Department of Health No Secrets Policy

There can be no secrets and no hiding place when it comes to exposing the abuse of vulnerable adults. The Government’s White Paper, ‘Modernising Social Services’, published at the end of 1998, signalled our intention to provide better protection for individuals needing care and support. This is being taken up through the Care Standards Bill.

We are also committed to providing greater protection to victims and witnesses, and the Government is actively implementing the measures proposed in ‘Speaking Up for Justice’, the report on the treatment of vulnerable or intimidated witnesses in the criminal justice system. That report recognised that there were concerns about both the identification and reporting of crime against vulnerable adults in care settings, and endorsed the proposals made by the Association of Directors of Social Services, and others, that a national policy should be developed for the protection of vulnerable adults. It was agreed that local multi-agency codes of practice would be the best way forward.

The development of these codes of practice should be co-ordinated locally by each local authority social services department. To support this process this guidance is being issued under Section 7 of the Local Authority Social Services Act 1970. Government departments have worked closely together on the preparation of this guidance and we commend it to local authority social services departments, the police service, and the health service. It will also be of interest to the independent sector, as well as users and carers.

In recent years several serious incidents have demonstrated the need for immediate action to ensure that vulnerable adults, who are at risk of abuse, receive protection and support. The Government gives a high priority to such action and sees local statutory agencies and other relevant agencies as important partners in ensuring such action is taken wherever needed. This guidance builds on the Government’s respect for human rights and results from its firm intention to close a significant gap in the delivery of those rights alongside the coming into force of the Human Rights Act 1998.

The aim should be to create a framework for action within which all responsible agencies work together to ensure a coherent policy for the protection of vulnerable adults at risk of abuse and a consistent and effective response to any circumstances giving ground for concern or formal complaints or expressions of anxiety. The agencies’ primary aim should be to prevent abuse where possible but, if the preventive strategy fails, agencies should ensure that robust procedures are in place for dealing with incidents of abuse. The circumstances in which harm and exploitation occur are known to be extremely diverse, as is the membership of the at-risk group. The challenge has been to identify the next step forward in responding to this diversity.

This guidance is issued in furtherance of the Government’s commitment to develop such policies at national and local level. It is commended to all commissioners and providers of health and social care services including primary care groups, regulators of such care services and appropriate criminal justice agencies. These statutory agencies should work together in partnership (as advocated in the Health Act 1999) to ensure that appropriate policies, procedures and practices are in place and implemented locally. They should do so in collaboration with all agencies involved in the public, voluntary and private sectors and they should also consult service users, their carers and representative groups.

Local authority social services departments should play a co-ordinating role in developing the local policies and procedures for the protection of vulnerable adults from abuse. Social services departments should note that this guidance is issued under Section 7 of the Local Authority Social Services Act 1970, which requires local authorities in their social services functions to act under the general guidance of the Secretary of State. As such, this document does not have the full force of statute, but should be complied with unless local circumstances indicate exceptional reasons which justify a variation.

This document gives guidance to local agencies who have a responsibility to investigate and take action when a vulnerable adult is believed to be suffering abuse. It offers a structure and content for the development of local inter-agency policies, procedures and joint protocols which will draw on good practice nationally and locally. Coherent strategies should be developed, in all areas of the country, by all the statutory, voluntary and private agencies that work with vulnerable adults.

Structure of this document. Section 2 covers issues of definition. Sections 3, 4, 5 and 6 provide guidance about the protection from abuse of vulnerable adults by the creation of a multi-agency administrative framework (Section 3), the development of inter-agency policies and strategies (Sections 4 and 5), and the formulation of inter-agency operational procedures designed to implement those policies when instances of abuse or suspected abuse come to light (Section 6). Section 7 discusses the provision of broader guidance for staff, users, carers and members of the public.

When developing operational guidance, local agencies should refer to the publications dealing with the abuse of vulnerable adults which appear in Appendix II.

The broad definition of a ‘vulnerable adult’ referred to in the 1997 Consultation Paper Who decides?,* issued by the Lord Chancellor’s Department, is a person: “who is or may be in need of community care services by reason of mental or other disability, age or illness; and

* See also Making decisions – a report issued in the light of responses to the consultation on the Law Commission’s document (1999). who is or may be unable to take care of him or herself, or unable to protect him or herself against significant harm or exploitation”.

For the purposes of this guidance ‘community care services’ will be taken to include all care services provided in any setting or context.

What constitutes abuse? In drawing up guidance locally, it needs to be recognised that the term ‘abuse’ can be subject to wide interpretation. The starting point for a definition is the following statement:

Abuse is a 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 or an omission to act, or it may occur when a vulnerable person is persuaded to enter into a financial or sexual transaction to which he or she has 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.

A consensus has emerged identifying the following main different forms of abuse:
• physical abuse, including hitting, slapping, pushing, kicking, misuse of medication, restraint, or inappropriate sanctions;
• sexual abuse, including rape and sexual assault or sexual acts to which the vulnerable adult has not consented, or could not consent 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, isolation or withdrawal from services or supportive networks;
• financial or material abuse, including theft, fraud, exploitation, pressure in connection with wills, property or inheritance or financial transactions,
or the misuse or misappropriation of property, possessions or benefits;

• neglect and acts of omission, including ignoring medical or physical care needs, failure to provide access to appropriate health, social care or educational services, the withholding of the necessities of life, such as medication, adequate nutrition and heating; and • discriminatory abuse, including racist, sexist, that based on a person’s disability, and other forms of harassment, slurs or similar treatment.

Any or all of these types of abuse may be perpetrated as the result of deliberate intent, negligence or ignorance.

Incidents of abuse may be multiple, either to one person in a continuing relationship or service context, or to more than one person at a time. This makes it important to look beyond the single incident or breach in standards to underlying dynamics and patterns of harm. Some instances of abuse will constitute a criminal offence . In this respect vulnerable adults are entitled to the protection of the law in the same way as any other member of the public. In addition, statutory offences have been created which specifically protect those who may be incapacitated in various ways.

Examples of actions which may constitute criminal offences are assault, whether physical or psychological, sexual assault and rape, theft, fraud or other forms of financial exploitation, and certain forms of discrimination, whether on racial or gender grounds. Alleged criminal offences differ from all other non-criminal forms of abuse in that the responsibility for initiating action invariably rests with the state in the form of the police and the Crown Prosecution Service (private prosecutions are theoretically possible but wholly exceptional in practice). Accordingly, when complaints about alleged abuse suggest that a criminal offence may have been committed it is imperative that reference should be made to the police as a matter of urgency. Criminal investigation by the police takes priority over all other lines of enquiry.

Neglect and poor professional practice also need to be taken into account. This may take the form of isolated incidents of poor or unsatisfactory professional practice, at one end of the spectrum, through to pervasive ill treatment or gross misconduct at the other. Repeated instances of poor care may be an indication of more serious problems and this is sometimes referred to as institutional abuse .

2.10 Who may be the abuser? Vulnerable adult(s) may be abused by a wide range of people including relatives and family members, professional staff, paid care workers, volunteers, other service users, neighbours, friends and associates, people who deliberately exploit vulnerable people and strangers.

2.11 There is often particular concern when abuse is perpetrated by someone in a position of power or authority who uses his or her position to the detriment of the health, safety, welfare and general wellbeing of a vulnerable person. 2.12 Agencies not only have a responsibility to all vulnerable adults who have been abused but may also have responsibilities in relation to some perpetrators of abuse. The roles, powers and duties of the various agencies in relation to the perpetrator will vary depending on whether the latter is:

• a member of staff, proprietor or service manager;
• a member of a recognised professional group;
• a volunteer or member of a community group such as place of worship or social club
• another service user;
• a spouse, relative or member of the person’s social network;
• a carer; ie: someone who is eligible for an assessment under the Carers (Recognition and Services) Act 1996;
• a neighbour, member of the public or stranger; or
• a person who deliberately targets vulnerable people in order to exploit them.

Stranger abuse will warrant a different kind of response from that appropriate to abuse in an ongoing relationship or in a care location. Nevertheless, in some instances it may be appropriate to use the locally agreed inter-agency adult protection procedures to ensure that the vulnerable person receives the services and support that they need. Such procedures may also be used when there is the potential for harm to other vulnerable people.

In what circumstances may abuse occur? Abuse can take place in any context. It may occur when a vulnerable adult lives alone or with a relative; it may also occur within nursing, residential or day care settings, in hospitals, custodial situations, support services into people’s own homes, and other places previously assumed safe, or in public places.

Intervention will partly be determined by the environment or the context in which the abuse has occurred. Nursing, residential care homes and placement schemes are subject to regulatory controls set out in legislation and relevant guidance. Day care settings are not currently regulated in this way and require different kinds of monitoring and intervention to address similar risks. Paid care staff in domiciliary services may work with little or no supervision or scrutiny, and unregulated locations such as sheltered housing may require particular vigilance.

Personal and family relationships within domiciliary locations may be equally complex and difficult to assess and intervene in. 2.16 Assessment of the environment, or context, is relevant, because exploitation, deception, misuse of authority, intimidation or coercion may render a vulnerable adult incapable of making his or her own decisions. Thus, it may be important for the vulnerable adult to be away from the sphere of influence of the abusive person or the setting in order to be able to make a free choice about how to proceed. An initial rejection of help should not always be taken at face value.

• 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 abuse;
• long term abuse in the context of an ongoing family relationship such as domestic violence between spouses or generations;
• opportunistic abuse such as theft occurring because money has been left around;
• situational abuse which arises because pressures have built up and/or because of difficult or challenging behaviour;
• neglect of a person’s needs because those around him or her are not able to be responsible for their care, for example if the carer has difficulties attributable to such issues as debt, alcohol or mental health problems;

• institutional abuse which features poor care standards, lack of positive responses to complex needs, rigid routines, inadequate staffing and an insufficient knowledge base within the service;
• unacceptable ‘treatments’ or programmes which include sanctions or punishment such as withholding of food and drink, seclusion, unnecessary and unauthorised use of control and restraint (see Harris et al 1996) or over-medication;

• failure of agencies to ensure staff receive appropriate guidance on anti-racist and anti-discriminatory practice;
• failure to access key services such as health care, dentistry, prostheses;
• misappropriation of benefits and/or use of the person’s money by other members of the household;
• fraud or intimidation in connection with wills, property or other assets.

What degree of abuse justifies intervention? In determining how serious or extensive abuse must be to justify intervention a useful starting point can be found in Who decides? . Building on the concept of ‘significant harm’ introduced in the Children Act, the Law Commission suggested that:

“‘harm’ should be taken to include not only ill treatment (including sexual abuse and forms of ill treatment which are not physical), but also the impairment of, or an avoidable deterioration in, physical or mental health; and the impairment of physical, intellectual, emotional, social or behavioural development’.”

2.19 The seriousness or extent of abuse is often not clear when anxiety is first expressed. It is important, therefore, when considering the appropriateness of intervention, to approach reports of incidents or allegations with an open mind. In making any assessment of seriousness the following factors need to be considered:

• the vulnerability of the individual;
• the nature and extent of the abuse;

• the length of time it has been occurring;
• the impact on the individual; and
• the risk of repeated or increasingly serious acts involving this or other vulnerable adults.
2.20 What this means in practice is working through a process of assessment

to evaluate:
• Is the person suffering harm or exploitation?
• Does the person suffering or causing harm/exploitation meet the NHS and Community Care Act (1990) eligibility criteria?
• Is the intervention in the best interests of the vulnerable adult fitting the criteria and/or in the public interest?
• Does the assessment account for the depth and conviction of the feelings of the person alleging the abuse?

This is an area of practice which requires partnership working between statutory agencies to create a framework of inter-agency arrangements.

Local agencies should collaborate and work together within the overall framework of DH guidance on joint working. The lead agency with responsibility for co-ordinating such activity should be the local Social Services Authority but all agencies should designate a lead officer.

Elements of an inter-agency administrative framework. The first step in creating the necessary framework will be to identify all the responsible and relevant agencies, including:

commissioners of health and social care services;
providers of health and social care services;
providers of sheltered and supported housing;
regulators of services;
the police and other relevant law enforcement agencies (including the Crown Prosecution Service);
voluntary and private sector agencies;
other local authority departments, eg housing and education; probation departments;
DSS Benefit Agencies;
carer support groups;
user groups and user-led services;

• advocacy and advisory services;
• community safety partnerships;
• services meeting the needs of specific groups experiencing violence; and
• agencies offering legal advice and representation.

A multi-agency management committee. To achieve effective inter-agency working, agencies may consider that there are merits in establishing a multi-agency management committee (adult protection), which is a standing committee of lead officers. Such a body should have a clearly defined remit and lines of accountability, and it should identify agreed objectives and priorities for its work. Such committees should determine policy, co-ordinate activity between agencies, facilitate joint training, and monitor and review progress.

Experience in other areas of practice has shown that such committees are often most effective where agency boundaries are coterminous.

Further actions in such a framework will be to:
• identify role, responsibility, authority and accountability with regard to the action each agency and professional group should take to ensure the protection of vulnerable adults;
• establish mechanisms for developing policies and strategies for protecting vulnerable adults which should be formulated, not only in collaboration and consultation with all relevant agencies but also take account of the views of service users, families and care.