SCIE Practice guide 7: Making referrals to the POVA list
Deciding to make a POVA list referral
Practice point: Grounds for referral
Grounds for referring care workers
Employers must refer a current employee/care worker to the POVA team when they reasonably consider that person to be guilty of misconduct (at work or elsewhere) that harmed or placed at risk of harm a vulnerable adult, and where:
- they have dismissed the worker
- the worker has resigned, retired or been made redundant in circumstances in which the employer would have dismissed them, or would have considered dismissing them
- the employer has transferred the worker to a non-care position or has provisionally transferred the worker pending a further decision
- the employer has suspended the worker on these grounds pending further investigation and decision
- a care worker has been suspended, dismissed or has resigned after having been charged by the police with offences against vulnerable adults, and is awaiting the outcome of a criminal investigation or trial.
Example
A member of staff at a residential service for adults with learning disabilities was found asleep on a waking night shift, which put service users at risk of harm. The worker was dismissed and a POVA referral was made. The manager was new and unfamiliar with the POVA referral process. She took advice from her manager and the local adult protection team who had been involved throughout the disciplinary process in line with the local adult protection procedures. The manager followed the practice guidance step by step and contacted the POVA team for advice on a couple of queries. She found everyone really helpful and the referral process easy to follow. In the end, the person was not listed, but the manager was satisfied that she had fulfilled her responsibilities and accepted the final decision of the Secretary of State. Her advice to others making POVA referrals is to get support, follow the guidance and use the POVA helpline if you are unsure about something.
Grounds for referring workers supplied by employment agencies and businesses
Using the same criteria, referrals about supply workers must be made where:
- the agency or business has decided not to do any further business with the worker on grounds of misconduct that harmed or placed at risk of harm a vulnerable adult
- the agency or business has decided not to supply the worker for further employment in a care position.
In these cases, there needs to be good communication between the home and the agency when allegations are made. The agency makes the referral, and the home is responsible for ensuring that the referral is made.
Example
Two carers were both registered with the same two employment agencies, who secured them work in local CSCI-registered care homes and domiciliary care agencies. It came to light that they were implicated in neglecting vulnerable adults, to the point that serious harm and risk of harm ensued. The two agencies worked together effectively with the care home where the abuse took place to ensure that an effective well-supported referral was made. This resulted in both carers being provisionally included on the POVA list within a short period of time.
Recognising harm
In deciding whether an individual should be referred to the Secretary of State for inclusion on the POVA list, employment agencies and businesses and other providers of care must decide whether, in their view, the individual is guilty of misconduct that has harmed or placed at risk of harm a vulnerable adult.
To do this, they must be able to recognise different types of harm. The definitions and descriptions in No secrets and In safe hands (both available on the Department of Health Website) will assist employers in deciding whether harm has been caused, and in what way.
The King's College research study ( Manthorpe and Stevens, 2005 ) showed that nearly all of the first 100 POVA referrals involved either neglect, physical abuse or financial abuse. Neglect and physical abuse were more likely to be found in residential settings, and financial abuse was more common in domiciliary care.
Southern Cross Healthcare has provided its managers with the following definitions for different types of abuse. This is not intended to be an exhaustive list, but it does helps staff understand which warning signs to look for.
| Abuse type | Definition | Examples/warning signs |
|---|---|---|
| Physical abuse | Any physical contact that results in discomfort, pain or injury | Hitting, slapping, pushing, shaking. Bruising, finger marks, burns, untreated sores or wounds, under- or over-used medication or inappropriate medication, use of restraint. |
| Verbal abuse | Any remark or comment by others that causes distress | Demeaning, disrespectful, humiliating, racist, sexist or sarcastic comments. Condescending tone of voice, excessive or unwanted familiarity, shouting, swearing, name-calling. |
| Psychological or emotional abuse | Action or inaction by others that causes mental anguish | Inflexible regimes and lack of choice. Mocking, coercing denying privacy, threatening behaviour, bullying, intimidation, harassment deliberate isolation. |
| Sexual abuse | Coercion or force to take part in sexual act | Inappropriate touching. Pain, itching, bleeding, bruising or injury in the anal, genital or abdominal area. Sexually transmitted disease or recurrent bouts of cystitis. Unexplained problems with catheters. Stained, torn underclothes or sheets. |
| Financial abuse | Misuse of money, valuables or property | Unexplained withdrawals from resident's account, unexplained shortage of money, reluctance by relatives to pay for replacement clothes or personal needs, theft, fraud, pressure in connection with wills or inheritance. |
| Information abuse | Failure to adhere to relevant data protection guidance and lack of appropriate information about care | Breach of confidentiality, inappropriate disclosures of information, failing to pass on essential care information. |
| Institutional abuse | Failure to recognise individuality and rights as a citizen | Inflexible, regimented regimes and lack of choice, communal clothing, overuse of wheelchairs leading to loss of independence, lack of individualised care planning. |
| Abuse by omission | Failure to identify and/or meet care needs of individual | Untreated weight loss, pressure sores or uncharacteristic problems with continence. Poor hygiene, dirty clothes, insufficient food or drink, ignoring resident's requests, unmet social needs. |
| Political abuse | When older individuals are denied access to treatment due to their age | Refer to Evans, G (1999) ' Elder abuse: Implications for practice', Nursing Times Clinical Monograph no 6. |
Source: Southern Cross Healthcare Prevention of Abuse policy 32 Making referrals to the POVA list.
Assessing the impact of harm can be difficult, particularly where service users are unable to tell staff what has happened. In such cases, employers and managers will need to take account of:
- changes in behaviour
- unusual distress
- unusual behaviour or reactions - for example, becoming fearful of a shift worker
- observations of staff who know the service user well
- assessments (before and after)
- statements from others - staff, visitors, relatives or service users
- psychologists' reports
- service user's history - any previous allegations?
Neglect
Harm can be caused by inaction or neglect as well as by specific actions. Some employers have found it hard to distinguish between actions/inactions that support independence and appropriate, informed risk-taking by vulnerable adults, and those of neglect. Where this is in doubt, reference to the care plan of the vulnerable adult will clarify agreements about acceptable and informed risk-taking.
Examples
- Support: A care worker, Mrs D, worked for a domiciliary care agency where she looked after service user Mrs B. Mrs B had health problems that greatly restricted her mobility and meant that there was a risk of harm when she was being transferred from place to place. Her care plan, therefore, stated that two workers were required to get her out of bed each morning. One morning, the second carer was late arriving. Mrs B was insistent that she needed to be up, as she was visiting her daughter that day. Mrs D assessed the situation and, without the assistance of the other carer, helped her get up. Mrs B suffered a strain during this. Although Mrs B did not complain about her injury, Mrs D was dismissed when the issue came to the attention of the agency's management, and a referral was made to the DfES POVA team. However, having taken account of all the circumstances and, in particular, the fact that this had been a one-off incident where the care worker had been seeking to meet the service user's wishes, it was concluded that Mrs D did not pose an ongoing risk to vulnerable adults and, therefore, she was not included on the POVA list.
- Neglect: As an experienced carer working for a domiciliary care agency, Mrs M's duties included getting service users up in the morning. Most of them were very frail and Mrs M needed the support of another carer to get them out of bed - a requirement that was fully documented in their care plans. Despite this, Mrs M routinely ignored the plans and arrived at the service users' homes at her own convenience and got them up on her own, whatever the risk. While some of the service users were not unhappy with this arrangement, others felt bullied. When the situation became known to management, Mrs M was dismissed and a referral made to the DfES POVA team. It was concluded that she was guilty of misconduct that risked harm to vulnerable adults and that she was an ongoing and real risk to them in putting her own requirements before their care needs. She was, therefore, confirmed on the POVA list.
Making judgements - messages from research
The King's College research into the first 100 referrals to the POVA list identified some of the complex judgements that employers and managers make in investigating and assessing allegations of misconduct.
Determining the seriousness of the misconduct
- Is it a single incident or is there a history of allegations?
- What is the degree of harm caused - visible, psychological?
- Is there a breach of policies designed to protect vulnerable adults?
- Has there been inadequate management, poor clinical judgement or deliberateabuse?
- Statements from other staff can be revealing - for example, in cases of bullying or intimidation.
- The perspectives of other agencies such as adult protection teams can be useful.
Establishing the facts of the case
The normal disciplinary process and reports from these proceedings provide the basis of the POVA referral. Robust investigation is particularly important when staff deny the allegation and their involvement:
- importance of good evidence and quality of investigation
- skills in taking and assessing witness statements
- making sense of conflicting interpretations
- level of proof required - assessing on the balance of probabilities.
Interpreting the significance of events
Employers must use their judgement to determine if there has been deliberate abuse or incompetence, remembering that a POVA referral must be made when harm has been caused or if there is a risk of harm. Examples include:
- poor practice and over-involvement in managing money - for example, when acting on behalf of service users
- inappropriate reactions to challenging behaviour - for example, an instinctive reaction that is abusive
- overstepping emotional involvement - for example, when banter goes too far
- blurred lines between incompetence and deliberate abuse, especially in cases of neglect - for example, not responding to alarm calls
- poor-quality service generally, as well as the specific actions of the individual worker.
Staff mitigation
Staff may claim a variety of reasons for their behaviour, which employers need to weigh up in their decision-making:
- poor working conditions: understaffing and overwork
- lack of training: inadequate training or incompetence in doing the work
- mental health: personal stress often linked to working conditions
- intentions: misunderstood or accidental - the person never meant to harm vulnerable adults.
Each case is considered on its merits, and the Secretary of State will give due consideration to mitigating factors. However, while such factors may be used by staff in their defence, none of them justifies harming vulnerable adults or putting them at risk of harm. In addition, employers are entitled to dispute any of these factors if they are not true.
