Report 41: Prevention in adult safeguarding
'People who use services are clear that effective prevention in safeguarding is not about over-protective paternalism or risk-averse practice.'
This review outlines the literature on the range of methods of preventing the abuse of adult at risk, from public awareness campaigns through to approaches that empower the individual to be able to recognise, address and report abuse. In addition, this review reports on policy and practice guidance and examples of emerging practice. The review has been informed by SCIE's Adult Safeguarding Service User Advisory Group.
Prevention as a priorityOpen
Prevention of abuse has not always been high on the adult safeguarding agenda. The publication of 'No secrets: Guidance on developing and implementing multi-agency policies and procedures to protect adult at risk from abuse' in 2000 was a landmark in setting up a framework for adult safeguarding.(1) It emphasised the importance of inter-agency working and established that local authorities should lead on adult safeguarding. Its agenda was set largely by the incidents of serious abuse revealed over the previous decade, resulting in a focus on ensuring that agencies be alert to the signs of abuse taking place and respond appropriately.
Nine years later, the findings of 'Safeguarding adults: Report on the consultation on the review of No secrets' placed a new emphasis on prevention and on empowering individuals to maintain their own safety.(2) The consultation found that safeguarding can be experienced as 'safety at the expense of other qualities of life, such as self determination and the right to family life'. The report highlighted the importance of achieving a balance between keeping people safe and enabling the independence associated with personalisation in adult social care.
Around the same time as the 'No secrets' review consultation, the Commission for Social Care Inspection carried out a study of local safeguarding arrangements to protect adults from abuse, which included examination of 23 CSCI inspections of councils, fieldwork in five council locations as well as inspections of care homes and home care agencies.(3) They found that actions to prevent abuse were variable across councils and within individual care services. They highlighted the need for a greater emphasis on prevention by 'designing safeguarding into services'.
What is prevention?Open
Most people would agree that 'prevention is better than cure'. However, identifying what works – and for whom and in what situations – is very difficult where the prevention of abuse and neglect of vulnerable adults is concerned. Much abuse and neglect takes place in secret. This makes it hard to prove that an abusive event has occurred, and almost impossible to demonstrate that an abusive event has been prevented. Put another way, it is very difficult to judge what constitutes a successful prevention intervention.
An increase in referrals might indicate an increase in awareness (and hence action) or it could mean an increase in abuse taking place. Hester and Westmarland in their evaluation of the 27 domestic violence projects usefully suggest that, while domestic violence remains an under-reported crime, projects should aim to increase reported incidents in the short term and decrease them in the longer term.(4) This could reasonably be extended to the field of adult safeguarding as a whole. Similarly, CSCI referred to low referral rates as a proxy for low levels of awareness about abuse.(3)
People who use services are clear that effective prevention in safeguarding is not about over-protective paternalism or risk-averse practice. Instead, the prevention of abuse should occur in the context of person-centred support and personalisation, with individuals empowered to make choices and supported to manage risks.(5, 3, 6) This desire for people who use services to be empowered to prevent abuse is reflected in the 'No secrets' consultation report:
One of the strongest messages from the engagement with non-professionals was that safeguarding must be built on empowerment – on listening very carefully to the voices of individuals who are at risk, and those who have been harmed. Without empowerment, without people's voices, safeguarding did not work.(2)
This suggests that prevention in safeguarding needs to be broadly defined, informed by personalisation and include all social care user groups and service configurations. It includes multi-agency working (including information sharing), community safety, community participation and public awareness, as well as awareness raising and skills development with adult at risk.
Prevention in actionOpen
CSCI identified the following building blocks for prevention and early intervention:
- people being informed of their rights to be free from abuse and supported to exercise these rights, including access to advocacy
- a well trained workforce operating in a culture of zero tolerance of abuse
- sound framework for confidentiality and information sharing across agencies
- good universal services, such as community safety services
- needs and risk assessments to inform people's choices
- a range of options for support to keep safe from abuse tailored to people's individual needs
- services that prioritise both safeguarding and independence
- public awareness of the issues.
CSCI found that these building blocks are not consistently in place across different local authorities.(2)
Kalaga and Kingston in their review of the literature on 'effective interventions that prevent and respond to harm against adults' categorise interventions at primary, secondary and tertiary levels:
- primary interventions: aim to prevent abuse occurring in the first instance
- secondary interventions: aim to identify and respond directly to allegations of abuse
- tertiary interventions: aim to remedy any negative and harmful consequences of abuse and to put in place measures to prevent future occurrences.(7)
Legislative and policy driversOpen
There are a number of legislative, regulatory and policy-based drivers for local authorities to undertake preventative work. These include:
- The NHS and Community Care Act 1990:Section 47(5) allows urgent temporary services to be provided in lieu of an assessment. Paragraph 16 of the Fair Access to Care Services guidance refers to the occurrence or likely occurrence of abuse or neglect as indicating critical or substantial needs for services.(8)
- The above approach was supported with the publication of 'Guidance on eligibility criteria for adult social care.'(9) This was published to reflect the increased focus on personalisation featured in 'Putting people first.'(10)
- The Health and Social Care Act 2008. This requires registered providers to take 'reasonable steps to identify the possibility of abuse and prevent it before it occurs' (Regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010).
- The 2005 Association of Directors of Adult Social Services report, 'Safeguarding adults: A national framework of standards for good practice and outcomes in adult protection work.'(11) Standards 3, 4 and 5 relate to the prevention of abuse:
Standard 3: Every person has the right to live a life free from abuse and neglect; this message is actively promoted to the public by the Local Strategic Partnership, the 'Safeguarding Adults' partnership, and its member organisations.
Standard 4: Each partner agency has a clear, well-publicised policy of zero-tolerance of abuse within the organisation.
Standard 5: The 'Safeguarding Adults' partnership oversees a multi-agency workforce development/training sub-group. The partnership has a workforce development/training strategy and ensures that it is appropriately resourced.
- Safeguarding Vulnerable Groups Act 2006 (SVG) and the Protection of Freedoms Bill - The SVG Act was passed to help avoid harm, or risk of harm, by preventing people who are deemed unsuitable to work with children and vulnerable adults from gaining access to them through their work. The Independent Safeguarding Authority was established as a result of this Act. On 1 December 2012 the Criminal Records Bureau and Independent Safeguarding Authority merged to become the Disclosure and Barring Service (DBS). Organisations with responsibility for providing services or personnel to vulnerable groups have a legal obligation to refer relevant information to the service. The Protection of Freedoms Bill (chapter 1 of Part 5) amends the Safeguarding Vulnerable Groups Act 2006, retaining the national barring function whilst abolishing registration and monitoring requirements. For further information see the Protection of Freedoms Bill Home Office Fact Sheet.
What is 'abuse'?Open
According to 'No secrets', 'Abuse is a violation of a person's human and civil rights by another person or persons.'(1) 'No secrets' includes the following definitions of abuse:
- physical abuse: including hitting, slapping, pushing, kicking, misuse of medication, restraint or inappropriate sanctions
- sexual abuse: including rape and sexual assault or sexual acts to which the adult at risk has not consented, or could not consent or was pressured into consenting
- psychological abuse: including emotional abuse, threats of harm or abandonment, deprivation of contact, humiliation, blaming, controlling, intimidation, coercion, harassment, verbal abuse, isolation or withdrawal from services or supportive networks
- financial or material abuse: including theft, fraud, exploitation, pressure in connection with wills, property or inheritance or financial transactions or the misuse or misappropriation of property, possessions or benefits
- neglect and acts of omission: including ignoring medical or physical care needs, failure to provide access to appropriate health, social care or educational services, the withholding of the necessities of life such as medication, adequate nutrition and heating
- discriminatory abuse: including racist, sexist, that based on a person's disability, and other forms of harassment, slurs or similar treatment.
The evidence baseOpen
Most of the identified literature focuses on older adults or people with learning disabilities, and there is some research on domestic violence. There is little on people with mental health problems or people with physical disabilities. A relatively small proportion of the literature reports on primary research. Several items are literature or policy reviews, or practice evaluations.
Most of the literature concerns psychological abuse, sexual abuse, physical abuse and domestic violence. There is less on financial abuse, despite the fact that it has been found to be second only to neglect in frequency among older adults living in the community in a large-scale survey funded by Comic Relief and the Department of Health.(13)
The evidence on 'what works' to prevent abuse in practice is thin. Many of the reported studies are small-scale studies with little evidence of generalisability. The term 'safeguarding adults' – an umbrella term to cover all adult at risk – is relatively new. It does not have a long research history and is intrinsically difficult to measure or prove. Northway et al, in a review of the literature on adult protection for people with learning disabilities, further point to the fact that much adult protection research has originated out of the concerns of practitioners; and therefore does not have a significant place in the academic literature.(14)
Similarly, Kalaga and Kingston state that the evidence base is sparse and that there is a need for researchers to analyse and evaluate interventions in the coming years.(7) Furthermore, the scoping work carried out by SCIE at the outset of this project suggests that positive examples of prevention work could usefully be disseminated across the sector in order to share the learning.
Structure of this reviewOpen
This review focuses mainly on what Kalaga and Kingston identify as primary interventions, with some consideration of tertiary interventions where they are aiming to prevent future occurrences of previous abuse.(7) It considers prevention in the following sections:
- identifying people at risk of abuse
- public awareness
- information, advice and advocacy
- training and education
- policies and procedures
- community links and community support
- regulation and legislation
- inter-agency collaboration
- empowerment and choice