Resident-to-resident harm in care homes and residential settings

Introduction

This report from Social Care Institute for Excellence (SCIE) aims to explore resident-to-resident harm in care homes, also referred to as resident-to-resident abuse. However, there is an important distinction to be made between harm and abuse as abuse occurs within relationships where there is the expectation of trust. That expectation cannot be applied to the relationship between residents. Having highlighted this key distinction, this report reflects the literature and so refers to resident-to-resident abuse (RRA) throughout.

SCIE provides adult safeguarding training to a wide range of organisations across sectors. When working with care home providers, including those providing care in secure accommodation for people sectioned under the Mental Health Act, the issue of resident-to-resident harm is frequently raised as an issue of concern. Staff have highlighted the difficulties of managing residents with high-level needs and behaviours that may cause risk to others that are often caused by cognitive impairment. These issues are exacerbated where many such people are housed in the same service. Staff working with these challenging issues have reported the difficulties it causes for them as social care practitioners, causing anxiety and stress for individuals who are expected to manage sometimes volatile situations.

This led SCIE to look at the research evidence to establish what techniques and practices might be considered best practice in this area of work. Unfortunately, the research review found little in the way of evidence to support good practice in this area.

Specifically, this report aims to identify current research, policy and practice about resident-to-resident abuse in care homes. The report explores:

• Definitions and types of resident-to-resident abuse
• Prevalence of resident-to-resident abuse
• Risk factors for resident-to-resident abuse
• Prevention of and interventions for resident-to-resident abuse
• Research gaps
• Potential case studies

Whilst this report focuses on care homes, we recognise that harm can occur between people who use services in other settings such as day services.

Key messages

• There is very little UK literature on resident-to-resident abuse or harm, with most being from the US. Of the UK literature that is available, much of it is policy or practice documents rather than empirical research.
• The focus of literature on resident-to-resident harm has been on older adults, with less available about people with learning disabilities and other groups.
• Types of resident-to-resident abuse included: verbal (yelling, screaming), physical (hitting, kicking, pushing, throwing things), sexual (inappropriate touch, exposing themselves), violation of privacy and taking/damaging another’s belongings. Linked to this was bullying, mainly highlighted in ‘senior living facilities’.
• Abusive behaviour was rarely documented or reported in some settings, with evidence that some care managers consider it an inevitable or predictable part of living in a residential setting. Some services allow harmful behaviours to be accepted and unchallenged.
• Research regarding the prevalence of resident-to-resident abuse is limited, yet information from a variety of sources suggests it occurs fairly frequently. Prevalence data is hard to compare across studies and settings due to very different methods being used.
• Resident characteristics that are a risk factor for resident-to-resident abuse include dementia, mental illness, behavioural symptoms that may disrupt others and a history of aggressive or negative interactions with others.
• Environmental characteristics that are risk factors for resident-to-resident harm include a crowded environment, inadequate staffing levels, lack of staff training, high numbers of residents with dementia, a lack of meaningful activities, crowded common areas and excessive noise.
• Many incidents of resident-to-resident harm are not witnessed by staff.
• There is significant overlap between interventions to prevent staff-to-resident abuse as for resident-to-resident harm. These include professional training, development of person-centred care practices, and the use of a multidisciplinary approach.
• Interventions to reduce resident-to-resident harm include both environmental considerations (such as reducing crowding, noise and clutter, and prompting meaningful activities) and care practices (including care plans, staff training, identifying risk factors, consistent staffing to build relationships)
• There is a paucity of research into resident-to-resident harm, including prevalence data, detailed identification of perpetrator and victim characteristic, developing/assessing environmental interventions, developing/assessing staff training interventions