Safeguarding adults is everybody’s business. If not you, then who?

1. Safeguarding adults is everybody’s business. If not you, then who?

2. Safeguarding Adults – BMA Toolkit Health professionals • Should be able to identify adults whose physical, psychological or social condition are likely to render them vulnerable • Should be able to recognise signs of abuse and neglect, including institutional neglect • Need to familiarise themselves with local procedures and protocols for supporting and protecting vulnerable adults

3. Do you know about these cases?

4. Scale of the problem • In 2012-13 there were 1,522 safeguarding adults referrals in Buckinghamshire, 587 went to full assessment • The majority of people have a GP • Serious case reviews nationally and locally almost always demonstrate GP involvement • A tiny number of alerts are made by GP practices

5. Legislation and guidance

6. Draft Care and Support Bill • Most important piece of adult social care legislation in 60 years • 40 statutes in one piece of legislation • New safeguarding duties • Adult Safeguarding Boards

7. Definitions Vulnerable Adult “Anyone aged 18 or over who is or may be in need of care services by reason of mental or other disability, age or illness; and who is unable to take care of him or herself or unable to protect him or herself against significant harm or exploitation” Significant Harm • Ill-treatment (includes sexual abuse and forms of ill-treatment that are not physical) • impairment of, or an avoidable deterioration in, physical or mental health • Impairment of physical, emotional, social or behavioral development Abuse “A violation of an individual’s human and civil rights by any other person or persons” “A single or repeated act or lack of appropriate action occurring in a relationship where there is an expectation of trust which causes harm or distress”

8. This includes people who have: • a mental health problem • (including dementia or memory problems) • a physical disability or illness • drug and alcohol related problems • a sensory impairment • a learning disability • an acquired brain injury • frailty or a temporary illness

9. What Can Practices Do? • Training and awareness • Information for patients • Asking questions • Consider in reviews e.g. chronic disease • Follow up non attenders e.g. Repeat prescriptions • Carers policy • Flag records of vulnerable adults • Discuss concerns and significant events • Contribute to meetings

10. Practice Checklist • Safeguarding adults policy • Safeguarding adults lead • See the child behind the vulnerable adult • Highlight records of vulnerable adults • Information available for patients • Regular training • Significant events reviewed discussed • Concerns shared with CCG • Application of Mental Capacity Act to practice • Minimum safety criteria for staff employment • Complaints and whistle-blowing policy

11. How can you recognise abuse? • There may be a perfectly reasonable rational explanation so ask some open questions • Remember that the carer or accompanying person may be the abuser so may not always give a true reflection of events • Check for corroboration from GP, community nurses or care home referral letter, ambulance notes etc • Look at the social history, medical history, list of medication, risk assessments and observations • When you have a fuller picture are you still worried?

12. Types of abuse • Physical • Sexual • Psychological (or emotional) • Neglect (or acts of omission) • Financial • Institutional • Discriminatory or rights abuse • (Domestic violence)

13. Physical Abuse • Is the non-accidental physical mistreatment of one person by another which may or may not result in physical injury. It can be the use of force that results in an unwanted change in a person’s physical state. • Physical violence: Hitting, slapping, pushing, kicking, shaking, scalding, dragging, pinching hair-pulling. • Rough or inappropriate handling: Careless/rough handling; force-feeding; inappropriate application of physical techniques such as manual handling, restraint or physical intervention; involuntary isolation or confinement. • Medical Mistreatment: Misuse of medication; withholding of medication; inappropriate use of medical procedures, such as catheterisation.

14. Physical abuse causes injury, fear, intimidation and sometimes death

15. Physical Abuse - possible Indicators • Delays in seeking medical attention. • Shaped injuries • Multiple old or new injuries • Records of different visits for treatment • Skin infections/Inconsistent or unexplained injuries (bruises, cuts, burns, blisters, scratches, fractures, sprains) • ions • Weight loss • Medications withheld or omitted • Fear/reluctance to be with someone • Incontinence • Changes in behaviour, mood or usual routine, (sleep patterns or eating habits).

16. Sexual Abuse • Is the direct or indirect involvement in any sexual activity to which a person does not give valid consent or cannot give valid consent. • A person cannot give valid consent when they lack capacity to make a decision or if they are coerced into activity because the other person is in a position of authority, trust or power. Non-contact abuse: Indecent exposure, inappropriate looking, photography, harassment, serious teasing or innuendo, pornography. Contact Abuse: • Rape or sexual assault, masturbation (of either or both persons), inappropriate touching of breast, genitals, anus, mouth.

17. Sexual abuse - possible Indicators • Bruising to inner thighs, genital or anal areas • Persistent and inappropriate sexual behaviour or pronounced overly affectionate behaviour • STI or unexpected pregnancy • Torn or blood stained clothing/bedding • Love bites • Obsessive behaviour/ Changed behaviour • Difficulty sitting/standing • Bulimia/Anorexia/Self Harm /Self neglect

18. Psychological abuse • Is the use of threats, humiliation, bullying, other verbal conduct or any other form of mental cruelty that results in mental or physical distress. • Emotional abuse is any act which negatively affects the emotional well being of a person or impairs their psychological development.

19. Psychological abuse – possible indicators • Anxiety • Low self esteem • Difficulty communicating with vulnerable person or gaining access to visit • Deference /submission to the perpetrator • Sleep disturbance • Confusion

20. Financial abuse • Is the unauthorised and improper use of funds, property or any resources belonging to an individual. • Unauthorised would include the coercion or misleading of an individual, or any lack of informed consent from the individual.

21. Financial abuse can lead to deprivation, humiliation and starvation

22. Financial abuse – possible indicators • Lack of basic necessities or inability to provide for basic needs (food, rent etc.) • Inability to retain control over home lifestyle and/or apparently chaotic lifestyle • Denying access to or controlling accounts • Removal of items without consent • Overcharging • Theft or “borrowing” • Unexplained financial activity • Unexplained interest in someone

23. Neglect • Poor personal hygiene or mouth care • Malnutrition and / or dehydration and weight loss • Constipation • Hypothermia • Inappropriate and / or dirty clothing • Category 3 or 4 pressure ulcers • Untreated or delay in seeking treatment for medical problems or falls resulting in injury • Incomplete or inconsistent records of care

24. Neglect is degrading and undignified and can endanger life

25. Institutional abuse • Rituals and routines • Confinements • Stark environments • Lack of stimulation • Lack of consultation • Use of restraint • Use of power/control

26. Discriminatory abuse • Is the harassment, unfair treatment, exploitation or denial of mainstream opportunities and services to individuals because of their race, religion, culture, gender, age, sexuality or disability. • Discrimination can be a motivating factor in other forms of abuse

27. Discriminatory abuse – possible indicators • Not providing food consistent with a person’s culture or beliefs • Use of derogatory names or teasing about differences • Lack of appropriate social contacts • Not allowing attendance or observance of at religious festivals • Low self esteem, confidence or expressions of low self-worth

28. Prevent Prevent is concerned with safeguarding individuals at risk of exposure to extreme ideologies, either through personal contact or via the internet These ideologies could be international terrorism, the extreme right or left wing, animal rights, environmental protest, the IRA etc The Prevent team provide awareness sessions for professionals working with vulnerable young people and adults and can be delivered across the Thames Valley at your convenience

29. Domestic Violence

30. Disclosure What should you do if someone discloses abuse to you? • Be calm and do not show shock or disbelief • Listen carefully to what is being said • Do not ask detailed or probing questions (investigator will do this) • Ensure that any emergency action needed has been taken to ensure the person’s safety • Do not attempt to confront the alleged perpetrator • Demonstrate a sympathetic approach by acknowledging regret and concern that what has been reported has happened • Confirm that the information will be treated seriously • Give them information about the steps that will be taken • Inform them that they will receive feedback as to the result of the concerns they have raised and from whom • Give the person contact details so that they can report any further issues or ask any questions that may arise • Ensure that an appropriate person within your organisation has been notified e.g.Line Manager, Safeguarding Adults Lead

31. The safeguarding process - reporting • Report the abuse • If in doubt then discuss concerns, better to over report than to say nothing • Liaise with Bucks CC &/or Safeguarding Lead • CQC? • Fill out the SVAB or local alert form • fax or email as instructed • Confirm receipt of fax • If member of staff or line manager suspected of being perpetrator refer direct to Senior Manager • Check whistleblowing policy? • Public Disclosure Act 1998

32. The safeguarding process – communicating and helping • Ensure persons safety and protection • Inform police if criminal act suspected • Protect evidence • Work with adult social care • Reassure • Explain processes • Consent and information sharing

33. Case One • Harry is 78 yrs old and lives alone in a flat • His daughter, Elaine, is very worried about him, he has always drank heavily but recently she feels he has worsened. She has seen bottles and rubbish strewn over the flat. Her dad looks very thin and observed injuries to his face she thinks are from falls. He refuses to let her take him to hospital, which was her plan • His daughter, upset and anxious, calls Social Services who advise her to phone Harry’s GP Practice and discuss her concerns. • What can the Practice do?

34. Case Two • Patricia has Dementia, she is in a nursing home and she experiences periods of agitation and confusion that make her management difficult. Patricia refuses to take the Trazodone that has been prescribed so staff ask you to write it up as a covert medication which they will put in to her drink. • What are the issues?

35. Summary of MCA Principles • Presumption of capacity. • Unwise decision making. • Practicable steps. • Best interest. • Least restrictive option

36. What is Capacity? Mental Capacity is the ability to make a decision e.g. • Daily life decisions. • Serious or significant decisions • Decisions that may have legal consequences. These decisions must be viewed as • Time specific • Decision specific

37. Decisions that cannot be made • Divorce • Marriage • Voting • Sexual relations • Adoption

38. New Power - Ill treatment or neglect. • For those who have care of someone who lacks or is believed to lack capacity • Also if they have LPA, EPA or are COP deputy • If found guilty of willful neglect or ill treatment liable to be imprisoned or fined or both S.44 Mental capacity Act 2005

39. Two Stage Test of Capacity

40. Arriving at a decision re capacity • Identify the Decision Maker: “The person who is most appropriate to make a particular decision or has the specific authority to make the decision • Reasonable belief ( on the balance of probability) • Acts or decisions must be made in the person’s best interests • Use a Best Interest checklist • Evidence how the decision was arrived at. • Record your decision, including date and time

41. Best Interests

42. Example Checklist • Is the person likely to regain capacity? Yes/No • If yes, is this likely to be in time to make the decision in question? Yes/No • Have all practicable steps been taken to encourage the person to participate in the decision? Yes/No • If Yes then briefly describe how….…………………………………………………………………………………………………………………………………………………………………………………………… • Have any statements or wishes of the person been taken in to account? Yes/No • If practicable and appropriate, have the following views been taken in to account: • Anyone named by the person to be consulted? Yes/No/Not Applicable • Anyone engaged in caring for the person? Yes/No/Not Applicable • Any Court Appointed Deputy? Yes/No/Not Applicable • The Attorney under any Lasting Power of Attorney? Yes/No/Not Applicable • Anyone interested in the welfare of the person? Yes/No/Not applicable • If Yes, name the person consulted……………………………… • IMCA if no close persons • How is this the least restrictive/harmful option?...................................................................

43. Best Interests • Following Best Interests assessment where no consensus can be reached, the Court of Protection must be approached to resolve the issue

44. Case Study • Selima is a 75 year old lady in a residential care home. She has dementia and she suffers periods of acute confusion and agitation, she also suffers from Asthma. It is October time and Selima is due a Flu vaccination which she refused. • What are the issues? • What information do you need and from where? • What needs to be documented? • Who is the decision maker?

45. Case Study Two • Sarah has complex learning and physical disabilities. She has never been sexually active, at her Annual Health Check should she have a Cervical Smear Test? • Issues? • Documentation?

46. Contact details Adult Social Care Teams • Out of hours 0800 9997677 • central access team adult social care 01296 383204 • SVABTeam at County Hall, Aylesbury • Duty Desk 01296 382423 • Careline 0800 137915 • Email: safeguardingadults@buckscc.gov.uk Police 101/999

47. Discussion and support Tania Atcheson Safeguarding Lead CCG’s 07768 023100 tania.atcheson@nhs.net Vikki Gray Safeguarding Manager CCG’s07909 887852 Victoria.gray3@nhs.net Sarah Pady Joint Mental Capacity Act Coordinator 01296 382195 spady@buckscc.gov.uk

48. Thank you • Key message from today? • Change to practice? • Further study/training? • Email presentation • Visit www.bsvab.org • Collect a Mental Capacity Act card as you leave

49. Call Careline 0800 137 915