Report 41: Prevention in adult safeguarding
Policies and procedures
'Whistle blowing is an important mechanism for exposing abuse and neglect in care settings… procedures [need] to enable staff to whistle blow.'(7)
Many policies and procedures within services – not just safeguarding policies and procedures – can support the prevention of adult abuse. Key to the successful prevention of abuse is an open culture with a genuinely person-centred approach to care underpinned by a zero tolerance policy towards abuse and neglect. Much of this literature relates to residential services, although a few relate to community settings.
A culture of zero toleranceOpen
The value of awareness raising about abuse within a service context lies in linking it with a zero tolerance policy on abuse and supportive policies and procedures to support whistle blowing.(7)
Benbow describes a whole-system approach in which policies and procedures should be in place to ensure clinical governance and person-centred care, and said that 'there is an urgent need for resources and working conditions that enable staff to provide the highest quality of care'.(30) Marsland et al, too, refer to the role of the overall culture and environment of care in explaining some of the underlying reasons why staff commit abuse.(29)
CSCI referred to the need for care providers to have an 'open culture' where people can feel safe to raise concerns. CSCI found a relationship between the star rating of a service and the proportion of people who use services who had received and understood information and felt that they could speak to a manager if they did not feel safe. Similarly, they found a negative correlation between the quality rating of the service and the likelihood of the Commission receiving a safeguarding alert about the service.(3)
Promoting positive practice Open
Minshull looked at older people's inpatient mental health care settings, and recommended the establishment of a forum along the lines of the Acute Care Forum in adult mental health care, the aim of which would be:
… to develop and sustain strong, visible, open, accountable and respectful working practices where innovation can flourish. Neglect and abuse will quickly be identified and will not be tolerated by any member of the care team.(47)
Minshull refers to a paper by Richards et al which concluded that education alone is not enough to change practice in acute mental health care settings: that organisational regimes and routines can become more important than individual care.(48) Similarly, McCreadie suggested the need for an 'alert culture' with the potential for abuse explicitly recognised alongside the provision of awareness training.(35)
Whistle blowing Open
Kalaga and Kingston note whistle blowing as an important mechanism for exposing abuse and neglect in care settings, and emphasise the need for procedures to enable staff to whistle blow.(7)
Marsland et al observed that:
… potential whistle-blowers may already be identifying important indicators, but may encounter difficulties in using this knowledge to take protective action.(29)
Choice and quality Open
One of the issues highlighted is that where there is a shortage of beds or services, poor quality care is likely to flourish because of a lack of choice both for people who use services and for commissioners.(7)
This issue of choice was also raised by SCIE's Adult Safeguarding Service User Advisory Group: that people who use services may be unable to move out of a care home where they have experienced abuse if there is no other home available in the area.
Care planning and risk assessment Open
Effective care planning in the context of person-centred care is noted as a core element of good quality care, in conjunction with risk assessment. CSCI highlighted the need for care planning to consider the potential risks of abuse.(3) DeHart et al suggest that services need to adopt a 'cooperative working environment' in which staff are trained to communicate around, and recognise the role of, the care plan as one strand in the prevention of the abuse of older adults in nursing homes.(25)
Choi and Mayer recommend case management services with older people to include a comprehensive assessment of potential risks for abuse, neglect and exploitation.(24) McCreadie recommend inter-agency policy and guidance on risk assessment as well as the inclusion of risk assessment in care plans.(35) CSCI recommended comprehensive risk and needs assessment where a person has experienced abuse, in the interests of further preventing abuse and working to support the person.(3)
Recruitment, supervision and leadership Open
A number of authors mention recruitment practices should include regular hiring practices (using a minimum of bank and agency staff), the use of Criminal Records Bureau (CRB) checks and other pre-employment checks as a matter of course.(3, 49) Mustafa points out that staff are often appointed prior to completion of CRB checks and that staff employed prior to 2002 were not subject to CRB checks. In addition is the matter of ensuring enough staff are in place to manage the workload appropriately as this can be a major source of stress on staff (30, 47).
Staff supervision, staff development and support are also highlighted by a number of authors as an important means of communicating policies and reinforcing awareness about abuse as well as of supporting staff.(45, 30).
Several authors point to the importance of good leadership in determining the culture of services and modelling good practice. Equally, investigations into abusive incidents have highlighted the role of management failures.(30) From their research, Marsland et al identified the importance of managers who are 'skilled, competent and confident'.(29)
Measures to prevent financial abuse Open
Kalaga and Kingston recommend that care homes record and store information regarding an 'at risk' adult's guardianship, including the specific powers of the guardian, and that communication between the care home and other relevant parties occurs regularly and is recorded.(7)
McCreadie recommends that residential care homes have policies and procedures in place for dealing with finances and valuables, keep proper records and have formal arrangements for home care staff to take on financial responsibilities.(35)
Both refer to the importance of making appropriate use of mechanisms such as Enduring Powers of Attorney (now known as Lasting Power of Attorney), Appointeeship and Receivership (now known as Deputyship), and if necessary the Court of Protection.
Security measures Open
There are a range of devices that can be made available to people who use services and/or staff to maximise protection from abuse. Payne and Fletcher include building security as one of their categories for the prevention of abuse within services; their respondents mentioned using security systems, CCTV, visitor check-in arrangements and strategies to secure residents' valuables.(45)
Case study: Mate crime: the Safety Net project in CalderdaleOpen
Safety Net is one of two national pilot projects, begun in 2009 and funded by the Department of Health, to raise awareness of 'mate crime', or the exploitation of people who have a learning disability by people whom they believe to be their friends. The project in Calderdale, Yorkshire, is coordinated by David Grundy at ARC (Achieving Real Change). The other pilot is in north Devon.
The project is working with people with learning difficulties and support staff to gain an understanding of when a friendly relationship starts to become exploitative and what can be done about this when a person may find themselves being coerced, bullied or otherwise exploited on a regular basis.
The project is working at developing systems, processes and training with a range of organisations in Calderdale, including members of the Safeguarding Partnership and police, in order to shift perceptions of what should be seen as a hate crime where the person's perceived disability maybe the trigger for bullying or harassment. Most police officers are aware of hate crime related to racial abuse. The same level of awareness needs to be encouraged for crime related to disability.
David says, 'It's important that tolerance of even seemingly mild forms of bullying are challenged. There shouldn't be different thresholds of tolerance for different members of the community depending on whether or not they have a disability.'