What is abuse?

Definition of Abuse and the Types of Abuse and Neglect

‘Abuse’ is the violation of an individual’s human and civil rights by any other person or persons. In giving substance to that statement, however, consideration needs to be given to a number of factors: abuse may consist of a single act or repeated acts; it may be physical, verbal or psychological; it may be an act of neglect (as well as resulting from actions, abuse can also be a result of inaction); or it may occur when a vulnerable Staff Training Series – Adult Safeguarding Page13 person is persuaded to enter into a financial or sexual transaction to which they have not consented, or cannot consent. Abuse can occur in any relationship and may result in significant harm to, or exploitation of, the person subjected to it.

Types of Abuse and Neglect

  • Physical abuse – including assault; hitting; slapping; pushing; misuse of medication; restraint; and inappropriate physical sanctions
  • Domestic violence – including psychological, physical, sexual, financial, and emotional abuse; and so-called ‘honour’-based violence
  • Sexual abuse – including rape; indecent exposure; sexual harassment; inappropriate looking or touching; sexual teasing or innuendo; sexual photography; subjection to pornography or witnessing sexual acts; indecent exposure; and sexual assault or sexual acts to which the adult has not consented or was pressured into consenting
  • Psychological abuse – including emotional abuse; threats of harm or abandonment; deprivation of contact; humiliation; blaming; controlling; intimidation; coercion; harassment; verbal abuse; cyber bullying; isolation; and unreasonable or unjustified withdrawal of services or supportive networks
  • Financial or material abuse – including theft; fraud; internet scamming; coercion in relation to an adult’s financial affairs or arrangements, including in connection with wills, property, inheritance or financial transactions; and the misuse or misappropriation of property, possessions or benefits
  • Modern slavery – including slavery; human trafficking; forced labour; and domestic servitude. Traffickers and slave masters use every means at their disposal to coerce, deceive and force individuals into a life of abuse, servitude and inhumane treatment
  • Discriminatory abuse – including forms of harassment, slurs, or similar treatment on account of race, gender and gender identity, age, disability, sexual orientation or religion
  • Organisational abuse – including neglect and poor care practice within an institution or specific care setting, e.g. a hospital or care home, or in relation to care provided in one’s own home. This may range from one-off incidents to ongoing ill-treatment. It can be through neglect or poor professional practice as a result of the structure, policies, processes and practices within an organisation
  • 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; and the withholding of the necessities of life, such as medication, adequate nutrition and heating
  • Self-neglect – this covers a wide range of behaviour neglecting to care for one’s personal hygiene, health or surroundings and includes behaviour such as hoarding. Incidents of abuse may be one-off or multiple, and they can affect one person or more. Professionals and others should look beyond single incidents or individuals to identify patterns of harm, just as the CQC, as the regulator of service quality, does when it looks at the quality of care in health and care services. Repeated instances of poor care may indicate more serious problems (what is now described as ‘organisational abuse’). In order to see these patterns, it is important that information is recorded and appropriately shared.

Patterns of Abuse Vary and Include

  • Serial abuse in which the perpetrator seeks out and ‘grooms’ individuals. Sexual abuse sometimes falls into this pattern as do some forms of financial abuse.
  • Long-term abuse in the context of an ongoing family relationship, such as domestic violence between spouses or generations, or persistent psychological abuse.
  • Opportunistic abuse, such as theft occurring because money or jewellery has been left lying around.

Recognising the Signs and Symptoms of Possible Abuse

Adult abuse normally occurs when an adult who is in some way vulnerable is faced with a person or set of circumstances with a potential for harm. Some factors that may place people at particular risk of being abused are described below; however, the presence of one or more of these factors does not automatically imply that abuse will result, though it may increase the likelihood.

1. Poor communication or a breakdown of communication; immobility

2. Urinary or faecal incontinence

3. An inappropriate or dangerous physical or psychological environment (e.g. lack of
personal space)

4. Living in the same household as a known abuser or a person who has a history of mental health problems, alcohol or drug misuse, or sexual offending.

5. Mental health problems

6. Learning disabilities

7. Physical disabilities

8. Dependence on others and vice versa: unequal power relationships

9. Considerable change in the carer’s lifestyle

10.Emotional and social isolation

11.Caring needs in excess of the carer’s ability to meet them

12.Financial problems

What to Look for:

The following list highlights situations or events that may require closer attention. They are purely indicators: the presence of one or more does not automatically confirm abuse; however, a cluster of several indicators may suggest a potential for abuse and hence the need for further assessment. For ease of use, the indicators have been grouped under a number of headings; however, an abusive situation will typically involve indicators from a number of the groups in combination.

Physical Abuse

1. Any injury not fully explained by the history given

2. Self-inflicted injury

3. Unexplained bruises and welts on face, lips, mouth, torso, arms, back, buttocks or thighs in various stages of healing; clusters forming regular patterns, reflecting shape of an article, or on several different surfaces

4. Unexplained burns, especially on soles, palms and back; immersion burns or rope burns; electrical-appliance burns

5. Unexplained fractures to any part of the body in various stages of healing; multiple or spinal injuries

6. Unexplained lacerations or abrasions to mouth, lips, gums, eyes, or external genitalia

7. Malnutrition; rapid or continuous weight loss; no evidence of food; dehydration; complaints of hunger

8. Lack of personal care; inadequate or inappropriate clothing; inadequate heating

9. Untreated medical problems

10.Urinary or faecal incontinence

11.Signs of medication misuse (over- or under-medication)

Domestic Violence or Abuse

Any of the above categories may include domestic abuse or violence. A wide range of behaviours are involved, beyond solely physical violence, as indicated by the definition: “Any incident of threatening behaviour, violence or harm (psychological, physical, sexual, financial or emotional) between adults who are or have been intimate partners or family members, regardless of gender or sexuality” (Home Office, 2013). It is rarely a one-off incident, and it should be seen as a pattern of harmful and controlling behaviour through which the abuser seeks power over the victim. Examples are the same as those as for neglect and for psychological, emotional, physical, sexual, and financial/material abuse.

The signs and symptoms of domestic abuse or violence include the following (see also the signs and symptoms under psychological, physical, sexual, and financial abuse):

1. Appears to be afraid of partner and/or of making choices for themselves

2. Behaves as though they deserve to be hurt or mistreated

3. May have low self-esteem or appear to be withdrawn

4. Appears unable or unwilling to leave perpetrator

5. Leaves perpetrator and then returns to them

6. Makes excuses for or condones the behaviour of the perpetrator

7. Blames abuse on themselves

8. Minimises or denies abuse or seriousness of harm

9. Perpetrator is always with the victim and won’t let the victim speak for themselves,

e.g. at GP visits

Sexual Abuse

1. Difficulty in walking and sitting

2. Torn, stained or bloody underclothing

3. Pain or itching, bruises or bleeding in genital area

4. Sexually transmitted disease (STD); unitary tract- or vaginal infections

5. ‘Love bites’

6. Significant change in sexual behaviour or outlook

7. Bruising to thighs or upper arms

8. Pregnancy in a person who is unable to consent

9. Full or partial disclosure or hints of sexual abuse

Psychological Abuse

1. Ambivalence

2. Deference

3. Passivity

4. Resignation

5. Fearfulness expressed in the eyes; avoids looking at care giver; flinching on approach

6. Emotional withdrawal

7. Anxiety causing sleep disturbance

8. Low self-esteem

9. Unexplained fear or defensiveness

10.Anxiety that causes bed wetting or soiling

11.Poor concentration

Financial or Material Abuse

1. Unusual or inappropriate bank account activity

2. Lasting power of attorney (LPA) obtained when person is unable to comprehend

3. Recent changes to deeds or title of house

4. Person lacks belongings or services that they can clearly afford

5. Recent acquaintances expressing sudden or disproportionate affection for a person with means

6. Carer asks only financial questions of the worker, not questions about care

7. Withholding of money

8. Person managing financial affairs is evasive or uncooperative

Modern Slavery

1. Physical appearance. Victims may show signs of physical abuse, look malnourished or unkempt or appear withdrawn

2. Isolation. Victims may rarely be allowed to travel on their own, seen under the control, influence of others. Rarely interact and appear unfamiliar with their neighbourhood or where they have employment

3. Restricted freedom of movement. Victims will have little opportunity to move around freely and may not have access to such documents as their passport

4. Unusual travel times. People are dropped off very early for work or picked up a long time after work ends

5. Poor living conditions. Victims may be living is cramped, dirty, inadequate living conditions. It may often be overcrowded with people living and working at the same address

6. Reluctant to seek help. Victims may avoid eye contact, talking about themselves or family. They avoid strangers and any law enforcers. They have a great fear of being deported or violence happening to themselves or family

7. Victims may have no identity documents, have few personal belongings and often wear dirty clothes or clothes inappropriate for the work they are doing.

Discriminatory Abuse

This includes “hate crimes”, and it exists when values, beliefs or culture result in a misuse of power that denies opportunity to some groups or individuals.

1. Verbal abuse

2. Harassment or similar treatment

3. Unequal treatment

4. Deliberate exclusion from services such as education, health and justice, and access to services and protection

5. Harmful or derisive attitudes

6. Inappropriate use of language

Organisational Abuse

1. No flexibility in bedtime and/or deliberate waking

2. One commode used by several people; people left on commode for long periods or too long

3. Dirty clothing and bed linen, only changed when staff consider it necessary

4. Lack of personal clothing and possessions

5. Inappropriate use of tip-back chairs; excessive use of cot sides

6. Unhomely, stark living areas

7. Deprived environment and lack of stimulation

8. Inappropriate nursing or medical procedures (e.g. enemas or catheterization)

9. “Batch care”: lack of individual care plans, ritualised care; no person-centred care planning

10.Inappropriate confinement or restriction

11.Inappropriate use of power or control

12.Coercion
13.Distress caused to a person by locking them in at home, in their car, etc.
14.No visitors or phone calls allowed
15.Inappropriate clothing
16.Sensory deprivation: not allowed to have hearing aid, glasses, etc.
17.Restricted access to personal hygiene and toilet
18.Lack of respect for the dependent person as an individual
19.Carer does not provide personal hygiene or allow medical care, etc.
20.Use of furniture and other equipment to restrict movement

Neglect and Acts of Omission

1. Neglect of accommodation

2. Inadequate heating

3. Inadequate lighting

4. Poor physical condition of person, e.g. ulcers or beds sores

5. Person’s clothing in bad condition, e.g. unclean or wet

6. Failure to visit or engage in social interaction

7. Malnutrition

8. Failure to give prescribed medication

9. Failure to access appropriate medical care

10.Failure to ensure appropriate privacy and dignity

11.Inconsistent or reluctant contact with health or social agencies

12.Refusal of access to callers or visitors

Self Neglect

1. Dehydration

2. Untreated or improperly attended medical conditions

3. Poor personal hygiene

4. Hazards or unsafe living conditions

5. Unsanitary or unclean living quarters

6. Inappropriate or inadequate clothing

7. Lack of necessaary medical aids e.g. hearing aid or spectacles

8. Homelessness

Who Abuses and Neglects Adults?

Anyone can carry out abuse or neglect, including the following:

  • Spouses or partners
  • Other family members
  • Neighbours
  • Friends
  • Acquaintances
  • Local residents
  • People who deliberately exploit adults they perceive as vulnerable to abuse
  • Paid staff or professionals
  • Volunteers and strangers

While a lot of attention is paid to targeted fraud or internet scams perpetrated by complete strangers, it is far more likely that the person responsible for abuse is known to the adult and in a position of trust and power in relation to them.

Spotting Signs of Abuse and Neglect

Workers, across a wide range of organisations, need to be vigilant about adult safeguarding concerns in all walks of life, including (amongst others) in health and social care; welfare; policing; banking; fire and rescue services; trading standards;

leisure services; faith groups; and housing. GP’s in particular are often well-placed to notice the changes in an adult that may indicate they are being abused or neglected. Findings from Serious Case Reviews have sometimes stated that if professionals or other staff had acted upon their concerns or sought more information then death or serious harm might have been prevented. The following example illustrates that someone who might not typically be thought of, in this case the neighbour, does in fact have an important role to play in identifying when an adult is at risk.

Alerting and Reporting

Safeguarding Adults Board

It is a requirement of the Care Act 2014 that all Local Authorities are required to create a Safeguarding Adults Board from 2015.

The Safeguarding Boards:

  • Set out the ways in which safeguarding procedures are put into practice in the local area
  • Promote information sharing between workers and organisations to meet the needs of the individual.

Multi-Agency Safeguarding Protocol

Each county has its own Safeguarding Adult Board (SAB) which issues the Multi Agency Safeguarding Protocol, this protocol is agreed by the Local Authority Adult Social Services, the NHS and the Police.

The protocol lays out procedures that must be followed in relation to recognising; alerting, reporting, making enquiries, investigating and reviewing the Safeguarding of Adults.

Your organisational policy on Safeguarding will reflect this multi-agency protocol and clearly outline your responsibilities.

In general terms; It is the Health or Social Care Providers responsibility to alert and report actual or potential Safeguarding incidents.

Northumberland safeguarding information available at Northumberland County Council – Safeguarding adults

North Tyneside safeguarding information available at Safeguarding adults | North Tyneside Council

South Tyneside safeguarding information available at South Tyneside Safeguarding Children and Adults Partnership APPP – South Tyneside Safeguarding Children and Adults Partnership APPP (southtynesidesafeguardingappp.co.uk)

Alerting

  • Always believe the individual that is disclosing the actual or potential abuse or neglect
  • The worker should be supportive and listen but should not ask investigative questions
  • It is not the workers job to decide if they are telling the truth or not but it is their responsibility to report it to the person in charge
  • Even if the individual asks for it not to be reported, it is the worker’s responsibility to report and explain that they have no choice but to follow policy
  • It is also important to tell the individual to whom the report will be made and that they will need to come and talk to them about it
  • Remember it is your responsibility to report – the Safeguarding Unit will make or arrange the enquiries and listen to the individual’s views and choices
  • In cases where the adult is in imminent danger, urgent action to protect the individual should be taken by calling the relevant emergency services. E.g. the ambulance and police service
  • Do not confront the abuser or alert them to what has been alleged, do not put yourself in danger and call for backup as soon as is possible
  • Support needs to be given to the individual especially through the initial stages of the enquiries and later if an investigation takes place
  • If there is a possibility that forensic evidence can be identified, protect the individual and the evidence, do not clean up. Inform your manager and follow organisational policy and procedure
  • You will be required to complete documents, recording what you have seen or has been disclosed to you, using correct reporting documents record only the facts and not your opinion or views
  • These documents may need to be used at a Safeguarding hearing or in a court of law and therefore written accounts must be contemporaneous, factual, legible and signed and dated by the necessary people
  • Confidentiality is paramount and it is important that people are informed on a need to know basis only. When these situations are discussed with other staff members it should be in a formal and confidential environment.

Reporting

  • The Registered Manager or personnel working on their behalf will report the Safeguarding to the Local Safeguarding Unit. This must include the following:

    • Personal details of adult at risk
    • Who you are and why you are involved
    • What happened, when and where?
    • Details of alleged abuser(s)
    • Are there any other people at risk including any children?
    • Details of any other agencies involved
    • Is the adult at risk aware of the referral and have they consented?
    • State whether the adult at risk has the capacity to make the decision to consent to the safeguarding referral.
  • There are specific reporting documents that must be used and sent electronically to the Safeguarding Unit.
  • It is important that the organisation keeps copies of these documents and all other related information.
  • A safeguarding log must be in place to record all safeguarding alerts or reports
  • At the same time the manager is required to email a statutory notification to CQC
  • CQC do not usually investigate but they monitor how the situation is being managed and liaises with other participating organisations such as the

Poor Practice Vs Possible Abuse

A key skill for any referrer is the ability to make informed decisions between what constitutes poor practice compared to possible abuse.

  • Poor Practice-situations where a genuine mistake is made and immediate steps taken to remedy it at a local level. No harm to the service user.
  • Possible abuse- situations where there has been significant harm to an individual caused through intentional or unintentional abuse or neglect.

Safeguarding Unit

Enquiries

  • Section 42 Enquiries are the mechanism for safeguarding enquiries as set out in the Care Act 2014 Chapter 14. It is a legal duty for local authorities to make enquires or cause someone else to make enquiries
  • An enquiry could range from a conversation with the adult, or if they lack capacity, or have substantial difficulty in understanding the enquiry their representative or advocate, prior to initiating a formal enquiry, right through to a much more formal multi-agency plan or course of action
  • The professional concerned should record the concern, the adult’s views and wishes, any immediate action that has been taken and the reasons for those actions
  • The purpose of the enquiry is to decide whether or not the local authority or another organisation, or person, should do something to help and protect the adult
  • If the local authority decides that another organisation should make the enquiry, for example a care provider, then the local authority should be clear about timescales, the need to know the outcomes of the enquiry and what action will follow if this is not done
  • What happens as a result of an enquiry should reflect the adult ‘s wishes wherever possible, as stated by them or by their representative or advocate
  • If they lack capacity it should be in their best interests if they are not able to make the decision, and be proportionate to the level of concern
  • The adult should always be involved from the beginning of the enquiry unless there are exceptional circumstances that would increase the risk of abuse
  • If the adult has substantial difficulty in being involved, and where there is no one appropriate to support them, then the local authority must arrange for an independent advocate to represent them for the purpose of facilitating their involvement

Professionals and other staff need to handle enquiries in a sensitive and skilled way to ensure distress to the adult is minimised. It is likely that many enquiries, particularly the more complex situations, will require the input and supervision of a social worker in order to support the adult to realise the outcomes they want and to reach a resolution or recovery; for example, where abuse or neglect is suspected within a family or informal relationship it is likely that a social worker will be the most appropriate lead. Personal and family relationships within community settings can prove both difficult and complex to assess and intervene in. The dynamics of personal relationships can be extremely difficult to judge and rebalance; for example, an adult may make the choice to be in a relationship that causes them emotional distress because, in their mind, it outweighs the unhappiness of not maintaining the relationship.

Whilst work with the adult may frequently require the input of a social worker, other aspects of enquiries may be best undertaken by others with more appropriate skills and knowledge; for example, health professionals should undertake enquiries and treatment plans relating to medicines management or pressure ulcers.

Investigation

  • The Multi-Agency Protocol identifies the process of the investigation and the timescales that should be followed by all agencies that are involved.
  • There are times when after an initial investigation and on speaking with the adult there is no further action because of the nature of the event and the wishes of the adult
  • In other situations, safeguarding meetings will be held with all agencies involved to determine cause and identify how the situation will be managed and timescales put in place for this to happen

Information Sharing

Early sharing of information is the key to providing an effective response where there are emerging concerns. To ensure effective safeguarding arrangements:

  • All organisations must have arrangements in place that set out clearly the processes and the principles for sharing information between each other, with other professionals and the Safeguarding Adult Board (SAB); this could be via an Information Sharing Agreement to formalise the arrangements
  • No professional should assume that someone else will pass on information that they think may be critical to the safety and wellbeing of the adult. If a professional has concerns about the adult’s welfare and believes they are suffering or likely to suffer abuse or neglect, they should share the information with the local authority and/or the police if they believe or suspect that a crime has been committed