Safeguarding Adults Awareness

1. Safeguarding Adults Awareness Safeguarding Adults Nhamo Pazvakavambwa Safeguarding Adults Lead

2. Safeguarding is defined as ‘protecting an adult’s right to live in safety, free from abuse and neglect.’ • Abuse is a violation of an individual’s human and civil rights by any other person or persons. It can be committed by a person or persons in single or repeated acts, directly or indirectly.

3. Six principles that underpin all adult safeguarding work • Empowerment • Prevention • Proportionate • Protection • Partnerships • Accountable

4. Adult at Risk Is a person aged 18 or over who is in need of care and support regardless of whether they are receiving them or not, and because of those needs are unable to protect themselves against abuse or neglect. Who do adult safeguarding duties apply to? In the context of the legislation (Care Act) , specific adult safeguarding duties apply to any adult who: • Has care and support needs, and • Is experiencing, or is at risk of, abuse or neglect, and • Is unable to protect themselves from either the risk of, or the experience of abuse or neglect, because of those needs.

5. What makes you more vulnerable to abuse ? • a mental health problem (including dementia or memory problems) • a physical disability or illness (including long term illnesses) • drug and alcohol related problems • a sensory impairment • a learning disability • an acquired brain injury • frailty or a temporary illness

6. Who abuses and in when does abuse occur? • Adults at risk may be abused by relatives and family members, professional staff, paid care workers, volunteers, neighbours , or friends and associates… • Abuse can occur in any setting: when the adult at risk lives aloneor with a relative, in nursing and residential homes, day care settings, hospitals, custodial situations, in other places previously presumed safe or in public places.

7. Types of Abuse and Neglect • Physical abuse – including assault, hitting, slapping, pushing, misuse of medication, restraint or inappropriate physical sanctions • Domestic violence – including psychological, physical, coercion, stalking, sexual, financial, emotional abuse and so called ‘honour’ based violence • 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, servitude and inhumane treatment. • Psychological abuse – including emotional abuse, threats of harm or abandonment, deprivation of contact, humiliation, blaming, controlling, intimidation, coercion, harassment, verbal abuse, isolation or unreasonable and unjustified withdrawal of services or supportive networks

8. Types of abuse cont. • Financial or material abuse – including theft, fraud, coercion in relation to an adult’s financial affairs or arrangements, including in connection with wills, property, inheritance or financial transactions • Discriminatory abuse – including forms of harassment, or similar treatment; because of race, gender and gender identity, age, disability, sexual orientation or religion (criminal offence) • Neglect and acts of omission – including ignoring medical, emotional or physical care needs, failure to provide access to appropriate health, care and support or educational services, the withholding of the necessities of life, such as medication and adequate nutrition/heating etc • Self-neglect – neglecting to care for one’s personal hygiene, health or surroundings and includes behaviour such as hoarding.

9. Types of abuse cont. • Sexual- Unwanted physical contact, intercourse with somebody who lacks capacity to consent, rape, indecent exposure, sexual harassment, verbal or physical display, pornographic lit or videos. Inappropriate sexual material, gross indecency Non Contact:- Looking, photography, indecent exposure, harassment, serious teasing, innuendo, pornography Contact:- touching /fondling of Breasts, genitals, mouth with or by penis, fingers or other objects

10. Types of abuse cont. • Organisational abuse -The mistreatment of people brought about by poor or inadequate care or support, or systematic poor practice that affects the whole care setting. ‘is the mistreatment, abuse or neglect of an adult at risk by a regime or individuals within settings and services that adults at risk live in or use, that violate the person’s dignity, resulting in lack of respect for their human rights.’ (Care and Support Statutory Guidance2012) This is what was historically classed as institutional abuse before The Care Act

11. How/why is organisational abuse allowed to happen? • Receive little support from management • Are inadequately trained • Are poorly supervised and poorly supported in their work • Receive inadequate guidance • Poor Management • Low staff moral • Culture of acceptance

12. Why don’t patients report abuse? • They don’t realise its happening (unaware that what they are experiencing is defined as abuse) • They are afraid of retaliation (withdrawal of support) • They think its their fault • They fear no one will believe them • They are ashamed • They fear they will be placed in an institution

13. CONSENT ISSUES Consent: The adult at risk needs to give consent to the Safeguarding Adult process However: Where a carer or relative is suspected of abusing someone who lacks capacity it may be necessary to progress a referralwithout consent in the person’s best interests. When there is a public interest and others may be at risk, it may also be necessary to proceed with the referral withoutthe persons consent. e.g. domestic violence where the act of requesting consent may further endanger the victim or where a paid carer who has contact with other vulnerable adults is alleged to have caused harm.

14. The Mental Capacity Act (2005) • The Mental Capacity Act was introduced in England and Wales in 2007 to provide a framework for making decisions on the behalf of others. • It tells us what to do if we are involved in the care, treatment or support of adults aged or young adults 16 years and older who may lack the capacity to make decisions.

15. The Five Core Principles In any assessment of or decision about a person’s capacity the following core principles must be followed: • Capacity is assumed (unless established otherwise) • All practicable steps to help (taken without success) • Unwise decisions (do not equal lack of capacity) • Best Interests (of the person who lacks capacity) • Least restrictive (consider other effective options)

16. Two Stage Mental Capacity Assessment * Before you set off, remember that assessing mental capacity is decision and time specific… Two Stage Mental Capacity Assessment (Test): Stage 1: Is there an impairment of the mind or brain? e.g. LD, Dementia, UTI, excessive alcohol (impairment can be temporary or permanent) Stage 2: Is the impairment significant enough to disable the person’s ability to decide? 2a) Is the person able to understand information relevant to the decision 2b) Can they retain the information long enough to make a decision 2c) Can they weigh up the consequences of each option against their own values and morals? 2d) Are they able to communicate their decision, by any means

17. When should capacity be assessed? The Code of Practice states that an assessment should take place when: • the person’s behaviour or circumstances cause doubt as to whether they have the capacity to make a decision; • somebody else says they are concerned about the person’s capacity; • the person has previously been diagnosed with an impairment or disturbance that affects the way their mind or brain works, and it has already been shown they lack capacity to make other decisions in their life. • Trust policy states that capacity to consent to any informal admission must be assessed prior to, or as soon as possible after, admission to hospital

18. When should capacity be re-assessed? In delivering on-going treatment or care for a person who it is felt might lack capacity to consent to those arrangements a new capacity assessment should be undertaken whenever: • the information relevant to that decision has changed significantly (e.g. a significant alteration to a care or treatment plan, or a significant alteration in the circumstances of the patient’s admission); or • it is thought that there may have been a significant change in the person’s capacity to make that decision for themself

19. Who can do the test of capacity? • Anyone can do the test – the Act does not name any professional group with special authority to apply it. • The assessment should be carried out by the person proposing the health or social care decision or with the authority to make such as decision. • For example, in prescribing medication, the appropriate assessor is likely to be a doctor or non-medical prescriber. • The Code of Practice explains: ‘…a care worker might assess if the person can agree to being bathed, a district nurse might assess if the person can consent to having a dressing changed.’

20. Avoid unwarranted assumptions An assessment that a person lacks capacity to make a decision must never be based simply on: • age; • appearance; • assumptions about their condition; • any aspect of their behaviour.

21. Best Interest Decisions • When a person is assessed as lacking capacity to make a specific decision, the Act allows another person to make that decision in that person’s best interests (which is not necessarily the same as their best clinical interests) • There is no legal definition of “best interests”, instead the Act provides a checklist determining how decision makers should acquire the evidence to inform their decision • Decision makers are protected if they make a reasonable decision, based on the evidence acquired by following the best interests checklist

22. Best Interests Checklist All relevant circumstances must be considered, and in particular the following steps must be taken: • Consider whether the person is likely, at some point in the future, to recover his or her decision-making capacity in relation to the matter in question. • So far as reasonably practicable, permit and encourage the person to participate, or to improve his ability to participate, as fully as possible in any act done for him or decision affecting him. • Consider, so far as is reasonably ascertainable: • the person’s past and present wishes and feelings (and, in particular, any relevant written statement made by them when they had capacity), • the beliefs and values that would be likely to influence the person’s decision if they had capacity, and • the other factors that they would be likely to consider if they were able to do so.

23. Recording significant decisions • For serious, significant or complex decisions, assessments need to be recorded using the RiO Mental Capacity Assessment form and Best Interests Considerationform. • Decisions requiring formal recording include: • informal admission to hospital; • the implementation or significant alteration of a plan of medical treatment; • breach of confidentiality (i.e. where personal information about the service user may be given to a third party); • change of long-term accommodation.

24. Recording day-to-day care decisions • Any routine acts of day-to-day care provided under the MCA which are not significant enough to require the formal recording of a capacity assessment should still be carefully recorded in the patient’s care plan. • Briefly assess capacity and (if lacking capacity) confirm that plan is in best interests under client view • The Code of Practice states that if these steps are taken nursing staff will usually be protected against liability if they are working to that care plan and agree with the assessments recorded

25. When should Pressure Ulcers be referred as a ‘Safeguarding’ concern? All pressure ulcers must be considered as requiring early intervention to prevent further damage. If there are concerns regarding poor practice, an appropriate escalation must be considered, i.e. raising a clinical incident. A safeguarding concern should be made if there is: • Significant skin damage* (i.e. category/ grade 3 or 4, un-gradable, deep tissue injury ulceration or multiple grade 2 pressure ulcers) or

26. There are reasonable grounds to suspect that it was preventable or • Inadequate measures taken to prevent the development of pressure ulcer, or • Inadequate evidence to demonstrate the above For further advice, contact Sarah Kiernan Consultant Nurse – Tissue Viability Tel: 020 8702 5880 Mob: 020 8702 6433 Email: Sarah.Kiernan@enfield.nhs.uk

27. Case Discussion On admission you notice that Mrs Adams has bruising on her arms and inner thighs. Mrs Adams has carers supporting her visiting 3 times daily. Mrs Adams also has a early onset dementia and blood clotting disorder. Mr Adams cannot explain the bruising and thinks she may have fallen. • What questions would you ask? • What would you do ? • Who else might you talk to?

28. Case discussion Mrs Jones is a 78 year old lady who lives with her 80 year old husband. Mr Jones has dementia and Mrs Jones had a stroke 4 years ago. Mrs Jones has capacity to make all her own decisions. The family report that the house is filled with clutter, newspapers are piled four foot high in some places and flies lift from the debris on the floor. Mrs Jones says that this is just the way that they live and says that she does not want any support from anyone, she does not consent to the safeguarding referral. Mrs Jones also states that she would like her husband to return home after this care episode. •What you need to consider / do? •With whom can you share information? •What is your rationale?

29. Answers With whom can you share information? Local Authority Housing GP What is your rationale? •Potential risk to others •Potential crime •Potential public health issues •S11 Care Act – duty to assess (Safeguarding & potential lack of capacity to make decisions – Mr Jones) •What you need to consider / do? • Safeguarding referral • Carer responsibilities – and potential crime • Carers Assessment • Assessment – Mr Jones • Potential for domestic abuse – coercive and controlling behaviour • Potential risk to others • Potential public health issues • Housing who owns tenancy? • Capacity assessments for Mr Jones • GP • Potentially speak to family (Children)

30. Managing a disclosure Of Abuse-Do’s and Don'ts • Do make the person safe • Do give time and let them say what they need torecord their exact and precise words • Do take what they have said seriously and tell them you will treat it seriously • Do offer them reassurance and let them know they did the right thing telling you • Do explain that any action will be managed with sensitivity and that they will be central to the process • Do where and when possible, act in accordance with their wishes and try to gain consent wherever possible • Don’tpromise to keep secrets • Don’tcontact or confront the person who have caused the harm • Don’tstart an investigation on your own and decide if they are telling the truth If a crime is suspected you must report to the Police.

31. Raising a concern • Report to Team Manager and adult social care safeguarding team • Write comprehensive notes on RiO • DATIX • Inform the Trust Safeguarding Team via the inbox beh-tr.safeguarding@nhs.net • Team Manager and Safeguarding Team are not gatekeepers of safeguarding process. i.e. you can seek support and advise from us but we cannot tell you not to raise a safeguarding.

32. What happens when we refer to social services? • Social services may contact you for further information or to clarify information, for example, they may require an RCA, chronology of events, or preliminary reports. • They will contact the patient (when safe to do so) to obtain their views on the situation and this will determine if they proceed or not • If the local authority are best placed to make enquiries then they will lead on this. Where other organisations are best placed to make enquiries, they will instruct them to do so

33. The Safeguarding Team • Executive Director of Nursing Quality and Governance - Executive Lead for Safeguarding • Head of Safeguarding People – Ruth Vines on 020 8702 3995 • Trust wide Safeguarding Adults Lead – Nhamo Pazvakavambwa on 02087023118 • Trust wide Safeguarding Children Lead – Celia Jeffreys 02087024918 Or you can contact CEO direct in the strictest confidence - 07943 702033? If you do not feel able to talk about it yet, you should make notes including dates and details which will help recall events clearly at a later date.

34. Questions?