Report 47: User involvement in adult safeguarding
Safeguarding adults policy
The consultation [on No secrets] placed sharper focus on the balance between…rights of choice, self-determination and autonomy, and…statutory obligations to protect people from risk of abuse and harm.
'No secrets' guidanceOpen
The statutory guidance, 'No secrets', set out the first comprehensive policy framework on adult safeguarding.(18) Calling for partnership work, it gave local authorities the lead role in developing local policies and procedures on adult safeguarding.
'No secrets' set out some basic principles of empowerment, confidentiality, information, advocacy and rights, to be balanced with risks to the self and others. It stated that outcomes should be audited routinely so that problems can be learned from and practice improved. The balance of risk on the one hand and freedom of choice on the other is a clear tension throughout the No secrets guidance, and another is the balance between openness and confidentiality.
Key definitions in 'No secrets'Open
'No secrets' defined a vulnerable adult or 'adult at risk' as:
[a person over 18] who is or may be in need of community care services by reason of mental or other disability, age or illness; and who is or may be unable to take care of him or herself, or unable to protect him or herself against significant harm or exploitation.(18)
'No secrets' defined abuse in terms of single or repeated acts which may be physical, verbal or psychological abuse, or may be acts of neglect or omission to act, or may occur 'when a vulnerable person is persuaded into a financial or sexual transaction to which he or she has not consented or cannot consent'. Some types of abuse may be defined as criminal offences, for example assault. Neglect and poor professional practice is sometimes referred to as 'institutional abuse'. Abusers may be relatives, professional staff, paid care workers, volunteers, other service users, friends or neighbours, or may be strangers. Abuse can happen in any context or environment.
'No secrets' did not include self-neglect or self-harm within its definition of abuse. Braye and Preston Shoot systematically reviewed literature on the concept of self-neglect as interpreted in adult safeguarding practice, finding that in the UK, as opposed to the USA, self-neglect is seen as outside the remit of adult safeguarding.(19) As a result, responses to self-neglect differ across localities, sometimes being led by adult social care and sometimes through safeguarding procedures.
'No secrets' and user involvementOpen
'No secrets' contained a number of references to the involvement of people who use services. It included 'user groups and user-led services' among the list of 'responsible and relevant agencies' when it comes to creating and implementing the guidance'. It also recommended that:
- the inter-agency framework must take account of the views of service users, families and carer representatives.
- the multi-agency management committee should audit (preferably annually) the working of its policies and procedures, including evaluation of community understanding of them.
- agencies should learn from experience by routinely gathering information on the outcomes of investigations and users'/carers' views on how policy has worked for them.
- inter-agency policy should be available as a matter of routine, in an appropriate form to families and carers and (where appropriate) to service users.(18)
'No secrets' specified that advocates are to be appointed where necessary, and that agencies must set out how the services of advocates can be accessed and their role, and that information for people who use services, carers and the general public should be available in user friendly formats, with explanation what abuse is, how to raise a concern or complaint, and what they can expect.
One notable omission from 'No secrets' was that it contained no recommendation for the training for staff and volunteers to include training in involving users.
ADASS safeguarding standardsOpen
In 2005, the Association of Directors of Adult Social Services produced a framework for the implementation of adult safeguarding, which set out 11 standards for how local authorities should work.(20) Standards 10 and 11 state respectively that safeguarding procedures should be accessible to all adults covered by the policy, and that safeguarding adults partnerships must include service users as key partners in all aspects of their work, as members and participants in strategic planning and training, and in 'planning and implementation of their individual safeguarding assessment and plans'.
Review of 'No secrets'Open
In 2007 the Department of Health announced a review of 'No secrets'.(21) The consultation received responses from 12,000 people. Most challenged the term 'vulnerable adult', and as a result the report used the term 'adult'.
A key message from the consultation was the central role of empowerment or 'listening to the victim's voice'. Some groups, in particular people from black and minority ethnic backgrounds, and the older generation, had less understanding of what abuse meant and how to get help. Participants expressed concern that the balance of choice and risk flagged up in 'No secrets' is still undetermined, and the need to clarify this given the personalisation agenda.
As part of the review, Mind carried out a study which involved surveys and focus groups of people who use services and voluntary organisations, to gain insight into people's experiences of abuse and what they wanted from statutory agencies.(22)
Confirming the findings of earlier research – for example Cambridge and Parkes, and Lewis (23, 9) – Mind found evidence of exclusion of people with mental health problems from involvement. People who use mental health services often resist being labeled as 'vulnerable' or 'at risk' simply on the basis of their diagnosis. The Mind research also suggested that institutional abuse within the NHS is widespread and unchecked, since the NHS deals internally with allegations of abuse rather than engaging with the police or adult safeguarding teams.
The consultation placed sharper focus on the balance between, on the one hand, rights of choice, self-determination and autonomy, and on the other hand, statutory obligations to protect people from risk of abuse and harm. It showed up particular issues relating to people who use mental health services, who may be pre-judged as 'vulnerable' because of their diagnosis or excluded from consultation, and the difficulty for people in care services to report abuse. It showed that people generally need to be better involved and informed about safeguarding and their own individual safeguarding processes. Legislative change to place a legal duty on local authorities to investigate suspected abuse was generally supported, though with caveats about how these powers should be balanced with rights to autonomy
CSCI and user involvementOpen
The Commission for Social Care Inspection (CSCI) completed two significant pieces of work on safeguarding: first, a seminar to access the views of people who use services on safeguarding and second, a study of the effectiveness of arrangements to prevent abuse and support victims of abuse.(24, 25)
Participants at the CSCI stakeholder seminar agreed that vulnerability relates to circumstances rather than being an inherent quality, so they called for an alternative to the 'No secrets' definition of 'vulnerable adults'. Participants saw empowerment as a crucial factor. They drew attention to the often delicate balancing of choice and risk and called for training for service providers in supporting individuals to take risks and make choices, while also being able to listen, respond and act if told about experiences that may be abusive. They called for debates in adult safeguarding to focus on rights and wellbeing, not just on abuse and protection. Personalisation was seen as the opposite of over-protective paternalistic services.
CSCI's study on safeguarding drew on a range of evidence: self-assessment reports from 150 councils, CSCI service inspections, specific inspections of care homes and services to ask about safeguarding, and in-depth accounts from 30 people in five council locations on how the arrangements to protect them from abuse worked for them. CSCI found some good practice in raising public awareness of abuse and safeguarding, and in some councils, good work is being done to communicate with people with learning disabilities living in the community. CSCI found that more information about safeguarding was targeted at older and disabled people. However, they also found uneven progress in developing safeguarding procedures and the quality of support given to people who have been abused.
Confirming the findings of Furness (26), CSCI found that users in 82 per cent of care services did feel able to speak to staff if they felt unsafe, but users in only 61 per cent of services were confident their concerns would be acted on. Advocacy was valued but 58 per cent of councils had shortfalls in the provision of advocacy, and the Independent Mental Capacity Advocacy (IMCA) service was still at an early stage of development. They found that most safeguarding adults boards were struggling to find practical ways of engaging local people who use services and other members of the community in decision making, service design and strategic development.(24)
CSCI recommended that more personalised protection planning is needed, and suggested that most councils and care services put in place systems 'to obtain feedback from people who have experienced abuse and monitor the outcomes for people in order to improve services'. They also recommended that information about safeguarding be better targeted, as they found evidence that people using mental health services, people misusing drugs or alcohol, people from black and minority ethnic communities and those funding their own care may be missing out on information.(24)
Safeguarding guidance for LondonOpen
A recent development is the production of two key regional guidance documents on adult safeguarding – one for London and one for Wales – in order to bring greater consistency to policy and procedures in these regions. Both documents make explicit reference to involving people who use services.
London's multi-agency policy, 'Protecting adults at risk,' refers to 'adults at risk', rather than 'vulnerable adults', as suggested during the 'No secrets' consultation.(4) The policy includes a key commitment to 'empower and support people to make their own choices' but warns about the limits to involvement given the need for confidentiality and safety, and the mental capacity of the adult at risk. The priority throughout is the safety and protection of adults at risk but this is balanced by considerations of choice, informed consent, and capacity to make decisions. The policy includes suggests ways to support choice, such as collaborative work with people who use services and carers, accessible information, access to advocates or IMCAs, and access to complaints procedures. Safeguarding adults managers are expected to ensure that adults at risk are involved in all decisions that affect their daily life, and to ensure that if a protection plan is needed, the person is involved in and consents to this, if they have capacity to participate, or to ensure the plan is in the person's best interest if they do not have capacity.
Safeguarding guidance for WalesOpen
The 'Wales' 'interim policy and procedures for the protection of vulnerable adults from abuse' retains the term 'vulnerable adult'.(16) It covers similar ground to the London policy, but the first part of the document sets out principles on the rights of vulnerable adults to be involved. It later states that vulnerable adults 'have the right to be supported and empowered when adult protection procedures are used, and to have an independent advocate if they wish'.
The section on risk assessment argues that it is very important to involve people who use services on three grounds:
- 'there are citizens' rights/human rights issues involved
- the greater commitment which involvement will bring may be crucial in achieving positive outcomes
- the greater trust, which will be engendered by involvement, will enhance the information available from the service user towards a more effective assessment.'
Collins advises adult protection committees to provide discussion sessions for vulnerable people about abuse, adult protection and rights, perhaps in conjunction with user/carer or advocacy groups. He mentions that in some parts of Wales voluntary sector organisations have been involved in delivering this training, sometimes run by vulnerable people themselves to increase awareness about abuse and how to keep safe.
Many pieces of legislation have implications for adult safeguarding, including for example:
- the Human Rights Act 1998 which gives legal force to ensure respect for human rights and high standards of practice by public bodies
- the Care Standards Act 2000 and subsequent regulations placed a requirement on care providers to create procedures to protect people in their care from abuse or harm
- the Mental Capacity Act 2005 makes it an offence to mistreat or willfully neglect people thought to lack mental capacity, and the Mental Health Act 2007 contains a similar offence.
The general call for legislation to strengthen guidance on safeguarding – in particular highlighted in the review of 'No 'secrets (21) – has been taken up by the Law Commission, who have proposed a new adult social care law.(27) The purpose of this to streamline what David Brindle, 'Guardian' columnist, describes as 'a "hodgepodge" of almost 40 laws governing the care and support of older and disabled people'.(28) The proposed new law includes a legal duty on local authorities to make enquiries where it has reasonable cause to suspect that a person appears to be an adult at risk.
Many of those who were consulted by the Law Commission about the need for a new law drew attention to the UN Convention on the Rights of Disabled Persons, pointing out that this convention requires states to take legislative as well as other measures 'to protect persons with disabilities, both within and outside the home, from all forms of exploitation, violence and abuse, including their gender-based aspects'.(29,30) They also pointed out that new legislative powers must be reconciled with Article 3 of the UN Convention which emphasises dignity, autonomy and choice, commenting that 'supporting autonomy and protecting from abuse do not have to be seen as opposites and can go hand in hand' though 'translating this into legislative form is not an easy task'.