together with the indicators. 2.10 Indicators of abuse The following lists are purely indicators. The presence of one or more does not necessarily confirm abuse. The lists are not definitive. 16
2.11 Definition of Physical Abuse and what to look for Physical Abuse is the physical mistreatment of one person by another which may or may not result in physical injury. Types of Physical Mistreatment Unreasonable confinement Beating Punching Shaking Slapping Misuse of manual handling Misuse of medication Pushing Burning Force-feeding Misuse of restraint Pinching What to look for - Signs of being abused Over or under medication Burns in unusual areas e.g. palm of hands, soles of feet Sudden incontinence Unexplained bruising Bruising at various healing stages Cuts and scratches to lips, eyes, gums, genitalia Bite marks Disclosure Unattended medical problems Bruising corresponding to the shape of an object Unexplained fractures Unexplained burns Unexplained injuries Flinches from physical contact Reluctance to uncover parts of the body What to look for Person who is abusing Explanations of injuries are not consistent with situation/lifestyle Lack of understanding of the needs of the adult Adult in need of safeguarding is perceived as un-cooperative or ungrateful for care/support 17
2.12 Definition of Sexual Abuse and what to look for Sexual Abuse is any form of sexual activity that the adult does not want and to which they have not consented, or to which they cannot give informed consent or were pressured into consenting. Types of Sexual Abuse Serial abuse over a long period of time after identifying a person perceived as vulnerable Assault by penetration (of mouth, vagina, anus by any body-part or any object) Use of offensive or suggestive language Abuser exposing genitals Forcing the person to watch/look at pornography Full sexual intercourse Rewards for sexual acts Rape (penetration of mouth, vagina, anus with penis) Sexual activity with a mentally disordered person Abuser touching victim s body Sexual relationships instigated by those in a position of trust What to look for - Signs of being abused Recoiling from physical contact Genital discharge Fear of males or females Persistent and inappropriate sexual behaviour especially in the presence of certain persons Torn, stained or bloody garments Not consenting to or understanding sexual activity Sudden use of offensive sexual language Bruising / lacerations to upper thighs Recurring genital irritation Unexplained sexually transmitted diseases Disclosure Pronounced overly affectionate behaviour Pregnancy Unusual difficulty walking What to look for Person who is abusing Personal care tasks taking significantly longer to perform than usual Use of offensive or suggestive sexual language Over enthusiastic in carrying out personal care tasks, working alone with clients Openly showing favouritism and/or the giving of gifts for no apparent reason 18
2.13 Definitions of Psychological Abuse and what to look for Psychological Abuse may involve the use of intimidation, indifference, hostility, rejection, threats, humiliation, shouting, swearing or the use of discriminatory and/or oppressive language. Types of Psychological Abuse Gross restriction of freedom Person s access to personal hygiene and toilet restricted Threat to withdraw care/support Withholding of security and affection Name-calling Humiliation or ridicule not treating with respect Denial of the opportunity for privacy Threat of institutional care Provoking fear of violence Shouting and swearing Adult s choices, opinions and wishes being neglected/rejected Use of bribes or threats What to look for - Signs of being abused Stress and / or anxiety in response to certain people Displays compulsive behaviour Withdrawn, unresponsive and displays overly compliant behaviour Disclosure Reduction in skills and concentration Lack of trust particularly with significant others Changes in sleep pattern Frightened of specific individuals Lack of self esteem What to look for - Person who is abusing Withholding affection Denial of social and cultural contact Discriminatory comments Denial of reasonable requests Use of abusive language or shouting Denying privacy Lack of understanding of the needs of the adult Ignoring the person Use of threats Adult in need of safeguarding is perceived as un-cooperative or ungrateful for care/support 19
2.14 Definition of Financial Abuse and what to look for Financial Abuse is the misappropriation or misuse of money / assets, or transactions to which the person could not consent or which were invalidated by intimidation / deception. Types of Financial Abuse Not allowing the person access to their money Not spending allowances on the individual Use of personal allowances to pay for care Theft of monies Denying access to money Embezzlement Mismanagement of bank accounts Misuse of Power of Attorney Theft of property Withholding pension or Building society book Misuse of benefits Unreasonable restriction of a person s right to control their lives to the best of their ability What to look for - Signs of being abused Over protection of money or property Money not available Forged signatures Unexplained withdrawals from accounts Account does not balance Disclosure Lack of money especially after benefit day Unable to account for monies being spent Accounts balancing but errors found in accounting for activities Inability to pay bills Losses from accounts disguised for activities Insufficient funds in account What to look for Person who is abusing Money earned by carers does not equal that being spent Evasive when discussing finances Buying goods with own preference as a priority Goods bought being frequently worn, used or in the possession of the abuser Over keenness to participate in activities involving individual s monies 20
2.15 Definition of Neglect and what to look for Neglect / Acts of Omission is behaviour by carers that results in the persistent or severe failure to meet the physical and / or psychological needs of an individual in their care. Types of Neglect Wilful failure to intervene, or consider the implications of non-intervention in behaviour which is dangerous to the individual concerned or to others Failure to use agreed risk-taking procedures resulting in the person taking unnecessary risks Inadequate care in hospital/residential settings Denying access to services or advocacy Withholding affection or communication Withholding food/drinks/heat/light/clothing Withholding of aids, e.g. hearing aids, spectacles, walking aids Inadequate furnishings Limiting choice Not providing access to medical care or giving personal care What to look for - Signs of being abused Depression / fear Person is isolated Continence problems Dehydration Unkempt look Person not allowed visitors or phone Person locked in room Demanding e.g. food and / or drink Access to personal hygiene and toilet is restricted Deterioration of health Pressure ulcers Complaints of pain or discomfort Sleep disturbance Disclosure by person using service Low self esteem Unexplained accidents Exposed to inappropriate stimuli Disclosure What to look for Person who is abusing Seemingly uncaring attitude and cold detachment from individual Frequent failure to report individual s progress to others Denying individual s requests General lack of consideration toward the needs of the individual Individual perceived as uncooperative or ungrateful for care / support given Denying others, including health and social care professionals, access to the individual 21
2.16 Definition of Discriminatory Abuse and what to look for Discriminatory Abuse is based on a person s race, culture, belief, gender, age, disability, sexual orientation and may be the motivating factor in other forms of abuse. Types of Discriminatory Abuse Any form of discrimination both direct and indirect based on the person s colour, language, faith and belief and his or her cultural norms and values, gender, sexuality, disability, class, age, HIV status Can be in the form of personal or institutional discrimination Institutional discrimination being where systems and structures directly or indirectly discriminate against potential or actual users of the service Personal discrimination being the prejudice of the individual Hate crime What to look for - Signs of being abused Withdrawal or rejection of culturally inappropriate services e.g. food, mixed gender groups or activities Sometimes the individual may agree with the abuser just to have an easier life Disclosure Low self esteem What to look for Person who is abusing May react when challenged by saying I treat everyone the same or they are getting the same treatment as everyone else Enforcing rules and procedures which undermine the individual s well-being Sees individual as not conforming to the system Use of inappropriate nick names Use of derogatory language / terminology Sees individual as uncooperative Lack of understanding and / or respect for Denial of social and cultural contact Stereotyped views of the individual 22
2.17 Definition of Institutional Abuse and what to look for Institutional Abuse is repeated incidents of poor professional practice or neglect or inflexible services based on the needs of providers rather than the person receiving services. Types of Institutional Abuse People using the service required to fit in excessively to the routine of the service System that encourages/allows or condones poor practice Deprived environment Lack of procedure / guidelines for staff One commode used for a number of people Repeated/unaddressed incidents of poor practice No or little evidence of training Manager/person in charge implicated in poor practice Lack of staff support/guidance Lack of homely environment, stark living areas Lack of privacy for personal care What to look for - Signs of being abused Lack of personal clothing / possessions No support plan Lack of stimulation Left on commode for long periods No or inadequate risk assessment/management plans Unexplained bruising / burns Repeated infections Repeated falls Recoiling from specific individuals Unauthorised deprivation of liberty Pressure ulcers Limited or no access to primary / secondary healthcare What to look for Person who is abusing Lack of understanding of people s disability/conditions Misuse of medication Use of illegal control and restraint Staff seeing people using the service as a nuisance Inappropriate use of power/control Undue/inappropriate physical intervention Rough handling Coercion Misuse of nursing/medical procedures Staff seeing that their wishes/needs take priority over those of the people they support 23
Section 3 3 How to raise an adult safeguarding concern (alert) flow chart Harm or abuse discovered or suspected? No Is the adult at risk or in immediate danger? Yes Contact your line manager If your line manager is implicated contact your senior manager without delay In an emergency dial 999 for emergency services. Do not begin the investigation yourself. Contact your manager or senior manager as soon as possible If you are asked to make a referral or you are an autonomous professional making a referral. Ring Careline on 0151 233 3800 Details of the person Your details Reason for concern Date / time / location of any incident Objective, professional description of any act witnessed or detailed by alleged victim Details of any possible witnesses Details of any possible evidence - written records should be stored securely Alleged Perpetrators Name; Address; Gender; relationship to alleged victim what contact they may have with alleged victim and others If the alleged perpetrator is a member of staff, what actions have been taken prior to referral, e.g. suspension? If you suspect a crime has been committed you may need to preserve evidence Where possible leave and lock the room If not try not to disturb the scene Do not clean up Do not wash the person s clothes or bedding Do not let the person bathe If possible do not let the person use the toilet Unless directly handed to you do not touch weapons Put any items removed in a clean dry place Other Evidence Not interviewing the victim Not interviewing the witnesses Not speaking to the alleged perpetrator at any point Make notes of times, place, those present, what you saw or heard Your role as alerter is now complete Await further instruction/information from your manager 24
Section 4 4 Core responsibilities of alerter Anyone can raise a safeguarding alert for themselves or another person. All organisations will have internal guidance for their staff and volunteers that complements this inter-agency procedure. Staff should be aware of how to access both the internal and inter-agency procedures. It is the duty of all staff and volunteers in all organisations to: Recognise signs of abuse and ongoing bad practice Alert an appropriate manager, without delay, to any concerns, allegations or disclosures of abuse that they may see or hear about Co-operate with any investigation of concerns, allegations or disclosures of abuse by providing all the evidence that may be known to them Never prevent or persuade another person from raising concerns or presenting evidence Record all factual information accurately and clearly, in line with their employing organisation's requirements Follow this inter-agency procedure and their agency s internal procedures. As an alerter you are: Not asked to verify or prove that information is true Required to log your concerns and report them to an appropriate person for example your manager Expected to make a referral directly to Careline 0151 233 3800 if you are an autonomous practitioner. Only the police have the responsibility to establish if a criminal offence has been committed. Alerting through the formal channels will enable a proper assessment or investigation to be co-ordinated. This will avoid any confusion or conflict between complaints, disciplinary and safeguarding investigation processes. All those making a complaint or allegation or expressing concern, whether they are staff, service users, carers, members of the public, can be reassured that: They will be taken seriously Their comments will be treated confidentially but their concerns may be shared if they or others are at risk 25
If they are a service user action will be taken to minimise the risk of further abuse, reprisals or intimidation If they are staff they will be given support and afforded protection if necessary e.g. under the Public Interest Disclosure Act 1998; Crime & Disorder Act 1998, s. 115 If a concern is raised in good faith they will be supported whatever the outcome of the investigation They will be dealt with fairly and in a non-discriminatory manner They will be kept informed of action that has been taken and its outcome as far as possible. You will not be criticised for following procedure Failure to report a concern, allegation or disclosure will be viewed extremely seriously and may result in any or all of the following: Criticism of your practice Disciplinary action Suspension Dismissal A report being forwarded to your professional body. Any such failure will be regarded as colluding with the abuse 4.1 Alerting procedure This procedure applies to any adult safeguarding concern, allegation or disclosure in any setting In an emergency you must dial 999 for either the police or ambulance services. You do not have to wait for permission from your line manager to do this Where appropriate action should be taken to prevent harm However, YOU MUST NOT PUT YOURSELF AT RISK. If you suspect a crime has been committed you may need to preserve evidence for forensic examination, so avoid touching/moving objects or furnishings and request a forensic medical examination and treatment of any injuries/conditions before any other intervention. NB - The victim is the primary crime scene and should be treated as such. (See Section 3 - Flow chart how to raise an adult safeguarding concern) 26
In all cases of concern, allegation or disclosure of abuse you must inform your manager as soon as possible. NB - Professionals who are autonomous practitioners, for example doctors, dentists, district nurses, health visitors, therapists, can and do act independently, but are subject to the relevant professional code of conduct and organisational policies and procedures. Autonomous practitioners would be expected to make a safeguarding adults referral directly to- Careline: 0151 233 3800 If you suspect your manager is involved in the abuse you must report to a senior manager as soon as possible. If someone makes an allegation or discloses abuse to you, you must make a note as soon as possible of what they said. Make sure that you use the person s own words. You must never keep secrets, even if the person asks you not to tell anyone else. You must always share concerns, allegations or disclosures with your manager. Do not start the investigation yourself! You will be expected to co-operate with the investigation. You may be required to provide a statement, attend a strategy meeting or be interviewed by the police. Do not discuss what has happened with members of staff who have no direct involvement in the situation. If a family member is raising the concerns you should explain the safeguarding process to them and the next steps. If the family is unaware of an incident you should take advice in relation to the appropriate timing of sharing information with them. 4.2 Making a referral Your manager may ask you to make the referral to Careline. The quality of information given when making a referral is very important. The following guidance should assist you: Allegation / Concern Details of the person Details of the person raising the alert 27
Reason for concern Date / time / location of any incident Location of victim Objective, professional description of any act witnessed or detailed by alleged victim Details of any possible witnesses Details of any possible evidence - written records should be stored securely. Alleged perpetrator Name Address Gender Relationship to alleged victim Location of the perpetrator at the time of the referral if known What contact they may have with alleged victim and / or others If the alleged perpetrator is a member of staff, what actions have been taken prior to referral, e.g. suspension? 4.3 Responding to disclosure Incidents of abuse or crimes may only come to light because the abused person tells someone The person may not consider that they are being abused when they tell you what is happening to them Disclosure may take place many years after the actual event Disclosure may take place when the person has left the setting where the abuse took place Even if there is a delay, the information must be taken seriously Reassure the person that you are taking what they say seriously. If someone makes an allegation or discloses abuse to you: DO Stay calm and try not to show shock Listen carefully Be sympathetic Tell the person that: 28
Telling you was the right thing to do You will treat the information seriously It was not their fault You will have to report the information to your manager Report to your manager Write down what the person said to you as soon as possible. DO NOT Question the person about the incident Ask the person who, what, why, where, when questions. This is the role of the police Promise to keep secrets Make promises that you cannot keep, for example, This will not happen to you again Contact the alleged abuser Be judgmental, for example, Why didn t you run away? Gossip about the incident. When in doubt seek advice from your manager. 29
SECTION 5 5 Threshold for Initiating Safeguarding Procedures This guidance and process aims to ensure that concerns involving possible harm to vulnerable adults is dealt with in the most appropriate way. This guidance is intended to assist best practice in decision making when trying to identify when a concern being raised is about the quality of a service or a safeguarding concern. It is intended to ensure that we use resources effectively targeting the most vulnerable in the highest risk situations. 5.1 Considerations When a referrer contacts Careline it is important to establish if the concerns being raised are best addressed by initiating the safeguarding procedure or by using an alternative pathway. Careline should establish if the information relates to a vulnerable adult and, if so, does it indicate that harm has occurred? Does the initial information gathered suggest that the degree of harm would require a safeguarding investigation carried out by a social worker? What are the expectations of the referrer? Do they wish to raise a complaint or a safeguarding referral? 5.2 Determining Factors The factors to be considered to determine what degree of harm justifies intervention using the safeguarding procedure will include: The vulnerability of the service user Capacity of the victim and alleged perpetrator Balance of power of the victim and alleged perpetrator The nature and extent of harm caused The frequency of incidents Impact on the person 30
Their views and those of the family if known Are there any indicators that a crime may have taken place Are there any indicators that other vulnerable adults or children are at risk? Abuse that causes harm may not be deliberate or intentional however it is important that situations where significant harm has occurred are investigated under these procedures In order to determine whether or not abuse has taken place is not always a straightforward matter, particularly when concerns relate to a potential neglect situation. A decision may be needed to ascertain if an act or the omission of an act has caused harm. 5.3 Guidance for Thresholds Each situation is unique and needs to be risk assessed to take account of the particular circumstances, nature of the incident and seriousness together with the well-being of the service user. The table below is to be used as a guide and to assist you to make a decision based upon your professional judgment. Area of Concern 1. Failure to provide assistance with food/drink Concerns regarding quality of service. Person does not receive necessary help to have a drink/meal. If this happens once and a reasonable explanation is given e.g. unplanned staffing problem, emergency occurring elsewhere in the home, dealt with under staff disciplinary procedures; would not be referred under safeguarding Social Work Investigation Possible abuse which requires reporting as such, and the instigation of safeguarding procedures Person does not receive necessary help to have drink/meal and this is a recurring event, or is happening to more than one person. This constitutes neglectful practice, may be evidence of institutional abuse and would prompt a safeguarding 31
adults procedures investigation. 2. Failure to provide assistance to maintain continence 3. Failure to seek assessment re pressure area management Person does not receive necessary help to get to the toilet to maintain continence or have appropriate assistance such as changed incontinence pads. If this happens once and a reasonable explanation is given e.g. unplanned staffing problem, emergency occurring elsewhere in the home, dealt with under staff disciplinary procedures; would not be referred under safeguarding adults procedures Person known to be susceptible to pressure ulcers, has not been formally assessed with respect to pressure area management but no discernible harm has arisen. This may need to be dealt with under disciplinary procedures. Harm: malnutrition, dehydration, constipation, tissue viability problems. Person does not receive necessary help to get to the toilet to maintain continence and this is a recurring event, or is happening to more than one person neglectful practice, may be evidence of institutional abuse and would prompt a safeguarding investigation Harm: pain, constipation, loss of dignity, humiliation, skin problems. Person is frail and has been admitted without formal assessment with respect to pressure area management (or plan not followed). Care provided with no reference to specialist advice re diet, care or equipment. Pressure damage occurs. Neglectful practice, breach of regulations and contract, possible institutional abuse. Safeguarding procedures should be instigated. Harm: avoidable tissue viability problems. 4. Medication not administered Person does not receive medication as prescribed on one occasion but no harm occurs. Internal investigation should Person does not receive medication as a recurring event, or it is happening to more than one person. Neglect of 32
5.Moving and handling procedures not followed 6. Failure to provide support to maintain mobility 7. Failure to provide medical care 8. Inappropriate comments from staff be undertaken, possible disciplinary action depending on severity of situation including type of medication. Appropriate moving and handling procedures not followed but person does not experience harm. Provider acknowledges departure from procedures and inappropriate practice and deals with this appropriately under disciplinary procedures, to the satisfaction of person involved. Person not given recommended assistance to maintain mobility on one occasion. Adult at risk in pain or otherwise in need of medical care such as dental, optical, audiology assessment, foot care or therapy does not on one occasion receive required medical attention in a timely manner. Person is spoken to in a rude, insulting, humiliating or other inappropriate way by a member of staff. They are not distressed and this is an isolated incident. Partnership takes appropriate action, to the satisfaction of the person involved practice, regulatory breach, breach of professional code of conduct if nursing care provided. Dependent on degree of harm, possible criminal offence, safeguarding procedures should be implemented. Harm: pain not controlled, risk to health, avoidable symptoms. One or more people experience harm through failure to follow correct moving and handling procedures or frequent failure to follow moving and handling procedures make this likely to happen. Neglectful practice safeguarding procedures. Recurring event, or is happening to more than one adult at risk resulting in reduced mobility. Adult at risk is provided with an evidently inferior medical service or no service, and this is likely to be because of their disability or age. Person is frequently spoken to in a rude, insulting, humiliating or other inappropriate way or it happens to more than one person. Regime in the home doesn t 33
9.Significant need not addressed in care plan 10. Care plan not followed Person does not have within their care plan / service delivery plan / treatment plan a section which addresses a significant assessed need, for example: Management of behaviour to protect self or others Liquid diet because of swallowing difficulty Bed rails to prevent falls and injuries but no harm occurs. Person s needs are specified in treatment or care plan. Plan not followed, need not met as specified but no harm occurs. respect people s dignity and staff frequently use derogatory terms and are abusive to residents. Failure to specify in a patient / client s plan how a significant need must be met. Inappropriate action or inaction related to this results in: Harm: such as injury, choking etc. Failure to address a need specified in adult at risk s plan results in harm. This is especially serious if it is a recurring event or is happening to more than one adult at risk 11. Failure to respond to person s mental health needs Adult at Risk known to mental health services is identified as being at risk. Previous risk assessment identifies same day response is required. Response is not made that day but no harm occurs. Patient is known to be high risk, a timely response is not made and harm occurs. Harm: physical injury, emotional distress, death. 12. Person deprived of liberty without referral for Person has been formally assessed under the Mental Capacity Act and lacks Restraint / possible deprivation of liberty is occurring or has 34
Deprivation of Liberty Safeguards 13. Inappropriate discharge from hospital 14. Domiciliary care visit missed capacity to recognise danger e.g. from traffic. Steps taken to protect them are not least restrictive. Steps need to be reviewed and referral for Deprivation of Liberty Safeguards may be required. Vulnerable patient is discharged from hospital without adequate discharge planning involving assessment for care /therapeutic services, procedures not followed but no harm occurs. Person does not receive a scheduled domiciliary care visit and no other contact is made to check on their wellbeing, but no harm occurs. Partnership deals with this appropriately through internal investigation, to the satisfaction of person involved. occurred (e.g. bed rails, locked doors, medication) and adult at risk has not been referred for a Deprivation of Liberty Safeguards assessment although this had been recommended. Best interest has been ignored or presumed. Unlawful DoL has occurred). Harm: Loss of liberty and freedom of movement, emotional distress Vulnerable patient is discharged without adequate discharge planning, procedures not followed and experiences harm as a consequence. Harm: care not provided resulting in risks and/ or deterioration in health and confidence; avoidable re-admission. Person does not receive scheduled domiciliary care visit(s) and no other contact is made to check on their well-being resulting in harm or potentially serious risk to the person. Safeguarding procedures should be instigated. 15. Abuse of a service user by another service user One adult at risk verbally abuses or taps or slaps or grabs another adult at risk but has left no mark or bruise, victim is not intimidated and shows no signs of distress and significant harm has not Predictable and preventable (by staff) incident between two adults at risk occurs where bruising, abrasions or other injury has been sustained and 35