Adult safeguarding practice questions
Published: March 2015
This guidance is for frontline practitioners and managers who work with adults who have care and support needs and who may be at risk of abuse or neglect. It is relevant to people in health, housing, the police, as well as in social care – both statutory social workers, and staff in the regulated and non-regulated provider sectors. The guidance identifies a number of challenging safeguarding dilemmas, and aims to make clear how these should be handled within the new legal framework. It does not address strategic commissioning issues or discuss the role of Safeguarding Adults Boards (SABs).
The guidance has been commented upon and strengthened by an advisory group that includes people with care and support needs and carers, Department of Health officials, representatives of Making Safeguarding Personal – a sector-led initiative which aims to develop an outcomes focus to safeguarding work – and professionals from the health sector, housing, the police and social work and social care.
View SCIE’s information on SABs, Safeguarding Adults Reviews and sharing safeguarding information under the Care Act 2014.
1. Who does safeguarding apply to? Open
People’s wellbeing is at the heart of the care and support system under the Care Act 2014, and the prevention of abuse and neglect is one of the elements identified as going to make up a person’s wellbeing.
In the context of the legislation, specific adult safeguarding duties apply to any adult who:
- has care and support needs and
- is experiencing, or is at risk of, abuse or neglect and
- is unable to protect themselves because of their care and support needs.
Local authorities also have safeguarding responsibilities for carers and a general duty to promote the wellbeing of the wider population in the communities they serve.
Safeguarding duties apply regardless of whether a person’s care and support needs are being met, whether by the local authority or anyone else. They also apply to people who pay for their own care and support services.
An adult with care and support needs may be:
- an older person
- a person with a physical disability, a learning difficulty or a sensory impairment
- someone with mental health needs, including dementia or a personality disorder
- a person with a long-term health condition
- someone who misuses substances or alcohol to the extent that it affects their ability to manage day-to-day living.
This is not an exhaustive list. In its definition of who should receive a safeguarding response, the legislation also includes people who are victims of sexual exploitation, domestic abuse and modern slavery. These are all largely criminal matters, however, and safeguarding duties would not be an alternative to police involvement, and would only be applicable at all where a person has care and support needs that mean that they are not able to protect themselves.
Adult safeguarding duties apply in whatever setting people live, with the exception of prisons and approved premises such as bail hostels. They apply regardless of whether or not someone has the ability to make specific decisions for themselves at specific times. There may be times when a person has care and support needs and is unable to protect themselves for a short, temporary period – for example, when they are in hospital under anaesthetic.
People with care and support needs are not inherently vulnerable, but they may come to be at risk of abuse or neglect at any point due to:
- physical or mental ill-health
- becoming disabled
- getting older
- not having support networks
- inappropriate accommodation
- financial circumstances or
- being socially isolated.
Local authorities have a duty to make sure that the care and support services they commission are provided safely and to a high standard, while also recognising and tackling the abuse and neglect that happens in community and domestic settings.
Working with their partner organisations – including housing organisations, the National Health Service (NHS) and the police – local authorities should make sure that adults who may be at risk of abuse or neglect are enabled to live as safely and independently as possible, making their own decisions and taking control of their own lives.
2. Are people whose care and support needs do not have a significant impact on their wellbeing eligible for a safeguarding service? Open
There are no eligibility criteria for adult safeguarding services. If an adult at risk of being abused or neglected cannot keep themselves safe from abuse or neglect because of their care and support needs, then the local authority’s safeguarding duty applies. If they are able to protect themselves, despite having care and support needs, then a safeguarding response may not be appropriate.
Local authorities are responsible for looking at any safeguarding concerns raised with them about any adult who has care and support needs and deciding whether it is necessary to carry out an enquiry. This should include the person themselves, whose own wishes and preferences should be acted on as far as possible, in keeping with the principles set out in ‘Making Safeguarding Personal’.
The role of adult social care staff is to help people to make choices and support them to manage any risks. Adult social care staff should also recognise that others can help to keep people safe, and an intervention from statutory services is not always required. For example, relatives, housing staff or health professionals could all have a key role to play.
3. How can practitioners work with adults with care and support needs to prevent abuse or neglect from occurring? Open
The Care Act 2014 explicitly requires local authorities to work with partner agencies to actively promote people's independence and wellbeing, not just to respond to crises when they occur. This applies to the safeguarding of adults with care and support needs, where the aim should be to prevent abuse and neglect from occurring (or recurring) wherever possible.
Safeguarding practice under the new legislation should centre on giving people more control over, and supporting them to make choices about, their lives. As part of an approach to care and support that puts the person at the centre, practitioners should work with adults who may be at risk to help them recognise potentially abusive situations and understand how they can protect themselves. Frontline preventative practice should be supported by preventative strategies from the local Safeguarding Adults Board (SAB), for instance on how certain communities and groups – such as older people living alone – can be supported to stay safe through targeted information.
A starting point for practitioners is to talk to adults with care and support needs about what their goals are and how they want to live their lives. The aim is to help people to develop their resilience and retain their independence. The focus should be on all aspects of the person's wellbeing, not just their safety.
Adults with care and support needs should be encouraged to think about their strengths, existing resources and any informal support networks they have around them. They can then be helped to identify what their particular needs are, what complex situations may exist and whether they face any risks.
Practitioners in any setting can help by providing information for adults with care and support needs – and their families – on what abuse looks like and how to recognise potential warning signs. They should ensure that people understand what their rights and choices are, and where they can get help and support if they need it.
Information and support should be targeted at people's individual needs. People who pay for their own care and support services, direct their own support or receive a personal budget may need particular guidance about how they can protect themselves.
Adults with care and support needs can also be encouraged to reduce their potential isolation by making links with their wider community, to increase the number of people who will 'look out for them' and support them.
4. What safeguarding services should be available to people who fund their own care and support?Open
Every adult with care and support needs has the right to a safeguarding service, if they are at risk of abuse or neglect and are unable to protect themselves.
People who fund their own care and support (self-funders) should receive the same service from adult social care departments as people whose care and support are funded by their local authority or another agency, such as the NHS. Local authorities are responsible for making sure that self-funders have the information and advice they need on how to access care and support, and on their rights more generally.
If a person who funds their own care is living in a care home in a different local authority area to their original 'home' area, their new home authority has responsibility for responding to any safeguarding concerns and carrying out – or causing others to carry out – any enquiries that are needed.
Local authorities will not be aware of all situations in which an adult may be at risk of abuse or neglect, particularly if an individual is funding their own care in their own home. The legislation does not require a local authority to go looking for these situations, but to consider action as soon as it is made aware of them.
Scenario: An older person at risk of financial abuse from paid care staff in her own home
Mrs S is 90 years old and lives alone in her own home. She is very frail, she is not able to move about easily and her eyesight is restricted. She has also been diagnosed with dementia. Mrs S is not eligible for care and support services funded by her local authority. She relies on visits from family members and care workers from a private home care agency four times a day, to help her with washing, dressing, eating and most other aspects of daily life.
Her daughter suspects that care workers are taking money from Mrs S's purse. She also believes that small, valuable items are going missing from her mother's home. She has raised her concerns with the agency, but admits that it is possible that her mother is giving money and personal items as gifts to people who come into her home.
Once notified of Mrs S's family's concerns, the care agency should consider alerting the adult services department at the local authority and the Care Quality Commission, if the agency is registered with them. If alerted, the local authority should then either carry out an enquiry itself, or ensure that the agency conducts a satisfactory enquiry. The police may be involved if Mrs S or her family wants the possibility of theft or exploitation to be the subject of a criminal investigation. The agency should think about whether other adults it provides care services to may be at risk, and take action to remove the risk.
If Mrs S is in fact giving away money and personal items, an assessment should be made of her capacity to decide to do this. Depending on the outcome, an action plan should then be put in place to protect Mrs S's finances and possessions, either with her involvement and consent or in her best interests, under the Mental Capacity Act 2005. Additionally, even if no theft is taking place, there may be a disciplinary issue for the care agency to address, as its staff are likely to be bound by a rule preventing them from accepting gifts from people who use services.
5. In what circumstances should a care provider, housing provider or health professional contact adult services about an adult who may be at risk of abuse or neglect?Open
As always, there is a balance to be struck between sticking strictly to procedures to protect adults who may be at risk of abuse or neglect, and responding to the needs, wishes and circumstances of individual people.
The legislation requires SABs to create an open culture around safeguarding, working in partnership with care providers and other partner agencies so that the best outcomes for people who use care and support services are achieved. Local authorities should come to an agreement with other local agencies about how the new arrangements will work in their area. This will be reflected in local policies and procedures.
These multi-agency procedures must reflect statutory guidance. They should also spell out for local care providers the circumstances in which the police should be involved and when other agencies (including the local authority, NHS clinical commissioning group and the Care Quality Commission) should be notified, and what their role should be. There may be occasions when the local authority will be notified in its role as commissioner, without the adult safeguarding team being involved.
The procedures should also clarify the expectations of other service providers, and what they should do and when. The aim should be to:
- prevent, reduce or remove specific risks
- support individual adults to recover from any abuse or neglect they have experienced
- help people make the decisions they feel are right for them.
Members of the public and staff from a wide variety of agencies may report safeguarding concerns to adult services for various types of abuse and neglect, including physical, psychological and financial abuse and exploitation.
On the quality of care and clinical issues such as wrongly administered medication, pressure sores and falls – where the cause may be poor care (see Question 8) rather than intentional harm – local policies should spell out the appropriate responses, such as intervention by the local clinical commissioning group or reporting to the Care Quality Commission. Local policies should set out the extent to which the local authority expects to be notified of these by service providers. It may be that the local authority will want this information to be passed, where significant, to the local Safeguarding Adults Board as well as to local commissioners.
In relation to health and social care services, the Care Quality Commission will want to satisfy itself (through registration and inspection) that where poor care occurs, the provider is competent to address it quickly and effectively.
If abuse or neglect takes place in a service such as a care home, home care agency, day centre, hospital or college, the first responsibility to act lies with the employing organisation as the provider of the service. When an employer or manager is aware of abuse or neglect happening in their organisation, they should do two things:
- inform the local authority (and the local clinical commissioning group, if the NHS is the commissioner), taking into account the person’s wishes
- take action to protect the adult concerned from further harm (such as by removing the staff or volunteers involved, or by providing them with additional training or supervision).
The employer (a term also used here to cover managers in places where there is no employer, such as in a volunteer-run service) should carry out their own initial investigation of any safeguarding concern. This should happen unless there is a compelling reason why it is thought to be inappropriate or unsafe, for example:
- there is a serious conflict of interest (such as a small, family-run home where a wife might be investigating her husband)
- there is reason to believe that the matter will not be responded to effectively (such as in a small or volunteer-led body where there isn’t sufficient expertise or experience) or
- there is a reasonable suspicion that a criminal offence has taken place.
The wellbeing of the person concerned should be of paramount importance.
Where a safeguarding concern has been reported to a local authority, it has a duty to find out what has happened and to decide what further action, if any, should be taken. The local authority needs to be satisfied that the service provider is responding adequately, and may need to carry out an enquiry of its own and oversee any follow-up action. It may, for example, advise that the service provider notifies the Care Quality Commission, the Disclosure and Barring Service or the relevant professional regulator (where there is one). All action taken and decisions made should be clearly recorded.
6. Who should be involved in safeguarding adults who may be at risk?Open
Making Safeguarding Personal shows that people with care and support needs, and their carers, should be as fully involved in decisions about their safety and wellbeing as they are able or wish to be.
Local authorities’ safeguarding systems should be personalised to the needs and circumstances of the individual people they are designed to support and protect. All adults should be at the centre of decision-making about their lives, and should have the opportunity to make choices about and have control over how they live. Supporting people’s dignity is essential, and if a safeguarding plan is needed to keep an adult safe, they – or their advocate or representative – should contribute to this and agree to it.
As well as the involvement of the adult with care and support needs, multi-agency partnership is also at the heart of the national safeguarding principles set out in the Care Act 2014. Yet it is one of the hardest elements to get right, and an area where safeguarding practice often fails.
Effective safeguarding cannot be achieved without a large number of organisations and individuals working closely together, and there being an explicit recognition that safeguarding is everyone’s concern. Each partner organisation brings a different perspective and body of knowledge.
Key partners include:
- local authorities (including parts of the local authority other than adult services, such as environmental health)
- the police and other law enforcement agencies
- health services
- fire and rescue services
- prison and probation services
- housing organisations, including local housing authorities
- voluntary and independent sector organisations
- organisations that provide advocacy and support
- faith communities
- the Care Quality Commission
- the Crown Prosecution Service
- the Disclosure and Barring Service
- the Office of the Public Guardian.
Adult services departments should take the lead coordinating role in safeguarding adults who may be at risk. (The police, of course, will lead on all criminal investigations.)
The police, health services and individual health professionals, including GPs, have a duty to cooperate and have a vital role to play in preventing, reporting and responding to allegations of abuse or neglect. They also need to support the recovery of adults who have been victims of abuse, as well as working with those who are abusive.
NHS accident and emergency (A&E) departments (plus ambulance services and fire and rescue services) can function as an early warning system about possible safeguarding concerns. This is also true of complaints systems. It may therefore be appropriate to think of a complaint as a safeguarding concern and respond accordingly.
Social care staff should work closely with housing staff, who are often well placed to identify adults who have care and support needs and may be at risk of abuse. Some serious case reviews have concluded in the past that housing providers could play a more effective role in safeguarding.
7. Is self-neglect a safeguarding issue?Open
Self-neglect can be a complex and challenging issue for practitioners to address, because of the need to find the right balance between respecting a person's autonomy and fulfilling their duty to protect the adult's health and wellbeing. Both perspectives can be supported by human rights arguments.
The Care Act 2014 statutory guidance includes self-neglect in the categories of abuse or neglect relevant to safeguarding adults with care and support needs. In some circumstances, where there is a serious risk to the health and wellbeing of an individual, it may be appropriate to raise self-neglect as a safeguarding concern. However, interventions on self-neglect are usually more appropriate under the parts of the Care Act dealing with assessment, planning, information and advice, and prevention.
It is vital to establish whether the person has capacity to make decisions about their own wellbeing, and whether or not they are able or willing to care for themselves. An adult who is able to make choices may make decisions that others think of as self-neglect.
If the person does not want any safeguarding action to be taken, it may be reasonable not to intervene further, as long as:
- no-one else is at risk
- their 'vital interests' are not compromised – that is, there is no immediate risk of death or major harm
- all decisions are fully explained and recorded
- other agencies have been informed and involved as necessary.
Risk and capacity assessments are likely to be useful. The legislation makes clear that adult safeguarding responses should be guided by the adult themselves, to achieve the outcomes that they want to achieve.
Carrying out an assessment may be difficult, if the person is reluctant. The Department of Health advises (in statutory guidance on the implementation of the Care Act 2014) that adult social care departments should record all the steps they have taken to complete an assessment of the things that a person wants to achieve and the care and support that they need. Research indicates that intervening successfully depends on practitioners taking time to gain the person's trust and build a relationship, and going at the person’s own pace.
If it is impossible to complete the assessment, or if the person refuses to accept care and support services, you should be able to show that you have tried, and that information and advice have been made available to the person on how to access care and support and how to raise any safeguarding concerns. All your decisions, and the considerations that have led to them, should be recorded in light of the person's wishes and their particular circumstances. You should be able to show that whatever action you have taken is reasonable and proportionate.
The aim of every commissioner and service provider should be effective, high-quality care and support for every individual. When this falls short, people are put at risk and safeguarding referrals rise. There is evidence that many of the issues raised as safeguarding concerns – such as falls, pressure sores, wrongly administered medication or poor nutritional care – are rooted not in malicious harm but in poor practice and poor-quality care. Nonetheless, the impact on the adult at risk can be just as great, regardless of whether harm is intended.
It is important to differentiate between the two, in order to address problems in the right way, so that all adults at risk receive safe, high-quality care and support. It is also important to avoid making safeguarding enquiries unnecessarily, so that police and adult safeguarding teams are able to focus on potentially criminal acts and malicious behaviour rather than on poor care practices. There will need to be a clear common understanding of this across agencies, since some past cases of abuse were first thought to be poor care.
The multi-agency policies and procedures that apply in your area should make clear when to refer concerns about an adult at risk to local safeguarding channels, although you will always have to use your professional judgement on this, supported by your manager. The police should advise on whether a crime has potentially been committed. Poor care should be identified and addressed by the service provider, using supervision, training and other mechanisms to improve practice.
It is good practice to keep the commissioner and the Care Quality Commission fully informed of action that is being taken. Where single instances of poor or neglectful care are repeated, patterns of harm are identified and other people are put at risk, the Care Quality Commission and commissioners must be told and should take decisive action. Of course, the Care Quality Commission doesn’t cover every type of support, and where poor care is delivered by a personal assistant, with no employer other than the person with care and support needs themselves, it can be hard to identify and tackle. Whoever arranged the care and support, usually the local authority, should satisfy itself that a person with care and support needs knows who they can talk to if they are dissatisfied with the support they’re getting. The Safeguarding Adults Board should be made aware of any such concerns in its area, and of any actions being taken to remedy failings.
Repeated instances of poor care indicate serious underlying problems and point towards organisational abuse, which happens when standards of care are so poor that adults are put at increased risk. The importance of recording everything – and regularly reading what has been recorded by everyone – cannot be overstated. Only through good recording can patterns of incidents over time be tracked and analysed, and therefore addressed.
Differentiating between poor care and potential safeguarding issues
- A one-off medication error (although this could, of course, have very serious consequences).
- An incident of understaffing, resulting in a person’s incontinence pad being unchanged all day.
- Poor-quality, unappetising food.
- One missed visit by a care worker from a home care agency.
Potential causes for concern
- A series of medication errors.
- An increase in the number of visits to A&E, especially if the same injuries happen more than once.
- Changes in the behaviour and demeanour of an adult with care and support needs.
- Nutritionally inadequate food.
- Signs of neglect such as clothes being dirty.
- Repeated missed visits by a home care agency.
- An increase in the number of complaints received about the service.
- An increase in the use of agency or bank staff.
- A pattern of missed GP or dental appointments.
- An unusually high or unusually low number of safeguarding concerns.
9. How should you respond to pressure ulcers?Open
Pressure ulcers illustrate well the challenge of finding out whether an issue is caused by poor care or avoidable neglect, or whether it is the unavoidable result of a person’s current condition. While pressure ulcers are always a risk for people who are frail and are not able to move about easily, with good management and care they can usually be avoided.
The simple fact that an adult at risk has a pressure ulcer – even a serious one – is not in itself a reason to suspect abuse or neglect. There are a number of factors to help you decide whether it potentially indicates neglect, or whether it indicates a need for care providers to improve their practice.
These factors include:
- the person's physical health and existing medical conditions
- any skin conditions the person may have
- any other signs of neglect, such as poor personal hygiene
- the appropriateness of their care plan and whether it has been properly carried out
- the person's own views, and the views of their family and friends, on their treatment and care.
These factors should be looked at by a clinician asked by the local NHS trust or clinical commissioning group to establish whether the person's pressure ulcers are the result of poor practice that can be improved, or whether intentional or avoidable neglect is taking place. If the issue is neglect, a decision will need to be made as to whether there is a risk to other adults receiving services from the same provider.
The nature and timing of this, and who leads it, will depend on the circumstances of the individual case. The conclusion may be that the problem can be resolved by the service provider, and that a disciplinary response is appropriate. Or it may be apparent that external clinical intervention or regulatory enforcement action is required. Even where it appears that the pressure ulcers are the result of abuse or neglect, these responses would all usually be more appropriate than a local authority/social worker-led enquiry under Section 42 of the Care Act 2014. If the pressure ulcers amount to the wilful neglect of people who lack mental capacity, a crime under Section 44 of the Mental Capacity Act 2005 may have occurred, and the police should be informed. So too should the SAB if there appear to be significant problems with the quality of local provision.
10. When is it necessary to carry out an enquiry under Section 42 of the Care Act 2014?Open
An enquiry is any action that is taken (or instigated) by a local authority, under Section 42 of the Care Act 2014, in response to indications of abuse or neglect in relation to an adult with care and support needs who is at risk and is unable to protect themselves because of those needs.
The Care Act requires local authorities to make proportionate enquiries (or to make sure that, as the lead agency, enquiries are carried out by the relevant organisation) where there is a concern about the possible abuse or neglect of an adult at risk.
This may or may not be preceded by an informal information-gathering process, if that is necessary to find out whether abuse has occurred or is occurring and therefore whether the Section 42 duty applies.
An enquiry may take the form of a conversation with the individual concerned (or with their representative or advocate). It may need the involvement of another organisation or individual. Or it may require a more formal process, perhaps leading to a formal multi-agency plan to ensure the wellbeing of the adult concerned.
It is important that at all points, the six safeguarding principles are considered in determining the next course of action:
- empowerment – people should be supported and encouraged to make their own decisions and give informed consent
- prevention – it is better to take action before harm occurs rather than waiting until it does occur
- proportionality – the response should be the least intrusive and the most appropriate to the risk presented
- protection – there should be support and representation for those in greatest need
- partnership – services should work with their communities to produce local solutions; communities have a part to play in preventing, detecting and reporting neglect and abuse
- accountability – safeguarding practice should be accountable and transparent.
A Section 42 enquiry must take place if there is reason to believe that abuse or neglect is taking place or is at risk of taking place, and the local authority believes that an enquiry is needed to help it to decide what action to take to support and protect the person in question. The particular circumstances of each individual case will determine the scope of each enquiry, as well as who leads it and the form it takes.
While many enquiries will need a lot of input from a social care practitioner – often a social worker – there will be aspects that should be carried out by other professionals with the necessary skills and knowledge. For example, it may be a health professional who has the closest relationship with the individual and is best placed to explore a particular concern with them in the first instance.
The local authority may decide that another organisation should carry out the enquiry, but the local authority will retain overall accountability. The local authority must satisfy itself that the organisation will meet agreed timescales and follow-up actions. Whatever form the enquiry takes, the following must be recorded:
- details of the safeguarding concern and who raised it
- the views and wishes of the adult affected, at the beginning and over time, and where appropriate the views of their family
- any immediate action agreed with the adult or their representative
- the reasons for all actions and decisions
- details of who else is consulted or the concern is discussed with
- any timescales agreed for actions
- sign-off from a line manager and/or the local safeguarding lead or designated adult safeguarding manager.
Also, the local authority will need to record data for the Health and Social Care Information Centre's Safeguarding Adults Collection, and practitioners will need to make sure that their recording captures everything necessary for this, as spelled out in local procedures.
Non-statutory enquiries (known as 'other safeguarding enquiries') may also be carried out or instigated by local authorities in response to concerns about carers, or about adults who do not have care and support needs but who may still be at risk of abuse or neglect and to whom the local authority has a 'wellbeing' duty under Section 1 of the Care Act 2014.
Scenario: An individual who has bruises
Mr M is 75 years old and lives alone in his own home, with care and support services funded by his local authority. He has Parkinson's disease, dementia, and has poor balance and mobility, which puts him at an increased risk of falling. When Mr M has a fall in his bathroom, he is seen by his GP and a report is sent to the local authority.
When the authority gathers information about the incident, Mr M's bruises tally with the report that was submitted, and the GP confirms that these are consistent with a heavy fall. The authority believes that it has enough information about what happened to Mr M to indicate that abuse has not occurred and that a Section 42 enquiry is therefore unnecessary.
Mr P is 82 years old and also lives in sheltered housing. Like Mr M, he has poor balance and mobility, and a diagnosis of dementia. He funds the care and support services he receives from his own savings. On one of his grand-daughter's regular visits, she expresses concern about some bruises she can see. She raises her concerns with the home care agency and the housing provider, and also with adult services at the local authority.
The local authority asks the agency about Mr P's bruising, and receives a reply that he must have fallen. But there is no record of any fall, and Mr P has not been seen by his GP or any other doctor. The local authority decides that it does not have enough information to be satisfied that Mr P is safe. As there are reasonable grounds to think that Mr P – a person with care and support needs that would make it difficult for him to protect himself – may have experienced abuse, the local authority instigates a Section 42 enquiry. This takes place in collaboration with the home care agency and the housing provider, and is led by a social worker.
11. At what point should the police become involved in a safeguarding investigation? Open
The police are a key safeguarding partner. The answer to this question will depend on a number of factors, including:
- the views and wishes of the adult at risk
- whether a criminal offence as defined by law has been disclosed
- the exact circumstances surrounding each individual case of suspected abuse or neglect.
In general terms, if there is a reasonable suspicion that a crime may have been committed and the harm caused to the adult concerned was deliberate, malicious or reckless, then it is sensible to have a discussion with the lead officer in the local police force.
Of course, the police may need to be involved in an emergency situation if there are concerns that an adult is at immediate risk of serious harm. The police have powers to intervene if a person needs immediate assistance due to a health condition, injury or other life-threatening situation.
If the situation is not an emergency, it is important to find out from the person whether they want the police to be involved, especially where there are complex family dynamics or personal relationships. Risk of harm to others should also be considered in these circumstances, and so the person's wishes would not be the sole consideration. Local policies and procedures should be followed to ensure that information is shared appropriately.
If an adult has been harmed by an action that was possibly intended to cause them harm, a practitioner would need to consider not just how best to protect that person but also whether to refer the case to the police for a possible criminal investigation. The same applies if someone is acting in a way that is designed to hurt another person, even if no actual harm occurs – for example, one person trying to hit another person.
There are likely to be occasions when something occurs that is technically a crime, for example:
- a resident in a care home stealing a few pounds from another resident
- a minor physical altercation between two people in a supported living flat
- an apparently overstretched carer who has been subjected to physical abuse hitting back.
While none of these are acceptable, it is important to focus on what type of intervention will lead to the desired outcomes.
Whether such situations are best resolved with police involvement should be thought through, and the principle of proportionality – that the response should be the least intrusive and the most appropriate to the seriousness of the situation – should underpin the decision made. Other remedies may be useful, for example, restorative justice, where the 'victim' explains to the 'offender' the impact that the crime has had on them. As ever, the person's own wishes should be considered as part of the deliberations.
Local policies and procedures should make clear the circumstances in which the police should be informed. In many cases it may be best to have an informal discussion with the police, together with the affected adult or their representative, to decide whether a police response is necessary.
It is essential to avoid a situation where a crime is effectively concealed by agencies carrying out their own enquiries. If a decision has been made to call in the police, they should be involved at the earliest opportunity. This is to ensure that key forensic evidence is not lost or damaged, and because a higher standard of proof is required in criminal proceedings than in disciplinary or regulatory proceedings. Early contact with the police may therefore help in obtaining and securing vital evidence and witness statements, leading to a successful prosecution.
Once the police are involved, their enquiries may take precedence over any others that may be in progress, and how these interact with matters such as internal disciplinary hearings will need to be coordinated locally.
Scenario: Responding to a carer's admission of assault
Mr and Mrs B live in sheltered housing. Mrs B has dementia. Mr B has been adamant that he wants to care for his wife to the end, despite his own failing health.
Mrs B no longer recognises her husband, and sometimes becomes very frightened because she thinks he is an intruder. She has hit him on numerous occasions and is very threatening towards him. When her medical consultant asks Mr B about his ongoing ability to cope, he admits that he has recently hit his wife in retaliation after she hit him.
With the couple's agreement, the consultant involves the local authority, explaining to Mr B that he thinks that the situation has become very stressful for both of them, and that it is better to ask for help before it deteriorates further.
A social worker then talks to Mr and Mrs B, both together and separately, to find out what they want to happen and what support they need. There is no suggestion that an incident like this has ever happened before.
A multi-agency support plan is put in place, identifying extra support for Mrs B at those times when she is more likely to hit out at her husband, and support for Mr B on how to deal with his wife's outbursts. An early review date is put in place. The police are not involved, but this decision is recorded. The couple's support package is monitored more closely.
12. How should you handle it if a partner organisation fails to share information about an individual that is relevant to safeguarding? Open
Given the duty to cooperate in the Care Act 2014, there are only a limited number of circumstances in which it would be acceptable not to share information pertinent to safeguarding with relevant multi-agency safeguarding partners. These would be where the person involved has the mental capacity to make the decision in question and does not want their information shared, and:
- their 'vital interests' do not need to be protected
- nobody else is at risk
- there is no wider public interest
- no serious crime has been or may be committed
- the alleged abuser has no care and support needs
- no staff are implicated
- no coercion or duress is suspected
- the risk is not high enough to warrant a referral to a Multi-Agency Risk Assessment Conference (MARAC)
- no other legal authority has requested the information.
If there is continued reluctance from one partner to share information on a safeguarding concern, or in instances where an alerting organisation thinks that the local authority response is not sufficient, then the matter should be referred to the Safeguarding Adults Board (SAB). The SAB should discuss the issue, including the organisation's stated reasons for not sharing the information. The SAB will decide what course of action to take.
The SAB can also consider whether the concern warrants a request, under Clause 45 of the Care Act 2014, for the ‘supply of information’.
The local authority, as lead safeguarding agency, should make sure that all partner organisations – not just statutory partners but also housing organisations, care providers and others – have signed up to a local information-sharing protocol.
13. How does the Mental Capacity Act 2005 interact with the Care Act 2014 with regard to safeguarding? Open
The Mental Capacity Act 2005 (MCA) is an essential tool to support decision-making in health and social care. The MCA and the Care Act work together to promote the empowerment, safety and wellbeing of adults with care and support needs. Section 44 of the MCA prioritises people’s safety by making wilful neglect or mistreatment of an adult who lacks capacity to make decisions a criminal offence.
There is nothing in the Care Act that replaces or undermines the MCA when it comes to making decisions with or on behalf of adults who lack capacity. The principles of the MCA remain as important as ever.
Both pieces of legislation should enable individuals to maintain their independence and exercise as much control as possible over their lives and any care and support they receive. This is just as relevant in adult safeguarding enquiries as in other areas. You should make sure that you have a good understanding of the MCA, and that you put into practice its five key principles:
- Assume that a person has capacity to make decisions, unless there is evidence otherwise.
- Do all you can to maximise a person’s capacity.
- Unwise or eccentric decisions do not in themselves prove lack of capacity.
- If you are making a decision for or about a person who lacks capacity, act in their best interests.
- Look for the least restrictive option that will meet the need.
You should also expect to make available any help and support that a person may need to make a specific decision. This could include help with communication or, wherever possible, making sure that you talk to the person at a time when they are best able to make the decision for themselves.
It is important to be aware that there will be some safeguarding situations where the person may appear to be mentally capacitated, but is in fact subject to duress or coercion by another person. If this is the case, MCA procedures may not cover the particular situation. Professionals from a range of disciplines will need to work with the person, to explore options that may be available to keep them safe. Supporting people who are subject to coercion is often complex and challenging work. If the situation cannot be resolved in other ways, you may need to apply to the inherent jurisdiction of the High Court.
The MCA makes clear that your role is to establish whether a person lacks capacity in relation to a specific matter at a specific time, following the two-stage test set out in the Act. In relation to safeguarding, you may need to consider whether, for example, the person has the capacity to decide about their own situation, or whether they can refuse consent for information to be shared in any safeguarding enquiry.
Scenario: A young man who wants an independent relationship with friends
C is a young man in his early 20s with mild learning disabilities. He lives in a supported living set-up, where he receives day-to-day support, and attends college. He enjoys going to his local pub, and spends time there most evenings with various other regulars who he has become friendly with.
C’s parents are concerned that he is being taken advantage of by people who are not really his friends, and that he is spending a lot of money that he can’t afford on rounds of drinks for these people. His support worker has the same worries, and wants to raise a safeguarding concern. C is adamant that he is happy with the situation, and that he wants nothing to be done, because he does not want the information about the risks he’s taking shared with his parents, fearing that they may want to keep more of an eye on him if they find out. As he has the capacity to make this decision, no-one else is at risk and no serious crime is taking place, his decision not to have safeguarding information about him shared has to be respected. While this personalised approach to safeguarding is important in respecting C’s wishes, it does not mean that the support worker and others should not discuss with C ways in which the risks can be reduced, perhaps by taking less money to the pub. It may well be that the local authority or SAB has produced useful information for people on how to keep themselves safe from financial exploitation.
The principle of the assumption of capacity does not exempt professionals from conducting robust assessments and asking challenging and searching questions about people who are making choices that are problematic or manifestly not good for their wellbeing.
14. How should you address domestic abuse in a safeguarding context? Open
A considerable amount of adult safeguarding work in people’s homes relates to the domestic abuse of people with care and support needs. There is a good deal of overlap between safeguarding and domestic abuse procedures. Practitioners have to decide which approach is the correct one for the person who is at risk, and ensure that the person themselves remains at the centre of all decision-making.
According to Home Office guidance, domestic abuse encompasses not just physical violence but also psychological, sexual, financial and emotional abuse. It happens not just between intimate partners but also between other family members, regardless of age, gender or sexuality.
The approach that you take as a practitioner to situations where domestic abuse has happened may in some cases constitute a safeguarding response. For a safeguarding response to be required under the Care Act 2014, the person has to meet the usual three criteria:
- having care and support needs
- experiencing (or being at risk of) abuse or neglect
- being unable to protect themselves because of those needs.
'Adult safeguarding and domestic abuse' is a comprehensive guide that supports practitioners and managers in making decisions about how to respond to individual situations. It is a key resource in promoting more effective support for people who need an adult safeguarding service because of domestic abuse. In particular, it emphasises the need to:
- develop a good relationship with the adult at risk and put their views and wishes at the forefront of all discussions
- be alert to patterns of coercive or controlling behaviour, and be aware that an adult at risk may refuse to report abuse because of fear
- consider any additional likely impact of abuse on an adult with care and support needs
- understand how local safeguarding services and Multi-Agency Risk Assessment Conferences (MARACs) fit together
- be aware of the legislative options and local resources that are available both to safeguarding teams and to MARACs, so that practitioners know the full range of responses available to them when supporting an adult with care and support needs.
15. When should advocates be used in safeguarding?Open
The Care Act 2014 is clear that people’s wishes, needs and feelings should be at the heart of all care and support activity, including safeguarding, and that local authorities must involve individuals in all decisions about them. This ‘duty to involve’ applies in all settings and regardless of the complexity of a person’s situation. Effective adult safeguarding means promoting people’s rights as well as their physical safety.
The Care Act introduces a new advocacy duty for local authorities. This applies to adults who are the subject of a safeguarding enquiry or safeguarding adults review (SAR) if:
- they have care and support needs
- they have ‘substantial difficulty’ in being involved in decision-making
- there is no appropriate person available to support them and represent their wishes.
According to the legislation, there are four areas to consider when assessing whether an adult has substantial difficulty in being involved in a decision. Can the person:
- understand the relevant information?
- retain information?
- use or weigh up information?
- communicate their views, wishes and feelings?
If the person has substantial difficulty in being involved in a decision, an appropriate individual can support them and help them to be involved. This individual may be their family member or friend of the individual, but may not be someone who is paid to give care or treatment to them.
If no appropriate individual is able to help, then the local authority, or another agency on their behalf, should appoint an independent advocate. All agencies involved in safeguarding need to know how the services of an independent advocate can be obtained. If a safeguarding enquiry needs to begin urgently, then it can begin before an advocate is appointed – but the appointment should be made as soon as possible.
The role of an advocate is to support and represent the individual, and to help them be involved in key processes and interactions with the local authority. Advocates may also help people to get information and advice on being safe and to spot potential warning signs of abuse or neglect.
It is essential that the advocate is fully independent. The Care Act 2014 makes clear that advocates must not be employed by the local authority or by any organisation that has been commissioned to carry out assessments, care and support plans or reviews for the local authority.
Many adults who qualify for advocacy under the Care Act 2014 will also qualify for advocacy under the Mental Capacity Act 2005 (MCA). Both pieces of legislation recognise the same four areas of substantial difficulty, and both require representation by a family member, friend or independent advocate to help them communicate their views, wishes and feelings. The same advocate may provide advocacy for an individual under both Acts. It is often easier for the adult and for the agencies working with them to work with one advocate rather than two.
Under the MCA, local authorities, the NHS and other responsible bodies have a duty to make sure that an Independent Mental Capacity Advocate (IMCA) is available to represent an adult who lacks capacity to make specific decisions for themselves and who does not have a family member or friend to support them. IMCAs have a particular remit not just to support and represent the person, but also to make sure that the MCA is being followed.
IMCAs are primarily intended to support adults who do not have family or friends to support and represent them. However, in a safeguarding situation, an IMCA can be available even if a suitable family member or friend is also available.
16. What should you do when a person who has full mental capacity acts in a way that is a risk to their safety or wellbeing?Open
If someone makes a decision that you or others think is unwise or not in their interests, this does not necessarily mean that they lack the capacity to decide. It is inevitable that there will be times when an adult who has capacity decides to accept a situation that you perceive as potentially abusive or neglectful. This is a decision that they are free to make, unless:
- other people are being put at risk (for example, letting friends who are abusive or exploitative into a shared living environment, where they may put other residents at risk)
- a child is involved
- the alleged perpetrator has care and support needs and may also be at risk
- a serious crime has been committed
- staff are implicated
- coercion is involved.
It is worth bearing in mind that the Data Protection Act 1998 permits information to be shared in a situation of ‘vital interest’, where it is critical to prevent serious harm or distress or where someone’s life is threatened. However, if the only person who would suffer if the information is not shared is the subject of that information, and they have mental capacity to make a decision about it, then sharing it may not be justified.
You should make sure that the person is aware of any risks and the potential impact on their safety and wellbeing, and encourage them to develop strategies to protect themselves. This might involve them becoming involved with a user-led organisation or a support group, for example.
If someone’s decision is having a significant, negative impact on their own safety and wellbeing, you may wish to discuss this with colleagues and seek advice about what options may be available. Any action you take must be informed by the principles of choice, respect and dignity for the person concerned, with a clear focus at all times on helping them to achieve the outcomes they want.
It should be established whether the person is driven purely by their own views and wishes, or whether they are potentially being unduly influenced or coerced by another person. If you believe that they are being coerced, the inherent jurisdiction of the High Court could apply.
If you believe that a person is acting in a way that is a risk only to their own safety or wellbeing, and they are not being unduly influenced by anyone else, then you may decide not to intervene and not to share safeguarding information with other partners. If this is your decision, then you should ensure that you:
- support the person to weigh up the risks and benefits of different options
- make sure that they are aware of the level of risk and possible outcomes,
- agree on the level of risk they are taking
- offer to arrange an advocate or peer supporter for them, if they would like this
- offer support for them to build their confidence and self-esteem, if it appears relevant
- record your reasons for not intervening or sharing information, including every detail of your assessment of the person’s capacity and of your conversations with them about the potential risks posed by their chosen action
- review the situation regularly
- make sure that they understand where they can go if they want to seek help in the future
- try to build trust and use your professional skills and the relationship you have with the person to make it possible for them to better protect themselves, encouraging them to continue the conversation with other people who they trust, such as family members, friends and other professionals.
You may think that it is necessary to share information about the person outside your organisation without their consent, if you conclude that other people’s safety is potentially at risk. If this is the case, you should share the information. As long as it does not increase the risk to the person, you should inform them that you will share their information, and why. You should also:
- explore the reasons for their objections and find out what their concerns are
- explain why you are concerned about them and why you think it is important to share the information
- tell them who you would like to share it with and why
- explain what the benefits may be to the person of sharing information about them
- discuss the potential consequences of not sharing the information
- reassure them that their information will not be shared with anyone who does not need to know.
Scenario: A person who chooses to stay in a physically abusive living environment
Mr J has a range of physical and sensory disabilities that limit his mobility and independence, but his mental capacity is unaffected. He is cared for at home by his partner, Mr K, who has given up paid employment to become a full-time carer. There is evidence that Mr K is often violent towards Mr J, but Mr J is insistent that he wants to stay at home with his partner.
When adult services look into the couple’s situation more closely, they find that Mr J’s apparent choice to stay in an abusive environment has been made under duress, with Mr K coercing him both financially and emotionally. This coercion is grounds for the local authority to intervene. Unless doing so would place Mr J at more risk, this should be discussed with Mr J. The best approach to take from there would depend on the specifics of the situation, but a practitioner may want to discuss the matter within the Multi-Agency Risk Assessment Conference (MARAC) framework, or seek advice from specialist support groups.
Scenario: An older person who may be at risk of financial exploitation
Miss P is 83 years old and has severe arthritis and heart disease. She walks with sticks in her home, and can only get around outside her home if someone pushes her in a wheelchair. She lives alone and has no family living nearby, and her opportunities to go out shopping or socialising are limited. She is friendly with her long-time neighbour, Mrs Q, who is younger and fitter.
The two women have established a routine where Mrs Q does Miss P’s weekly shopping on a Friday morning. Mrs Q brings the shopping into Miss P’s house and helps her unpack it. She then stays for a cup of coffee and a chat. When she gives Miss P her change, she doesn’t usually return the full amount.
Miss P is aware that she doesn’t always receive her full change, and she mentions this in passing to one of her home care workers. The care worker reports this to her employer, and adult services are informed. When the local authority asks Miss P about her relationship with Mrs Q and the missing money, Miss P is adamant that she doesn’t want any action to be taken.
She is fond of Mrs Q, grateful for her help and appreciative of her company, and she doesn’t believe that she is being taken advantage of. After asking more questions, the authority is satisfied that Miss P has full capacity to make this decision, that she is not being coerced and that no safeguarding action is needed in this particular situation.
If Miss P agrees, an alternative may be to see if a facilitated conversation between the two could lead to an open agreement to pay Mrs Q for her help.
17. How should you respond if you are denied access to a person who may be at risk of abuse or neglect? What actions should you take before turning to legal options? Open
Local authorities' duty to make safeguarding enquiries, or cause enquiries to be made, does not give you an automatic legal right of access to the adult who is the subject of the enquiry if the person, or someone who is associated with them, tries to prevent you from seeing them.
Your options for gaining access to the person are unchanged by the Care Act 2014, but the complexities of this highlight the need for legal literacy – a general awareness of the law in this area – among safeguarding practitioners.
If you suspect the person may be a victim of abuse or neglect, and they may lack the mental capacity to make decisions about their situation, you will need to use your professional skills to try to find a ‘way in’, before any application is made to the Court of Protection to gain access to them.
Your priority should be to try to understand the person’s situation as fully as possible. You may find that you can talk to them away from their home, at a place they usually attend such as a college, day service or respite facility. Keeping lines of communication open with the family carer (or whoever is denying you access to the person) may help to break down their wariness and ultimately lead to access and a positive outcome.
There may be other protective factors in the person’s life, such as family, friends, community groups and other professionals, who are able to offer support to them and monitor ongoing risks. Informal networks may be well placed to understand the person’s circumstances and to continue the conversation directly with them about their risk of abuse or neglect. While statutory adult services may be seen by some people as a ‘threat’, voluntary sector bodies may be perceived in a more positive light. You may therefore want to identify any local charities that provide care or support to the person you are concerned about, and work closely with them.
If the person has capacity, but is unable to exercise this because of coercion or undue influence from another person, then you can apply to the inherent jurisdiction of the High Court.
The Mental Health Act 1983 includes powers for an approved mental health professional to enter the premises of a person with a mental disorder if there is reasonable cause to believe that the person is not receiving adequate care.
If you believe that a crime has been committed, or that there is an immediate, serious risk to a person or a property, you can ask the police to use their power to enter the premises without a warrant under the Police and Criminal Evidence Act 1984.
Whether any of these legal powers are necessary – and which ones might be used – will depend on the individual circumstances of the person concerned. You should only consider resorting to legal intervention if you have exhausted all other possible alternatives, given the difficulty of maintaining an ongoing relationship with an individual or their family once the courts are involved. The court will expect to see detailed evidence of all these alternatives.
18. What does good record-keeping look like? Open
Good record-keeping is central to effective safeguarding, even if 'safeguarding' is not the explicit theme. It is particularly important when you are assessing a person's capacity to make their own decisions. People benefit from records that promote good communication and high-quality care.
Failing to keep accurate records of decisions you have made and actions you have taken can put people at risk. It also puts the organisation you work for in a difficult position, and risks its reputation.
The term 'records' covers various types of documents, including:
- case notes
- any statements that the person has made about their wishes
- care plans
- risk and other assessments (such as Mental Capacity Act 2005 assessments)
- incident reports
- safeguarding referrals and enquiries
- medication records and administration sheets
- end-of-life care plans or advance decisions
- referrals to other organisations and professionals
- handover documents
- staff supervision and training records
All records must be written clearly, and in a manner that can be easily understood by others. They must be accessible to everyone who needs to see them. Any records that contain personal information should be kept in secure storage that is only accessible to those who have authorisation to access these records. Case notes should always be written in a way that respects the person's dignity. Records that are no longer needed should be disposed of confidentially, in line with your organisation's policy on this matter.
You should record decisions and actions that you decided not to take, as well as ones that you did, and explain your rationale in each case. You should also make very clear what is factual information and what is your own opinion or the opinion of other people.
Where an adult's finances are managed on their behalf – for example, by a care home, because they lack capacity to manage their own affairs, or because they have chosen to pass the handling of their money to the home – records must be subject to robust and regular checks.
Records should be kept of routine staff supervision, with written evidence that actions are followed up. (See Question 19.) Record-keeping practice should be reviewed regularly, with input from frontline staff.
How complaints are handled is an important aspect of an organisation's record-keeping, and your records should show that complaints are used to improve quality and practice. All complaints should be taken seriously, recorded fully and followed up. Where complaints highlight problems with a service, changes should be made and outcomes monitored.
19. How can managers ensure that the supervision they provide supports good safeguarding practice?Open
Supervision is fundamental to good safeguarding practice across a range of settings, and should therefore lead to better outcomes for people who need care and support. It should be an integral part of an organisation’s culture, recognising that the culture is what establishes the tone, values and behaviours that are expected from every employee.
The focus of supervision should be on good outcomes for adults in need of care and support. Managers are responsible for the standard of safeguarding practice within their team. They should make sure that supervision is used as an opportunity to challenge practice constructively, and to identify any barriers to effective practice – not simply to check compliance with procedures. Sessions may be one-to-one or in groups.
While supervision sessions should be flexible enough to allow supervisees to raise the issues they are most immediately concerned about, it might be useful to have safeguarding as a constant agenda item at every session, so that managers can be assured that staff are handling any potential safeguarding situations appropriately.
Managers should encourage reflective, critical thinking about safeguarding practice with specific people and situations. They should take notes to record discussions, and make sure that any decisions made during supervision about an adult at risk are recorded accurately, signed and logged on the person’s case file.
As well as regular, scheduled sessions, managers should try to maintain an ‘open door’ environment, so that practitioners feel able to discuss any individuals or situations they are concerned about at any time. The aim should be for managers to build an emotionally ‘safe’, supportive relationship with the people they supervise, so that difficult decisions are fully discussed and practitioners are able to seek advice.
Scenario: Supporting a young woman to make decisions about her life
K is a young woman with a mild learning disability who was in local authority care for most of her teenage years. When she left her foster family at the age of 18, her social worker, P, was concerned about the risks she took with her own safety, in particular the sexual relationships she had with a number of local men.
Supervision helped the social worker to manage her own anxiety about the situation, which became very high profile across health, social services and the local police. P’s manager used supervision to help her focus on the young woman herself – her needs and her options for her future – rather than on the attention the case was receiving.
With her manager’s support, P took her time exploring with K the kinds of things that she wanted to achieve in life. K eventually decided to move to another part of the county with her own flat and a new college placement. Supervision helped to avoid an overly heavy-handed approach, and ensured that K remained in control of the decisions about her life.
20. If the care provided in a particular care home is so bad that it constitutes organisational abuse, what should happen to the residents who live there?Open
Poor care can become a critical issue in a care home setting when single incidents join together to reveal patterns of harm. (See Question 8.) Repeated instances of neglect or poor practice may be a sign of organisational abuse within the setting, when standards of care are so poor that residents are put at risk.
Organisational abuse occurs when the routines, systems and procedures of a care home result in poor or inadequate standards of care, and when the organisation fails to address problems that are brought to its attention.
While it is not always easy to tell the difference between poor practice and ongoing organisational abuse, you should look out for things like:
- a lack of flexibility and choice for adults using the service
- inadequate staffing levels
- high or no staff turnover
- a failure to make sure that residents have privacy and personal dignity.
Other safeguarding concerns in an organisation may also help inform your decision.
If organisational abuse is happening at a care home, both the regulator and each local authority that has residents there should be aware of poor standards and the increased risk to residents at the home in question. It is their responsibility to discuss with the owner or manager what immediate action needs to be taken.
Closure of the home may need to be considered if the situation there has become so abusive that the safety of residents cannot be guaranteed, even if moving to a new home will be disruptive for them.
The Care Act 2014 gives details of the powers that a local authority has to intervene if there are urgent needs arising from a potential service failure. Your responsibility in these circumstances is to consider the needs, wishes and interests of each resident as an individual.
You should talk to each person (and their family or advocate, if appropriate) about what has occurred, and where they would like to live in future, regardless of whether the home is forced to close. You should reassure them that your priority is to ensure that they receive good-quality care and support in a safe environment.
Whether or not the home remains open, the health and wellbeing of the residents should be paramount and a plan should be put in place to prevent any further harm to adults at risk. This may involve finding an alternative place for the residents to live, where their needs will be met.
If the home remains open and residents decide to stay there, you will need to be satisfied that each individual resident is no longer at risk. It is a question of balancing the various risks that the residents may face, and deciding whether the risk of staying where they are outweighs the risk of moving, particularly in an unplanned way.
There also needs to be a recognition that individuals and their families may find it important to talk about what has happened and how they feel, so that they can begin to rebuild their confidence.
21. When should poor support from a family trigger a safeguarding enquiry?Open
Identifying the point at which poor care and support becomes a potential safeguarding issue is explored in Question 8. This dilemma, which does not always have a clear-cut answer when it applies to regulated services, is even less straightforward when the care is being provided by unpaid family carers.
This question is not about obvious signs of abuse – physical, psychological, financial or any other kind – but about the difficult area of 'care that is less than ideal'.
Family carers are obviously not required to meet specific care standards, although if wilful neglect or mistreatment has occurred, carers may be prosecuted under Section 44 of the Mental Capacity Act 2005. The quality of the care they provide is not subject to regulation or inspection, so it can be difficult for practitioners to decide when and how to intervene.
It is not always easy to pinpoint where private decision-making in families about how they want to do things should end and where intervention should begin, to ensure the safety and uphold the rights of the adult with care and support needs. Always bear in mind the wishes and feelings of the person with care and support needs as a guide.
You will undoubtedly come across care situations in domestic settings that you judge to be inadequate for the person being cared for and that would be unacceptable in a care home. There will be times when family carers act in a way that you would not expect a paid care worker to act. For example:
- medicine may not be given exactly as it is prescribed
- lifting and handling practices may not be ideal
- money that has been allocated to meet a disabled adult's needs may be spent on other family members.
If a paid carer was responsible, you would probably intervene. In a family setting, you may be unclear about whether to do anything about it.
The key issue is whether the person being cared for is at direct risk of harm, and the extent of any potential or actual harm. You have to act if, for example:
- hurtful comments or threats to abandon the person are causing them significant distress
- a carer's failure to reposition the person they care for regularly enough is causing pressure ulcers
- the person does not have enough food to eat or warm-enough clothes, while the money they have been given is going elsewhere.
You have to act even if it means entering the difficult territory of cultural differences. If a person is at risk of harm because of their carer's actions, then you should be prepared to step in.
It is important always to be aware of the pressure that family carers may be under, and to consider the reasons why they make particular decisions and take particular actions. Starting safeguarding procedures risks making a difficult situation harder for the family carer and the person they care for. The carer may be doing their best but still struggling. They may put the person at risk because they snap under pressure, rather than because they intend to deliberately cause them harm.
Obvious abuse or neglect should trigger an immediate safeguarding response. But in many cases, you may need to adopt a twin approach of supporting the carer while safeguarding the person they care for, and considering both their needs at the same time. Your response should be proportionate to the risk that is posed, with the aim of helping families manage their caring responsibilities more easily. Working with carers to identify what is putting them under the greatest pressure and what type of support would help, will often reduce the risk to the person they are caring for.
Supervision and discussion with other professionals may help in thinking through the risks. Other professionals may have valuable information or observations to share, and they can help with monitoring risks. Developing a safeguarding support plan is key to practice here.
22. How can practitioners support someone after a safeguarding incident, to prevent further abuse or neglect?Open
After a safeguarding incident has been reported and investigated, and action taken to ensure that the person is no longer at risk of abuse or neglect, practitioners should consider what ongoing support the person may need.
Follow-up support should include:
- discussing with the person the safeguarding support they received, and listening to their views and experiences, so that future support can be planned and shaped according to their needs, wishes and circumstances – there are some useful tools to help with this
- using a strengths-based approach to support the person, which involves looking at what the individual has available to them, rather than what they lack, and helping them to make use of their existing networks and relationships.
- working, where appropriate, with the person who has caused the harm that the adult at risk has experienced, to reduce the risk that abuse or neglect will happen again.
There are various resources and toolkits available to help practitioners develop the knowledge and skills they need to safeguard adults more effectively. These include ‘Making Safeguarding Personal’ and a number of guides and learning materials from the Social Care Institute for Excellence.
The information contained in the guidance is drawn from:
- the Care Act 2014
- the Mental Capacity Act 2005
- Department of Health statutory guidance on the Care Act 2014
- reports by Task and Finish Groups set up to advise on the implementation of the Care Act 2014 with regard to adult safeguarding
- Social Care Institute for Excellence (SCIE) research and practice guidance
- Adult safeguarding for housing staff
- Adult safeguarding: sharing information
- Adult safeguarding: mediation and family group conferences
- Adult safeguarding: e-learning
- Commissioning care homes: common safeguarding challenges
- Effective supervision in a variety of settings
- Gaining access to an adult suspected to be at risk of neglect or abuse
- Mental Capacity Act 2005
- Mental Capacity Act: What do IMCAs do?
- Prevention in Adult Safeguarding
- Self-neglect and adult safeguarding: findings from research
- Making Safeguarding Personal
- Adult safeguarding and domestic abuse: A guide to support practitioners and managers
- Home Office Guidance on domestic violence and abuse