Awareness of Risks and Responsibilities

1. Adult Support and Protection (Scotland) Act 2007 A S P Awareness of Risks and Responsibilities

2. Fire exits and alarms Breaks Refreshments Toilet facilities No Smoking

3. Course Content • Introduction • Definitions -- Adult at Risk and Harm • Risks • Responses • Information Roles and Responsibilities • Difficulties and Dilemmas • Procedures and Practice • Key Messages A S P

4. Course Material Much of the course has been drawn from training material developed by social work, health and police service staff in Edinburgh, the Lothians, Scottish Borders, and Perth & Kinross, with contributions from staff from the Scottish Government’s Adult Support and Protection Team concerning legislation and particularly the Adult Support and Protection (Scotland) Act 2007. All of the material can be customised for local use. The course is intended initially for staff who will have key roles in relation to the legislation, including Council Officers, and specialist NHS and Police staff, and within this context to complement training on the legislation and its practice implications. The wider workforce in social care, health and housing support services, and the police, as well as in a wide variety of other agencies, will also require to have knowledge and awareness of adult support and protection, and this half day awareness course is also designed for them. A S P

5. 1. Introduction A S P

6. Learning outcomesAt the end of this session participants will have an understanding of: • What is meant by the term ‘adult at risk’. • What is meant by the term ‘harm’. • What are the signs of harm. • What should be the response to concerns that an adult is at risk of harm. • What are the responsibilities for sharing information. • What principles should be followed and ethical dilemmas faced. • What local interagency Adult Support And Protection Guidelines exist . A S P

7. Session Rules • We will be discussing harm of adults in this session. • This can be an emotive and difficult subject. • It is therefore essential to create a safe learning environment for all participants. • Everyone’s comments will be respected. • All personal information shared within the room is confidential unless it raises concerns about an adult at risk. A S P

8. Background In 1997 the Scottish Law Commission published recommendations and a draft Bill in respect of ‘vulnerable adults’. Since then there have been several formal enquiries, where there have been failings in local services in individual cases. Local experience and practice has also developed considerably. National policy to protect people has also moved forwards, with new laws for adults with incapacity, mental health care and treatment, and most recently the Adult Support and Protection (Scotland) Act 2007. A S P

9. The Law Many laws are relevant to the support and protection of adults at risk, including: Adult Support and Protection (Scotland) Act 2007 Protection of Vulnerable Groups (Scotland) Act 2007 Vulnerable Witnesses (Scotland) Act 2004 The Mental Health (Care & Treatment) (Scotland) Act 2003 Regulation of Care (Scotland) Act 2001 Protection from Abuse (Scotland) Act 2001 Adults with Incapacity (Scotland) Act 2000 The Data Protection Act 1998 Human Rights Act 1998 Public Disclosure Act 1990 NHS and Community Care Act 1990 The Social Work (Scotland) Act 1968 The National Assistance Act 1948 Further information in relation to the above legislation can be accessed from the Scottish Government website at www.scotland.gov.uk A S P

10. Group exercise 1 • Attitudes • The aim of the exercise is to see what your initial feelings or perceptions are and to discuss the differences in your multi-agency groups. • Individually: • Take 5 minutes to read the scenarios. Rate them on the scale from 1 to10. • Each case must have a different rating attached to it, so that you have a list from 1 to 10 and from those you think are the least harmful to those you think are the most harmful. • In your groups: • Compare results. Discuss the choices you have made, and if you have rated them differently why that might be so. What personal and professional values may have influenced your ratings? A S P

11. Attitudes Exercise Consider the following scenarios and number according to level of harm There are no right or wrong answers. This activity works best if you answer the questions spontaneously. • Every day, Samuel, who was a refugee and was imprisoned and beaten in his country of origin, is visited by his 16 year old grandson. The grandson likes to sneak up behind his grandfather and shout “The prison guards are coming”. • George has severe emphysema and lives with his family. They all smoke inside the house. • Carer Eric gives his wife extra medication so he can get a good night’s sleep. • John visits his mother every week on pension day. After his visits, his mother never has any money. • Peter arranges for his mother’s pension to be paid into his own bank account and says he is saving for her funeral. She would like to spend a week by the seaside but Peter says she cannot afford it. • Phillip watches pornographic DVDs on TV in front of his mother, aged 74, every day. • A district nurse and carer talk about Edith and her condition in front of her and do not include her in the conversation. • Rosemary is very weak and unsteady on her feet, but would love to try to walk around the garden with her zimmer frame to look at the flowers. Her daughter says she must remain in the house. • A daughter says to her mother “If you don’t stop messing the bed, I’ll get you put away in one of those old people’s homes”. • A neighbour regularly shops for the old people living in the same block. She takes £2 for herself out of the money she is given for the shopping but does not tell the people she is doing this. A S P

12. 2. DefinitionsAdult at RiskandHarm A S P

13. What is meant by the term ‘adult at risk’? A S P

14. Who is an ‘Adult at Risk’? The Adult Support and Protection (Scotland) Act 2007 defines Adults at Risk, through a three-point test, as adults, aged 16 years or over, who: • are unable to safeguard their own well-being, property, rights or other interests; • are at risk of harm; and • because they are affected by disability, mental disorder, illness or physical or mental infirmity, are more vulnerable to being harmed than adults who are not so affected. A S P

15. The Three-Point Test Can you think of people you have worked with, who would: • Meet the three-point test, and be considered as adults at risk; • Meet only one or two elements of the three-point test, and not be considered as adults at risk. Three-point test -- unable to safeguard well-being, property etc; at risk of harm; and because they are affected by disability, etc are more vulnerable ...... A S P

16. What is meant by the term ‘harm’? A S P

17. Types of harm The following are the main forms of harm that have been identified: • Physical • Sexual • Psychological/emotional • Financial or material • Neglect and Acts of Omission • Discriminatory • Information • Human Rights A S P

18. Examples of types of harm • Neglect & Acts of Omission - withholding adequate nutrition, clothing, heating; failing to provide for medical or physical care needs; failure to give privacy and dignity; neglect of accommodation; self-neglect. • Financial harm/exploitation: theft; fraud; use or misuse of money or property without the adult’s consent; preventing access to money or property; pressure in connection with wills, property, inheritance or financial transactions. • Psychological harm: intimidation by word or act; bullying; verbal abuse; threats of harm or abandonment; deprivation of contact with others, or of something important to the adult; humiliation; blaming; controlling; coercion; taking away privacy; constant criticism. • Physical Harm: hitting, slapping, pinching, pushing, biting, burning, scalding, shaking; forcible feeding; inappropriate restraint and/or sanctions; improper use of medication; ‘rough-handling’; inappropriate sanctions; restriction of freedom of movement (e.g. locking the adult in a room, tying him/her to a bed or chair) • Sexual harm: contact – unwanted/non-consensual touching/kissing/sexual activity; non-contact – photographing; exposure to pornographic materials; being made to listen to sexual comments; indecent exposure; sexual harassment; voyeurism. • Discriminatory harm: actions (or omissions) of a prejudicial nature focusing on a person’s age, gender, disability, race, colour, cultural background, sexual/religious orientation. • Human Rights: denial of a liberty, fair hearing, freedom of speech or religion; slavery. A S P

19. What is ‘harm’? The Adult Support and Protection (Scotland) Act 2007 says: “harm” includes all harmful conduct and, in particular, includes: • conduct which causes physical harm; • conduct which causes psychological harm (e.g. by causing fear, alarm or distress); • unlawful conduct which appropriates or adversely affects property, rights or interests (e.g. theft, fraud, embezzlement or extortion); • conduct which causes self-harm. N.B - “conduct” includes neglect and other failures to act, which includes actions which are not planned or deliberate, but have harmful consequences. A S P

20. Group exercise 2 Place in order of the most prevalent form of harm to older people: • Sexual • Psychological • Physical • Neglect • Financial A S P

21. Exercise 2 – Survey Finding Answer (UK Figs)– percentage of the population: UK Study of Abuse and Neglect of Older People - National Centre for Social Research, King’s College London - June 2007 Note: The prevalence estimates are almost certainly lower than the actual level of mistreatment More men (5.2%) than women (3.6%) in Scotland – different from other UK countries A S P

22. Patterns of harm Patterns of harm vary and reflect very different dynamics. These include: • Neglect of a person’s needs because those around him or her are not able to be responsible for the person’s care or with deliberate intent; • Situational harm which arises because pressures have built up and/or because of difficult or challenging behaviour; • Long term harm in the context of an ongoing family relationships e.g. between siblings, generations; • Unacceptable ‘treatments’ or programmes which include sanctions or punishment such as withholding of food & drink, seclusion, unnecessary or unauthorised use of control & restraint; • Opportunistic harm such as theft occurring because money has been left around; • Institutional harm which features poor care standards, lack of positive responses to complex needs, rigid routines, inadequate staffing and an insufficient knowledge base within the service; • Serial abusing in which the perpetrator seeks out and ‘grooms’ vulnerable individuals. Sexual abuse usually falls into this pattern as do some forms of financial harm. Department of Health: No Secrets (2000) A S P

23. 3. Risks A S P

24. What are the signs of harm? A S P

25. People who are harmed People who are harmed very often have or are: • Socially isolated • Communication difficulties • Impaired intellect, memory or physical function • Behavioural problems • History of poor quality long term relationships • Pattern of family violence A S P

26. Risk factors People have been shown to be more at risk if their carer: • Has mental illness • Has drug +/or alcohol misuse • Has a past history of offending • Is financially dependent on client • Is socially isolated • Suffers from external stress – mainly associated with house sharing not work But anyone can end up harming! The harm may be perpetrated with or without deliberate intent. A S P

27. Signs of harm Staff and others should look out for the signs of abuse and harm, including: • Unusual or suspicious behaviour by client or carer • Delay in seeking advice for injuries • Over frequent / inappropriate referrals to outside agencies • Misuse of medication • Sudden increase in confusion • Unexplained physical deterioration • Difficulty in interviewing adult • Demonstration of fear • Anxious, disturbed or rejecting behaviour • Carer +/or client showing apathy, depression and withdrawal • Diagnosis of sexually transmitted disease • Serious or persistent failure to meet needs A S P

28. Who harms? People who abuse and harm others include: • Family/Informal carers • Spouses/partners or ex-spouses/ex-partners • Relatives • Volunteers • Neighbours • Friends and associates • Professional staff & care workers • People who deliberately exploit adults at risk • Strangers • Service users • Other adults at Risk A S P

29. Group exercise 3 Place in order of the most prevalent source of harm to older people: • Care workers • Partner • Close Friend • Other Family Member A S P

30. Exercise 3 – Survey Finding Answer (UK Figs)– percentage of the population: UK Study of Abuse and Neglect of Older People National Centre for Social Research, King’s College London - June 2007 Note: Respondents could mention more than one person A S P

31. Group Exercise 4 Place in order of the most prevalent places where harm to older people occurs: • Care home • Hospital • Own house • Sheltered housing • Other A S P

32. Exercise 4 – Survey Finding Answer (UK Figs)– percentage of the survey population: Source: Audit of calls to the AEA help line House of Commons Health Committee. Elder Abuse. Session 2003–04 A S P

33. 4. Responses A S P

34. What should be the response to concerns that an adult is at risk of harm? A S P

35. Group exercise 5 A S P It is common for an adult who is being harmed to deny this. Why?

36. Group exercise 6 Place in order of the most prevalent reactions of responses to disclosure of abuse to them by older people: • No reaction • Reacted verbally, physically, or confronted the perpetrator • Emotional reaction • Ignored it or walked away A S P

37. Exercise 6 – Survey Finding Answer (UK Figs)– percentage of the population: UK Study of Abuse and Neglect of Older People - National Centre for Social Research, King’s College London - June 2007 Note: Respondents could give more than one answer; Reaction questions were not asked for neglect A S P

38. Barriers to disclosure Barriers to disclosure commonly include: • Pride – not wanting to be viewed as stupid or vulnerable; • Loyalty –when family is involved, or towards friends or care/support staff; • Culture – generation which does not complain; • Fear – may make things worse, may have to go into care. A S P

39. Handling disclosures When someone discloses harm, then you should: • Ask client what happened & listen • Ask person who, what, where, when & why – obtain relevant information* • Remember this may be the only opportunity (e.g. client’s poor memory) • Restrict your questions to one interview • Take a note of points to remember • Try and avoid leading questions -- possible open questions include: *“do you want to talk about what happened?” “what has happened today?” “are you hurt anywhere?” “has this happened before?” “where were you?” “what do you think about this?” “who was around?” “what can de done to help just now?” “what do you want to happen now?” A S P

40. Disclosure – do / don’t Do: • Stay calm and listen carefully • Reassure person, show sympathy & concern • Explain what you are going to do • Report to your line manager • Write the facts of what you have been told Don’t • Make judgements, appear shocked, horrified or angry • Give assurances, promises – keep secrets • Confront or contact alleged perpetrator • Press the individual for details • Remove forensic evidence A S P

41. Immediate help required If the adult at risk appears to be in immediate physical danger or urgent medical attention is needed: • Contact appropriate emergency service (police, ambulance); • Consent & capacity is not an issue when in life and limb situation; • Medical care must be sought & provided if needed; • Staff must be aware of the preservation of evidence; • Staff members should not put themselves at risk; • Staff should always discuss and record action taken. A S P

42. Consult supervisor / manager Discuss with line manager, supervisor or suitable alternative manager as soon as possible about: • Suspected or actual harm, and the full facts and circumstances of the case; • An agreed action plan; • Whether there is a need to obtain more information; • Whether a referral to the local Social Work Team office is appropriate; • Consent and capacity issues, and duty to inform under the Act; • If a medical examination needs to take place and whether delay may jeopardise securing vital evidence; • Whether the adult at risk needs to be removed to a place of safety; • Whether immediate action would cause more distress and/or pose greater risks to the adult. All actions and decisions to be recorded. A S P

43. Who can help? • Senior staff member • Manager • Social Work • Care Commission / Mental Welfare Commission • Police • Family Protection Unit • Adult Protection Unit Never hesitate to ask or phone for advice if you are unsure about anything! A S P

44. Group exercise 7 In your groups discuss and assess the risk in one case scenario. What factors influence and inform your assessment? What factors hinder your assessment? A S P

45. Group exercise: case scenarios SCENARIO 1  Tom (19 ) Tom is a young Asian man who suffers from paranoid schizophrenia. His community health Nurse visits fortnightly. He lives alone in a second floor supported tenancy In a council estate. Children call him names and people throw stones at his window and kick his door. His girlfriend, who is 8 months pregnant and has a mild learning disability has her own tenancy down the road. She provides informal support for Tom and called the police on the last few occasions. Last week, a gang stuffed lit papers through his letter box. The police attended. Tom is frightened to go out and lives in fear of his neighbours. Yesterday, Tom’s community health nurse visited. She saw he was in a distressed state and seemed eager to tell her something. He repeatedly said to her “ If I tell you, you won’t tell anyone else will you ? What are the main concerns / risks ? SCENARIO 2 Rachael ( 75) Rachael, 75, was admitted to hospital having sustained a head injury. The meals on wheels person found her unconscious and called an ambulance. Over the past 6 months, Rachael has had numerous admissions with falls, fractures and unexplained major bruising. Rachael states she has become clumsy lately, no physical evidence has yet been established as a cause. At present, Rachael’s support includes an allocated care manager, meals on wheels and district nurse input. After being discharged, as the nurse was assisting Rachael to bath, she disclosed to her that her son had actually caused the injury as well as the previous injuries. Rachael went on to say her son had an alcohol problem and became physically violent towards her on pension days, when she refused to give him more money. She insisted the nurse keep this information confidential as she did not wish her son to get into trouble.  1. What are your main concerns ? 2. What action would you take ? SCENARIO 3 Ivy ( 51 )  Ivy lives alone in a ground floor flat. She has learning difficulties and cannot read or write. A couple of years ago her health deteriorated And now she cannot walk very far. The only time Ivy goes out is when she attends a luncheon club twice a week. Both a care manager and a home care worker have been involved with Ivy for some time. There have been concerns in the past when Ivy has said she has not got any money left. She has never said where the money has gone. Only on one occasion did she say she had given some money to her 25 year old daughter, Tracey. This weekend the police have been called out by a neighbour, who had heard Ivy shouting for help through the wall. When the neighbour went in she found Ivy crying and saying she was starving. It seems Tracey has come to visit and whilst Ivy was on the toilet she took all the money out of her purse and left the flat. Ivy had not eaten for three days. The home care worker arrives on Monday to find the neighbour with Ivy. They explain what has happened over the weekend and then Ivy says it has happened before. 1. What are your main concerns ? 2. What action would you take ? A S P

46. 5. Information Roles and Responsibilities A S P

47. What responsibilities are there to share information? A S P

48. Group exercise 8 A S P What may stop us from sharing concerns when witnessing practices or incidents that may have a negative effect on the welfare of an adult at risk?

49. Information sharing: the law • Various laws protect information. The rights to privacy and seeking consent should always be considered, but various laws also allow information sharing without consent: • The Human Rights Act 1998 • The Common Law Duty of Confidentiality • The Data Protection Act 1998 • These existing laws allow information to be disclosed without consent: • where such disclosure is required by law (either a court order or statute); • where such disclosure is for crime prevention, detection and prosecution; • where such disclosure is in the public interest (including the best interests of adults, who are or may be being harmed). • The Adult Support and Protection (Scotland) Act 2007 supports information sharing without consent when it is necessary to protect adults at risk. A S P

50. Information sharing: duties • The Adult Support and Protection (Scotland) Act 2007 says that where a public body* or office-holder knows or believes that a person is an adult at risk, and that action needs to be taken (under this Part or otherwise) in order to protect that person from harm, the public body or office-holder must report the facts and circumstances of the case to the council for the area where the person is. • Section 10 also provides for the examination of records and says that a council officer may require any person to give her/him health, financial or other records relating to an individual whom the officer knows or believes to be an adult at risk. Only a health professional can then inspect the health records (other than to determine whether they are health records). • These requirements conform with the Caldicott Principles that staff must understand and comply with the law. The other Caldicott Principles are that staff must understand their responsibilities; justify the purpose(s) for using confidential information; only use when absolutely necessary; use the minimum that is required; and provide access on a strict need to know basis. • * Local authorities, NHS Boards, Police Forces, the Care Commission, the Mental Welfare Commission for Scotland, the Public Guardian A S P