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1.4 Abuse

RELEVANT CHAPTER / SECTION

Specific Types of Abuse and Related Issues

Safeguarding Adults

Safeguarding Adults Procedures

November 2017: Section 4.9, Self-Neglect was updated to strengthen reference to mental capacity and best interests processes.

1. Introduction

See also Local Contacts for contact information for the Safeguarding Teams and the Emergency Duty Team.

For the purpose of this safeguarding adults policy and procedures the term abuse is defined as:

  • a violation of an individual’s human and civil rights by any other person;
  • or persons which may result in significant harm.

Abuse may be:

  • a single act or repeated acts;
  • an act of neglect or a failure to act;
  • multiple acts (for example, an adult may be neglected and financially abused).

Abuse is about the misuse of the power and control that one person has over another. Where there is dependency, there is a possibility of abuse or neglect unless adequate safeguards are put in place.

Intent is not necessarily an issue at the point of deciding whether an act or a failure to act is abuse; it is the impact of the act on the person and the harm or risk of harm to that individual.

Acts of abuse may constitute a criminal offence.

Safeguarding adults refers to an adult who is experiencing or at risk of abuse or neglect, hereon referred to as an adult.

2. Location of Abuse

Abuse can take place anywhere, for example:

  • the person’s own home, whether living alone, with relatives or others;
  • day or residential centres;
  • hospitals;
  • supported housing;
  • work settings;
  • educational establishments;
  • care homes;
  • clinics;
  • prisons;
  • other places in the community.

3. Who might Abuse?

Abuse can occur in any relationship and may result in significant harm to, or exploitation of, the adult/s at risk.

A wide range of people may harm adults. These include:

  • a member of staff, owner or manager at a residential or nursing home;
  • a professional worker such as a nurse, social worker or general practitioner (GP);
  • a volunteer or member of a ‘community group’ such as a social club or place of worship;
  • another service user;
  • a spouse, partner, relative or friend;
  • a carer;
  • a neighbour, member of the public or a stranger;
  • a person who deliberately targets adults in order to exploit them.

4. Types and Patterns of Abuse and Neglect

See also Introduction – Making enquiries: Abuse and neglect.

The local authority must enquiries where it has reasonable cause to suspect an adult in its area (whether or not ordinarily resident there):

  • has needs for care and support (whether or not the authority is meeting any of those needs);
  • is experiencing, or is at risk of, abuse or neglect; and
  • as a result of those needs is unable to protect himself or herself against the abuse or neglect or the risk of it.

The Care Act 2014 states the following factors are to be taken into account when making an assessment of the seriousness of risk to the person:

  • vulnerability of the person;
  • nature and extent of the abuse or neglect;
  • length of time the abuse or neglect has been occurring;
  • impact of the alleged abuse on the adult;
  • risk of repeated or increasingly serious acts of abuse or neglect;
  • risk that serious harm could result if no action is taken;
  • illegality of the act/s.

Abuse can be viewed in terms of the following categories (although this is not an exhaustive list):

Abusive behaviours may constitute a criminal offence. All suspected abuse must be investigated.

The presence of one or more of these signs does not confirm abuse. However, the presence of one or a number of these indicators may suggest the potential for abuse and a safeguarding referral must be made. See also Safeguarding Adults Process: Introduction and the Safeguarding Adults Process Flowchart.

4.1 Physical abuse

Physical abuse includes hitting, slapping, pushing, kicking, misuse of medication, being locked in a room, inappropriate sanctions or force feeding, inappropriate methods of restraint, and unlawfully depriving a person of their liberty.

4.1.1 Possible indicators

  • unexplained or inappropriately explained injuries;.
  • person exhibiting untypical self-harm;
  • unexplained cuts or scratches to mouth, lips, gums, eyes or external genitalia;
  • unexplained bruising to the face, torso, arms, back, buttocks, thighs, in various stages of healing. Collections of bruises that form regular patterns which correspond to the shape of an object or which appear on several areas of the body;
  • unexplained burns on unlikely areas of the body (for example, soles of the feet, palms of the hands, back), immersion burns (from scalding in hot water/liquid), rope burns, burns from an electrical appliance;
  • unexplained or inappropriately explained fractures at various stages of healing to any part of the body;
  • medical problems that go unattended;
  • sudden and unexplained urinary and / or faecal incontinence;
  • evidence of over-/under-medicating;
  • person flinches at physical contact;
  • person appears frightened or subdued in the presence of particular people;.
  • person asks not to be hurt;
  • person may repeat what the alleged abuser has said (for example ‘shut up or I’ll hit you’);
  • reluctance to undress or uncover parts of the body;
  • person wears clothes that cover all parts of their body or specific parts of their body;
  • a person without capacity not being allowed to go out of a care home when they ask to;
  • a person without capacity not being allowed to be discharged at the request of an unpaid carer / family member.

4.2 Sexual abuse

Sexual abuse includes rape and sexual assault or sexual acts that the adult has not consented to or could not consent to, or was pressured into.

It includes penetration of any sort, incest and situations where the alleged abuser touches the abused person’s body (for example breasts, buttocks, genital area), exposes his or her genitals (possibly encouraging the abused person to touch them) or coerces the abused person into participating in or looking at pornographic videos or photographs. Denial of a sexual life to consenting adults is also considered abusive practice.

Any sexual relationship that develops between adults where one is in a position of trust, power or authority in relation to the other (for example day centre worker / social worker / residential worker / health worker) may also constitute sexual abuse (see Stage 3: Undertaking Enquiries, Section 4.1, If the alleged person causing harm is an employee).

4.2.1 Possible Indicators

  • person has urinary tract infections, vaginal infections or sexually transmitted diseases that are not otherwise explained;
  • person appears unusually subdued, withdrawn or has poor concentration;
  • person exhibits significant changes in sexual behaviour or outlook;
  • person experiences pain, itching or bleeding in the genital / anal area;
  • person’s underclothing is torn, stained or bloody;
  • a woman who lacks the mental capacity to consent to sexual intercourse becomes pregnant;
  • sexual exploitation.

The sexual exploitation of adults involves exploitative situations, contexts and relationships where adults (or a third person or persons) receive ‘something’ (for example food, accommodation, drugs, alcohol, cigarettes, affection, gifts, money) as a result of performing, and / or others performing on them, sexual activities.

Sexual exploitation can occur through the use of technology without the person’s immediate recognition: this can include, being persuaded to post sexual images on the internet/a mobile phone or being sent such an image by the person alleged to be causing harm. In all cases those exploiting the adult have power over them by virtue of their age, gender, intellect, physical strength and/or economic or other resources.

4.3 Psychological abuse

Psychological abuse includes ‘emotional abuse’ and takes the form of threats of harm or abandonment, deprivation of contact, humiliation, rejection, blaming, controlling, intimidation, coercion, indifference, harassment, verbal abuse (including shouting or swearing), and isolation or withdrawal from services or support networks.

Psychological abuse is the denial of a person’s human and civil rights including choice and opinion, privacy and dignity and being able to follow one’s own spiritual and cultural beliefs or sexual orientation.

It includes preventing the adult from using services that would otherwise support them and enhance their lives. It also includes the intentional and / or unintentional withholding of information (for example information not being available in different formats / languages and so on).

4.3.1 Possible indicators

  • untypical ambivalence, deference, passivity, resignation;
  • person appears anxious or withdrawn, especially in the presence of the alleged abuser;
  • person exhibits low self-esteem;
  • untypical changes in behaviour (for example continence problems, sleep disturbance);
  • person is not allowed visitors / phone calls;
  • person is locked in a room / in their home;
  • person is denied access to aids or equipment, (for example glasses, dentures, hearing aid, crutches, etc.);
  • person’s access to personal hygiene and toilet is restricted;
  • person’s movement is restricted by use of furniture or other equipment;
  • bullying via social networking internet sites and persistent texting.

4.4 Financial or material abuse

This includes theft, fraud, exploitation, pressure in connection with wills or property and the misappropriation of property or benefits. It also includes the withholding of money or the unauthorised or improper use of a person’s money or property, usually to the disadvantage of the person to whom it belongs. Staff borrowing money or objects from a service user is also considered financial abuse.

Financial abuse can significantly impact on an adult’s health and well-being, and research has shown that where there are other forms of abuse, financial abuse is likely to be occurring.

Where abuse is perpetrated by someone who has the authority to manage and adult’s money, the relevant body should be informed. In the case of a deputy or attorney this will be the Office of the Public Guardian, and for appointees the Department for Work and Pensions.

4.4.1 Possible indicators

  • lack of money, especially after benefit day;
  • inadequately explained withdrawals from accounts;
  • disparity between assets / income and living conditions;
  • power of attorney obtained when the person lacks the capacity to make this decision;
  • recent changes of deeds / title of house;
  • recent acquaintances expressing sudden or disproportionate interest in the person and their money;
  • service user not in control of their direct payment or individualised budget;
  • misleading sales by door-to-door traders / cold callers;
  • illegal money lending.

4.5 Neglect and acts of omission

These include ignoring medical or physical care needs, failure to provide access to appropriate health, social care or educational services, and the withholding of the necessities of life such as medication, adequate nutrition and heating. Neglect also includes a failure to intervene in situations that are dangerous to the person concerned or to others, particularly when the person lacks the mental capacity to assess risk for themselves.

Neglect and poor professional practice may take the form of isolated incidents or pervasive ill treatment and gross misconduct. Neglect of this type may happen within a person’s own home or in an organisation. Repeated instances of poor care may be an indication of more serious problems. Neglect can be intentional or unintentional.

4.5.1 Possible Indicators

  • person has inadequate heating and / or lighting;
  • person’s physical condition/appearance is poor (for example ulcers, pressure sores, soiled or wet clothing);
  • person is malnourished, has sudden or continuous weight loss and / or is dehydrated;
  • person cannot access appropriate medication or medical care;
  • person is not afforded appropriate privacy or dignity;
  • person and / or a carer has inconsistent or reluctant contact with health and social services;
  • callers / visitors are refused access to the person;
  • person is exposed to unacceptable risk.

4.6 Discriminatory abuse

This includes discrimination on the grounds of race, faith or religion, age, disability, gender, sexual orientation and political views, along with racist, sexist, homophobic or ageist comments or jokes, or comments and jokes based on a person’s disability or any other form of harassment. It also includes not responding to dietary needs and not providing appropriate spiritual support. Excluding a person from activities on the basis they are ‘not liked’ is also discriminatory abuse.

4.6.1 Possible Indicators

Indicators for discriminatory abuse may not always be obvious and may also be linked to acts of physical abuse and assault, sexual abuse and assault, financial abuse, neglect, psychological abuse and harassment, so all the indicators listed above may apply to discriminatory abuse.

  • a person may reject their own cultural background and / or racial origin or other personal beliefs, sexual practices or lifestyle choices;
  • a person making complaints about the service not meeting their needs.

4.7 Organisational abuse

See also Inquiry Reports.

Organisational abuse is the mistreatment, abuse or neglect of an adult by a regime or individuals in a setting or service where the adult lives or that they use. Such abuse violates the person’s dignity and represents a lack of respect for their human rights.

Organisational abuse occurs when the routines, systems and regimes of an organisation result in poor or inadequate standards of care and poor practice which affect the whole setting and deny, restrict or curtail the dignity, privacy, choice, independence or fulfilment of adults.

Organisational abuse can occur in any setting providing health or social care. A number of inquiries into care in residential settings have highlighted that organisational abuse is most likely to occur when staff:

  • receive little support from management;
  • are inadequately trained;
  • are poorly supervised and poorly supported in their work;
  • receive inadequate guidance;

Such abuse is also more likely where there are inadequate quality assurance and monitoring systems in place.

4.7.1 Possible indicators

  • unnecessary or inappropriate rules and regulations;
  • lack of stimulation or the development of individual interests;
  • inappropriate staff behaviour, such as the development of factions, misuse of drugs or alcohol, failure to respond to leadership;
  • restriction of external contacts or opportunities to socialise.

4.8 Modern Slavery

See also Modern Slavery.

Modern slavery encompasses slavery, human trafficking, forced labour and domestic servitude. Traffickers and slave masters use whatever means they have at their disposal to coerce, deceive and force individuals into a life of abuse, and inhumane treatment.

4.9 Self-neglect

Self-neglect includes a wide range of behaviour that threatens the person’s own health and / or safety. It may include failure to on the part of the person to provide themselves with adequate food, water, clothing and shelter. It may mean neglecting to care for one’s personal health, hygiene or surroundings, including hoarding, taking adequate safety precautions and the misuse of drugs and alcohol.

Self-neglect differs from other types of abuse in that there is no third party involved. Furthermore, the definition of self-neglect excludes a situation in which a person who has capacity makes a decision to engage in acts that threaten their health and safety as a matter of choice.

Where there is concern that an individual has needs for care and support, then the local authority should offer an assessment relating to this in the first instance. If the person refuses to engage with a needs assessment then a mental capacity assessment should be considered (see Mental Capacity and Deprivation of Liberty Safeguards). If the individual has capacity in relation to their needs for care and support then use of the Vulnerable Adults Risk Management (VARM) process must be considered  (see VARM in Local Guidance and Templates). If the person is assessed as lacking capacity or refuses to engage in a mental capacity assessment and the safeguarding threshold is met, then follow the Mental Capacity Act and Best Interests process to inform decision making to safeguard the individual (see Safeguarding Adults Procedures).

4.10 Domestic Abuse and Violence

See also Domestic Abuse and Violence, Home Office.

Domestic abuse and violence is defined as ‘any incident of threatening behaviour, violence or abuse (psychological, physical, sexual, financial or emotional) between adults who are or have been intimate partners or family members regardless of gender or sexuality’. ‘Family members’ are defined as mother, father, son, daughter, brother, sister and grandparents, whether directly related, in-laws or step-family.

Whatever form it takes, domestic abuse and violence is rarely a one off incident and should instead be seen as a pattern of abusive and controlling behaviour through which the abuser seeks power over the victim. Domestic abuse and violence occurs across society, regardless of age, gender, race, sexuality, wealth and geography. The figures from reported incidents show, however, that it consists mainly of violence by men against women. Children are also affected both directly and indirectly and there is also a strong correlation between domestic abuse and violence and child abuse. See also the Domestic Abuse, Stalking and Harassment (DASH) Risk Assessment and Leicester, Leicestershire and Rutland Safeguarding Children Board procedures.

Effective safeguarding is achieved when agencies share information to obtain an accurate picture of the risk and then work together to ensure that the safety of the adult is prioritised. In high risk situations it may be relevant to access the Multi-agency Risk Assessment Conference (MARAC) process.

A MARAC is a meeting where information is shared on the highest risk domestic abuse and violence cases between representatives of the local police, probation, health, children and adult safeguarding bodies, housing practitioners, substance misuse services, Independent Domestic Abuse and Violence Advisers (IDVAs) and other specialists from the statutory and voluntary sectors.

The four aims of a MARAC are as follows:

  1. to safeguard adult victims who are at high risk of future Domestic abuse and violence
  2. to make links with other public protection arrangements in relation to children, people causing harm and vulnerable adults
  3. to safeguard agency staff
  4. to work towards addressing and managing the behaviour of the person causing harm.

Domestic Homicide Reviews (DHRs) were established on a statutory basis under the Domestic Abuse and Violence, Crime and Victims Act 2004. This provision came into force in 2011 and the purpose is to:

  • establish what lessons are to be learned from the domestic homicide regarding the way in which local professionals and organisations work individually and together to safeguard victims;
  • identify clearly what those lessons are, both within and between agencies, how and within what timescales they will be acted upon, and what is expected to change as a result;
  • apply these lessons to service responses including changes to policies and procedures as appropriate;
  • prevent domestic homicide and improve service responses for all domestic abuse and violence victims and their children through improved intra- and interagency working.

DHRs are not inquiries into how the victim died or into who is culpable and are not specifically part of any disciplinary inquiry or process. The rationale for the review process is to ensure agencies are responding appropriately to victims of domestic abuse and violence by offering and putting in place:

  • appropriate support mechanisms;
  • procedures;
  • resources and interventions with the aim of avoiding future incidents of domestic homicide and violence.

A DHR will also assess whether agencies have sufficient and robust procedures and protocols in place, which were in turn understood and adhered to by staff. The DHR process is similar to that of adult reviews and children’s serious case reviews. The main purpose is to learn lessons.

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